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OBJECTIVE To describe the baseline characteristics and two-year outcomes of patients with Child-Pugh grades A and B cirrhosis; and evaluate the predictive value of liver stiffness for the development of adverse outcomes (AOs) in this patient population. STUDY DESIGN A prospective cohort study. PLACE AND DURATION OF STUDY The Second Hospital, Cheeloo College of Medicine, Shandong University, China between September 2018 and March 2021. METHODOLOGY The present study consecutively included patients with Child-Pugh grades A and B cirrhosis. Patients were followed up every six months until two years. Baseline demographic characteristics and laboratory indexes were collected. Liver stiffness and controlled attenuation parameter were measured at baseline, month 6 and month 12. The observational endpoint was AOs, including liver-related patient death and hepatocellular carcinoma (HCC). RESULTS A total of 174 patients were included in the final cohort. Hepatitis B virus (HBV)-induced liver cirrhosis accounted for the vast majority of enrolled cases (82.2%). AOs were observed in six patients. Multivariate logistic regression model was performed and liver stiffness was considered as the only independent predictor for AOs (OR 1.071, p = 0.006). Liver stiffness was also significantly improved at 12 months compared with the baseline data (median 10.6 vs. 13.3 kPa, p

Precocious puberty is defined as the onset of secondary sexual characteristics before 8 years of age in girls and 9 years in boys. Central Precocious Puberty (CPP) is caused by early activation of the hypothalamic-pituitary-gonadal axis. Laboratory test of LH, FSH, and Estradiol is recommended for monitoring suppressive effects from GnRHa therapy in the early three months and every six months. This study aimed to report a case of CPP in a 3-year and 3-month-old girl. A 3-year and 3-month-old girl went to the hospital with vaginal bleeding (menstruation), breast development, and pubic and axilla hair for 7-month-old. Physical examination found moderately ill with obesity, body weight 20 kg, height 98 cm. Tanner stage was A2M3P2, café au lait was found in the left forehead with size 7x3.5 cm. In March 2015 before GnRHa therapy, LH, FSH and Estradiol level increased with levels of 4.32 mlU/mL, 6.01 mlU/mL, and 67 pg/mL, and after 3 months of the treatment was 0.87 mlU/mL, 2.51 mlU/mL and

Objective Fewer than 50% of children with developmental delay are identified before they start school, and only 10% of those identified receive services. Between May 2014 and August 2016, the Home Visiting Collaborative Improvement and Innovation Network (HV-CoIIN) aimed to improve early detection and linkage to services so that 80% of children with an identified developmental concern would receive timely, targeted developmental support. Methods HV-CoIIN enrolled 13 home visiting programs in eight states and one tribe in a Breakthrough Series Collaborative (BTS). These programs tested interventions aligned with five key drivers: early detection, referral and follow-up, home visitor capacity, families engaged in developmental promotion, and data systems. Run charts were used to study measures. The main outcome was the percent of children with an identified concern that were linked to developmental support. Process measures included the percent of visits where parents were asked if they had any concerns about their child's development and the percent of children screened every six months. Results The percent of children with an identified developmental concern that received support increased from 70% to 82%. Parents were asked about developmental concerns at 95% of visits (baseline = 75%), and 90% of children were screened every six months (baseline = 51%). Conclusion Home visiting programs can reliably execute early detection and linkage to services for at-risk populations they serve. BTS holds promise for improving implementation of federal public health programs to improve population health outcomes.

This article deals with the rare clinical observation of the patient with recurrent desmoid-type fibromatosis, who have achieved long-term stability after surgical treatment. A 24-year-old patient was diagnosed with retroperitoneal tumor which size was 8.85.613 cm in 2013, infiltrating the left psoas muscle, left kidney, left common and left external iliac arteries, descending colon and sigmoid colon. The patient underwent surgery in the volume of the tumor removal, resection of the left common iliac artery and prosthetics using GORE-TEX prosthesis, left hemicolectomy, left nephrectomy at Blokhin National Medical Research Center of Oncology. The first recurrence of the tumor was detected nine months after the surgery. Due to the subsequent growth of tumor mass, located along the left external iliac artery and in the inguinal canal, the repeated surgery was performed. Then the patient had a second relapse, and underwent surgery again. The third recurrence was detected seven months after the last surgery. During the multidisciplinary discussion, according to the absence of complaints and the small size of the recurrent tumor, as well as the absence of the risk of life-threatening complications, it was decided to stop on the observation. The patient was examined once every six months there were no data concerning recurrent tumor growth. Today, the patient is alive, does not have any complaints and is able-bodied. Our clinical observation demonstrates that active surgical tactics in case of the retroperitoneal fibromatosis recurrence not always can lead to long-term progression-free survival time and several patients can stay under the observation, using Look and Stay tactic.

Aim: The aim of this study is to highlight the effectiveness of music therapy in Alzheimer’s Disease (AD) and their caregivers. Methods: The biennial 2019 to 2020, 32 patients, with AD (ICD-10), were examined, by a research group composed by a Neurologist, a GP and a Music-psychotherapist. All patients were under pharmaceutical care. The patients’ medical record and musical profile was assessed. The answers were provided by the patients themselves or by their tutors. Then, personal or family sessions were organized with the participation of musical instruments. The patients staging and evaluation were made through MMSE. The test was repeated every six months under the Neurologist’s supervision. Finally, 31 totally patients succeeded to complete our intervention and to be estimated. Results: The duration of follow-up of the patients was 30 months. At the beginning and end of the sessions we obtained the following data: In a total of 32 patients with AD, initially 3 patients (9.37%) had Mild AD, 19 patients (59.37%) had Moderate AD, 10 patients (31.25%) severe AD, based on the MMSE evaluation. After 30 months, 11 patients had Mild AD (35.48%), number resulting from the music benefit of cognitive function in patients with moderate AD. 15 patients with Moderate AD (48.38%) were observed, out of the initial 19 (59.37%) patients with Moderate AD, a number attributed to the sum of patients who improved from severe AD and those who were transferred, benefiting from treatment, from Moderate AD disease to Mild AD. Finally 5 patients with severe AD disease were evaluated (16.12%), while before the treatment we had 10 patients (31.25%) with severe AD. Conclusions: Music therapy is a tool to increase the life quality of the participants. The results expected in the treatment of AD are obtained by means of good collaboration among the research team.

Aims: Diabetic patients in India present late in advanced stages of tissue loss and isolated occlusive infrapopliteal disease. We aim to determine the outcomes of angioplasty in these patients with SINBAD score >3 and infrapopliteal disease presenting with critical limb-threatening ischemia (CLTI) and tissue loss. Materials and Methods: A prospective, observational, single-center study was carried out of diabetic patients with infrapopliteal occlusive disease who underwent angioplasty for CLTI and tissue loss. Transatlantic society consensus (TASC) - classification was used for staging. Ischemia and Peripheral Artery Calcium Scoring was used to assess peripheral calcium. The patients were followed up till their ulcer healed and then every six months. Results: A total of 73 diabetic patients underwent angioplasty for CLTI. 21.8% (16/73) all-cause mortality was seen during the study. The average age was 68.9 years with 78.9% males. The average time to presentation was 55 days. 61.3% of patients had TASC C or D lesions. Technical success was achieved in 94.5% of patients. 27.4% of patients underwent angioplasty of multiple tibial vessels. The mean duration of follow-up was 2 years. 62.5% of patients had their ulcers completely heal in 6 months. Six patients went on to have major amputation. The amputation-free period was 500 days in this patient group. Ulcer healing was found to be dependent on successful revascularization. Conclusion: Mortality is seen in 1 in 10 and morbidity in 1 in 5 patients. It is difficult to accurately prognosticate healing in these patients. Successful revascularization is the only factor affecting healing in these patients.

Construct: Every six months, residency programs report their trainees’ Milestones Level achievement to the Accreditation Council for Graduate Medical Education (ACGME). Milestones should enable the...

