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Objective: To assess the effect of "hospital in the home" (HITH) services that significantly substitute for inhospital time on mortality, readmission rates, patient and carer satisfaction, and costs.Data Sources: MEDLINE, Embase, Social Sciences Citation Index, CINAHL, EconLit, PsycINFO and the Cochrane Database of Systematic Reviews, from the earliest date in each database to 1 February 2012.Study Selection: Randomised controlled trials (RCTs) comparing HITH care with inhospital treatment for patients aged > 16 years.Data Extraction: Potentially relevant studies were reviewed independently by two assessors, and data were extracted using a collection template and checklist.Data Synthesis: 61 RCTs met the inclusion criteria. HITH care led to reduced mortality (odds ratio [OR], 0.81; 95% CI, 0.69 to 0.95; P = 0.008; 42 RCTs with 6992 patients), readmission rates (OR, 0.75; 95% CI, 0.59 to 0.95; P = 0.02; 41 RCTs with 5372 patients) and cost (mean difference, -1567.11; 95% CI, -2069.53 to -1064.69; P < 0.001; 11 RCTs with 1215 patients). The number needed to treat at home to prevent one death was 50. No heterogeneity was observed for mortality data, but heterogeneity was observed for data relating to readmission rates and cost. Patient satisfaction was higher in HITH in 21 of 22 studies, and carer satisfaction was higher in and six of eight studies; carer burden was lower in eight of 11 studies, although not significantly (mean difference, 0.00; 95% CI, -0.19 to 0.19).Conclusion: HITH is associated with reductions in mortality, readmission rates and cost, and increases in patient and carer satisfaction, but no change in carer burden. [ABSTRACT FROM AUTHOR]

Background: Little is known about factors associated with the severity of cleft lip with or without cleft palate (CL/P) especially during the COVID-19 pandemic with its dramatic changes., Objectives: The aim of this multi-national study is to measure the association between CL/P severity, COVID-19 infection, and fear of COVID-19 in five Arab countries., Methods: This cross-sectional study took place in major governmental hospitals in five Arab countries from November 2020 to April 2023. Participants were infants born with CL/P and their mothers who were in their 1st trimester during the COVID-19 pandemic. Clinical examination was carried out, and CL/P cases were grouped according to phenotype: cleft lip and palate (CLP) versus cleft lip (CL), cleft extension (incomplete versus complete), and site (unilateral versus bilateral) to assess severity. Information on maternal COVID-19 infection and fear of COVID-19 were gathered., Results: The study recruited 273 CL/P infants. Maternal COVID-19 infection during one-month pre-gestation and 1st trimester was significantly associated with higher odds of CL/P severity (AOR = 2.707; P = 0.002) than mothers without the COVID-19 infection. Using supplements during pregnancy showed a protective effect (AOR = 0.573; P = 0.065)., Conclusion: Mothers infected with COVID-19 before and during pregnancy had more than twofold higher odds of