Purpose To describe a single-center 15-year experience of active surveillance (AS) for prostate cancer (PCa). Materials and Methods We retrospectively reviewed patients who underwent AS between 2003 and 2018. One hundred fifty-three patients were selected according to the following criteria: (1) biopsy Gleason pattern ≤3+4 with (2) ≤two positive core(s) and (3) ≤50% core involvement, clinical-stage ≤T2a, and prostate-specific antigen (PSA) ≤20 ng/mL. Follow-up included PSA measurement every six months, prostate biopsies at one year and then every 2–3 years, and MRI every year. Intervention was triggered by (1) Gleason score (GS) upgrading, (2) >two positive cores, or (3) PSA doubling-time in two positive cores (8.5%), abnormal PSA kinetics (11.9%), and patient preference (37.3%). Notably, 12 (25.5%) patients had pathologic GS ≥4+3 (unfavorable disease) and 3 (6.4%) patients had pathologic stage ≥T3a at radical prostatectomy. Median time to treatment-free survival was 19.5 months. Of the 59 patients who switched to intervention, biochemical recurrence was reported in only one (0.7%) patient. Conclusions AS is an available option for low-risk PCa in carefully selected patients. Further larger prospective studies are needed to determine the optimal criteria for AS, especially in Korean PCa patients., Graphical Abstract

To investigate the effects of overnight orthokeratology (OK) lenses wear on the interocular axial length (AL) difference in anisomyopic children.Sixty anisomyopic children (8-14 years old) were enrolled in this one-year prospective, randomised controlled study. Subjects were randomly assigned to wear OK lenses (OK group) or single-vision spectacles (control group). AL was monitored at baseline and every six months using an IOL Master biometer, and axial elongation and interocular AL differences were compared between the groups.In the control group, the more myopic eyes had similar axial elongation (0.36 ± 0.17 mm) to the less myopic eyes (0.37 ± 0.17 mm) at the one-year follow-up (P 0.05). In the OK group, the less myopic eyes exhibited significantly greater axial elongation (0.24 ± 0.17 mm) than the more myopic eyes (0.13 ± 0.13 mm) at the one-year follow-up (P 0.05). The mean interocular AL difference significantly decreased in the OK group over one year, from 0.47 ± 0.24 mm to 0.35 ± 0.22 mm (P 0.05). However, the mean interocular AL difference decreased only slightly in the control group, from 0.56 ± 0.28 mm to 0.55 ± 0.28 mm (P 0.05).This randomised, controlled study demonstrated that OK reduces the interocular AL difference in anisomyopic children due to stronger myopic control of the more myopic eye.

الملخص: أهداف البحث: تهدف هذه الدراسة إلى تحديد ومقارنة مستويات الإجهاد النفسي لدى طلاب الطب من السنة الأولى إلى السنة الخامسة، ومعرفة العوامل المسببة للإجهاد. طرق البحث: أجريت هذه الدراسة المستعرضة على ٤٦٨ من الإناث. استخدمت الدراسة أداة قياس الإجهاد النفسي ''كسلر ١٠''، واستبانة حول مختلف العوامل التي تسبب الإجهاد. النتائج: أبلغ ٦٧.٩ ٪ من الطالبات عن وجود الإجهاد الفسيولوجي لديهن. وبلغت نسبة الطالبات بدون إجهاد، وبإجهاد خفيف، وإجهاد معتدل، وإجهاد شديد ٣٢٪ و٢٤٪ و٢٢٪ و٢١.٨٪ على التوالي. وكان أعلى معدل انتشار للإجهاد الفسيولوجي عند طالبات السنة الأولى (٨٢.٦٪). وانخفضت درجات التوتر بشكل ملحوظ مع زيادة في السنة الدراسية، باستثناء السنة الأخيرة. وتضمنت متغيرات الدراسة السنة الأولى من الدراسة الطبية (٠.٠٢٢)، والإجهاد الأكاديمي (٠.٠٠١)، ووجود مشكلة جسدية (٠.٠٠١) والزواج (٠.٠٠٢)، وكانت عوامل الخطر المستقلة لارتفاع التوتر الملحوظ (درجة كسلر ١٠ > ٢٤). واستشار ١١.١٪ من الطالبات طبيب فيزيائي، في حين أن ٣.٤٪ من الطالبات يتناولن بعض الأدوية لعلاج الإجهاد. الاستنتاجات: خلصت الدراسة إلى أن السنة الأولى من الدراسة الطبية، والإجهاد الأكاديمي، ووجود مشكلة جسدية والزواج هي عوامل خطر مستقلة لارتفاع نسبة انتشار الإجهاد النفسي. نوصي بأن يكون فحص الإجهاد النفسي إلزاميا في كليات الطب. ويفضل أن يتكرر كل ستة أشهر، كما يجب تقديم المشورة لمن لديه إجهاد نفسي، وتقديم خدمات الصحة النفسية والمتابعة السليمة. Abstract: Objective: This study aimed to determine and compare degrees of psychological stress and inducing factors thereof among first to fifth year medical students (MS). Methods: This cross-sectional study was conducted on 468 female MS. We used the Kessler 10 Psychological Distress Inventory consisting of questions on a range of stress-inducing factors. Results: A total of 67.9% students reported physiological stress. The percentage of MS without stress and with mild, moderate, and severe stress was 32%, 24%, 22%, and 21.8%, respectively. The highest prevalence of physiological stress was found among first-year students (82.6%). Stress scores significantly decreased with advancement in the year of study, except for the final year (p = 0.001). We found that the first year of medical studies (0.022), academic stress (0.001), the presence of a physical problem (0.001), and being married (0.002) were independent risk factors for high perceived stress (HPS), as shown by K10 scores >24. A total of 11.1% students consulted a psychiatrist, whereas 3.4% admitted taking some medication for stress. Conclusion: This study infers that the first year of medical studies, academic stress, the presence of a physical problem, and being married are independent risk factors for HPS. We recommend mandatory stress screening for MS in all medical colleges. Ideally, the screening should be repeated every six months and students identified as having HPS should be provided with counselling, mental health services, and a proper follow-up. الكلمات المفتاحية: طلاب الطب, الضغط النفسي, عوامل الخطر, Keywords: Academic stress, Medical students, Psychological stress, Risk factors, Student counselling

Long-term and continuous nephrology care effects on post-dialysis mortality remain unclear. This study aims to systematically explore the causal effect of nephrology care on mortality for patients with dialysis initiation. We conducted a retrospective cohort study to include incident patients with dialysis for ≥ 3 months in Taiwan from 2004 through 2011. The continuous nephrology care of incident patients in the three years before their dialysis was measured every six months. Continuous nephrology care was determined by 0–6, 0–12, …, 0–36 months and their counterparts, and none, intermittent, 0–6 months, …, and 0–36 months. Simple and weighted hazards ratio (HR) and 95% confidence interval (CI) for one-year mortality were estimated after propensity score (PS) matching. We included a total of 44,698 patients (mean age 63.3 ± 14.2, male 51.9%). Receiving ≥ 1 year predialysis nephrology care was associated with a 22% lower post-dialysis mortality hazard. No different effects were found (ranges of PS matching HR: 0.77–0.80) when comparing the defined duration of nephrology care with their counterparts. Stepped survival benefits were newly identified in the intermittent care, which had slightly lower HRs (weighted HR: 0.88, 95% CI: 0.79–0.97), followed by reviving care over six months to two years (ranges of weighted HR: 0.60–0.65), and reviving care over two years (ranges of weighted HR: 0.48–0.52). There was no existing critical period of nephrology care effect on post-dialysis, but there were extra survival benefits when extending nephrology care to &gt, 2 years, which suggests that continuous and long-term care during pre-dialysis/chronic kidney disease phase is required.

Background Attention Deficit and Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition seen in 5% of school age children. Children who are commenced on ADHD medication require regular assessments to ensure safety and continuation of medication and to check progress of their condition. Objectives We would like to ascertain whether: . baseline cardiovascular assessment and measurements (height, weight, blood pressure and heart rate) have been carried out on children and young people prior to starting ADHD medication . the initial assessment and subsequent follow ups met the criteria outlined within NICE guidance (2019) . there are any safeguarding concerns and if present, escalated appropriately Methods The sample of children and young people was obtained randomly via SystmOne (electronic record) using the read code 'Attention deficit hyperactivity disorder' to identify them between January to December 2019. They were all started on one of the following medications: Medikinet, Medikinet XL, Matoride XL, Concerta XL, Equasym XL and Elvanse. They were assessed and reviewed by an array of different clinicians. The audit was reviewed against NICE guidance: Attention Deficit Hyperactivity Disorder: Diagnosis and Management (2019). Results 20 children and young people were included in the audit. All (100%) had a baseline height, weight, blood pressure and heart rate (H, W, BP and HR) taken and recorded at their initial assessment. 95% of the children had the baseline readings of their H, W, BP and HR documented on their clinic letter, and 75% had their BP and HR percentiles recorded. As per NICE guidance, children on ADHD medication require a repeat blood BP and HR after each dose change and every six months. 25% of the children in this audit had a repeat BP and HR within six months, associated with a medication change or dose adjustment. Similarly, NICE advises that children should have a follow up height every 6 months and a follow up weight every 3 months for children under the age of years and every 6 months for children over the age of 10 years. 20% of children in this audit had a repeat height and weight within these specified timeframes, and this was also associated with a medication change or dose adjustment. NICE guidance states that all children should have a cardiovascular assessment prior to starting ADHD medication;this audit found that 85% of children had documentation pertaining to 'normal heart sounds/heart murmur', and the ADHD pre-drug checklist was completed in 80% of cases. Safeguarding was also included in this audit, however only 15% had current or recent safeguarding needs and none of these required any further escalation. Conclusions Undoubtedly some of the results of this audit may have been impacted by the COVID 19 pandemic, which commenced in March 2019 and naturally had a significant impact on service delivery and provision during the months that followed. With regards to this audit, this is likely to be particularly relevant to the children's blood pressure and heart rate measurements and follow up appointments. To overcome this, Saturday Blood Pressure clinics were established locally and measurements were recorded along with centiles. Any children and young people who were due/overdue these checks were invited to attend to ensure ongoing holistic care. Escalation process is implemented to alert the child's paediatrician in case of concerns and for timely action.

Background Language is a critical development accomplishment of early childhood, enabling later literacy, education and employment. Previous studies have highlighted socioeconomic inequalities in the amount parents speak to their child, with researchers estimating by age four parents from professional backgrounds spoke 30 million more words to their children, than parents who were on welfare. Methods This study utilises innovative speech recognition technology called Language Environment Analysis (LENA), which counts the number of words children hear and speak over a day. LENA data is collected once every six months from 6 – 48 months of age, across two cohorts of children who are stratified by two levels of maternal education to examine the effects across socioeconomic groups. Results Results from the first three waves of data collection demonstrate that differences between education groups in the number of adult words spoken to the child are not evident until the children are 18 months old. Average change in adult word counts per day by maternal education show there is a difference of 17 words at 6 months, 568 words at 12 months and 3,851 words at 18 months. Conclusions This is the first study to be able to identify the age when socioeconomic differences in the amount of talk emerge. This has significant implications for the timing of interventions aiming to reduce the word gap, suggesting targeting the implementation of programs prior to 18 months. Key messages Socioeconomic differences in the amount parents talk to their children do not emerge until children are 18 months old.

Author(s): Steward, Wayne T; Agnew, Emily; de Kadt, Julia; Ratlhagana, Mary Jane; Sumitani, Jeri; Gilmore, Hailey J; Grignon, Jessica; Shade, Starley B; Tumbo, John; Barnhart, Scott; Lippman, Sheri A | Abstract: IntroductionFew interventions have demonstrated improved retention in care for people living with HIV (PLHIV) in sub-Saharan Africa. We tested the efficacy of two personal support interventions - one using text messaging (SMS-only) and the second pairing SMS with peer navigation (SMS+PN) - to improve HIV care retention over one year.MethodsIn a cluster randomized control trial (NCT# 02417233) in North West Province, South Africa, we randomized 17 government clinics to three conditions: SMS-only (6), SMS+PN (7) or standard of care (SOC; 4). Participants at SMS-only clinics received appointment reminders, biweekly healthy living messages and twice monthly SMS check-ins. Participants at SMS+PN clinics received SMS appointment reminders and healthy living messages and spoke at least twice monthly with peer navigators (PLHIV receiving care) to address barriers to care. Outcomes were collected through biweekly clinical record extraction and surveys at baseline, six and 12nmonths. Retention in HIV care over one year was defined as clinic visits every three months for participants on antiretroviral therapy (ART) and CD4 screening every six months for pre-ART participants. We used generalized estimating equations, adjusting for clustering by clinic, to test for differences across conditions.ResultsBetween October 2014 and April 2015, we enrolled 752 adult clients recently diagnosed with HIV (SOC: 167; SMS-only: 289; SMS+PN: 296). Individuals in the SMS+PN arm had approximately two more clinic visits over a year than those in other arms (pnln0.01) and were more likely to be retained in care over one year than those in SOC clinics (54% vs. 38%; OR: 1.77, CI: 1.02, 3.10). Differences between SMS+PN and SOC conditions remained significant when restricting analyses to the 628 participants on ART (61% vs. 45% retained; OR: 1.78, CI: 1.08, 2.93). The SMS-only intervention did not improve retention relative to SOC (40% vs. 38%, OR: 1.12, CI: 0.63, 1.98).ConclusionsA combination of SMS appointment reminders with personalized, peer-delivered support proved effective at enhancing retention in HIV care over one year. While some clients may only require appointment reminders, the SMS+PN approach offers increased flexibility and tailored, one-on-one support for patients struggling with more substantive challenges.

Background: The kinetics of B cell repopulation in MS patients treated with Ocrelizumab is highly variable, suggesting that a fixed dosage and time scheduling might be not optimal. We aimed to investigate whether B cell repopulation kinetics influences clinical and radiological outcomes and whether circulating immune asset at baseline affects B cell repopulation kinetics. Methods: 218 MS patients treated with Ocrelizumab were included. Every six months we collected data on clinical and magnetic resonance imaging (MRI) activity and lymphocyte subsets at baseline. According to B cell counts at six and twelve months, we identified two groups of patients, those with fast repopulation rate (FR) and those with slow repopulation rate (SR). Results: A significant reduction in clinical and radiological activity was found. One hundred fifty-five patients had complete data and received at least three treatment cycles (twelve-month follow-up). After six months, the FR patients were 41/155 (26.45%) and 10/41 (29.27%) remained non-depleted after twelve months. FR patients showed a significantly higher percentage of active MRI scan at twelve months (17.39% vs. 2.53%, p = 0,008). Furthermore, FR patients had a higher baseline B cell count compared to patients with an SR (p = 0.02 and p = 0.002, at the six- and twelve-month follow-ups, respectively). Conclusion: A considerable proportion of MS patients did not achieve a complete CD19 cell depletion and these patients had a higher baseline CD19 cell count. These findings, together with the higher MRI activity found in FR patients, suggest that the Ocrelizumab dosage could be tailored depending on CD19 cell counts at baseline in order to achieve complete disease control in all patients.

Introduction Blood is a valuable as well as a perishable commodity that has a limited lifespan. So, keeping it in a blood bank requires careful attention and management. In this study, a management model has been designed for the blood bank that can cover all the requests sent through the hospital subunits in such a way that it has the least waste. Materials and Methods First, by examining the blood inventory system of a hospital, the number of inventories per month and the distribution of blood products in subunits of the hospital, and the amount of blood wastage every six months were estimated. Then, using ARENA simulation, all parts of the blood bank, including the request section, emergency blood section, donated blood section, and other sections were simulated. Finally, 10 scenarios were extracted by placing various parameters and the best scenarios were discussed and concluded. Results and discussion The scenarios for the four blood groups included A, B, AB, and O were applied for six months in one year. The results showed that if the amount of blood injected into the blood bank is appropriate and at the right time, the amount of wastage can be reduced by up to 80% for most of the blood groups. Conclusion The results of this study showed that if the system of receiving blood products built upon a precise management model is predetermined and placed with appropriate parameters, the amount of wastage will be reduced to the minimum possible number.

The quality of a good medical record must meet the indicators of completeness and accuracy of filling, timeliness in safety and provision of medical records that meet legal requirements. The purpose of this study was to analyze the influence of procedures and supervision on the quality medical records for inpatient. This research is survey research with explanatory research design. The research was conducted at Imelda Hospital. The research population was 238 people and the sample was 100 people. The sampling technique is stratified random sampling which divides the population into homogeneous groups (strata) proportionally: 21 doctors, 65 nurses, and 14 medical records officers, from each stratum a random sample is taken. Data analysis using univariate, bivariate with the chi-square test, and multivariate using multiple logistic regression tests. The results showed that the procedure factor had no effect on the quality of medical records at the Imelda Hospital, p-value 0.520> 0.05. The controlling factor influences the quality of medical records at Imelda Hospital, p-value 0.001

Background: Since 2013, Tenofovir (TDF) and Zidovudine (AZT) based regimen are alternatively used as a fi rst line for treatment of HIV in Tanzania. CD4+ cells count, which is recommended after every six months monitors the immunological progression, and used as one of the indicators of treatment progression. However, there is little literature available information to compare the immunological outcomes of these two regimens.

Chronic lymphocytic leukemia is the most frequent adult leukemia. Eighty per cent of the patients are asymptomatic at diagnosis and 30% of the patients will be never treated. The diagnosis is based on the blood smear examination and immunophenotyping by flow cytometry of blood lymphocytes. The first line option is immunochemotherapy in 90% of the patients without genetic abnormalities associated with chemo resistance. The use of new compounds targeting different pathways is more frequent especially in relapsing patients and could be an alternative to the chemotherapy in the future. Asymptomatic patients with a stable disease assessed by the specialist can be followed by the general practitioner with a blood count and clinical examination every six months or once a year.

Introduction: The process to evaluate the effectiveness of preventive programs involves follow-up and monitoring activities, assessing if these programs really contribute to the improvement of oral health conditions of the target population. Objective: To evaluate the effectiveness of oral health programs, according to their levels of prevention, applied to schoolchildren at educational institutions in Chiclayo and Pimentel, in the district of Lambayeque, Peru. Materials and Methods: A retrospective, longitudinal and descriptive study was carried out on 237 schoolchildren between 6 and 7 years of age, from four educational institutions located in Chiclayo and Pimentel. A record of the oral hygiene index and caries’ incidence was carried out in four stages, including a baseline diagnosis and three follow-up evaluations every six months between 2016 and 2017, with a previously verified calibration process for the oral hygiene index (k=0.86) and for caries registration (k=0.79). Results: A greater effectiveness was observed in programs with level 2 prevention, achieving a progressive decrease in the oral hygiene index from a baseline mean of 2.04 to 1.98 at 6 months, 1.77 at 12 months and 1.64 at 18 months, with significant differences between them. Regarding the incidence of caries in permanent first molars, no significant differences were found in the effectiveness of programs with levels 1 and 2 of prevention, according to mixed factorial ANOVA (p

Background So far, the development and course of therapy-induced deficiencies in hypothalamic–pituitary hormones in adult patients with malignant gliomas has not received much attention. However, such deficiencies may impact patient’s quality of life substantially. Methods In this monocentric longitudinal trial, we examined hormonal levels of TSH, T3, T4, fT3, fT4, FSH, LH, testosterone, estradiol and prolactin in patients with malignant high grade gliomas before the start of radiochemotherapy (RCT), at the end of RCT and then every three months for newly diagnosed patients and every six months in patients diagnosed more than two years before study inclusion. Growth hormone was not measured in this trial. Results 436 patients (198 female, 238 male) with high-grade gliomas, aged 19–83 years (median 50 years), were included in this study. Low levels of thyroid hormones were observed in around 10% of patients within the first six months of follow up and increasingly after 36 months. Half of premenopausal women at study entry developed premature menopause, 35% showed hyperprolactinemia. Low testosterone levels were measured in 37% of men aged less than 50 years and in 35/63 (55%) of men aged 50 years or older. Discussion The results of this study show that a significant percentage of patients with malignant gliomas develop hormonal deficiencies mandating regular clinical follow up, state of the art counseling and if clinically necessary substitution therapy.

OBJECTIVE To investigate the effectiveness of re-sleeve gastrectomy (LRSG) in patients who had insufficient weight loss or weight regain after laparoscopic sleeve gastrectomy (LSG). STUDY DESIGN Descriptive study. PLACE AND DURATION OF STUDY Ortadogu Private Hospital, Turkey, between March 2013 and January 2017. METHODOLOGY Patients who underwent LRSG following LSG due to inadequate weight loss or weight regain retrospectively evaluated. Patients' demographics, comorbidities, and bariatric surgery outcomes, as well as hospitalisation rate, excess weight loss percentage (EWL%), and body mass index (BMI ) were recorded. Scheduled follow-up visits after surgery at 1, 3, 6, and 12 months post-surgery and every six months subsequently were done. RESULTS A total of 21 patients that underwent LRSG after LRG due to inadequate weight loss or a regain in weight. Of them, 7 (33.3%) were males, and 14 (66.7%) were females. The mean body weight index (BMI) before primary LSG was 52.3 ±4.7 Kg/m² and EWL% was 32.7 ±4.6. After an average follow-up of 24 months. BMI of patients before LRSG was 46.1 ±4.3 Kg/m². Following a 1-year observation, there was a substantial (p

Adverse effects following long-term use of highly active antiretroviral therapy (HAART), such as metabolic syndromes (MetS) and cardiovascular diseases (CVDs), have been reported. We determined whether patients with controlled pre-existing diabetes mellitus (DM) undergoing HAART are at high risk of long-term adverse effects, compared with HIV-infected patients without DM. In this prospective cohort study that recruited 172 HIV-infected patients, patients were followed up every six months for five years. Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D), a CVD risk score for HAART, and lab data, were compared between patients with controlled DM and non-DM patients matched on age and gender. HAART was less effective for HIV-infected patients with DM, with a higher plasma HIV RNA load in plasma viral load (PVL) testing (r=0.4868, P=0.0216) since the third year of follow-up. HAART increased the risk of CVDs for DM patients, with higher D:A:D (R) (r=0.1636, P=0.0336) and D:A:D (F) (r=0.1883, P=0.0142) scores at fifth year. DM patients presented with higher risk of advanced stages CKD (GFR

The relationships between depressive symptoms, viral suppression, and condomless sex were examined in a prospective cohort study of 369 HIV-positive Kenyan female sex workers. Participants were screened for depressive symptoms at baseline and every six months until completion of the study (up to 66 months). HIV viral load (VL) was measured every six months and prostate specific antigen (PSA) testing in vaginal secretions was performed quarterly. Mild or greater depressive symptoms were found in 100 (27.1%) women and were associated with increased risk of detectable VL (aRR 1.41, 95%CI 0.97–2.07, p-value = 0.07), but were not associated with detectable PSA. The co-occurrence of PSA detection and detectable VL at the same visit suggests the potential for HIV transmission but was uncommon (2.4% of visits). The prevalence of depressive symptoms and the association with detectable VL suggests the need for screening and treatment of depression for comprehensive HIV care in this population.

Objective The purpose of this study was to investigate the safety and effectiveness of the traditional dual growing rod (TDGR) technique, using only pedicle screws for fixation with more frequent lengthening while evaluating scoliosis correction in the growing spine, spinal growth rates, and the differences in lung volumes. Patients and methods In this single-centre prospective study, 27 patients with a follow-up of over three years were included in the study. Only pedicle screws were used as foundations for fixation. Routine lengthening procedures were performed every six months. Data were recorded including the age of initial surgery, gender, number of lengthenings, follow-up, and complications. The Cobb angle of the major curve, kyphosis angle, T1- S1 length, space available for lung (SAL) ratio, coronal and sagittal balance, and the height of all patients were measured and recorded preoperatively, immediately postoperatively, and finally before and after every lengthening. Results The average follow-up time was 46.3 months (36-64 months). The correction rate was 69.5% for Cobb angle and 43.2% for kyphosis between preoperative and final follow-up period. The time between two lengthenings was 6.9 months, and the mean T1-S1 length increase was 1.78 cm per year. The SAL ratio increased from 0.885 preinitially to 0.985 at the last follow-up. The complication rate was determined as 9.6% in 187 procedures. Acceptable improvements were determined in the specified parameters with low complication rates with the use of this technique. Conclusion The TDGR technique with proximal and distal pedicle screws as anchors is a safe and effective treatment for deformity control in selected patients with early onset scoliosis (EOS). Repetitive surgical interventions are the negative side of this technique.

Introduction Residual stone fragments remain a challenging topic for urologists following retrograde intrarenal surgery (RIRS). This study investigates the effectiveness of second-look flexible ureterorenoscopy (URS) to achieve a true stone-free status and decrease stone-related events. Material and Method A total of 176 consecutive patients treated with RIRS for kidney stones were included in the study. Patients were divided into two groups, group 1 receiving the standard of care (n=51) and group 2 receiving second-look flexible URS (n=125). In all cases, one or more calyceal stones of 1 to 4 mm were extracted with a basket at the time of stent removal. Unless earlier intervention was necessary, patients were followed up every six months to determine if they had experienced SREs. Results The mean follow-up time for the whole group was 21±11.1 months. The mean number of stones in group 1 and group 2 was 1.25±0.11 and 1.56±0.19, respectively. Postoperative stone-free rate after RIRS for group 1 and group 2 were 37.25% (n=19/51) and 40.8% (n=51/125), respectively. The SFR improved to 93.6% (n=117/125) in group 2. Multivariable analysis showed that type of intervention, stone size, and body mass index were independent prognostic factors for SREs. When group 2 was taken as a reference, the odds ratio for SREs was 8.48 (95% CI: 2.95–24.42) in group 1. Conclusion This study found that second-look flexible URS increased the SFRs and diminished the number of SREs. We propose performing second-look flexible URS following RIRS in the presence or suspicion of RSFs to provide better treatment results, less radiation exposure, and greater patient satisfaction. Key Words Retrograde Intrarenal Surgery, Flexible Ureteroscopy, Stone-free Rate, Residual stone Fragments, Stone-Related Event, Second-look Flexible Ureteroscopy.

BACKGROUND It is a policy objective for older people in need of care to be able to live at home for as long as possible and receive healthcare services outside of institutions. The degree of frailty in this group and consequent risk of emergency hospitalisation and death have not been widely studied. The objective of this project was to study these questions over a period of two years in a medium-sized Norwegian municipality. MATERIAL AND METHOD A sample of patients aged 65 years or older who received home care nursing services on a weekly basis were included. The patients underwent geriatric assessment in their own home every six months over two years. Their degree of frailty was measured using the Frailty Index. Deaths and emergency hospitalisations were recorded over two years. RESULTS Of the 271 patients who were asked to participate, 210 were included. Altogether 160 patients (76 %) were classified as moderately or severely frail. During the observation period, 307 hospital admissions were recorded, amounting to a total of 1 235 hospitalisation days. When compared to severely frail patients, those with mild degrees of frailty were less frequently hospitalised (hazard ratio (HR) 0.33; 95 % confidence interval (CI) 0.19-0.60). During the two-year observation period, 63 (30 %) patients died. The mortality rate was highest in patients with severe frailty. In an adjusted Cox regression, increasing age was associated with a higher risk of death, but not with acute hospitalisation. INTERPRETATION Older patients with home care nursing services have a high degree of frailty, and a high degree of frailty is associated with increased risk of hospitalisation and death.

Unibody bifurcated endografts have the advantage of reducing the operative time, avoiding migration and iliac limb dislocation in patient with abdominal aortic aneurysm (AAA). We report our longterm experience in patients who underwent endovascular aortic repair (EVAR) due to infrarenal AAA with Endologix AFX (R) endograft system. Between January 2013-December 2018, 68 patients with infrarenal AAA had EVAR procedure with Endologix AFX (R) endograft system. Mean follow-up was 40.4 +/- 19.5 months, and all patients had computed tomography periodically, with colored Doppler ultra-sonography (CDUS) every six months. Mean age was 68.5 +/- 7.1 years and, 63 (92.6%) patients were male. Early mortality, renal complications, stent-graft migration and cardiac complications were not seen in early post-operative period. There was no early mortality in the group and no conversion to open repair. In long-term follow-up 12 patients (17.6%) had endoleak (5 with type II, 7 with type III). Overall survival estimated by Kaplan-Meier analysis was 94.1% at 1 year, 85.2% at 2 years, 74.1% at 3 years and 54.0% at 5 years. Freedom from second intervention and conversion was 98.4% at 1 year, 95.3% at 2 years, 93.3% at 3 years and 87.4% at 5 years. Endologix AFX (R) endo-graft provides a fast, safe and effective endograft for the early period, therefore it seems more suitable for elderly and comorbid patients. This endograft has low reintervention rates however according to our results, aneurysms larger than 6 cm may have more sideway displacement possibility and by this way type III endoleak. Proper patient selection and sufficient overlap are the key issues. Close monitoring is mandatory at the follow-up period. WOS:000672805600023 2-s2.0-85111065516 PubMed: 34258912

Background To evaluate the impact of parental myopia and outdoor time on myopia among students in Wenzhou. Methods We examined 1388 primary students from first grade to third grade in Wenzhou from September 2012 to March 2015. We performed noncycloplegic refractometry on each student every six months and axial length (AL) measurements every year. At the commencement of our study, children were asked to complete a questionnaire regarding near work activity and outdoor activity, whereas parents were asked to complete a self-administered questionnaire regarding their background circumstances and their history of myopia. Results A total of 1294 students (93.2%) returned for follow-up examinations. Children with initial and final no myopia spent more time on outdoor activities than those with new onset myopia (1.92 vs. 1.81 h/d, p = 0.022), and elongation of AL in children with a high level (> 2.5 h/day) of outdoor time (0.22 ± 0.13 mm/Y) was less than those with a low level (≤ 1.5 h/day) of outdoor time (0.24 ± 0.14 mm/Y, p = 0.045). The proportion of rapid myopia progression (≤-0.5D/Y) was 16.7%, 20.2% and 31.5% among the children with no myopic parent, one myopic parent and two myopic parents, respectively (X2 = 28.076, p p p = 0.018). Conclusions In this sample, parental myopia and outdoor time were associated with myopia in children. A high level of outdoor time was a protective factor for children with one myopic parent.

Despite its frequent use, there is little evidence of adequate management of pessaries for treating pelvic organ prolapse (POP). Thus, the aims the study were to assess the rate of complications in women using ring-type pessaries with cleaning and monitoring every 6 months and to correlate the time of use of the pessary with possible complications. This is a cross-sectional study including women diagnosed with stage 3 or 4 genital prolapse, who were already in outpatient follow-up and who used a ring pessary. We excluded patients using another type of pessary, with severe comorbidities and with POP-Q ≤ 2 staging. The chi-square test or Fisher exact test was applied for categorical variables, the t-test for continuous variables with normal distribution and Mann-Whitney test for non-parametric variables. A total of 83 women using a ring pessary were assessed. The mean in months of pessary use was 31.8 ± 14.9 months. Vaginal discharge was the most frequent complaint representing 26.5%, followed by foul smell in 13.3%. No significant correlation was found between length of pessary use and clinical variables. However, a significant correlation was found between immediate complications and the length of pessary use (21.3 ± 5.9 months; p

AimsThis project aimed to improve adherence to regular monitoring of the physical health of inpatients within a medium secure forensic psychiatric unit. A computerised tool to remind doctors to do checks was created, which was proposed would improve adherence.BackgroundThe physical health of people with mental health problems is of some concern, with higher rates of physical comorbidity and mortality compared to the general population.The forensic inpatient population has a high burden of both severe mental illness and physical ill health, and a high medication burden with potential adverse effects on physical health.To support the health of patients in our medium secure unit, each should routinely have three physical health checks done at least every six months. These are 1) an electrocardiogram (ECG), 2) a set of blood tests and 3) a full physical examination.MethodPatient records for 26 patients across two medium secure psychiatric wards were checked for 1) an ECG, 2) a full set of blood tests and 3) a full general physical examination within the past 6 months.A tool was created that automatically calculated the next due date for each check and colour coded which were overdue (red) or within 30 days of the due date (yellow). This tool was given to the core trainees working on these wards to help them keep track of which checks needed to be done.The records for patients on the same two wards were rechecked four months later and the adherence rates compared.ResultOn both wards, for each of the three physical health checks, a substantial improvement was seen in the proportion completed within the past 6 months.ConclusionThe tool created was a useful means of presenting, in one place, relevant information needed by doctors working in medium secure forensic wards regarding physical health checks, and drawing their attention to tasks that needed to be done. This led to an improvement in the adherence to physical health monitoring in these wards. An area for future improvement was identified regarding the unit's capacity to perform ECGs in a timely manner.

Objective The authors conducted a case series to determine arrest of root surface caries lesions in older adults when teeth were treated topically with 38 % silver diamine fluoride (SDF). Methods The study was a prospective, single center case series. The patients were 62 older adults (age ≥55 years) who sought treatment at a dental school clinic. To be included, a patient needed to have at least one active root caries lesion. Lesions were rinsed and then dried with air, isolated, and then 38 % SDF was applied for two minutes with a microbrush. Treated lesions were re-evaluated at 2–3 weeks. Treatment was repeated every six months. Survival analysis methods for clustered data were used to estimate the caries lesion arrest probability over time separately for root surfaces and at crown margins. Results Fifty-five participants returned for follow-up (44 % female, mean age (SD) 79.8 (7.4)). The probability of a lesion arresting with treatment ranged from 82.9 to 91.6%. Arrest rates at 18 months were slightly higher in root surfaces than around crown margins, 91.6 % (95 % CI 69.1–97.1) versus 89.8 % (95 % CI 71.6–96.3). All furcal lesions (n = 7) were arrested by 6 months, 100 % (95 % CI 59–100). Conclusion and Clinical Significance Repeated application of 38 % SDF at 6-month intervals was effective in arresting decay of root surface lesions and lesions around crowns in older adults. Study outcomes support SDF treatment for older adult patients who are frail and residing in nursing homes or dependent living facilities.

Tooth loss from periodontal disease is a major public health burden in the United States. Standard clinical practice is to recommend a dental visit every six months; however, this practice is not evidence-based, and poor dental outcomes and increasing dental insurance premiums indicate room for improvement. We consider a tailored approach that recommends recall time based on patient characteristics and medical history to minimize disease progression without increasing resource expenditures. We formalize this method as a dynamic treatment regime which comprises a sequence of decisions, one per stage of intervention, that follow a decision rule which maps current patient information to a recommendation for their next visit time. The dynamics of periodontal health, visit frequency, and patient compliance are complex, yet the estimated optimal regime must be interpretable to domain experts if it is to be integrated into clinical practice. We combine non-parametric Bayesian dynamics modeling with policy-search algorithms to estimate the optimal dynamic treatment regime within an interpretable class of regimes. Both simulation experiments and application to a rich database of electronic dental records from the HealthPartners HMO shows that our proposed method leads to better dental health without increasing the average recommended recall time relative to competing methods.

Aim To analyse whether initial consultant–led simulation–based–teaching–sessions (SBTS) boost junior doctors participation levels’ as team leaders. To determine the influence of SBTS on non–clinical hospital doctors (NCHDs) baseline knowledge, confidence, comfort levels and situational awareness in stressful Paediatric/Neonatal situations. Method A two-part survey was designed and distributed at the start of the rotation in a formal setting of ‘SAFE’ (Situational Awareness For Everyone) by lead consultant.1 The first part included a comprehensive questionnaire outlining Paediatric BLS, ALS and Neonatal resuscitation to assess the baseline knowledge of all NCHDs. The second part helped us establish NCHDs experience, confidence and comfort levels when participating in SBTS sessions.1 2 Initial three months: Neonatal and Paediatric team leaders were designated among consultants to plan/coordinate among all NCHDs. A schedule of weekly Paediatric/Neonatal scenarios was distributed. Second three months: Team members volunteered to lead random scenarios per week. Overtime, situational awareness of team members was also assessed.1 After six months, the same survey was redistributed. Results NCHDS’ were categorised according to their level of experience in Paediatrics. NCHDs’ who had between 0–1 years’ experience in Paediatrics were not very confident and not very comfortable as team leaders and scored on average 63% on the baseline knowledge questionnaire. Post intervention most NCHDs had become very confident and very comfortable dealing with stressful situations and better retained baseline knowledge, scoring an average of 92%. NCHD’s who had 3+ years’ experience were confident and comfortable to begin with and those levels only improved over six months.1 2 Baseline knowledge was maintained, further refining from 81 – 96%. Conclusion Our main cohort of junior doctors is GP trainees who rotate from different specialities every six months with none - minimal Paediatric/Neonatal exposure and knowledge as evident from the above results. Initially they were reluctant to participate due to the fear of being judged. However, our consultant-led strategy boosted their knowledge, confidence and comfort levels as well as situational awareness to lead and deliver better patient care in stressful situations. References Rakshasbhuvankar, Abhijeet & Patole, Sanjay. ( 2014). Benefits of simulation based training for neonatal resuscitation education: A systematic review. Resuscitation. 85. 10.1016/j.resuscitation.2014.07.005. Schweich PJ, DeAngelis C, Duggan AK. Preparedness of practicing pediatricians to manage emergencies. Pediatrics 1991;88:223.

Background In this study, we aimed to evaluate the clinical characteristics, perioperative, and mid-term outcomes of patients with severe symptomatic aortic stenosis and active cancer disease and cancer survivors undergoing transcatheter aortic valve implantation. Methods Between December 2011 and March 2019, a total of 550 patients (248 males, 302 females; mean age: 77.6±7.9 years; range, 46 to 103 years) who underwent transcatheter aortic valve implantation for severe symptomatic aortic stenosis in our center were retrospectively analyzed. Baseline demographic characteristics, cancer type, laboratory data, procedural data, and outcome data of the patients were collected. The primary outcome measure was all-cause mortality at 30 days and every six months up to maximally available follow-up. Follow-up was performed at 30 days, six months, and 12 months after the procedure and annually thereafter. Results Of the patients, 36 had a cancer diagnosis-active (n=10) or cured (n=26). The most common types of cancer were colorectal (16.6%), prostate (13.8%), leukemia (11.1%), and bladder (11.1%) cancers. Post-procedural complication rates were similar between the two groups. No mortality was observed in the cancer group at one month of follow-up. During follow-up, seven patients died within one year due to non-cardiac reasons. Although mortality at one year was higher in cancer patients, it did not reach statistical significance (23.3% vs. 11.6%, respectively; p=0.061). The estimated cumulative survival rate was 71.0% in the non-cancer group and 58.3% in the cancer group. The multivariate Cox regression analysis revealed that cancer was independently associated with cumulative mortality after adjusting for age, sex, body mass index, and atrial fibrillation (p=0.008). Conclusion Our study results show that transcatheter aortic valve implantation is safe and feasible in active cancer patients and cancer survivors with similar short-term and mid-term mortality and procedure-related complication rates, compared to non-cancer patients.

Intraventricular meningiomas (IVMs) are notably limited tumors and express one of the most challenging tumors in neurosurgery. Gamma Knife radiosurgery (GKRS) as an alternative for IVMs has been reported only in a few case series. We aimed to present six patients with IVMs who were treated with GKRS and do a literature review. The data of patients were retrospectively reviewed. All patients underwent a single session of GKRS with a median marginal dose of 12 Gy (range, 11–13). Target volume ranged from 1.2 to 9.5 cc. Routine imaging with contrast-enhanced MRI scans was performed every six months initially and thereafter yearly. New neurological deficits and symptoms stated or observed during follow-up were recorded and investigated. The mean age was 41.3 years (range, 30–71). GKRS was used as a primary treatment in five patients and as adjunctive treatment in one patient. The most common presenting symptom was a headache. The median duration of symptoms was 30 months (range, 5–240). Four tumors (67%) were located in the left lateral ventricle, and two were in the right lateral ventricle. During a median follow-up of 71.5 months (range, 23–139), tumor volume was noted to have shrunk (median = 59.6%) in all patients (100%). One patient experienced post-GKRS peritumoral edema that resolved after a short course of steroids. The mean progression-free survival was 117.5 months (95% CI, 81–154 months). Neurologic symptoms and signs improved in all patients. GKRS may be a feasible treatment alternative in patients with small IVMs with low morbidity.

Objective The aim of this randomised non-inferiority clinical trial was to compare the effectiveness of semi-annual (every six months) applications of 25 % silver nitrate (AgNO3) solution followed by 5 % sodium fluoride (NaF) varnish to semi-annual applications of 38 % silver diamine fluoride (SDF) solution in arresting early childhood caries (ECC). Methods Three-year-old children with active cavitated carious lesions were recruited and randomly assigned to two intervention groups. Children in Group A received semi-annual applications of 25 % AgNO3 solution followed by 5 % NaF varnish on carious lesions. Children in Group B received semi-annual applications of 38 % SDF solution followed by a placebo varnish. One trained dentist assessed ECC status at baseline and in all follow-up examinations. An independent operator performed the interventions. The dentist, the children, and their caretakers were blinded to the intervention allocation. Data were analysed using a non-inferiority test. Group A’s non-inferiority would be accepted if the lower limit of the 95 % confidence interval (CI) for the difference in the mean number of arrested decayed surfaces (ds) was greater than −0.5. Results At baseline, 1,070 children were recruited, and 535 children were assigned to each group. After 30 months, the mean arrested ds in Groups A (n = 447) and B (n = 433) were 3.7 ± 3.6 and 3.6 ± 3.7, respectively (p = 0.694). The difference in the mean arrested ds between the two groups was 0.088 (95 % CI: -0.351 to 0.526). Conclusion Semi-annual application of 25 % AgNO3 followed by 5 % NaF is at least as effective as the semi-annual application of 38 % SDF in arresting ECC. Clinical significance Silver and fluoride products are effective in arresting caries. As a simple, non-invasive, and inexpensive strategy, it can be used in young children, elderly adults, and people with special needs.

Dental caries is the most prevalent oral disease in Ecuador. In our country, there are no studies that have included the population of the Galapagos Islands. Fluoride application to incipient lesions of dental caries has shown to be effective in avoiding the use of invasive restorative procedures.The objective of the EESO-Gal study is to determine the prevalence and incidence of dental caries and to evaluate the effect of supervised dental brushing, accompanied by periodic applications of fluoride varnish on incipient precarious lesions of schoolchildren in the Galapagos Islands. This article presents the protocol of the EESO-Gal study.A cohort is planned with Galapagos Islands schoolchildren to determine the prevalence and incidence of dental caries, with assessments every six months, during twenty-four months.We expect to determine the prevalence and incidence of caries every six months, for twenty-four months, in schoolchildren between three and ten years of age, and obtain data to show the state of the caries conditions in Galapagos schoolchildren, with the inclusion of daily brushing at school, supervised by the teacher, and with the application of fluoride varnish every six months.The prevalence of dental caries and incidence after the program will demonstrate the importance of implementing oral health prevention and promotion actions to create hygiene and health habits from an early age.La caries dental es la enfermedad bucal más prevalente en Ecuador. En nuestro país no existen estudios que hayan considerado a la población de las Islas Galápagos. La aplicación de flúor sobre lesiones incipientes de caries dental ha demostrado efectividad para evitar ejecutar procedimientos invasivos restauradores.El objetivo del Estudio de Salud Oral Galápagos, EESO-Gal, es determinar la prevalencia e incidencia de caries dental y evaluar el efecto de la acción del cepillado dental supervisado, acompañado de aplicaciones periódicas de flúor en barniz sobre lesiones cariosas incipientes en escolares de las Islas Galápagos. Con este informe se busca reportar el protocolo del Estudio de Salud Oral Galápagos.Se plantea realizar una cohorte con los escolares de las Islas Galápagos para determinar la prevalencia e incidencia de caries con evaluaciones cada seis meses durante veinticuatro meses.Se espera determinar la prevalencia e incidencia de caries cada seis meses durante veinticuatro meses en escolares de tres a diez años y obtener datos que permitan evidenciar el estado de las condiciones de caries en los escolares de Galápagos con la inclusión del cepillado diario en la escuela, supervisado por el docente, y con la aplicación semestral del barniz de flúor.La prevalencia de caries dental e incidencia después de las acciones tomadas demostrará la importancia de aplicar acciones de prevención y promoción de la salud oral, para crear hábitos de higiene y salud desde edades tempranas.

Background: Treatment outcomes of the shorter regimen for rifampicin-resistant tuberculosis are not completely established. We report on these outcomes two years after treatment completion among patients enrolled in an observational cohort study in nine African countries. Methods: 1,006 patients treated with the nine-month regimen were followed every six months with sputum cultures up to 24 months after treatment completion. The risk of any unfavourable outcome, of failure and relapse, and of death during and after treatment was analysed according to patient's characteristics and initial drug susceptibility by Cox proportional hazard models. Findings: Respectively 67.8% and 57.2% patients had >=1 culture result six months and 12 months after treatment completion. Fourteen relapses were diagnosed. The probability of relapse-free success was 79.3% (95% confidence interval [CI] 76.6–82.0%) overall, 80.9% (95% CI 78.0–84.0%) among HIV-negative and 72.5% (95% CI 66.5–78.9%) among HIV-infected patients. Initial fluoroquinolone (adjusted hazard ratio [aHR] 6.7 [95% CI 3.4–13.1]) and isoniazid resistance (aHR 9.4 [95% CI 1.3–68.0]) were significantly associated with increased risk of failure/relapse and of any unfavourable outcome. Interpretation: The close to 80% relapse-free success indicates the good outcome of the regimen in low-and middle-income settings. Results confirm the lesser effectiveness of the regimen in patients with initial resistance to fluoroquinolones and support the use of high-dose isoniazid, but do not support exclusion of patients for resistance to drugs other than fluoroquinolones. Funding: Expertise-France and Agence Française de Développement. Keywords: Tuberculosis, Multidrug-resistance, Treatment outcome, Recurrence, Cohort studies, Proportional hazard models, Short regimen, Developing countries, Isoniazid, Fluoroquinolones

Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity among teenager. For those indicated, early surgical intervention allows better surgical correction due to flexibility of the spine during teenage years, hence good functional outcome and better cosmetic can be expected. In this case report, there is the management of four patients surgically using the posterior spinal instrumentation and fusion. Pre-operatively patients were examined at IIUM Medical Centre spine clinic, all necessary investigations were carried out. A thorough explanation was done to patient and parents regarding procedure, risk and benefit. All patients were treated using the same surgical technique. Neuromonitoring was used throughout the whole surgery until skin closure. All patients were hospitalized around one week. Post-operatively patients were followed up at two weeks, six weeks, three months, and every six months thereafter. It is important for clinicians to identify patients with AIS as early detection and timely treatment will change the natural history of curve progression. Surgical intervention when necessary will be easier and with less risk of complications when surgery was carried out during teenage years as the spine is more flexible and the deformity is less severe.

Introduction World Health Organization (WHO) guidelines have shifted over time to recommend earlier initiation of antiretroviral therapy (ART) and now encourage ART initiation on the day of HIV diagnosis, if possible. However, barriers to ART access may delay initiation in resource‐limited settings. We characterized temporal trends and other factors influencing the interval between HIV diagnosis and ART initiation among participants enrolled in a clinic‐based cohort across four African countries. Methods The African Cohort Study enrols adults engaged in care at 12 sites in Uganda, Kenya, Tanzania and Nigeria. Participants provide a medical history, complete a physical examination and undergo laboratory assessments every six months. Participants with recorded dates of HIV diagnosis were categorized by WHO guideline era (50 years at diagnosis was independently associated with shorter time to ART initiation as compared to 18 to 29 years (HR: 1.38; 95% CI: 1.19 to 1.61). Conclusions Consistent with changing guidelines, the interval between diagnosis and ART initiation has decreased over time. Still, many adults living with HIV initiated treatment with low CD4, highlighting the need to diagnose HIV earlier while improving access to immediate ART after diagnosis.

BackgroundTwo types of mentalisation-based treatment (MBT) have been developed and empirically evaluated for borderline personality disorder (BPD): day hospital MBT (MBT-DH) and intensive out-patient MBT (MBT-IOP). No trial has yet compared their efficacy.AimsTo compare the efficacy of MBT-DH and MBT-IOP 18 months after start of treatment. MBT-DH was hypothesised to be superior to MBT-IOP because of its higher treatment intensity.MethodIn a multicentre randomised controlled trial (Nederlands Trial Register: NTR2292) conducted at three sites in the Netherlands, patients with BPD were randomly assigned to MBT-DH (n = 70) or MBT-IOP (n = 44). The primary outcome was symptom severity (Brief Symptom Inventory). Secondary outcome measures included borderline symptomatology, personality functioning, interpersonal functioning, quality of life and self-harm. Patients were assessed every 6 months from baseline to 18 months after start of treatment. Data were analysed using multilevel modelling based on intention-to-treat principles.ResultsSignificant improvements were found on all outcome measures, with moderate to very large effect sizes for both groups. MBT-DH was not superior to MBT-IOP on the primary outcome measure, but MBT-DH showed a clear tendency towards superiority on secondary outcomes.ConclusionsAlthough MBT-DH was not superior to MBT-IOP on the primary outcome measure despite its greater treatment intensity, MBT-DH showed a tendency to be more effective on secondary outcomes, particularly in terms of relational functioning. Patients receiving MBT-DH and MBT-IOP, thus, seem to follow different trajectories of change, which may have important implications for clinical decision-making. Longer-term follow-up and cost-effectiveness considerations may ultimately determine the optimal intensity of specialised treatments such as MBT for patients with BPD.

This study aimed to compare the efficacy of rituximab versus Cyclophosphamide on active secondary progressive multiple sclerosis (SPMS). The randomized clinical trial was performed from 2015 to 2017 in multiple sclerosis (MS) clinics affiliated to Isfahan MS society (IMSS). Patients were randomized to two groups, and one of them received Rituximab that was repeated every six months in case of medical indication. The other one received a monthly pulse of methylprednisolone plus cyclophosphamide (Endoxan, Baxter, UK) until two years. Expanded disabilities status scale (EDSS), clinical, and MRI findings were assessed every six months. Statistical analysis was performed using SPSS software. 39 patients in the Rituximab group and 30 in the Cyclophosphamide group with similar age and gender distribution were entered for analysis. At baseline, the mean number of attacks in the Rituximab group was significantly more than the Cyclophosphamide group (P=0.0001). After 6, 12, and 18 months of treatment, the rate of attacks was similar between groups although it increased significantly in the Rituximab group (P=0.030) after 24 months of treatment. EDSS was increased in the Rituximab group more than the other group at the end of the study. Both drugs were well-tolerated by patients. The EDSS was increased in the Rituximab group but the disability score did not worsen in the Cyclophosphamide group. Both therapies were associated with a reduction in disease attacks and improvement in radiologic findings in a two-year period of follow-up. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(8):484-491.

Purpose To evaluate the effects of increased endogenous Antisecretory Factor (AF) synthesis using specially processed cereals (SPC) in a sample of patients with defined unilateral Meniere’s disease (MD), compared to the results of a treatment protocol of intravenous glycerol and dexamethasone. Materials and methods Twenty-six patients with unilateral MD were divided in 2 groups and treated with SPC and with intravenous glycerol and dexamethasone for 24 months. Audio-vestibular evaluation was performed before (T0) and every six months. The number of vertigo spells were evaluated before and after therapy and the Efficacy Index (EI) was calculated. Questionnaires for hearing loss, tinnitus and quality of life were administered. Results EI decreased in the SPC group after 18 (T18) (p = .0017) and 24 (T24) months of therapy (p = .0111). There was a significant reduction for tinnitus score in the SPC group at T24 (p = .0131). No significant differences were found between the two groups at T0 (p = .4723), while a significant difference was found at T24 (p = .0027). Quality of life showed a significant improvement in daily activities in the SPC group (p = .0033) compared to the infusion therapy group. No statistically significant changes in PTA thresholds were found in both groups between T0 and T24. Conclusion The preliminary results of our study show a significant reduction of vertigo spells and a positive effect on tinnitus severity and on quality of life in patients with unilateral MD treated with SPC and when compared to patients treated with intravenous glycerol and dexamethasone. No effects on hearing thresholds were noted in both groups.

Purpose To evaluate if baseline ADC from DWI sequences could predict response to treatment in patients with sacral chordoma not suitable for surgery treated with carbon ion radiotherapy (CIRT) alone compared with volume changes. Methods Fifty-nine patients with sacral chordoma not suitable for surgery underwent one cycle of CIRT alone and a minimum of 12-months follow-up. All patients underwent MRI before treatment (baseline), every three months in the first two years after treatment, and every six months afterwards. For each MRI, lesion volume was obtained and median, kurtosis, and skewness ADC were analyzed within the whole lesion volume. Volume changes between baseline and the last available follow-up were used to divide patients with partial response, progression of disease and stable disease (PR, PD, and SD). Results Ten patients were excluded since DWI sequences from baseline MRI were not available. ADC maps obtained from baseline DWI examinations of 50 lesions in the remaining 49 patients were considered. Seven lesions were categorized as PD, 30 PR, and 13 SD. PD showed significantly higher median ADC values at baseline (p = 0.003) compared with both PR and SD (1665vs1253vs1263 *10−6 mm²/s), and more negative skewness values (-0.26vs0.26vs0.08), although not significantly different (p = 0.16). Conclusions Preliminary results suggest that baseline ADC could predict response to treatment with CIRT, particularly to detect potential non-responder patients.

Introduction Understanding diverse tobacco product consumption represents a crucial area for tobacco regulatory science. With the increase in dual/poly use of tobacco products, transition patterns among exclusive and dual users are of considerable interest. We describe transition patterns of dual users over 18 months. Methods A cohort of 145 adults in urban and rural Ohio who reported dual tobacco product use at least some days/week was enrolled during 2014–17. Participants completed follow-up interviews every six months where they were classified into one of five categories: 1) exclusive combustible, 2) exclusive smokeless, 3) exclusive e-cigarette, 4) dual (at least 2 of the previous 3 categories), and 5) less than some days/week. Participants categorized as exclusive and dual (1–4) used their products at least some days per week. Separately within the rural and urban cohorts, 6, 12, and 18 month transition probabilities between the categories were estimated. Results The probability of remaining a dual user after 6 months is 43% in the rural and 37% in the urban cohort. The decline continues through 18 months with 24% of rural and 22% of urban dual users remaining in the category. The probability of a dual user consuming combustibles and e-cigarettes transitioning to exclusive combustible use in 6 months is over 50% in both the rural and urban cohorts. Conclusions Dual use is an unstable state with users being more likely to transition to exclusive combustible use than to remain in the dual use category. Transitions are similar in the rural and urban cohorts., Highlights • Exclusive tobacco users remain loyal to their product category over time. • Dual tobacco users often transition to the use of an exclusive category. • Tobacco product transition patterns are similar between rural and urban cohorts.

BACKGROUND: There is paucity of evidence regarding the optimal follow-up (FU) regimen for lung cancer. Consequently, FU is organized differently across countries. The Danish FU regimen has short FU intervals with a computed tomography (CT) scan of the chest and upper abdomen every three months in the early phase (first 2 years), then every six months in the late phase of FU (3rd, 5th year). Characterizing recurrences missed by the FU program in terms of site, tumor histology, department, and phase of FU, could improve the FU program.MATERIAL AND METHOD: A case-control study of curatively treated stage I lung cancer patients who attended the Danish FU-program and had recurrence identified through the follow-up program (controls, FU group) or outside FU program (cases, symptomatic group).RESULTS: Of 233 included patients with recurrence, the FU group constituted 85% (n = 197). Among the 15% (n = 36) in the symptomatic group, 53% had involvement of the central nervous system compared with 3% in the FU group. The unadjusted odds ratio (OR) for having an isolated brain recurrence (IBR) in the symptomatic group was 52.3 (95%CI: 15.1-181.4) as compared with the FU group. The OR for having a symptomatic recurrence in the early phase of FU was 2.5 (95%CI: 0.7-8.7) compared with the late phase.CONCLUSIONS: The FU program did not identify the majority of patients with IBR. Including cerebral imaging in the FU program may result in an earlier detection of brain metastases. These matters should be studied in a prospective setting.

Background: The natural history of cervical disc prolapse is not fully known and clear indications for operative inter-vention, apart from evident weakness or radiological evidence of cord injury, cannot be established from the literature.Several studies have shown that the largest lumbar disc appear to have the greatest tendency to resolve but there are not enough studies about prolapsed cervical discs.Aim of the Study: The aim of this study was to investigate whether large lateral cervical prolapsed discs without mye-lopathy can be safely managed conservatively leading to clinical & radiological improvement.Patients and Methods: Twenty-four patients were studied by clinical assessments and magnetic resonance imaging (MRI) over the period of one year through which they received intermittent medical treatment (tizanidine, celecoxib, prega-balin).All patients had severe brachialgia at first presentation, but began to show clinical improvement despite the large lateral disc herniations evident on initial imaging. Clinical assessment was done by neurological appraisal. The karnofsky performance Scale was used to measure function and changes in function. Repeat MRI studies every six months allowed measurement of volume changes of the herniated disc material.Results: Initial follow up at three and six months showed positive response in twenty two patients (91.6%). Follow-up at an average of 12 months revealed that twenty-one patient (87.5%) had a complete and sustained recovery. Only threep-atients had unsatisfactory progress and required discectomy. The average karnofsky performance score improved from 60% to 90%.Volumetric analysis of serial MRI scansfound an average reduction of 50% in disc size. There was poor correlation between clinical improvement and the extent of disc resolution.Conclusion: A large lateral cervical disc herniation treat-edconservatively can pursue a favorable clinical course. If early progress is shown, the long-term prognosis is very good and even large disc herniations can be treated conservatively.

To evaluate the effectiveness of the orthokeratology (OK) lens slowing myopic progression compared with no intervention in pediatric eyes METHODS: A retrospective review of medical records was performed on 45 monocular myopic subjects 7 to 13 years of age who were treated with monocular ortho-k lens and followed-up for more than 12 months. The monocular myopia in the subjects' eyes was -0.75 to -4.25 D (diopter), and near emmetropia in the contralateral and with-the-rule astigmatism no greater than -1.50 D. Axial elongation OU, reflecting the progression of myopia was measured at baseline using the same AL-Scan Optical Biometer and compared between the two eyes of each individual every six months for one year in all subjects and for two years in 9 subjects.After 12 months of lens wear, axial length had increased by 0.36 ± 0.23mm in the control eyes (P0.001) but showed far less change (+0.07 ± 0.21 mm) in the OK eyes (P = 0.038). The nine subjects followed-up for 2 years showed no axial length change (+0.16 ± 0.25 mm) in the OK eyes (P = 0.095) after 24 months and significant axial length growth (+0.38 ± 0.26 mm; P = 0.002) in the control eyes. Control eyes showed progressive axial length growth throughout the study compared with the one OK lens eye.Using a contralateral eye study design, which prevented the influence of potential confounding factors, Effectiveness of the OK lens was proved. Myopic progression within a subject was excellent compared with no intervention.

OBJECTIVE: We assessed mobility disability trajectories before death in a large sample of very old adults using two analytic approaches to determine how well they correspond. DESIGN: Decedent sample from the Health, Aging and Body Composition Study (Health ABC). Data were collected between 1997 and 2015. SETTING: A population-based sample of 3075 participants, randomly selected from well-functioning White Medicare beneficiaries and all African American community residents meeting age criteria (70–79 years) in Pittsburgh, PA, and Memphis, TN. PARTICIPANTS: Of the 1991 participants who died by the end of the study, 1410 were interviewed for three years prior to death, including an interview six months before dying. EXPOSURES: Participants were interviewed in person or by phone at least every six months throughout the study. MEASUREMENTS: We analyzed self-reported mobility collected prospectively at six month intervals during the last three years of life. We derived trajectories in two ways: first by averaging decline within decedent groups pre-specified by clinical conditions and, second, by estimating trajectory models using maximum-likelihood semiparametric modeling. RESULTS: Classification by clinical conditions (sudden death, terminal, organ failure and frailty) accounted for 98% of decedents and produced groups with different characteristics. Five disability trajectories were identified: late decline, progressive disability, moderate disability, early decline, and persistent disability. Disability trajectory and clinical condition grouping both confirmed previous research but were only marginally related. CONCLUSIONS: Derived disability trajectories and grouping by clinical conditions both provide useful information about different facets of the end-of-life experience. The lack of fit between them suggests a need for greater attention to heterogeneity in disability in the period before death.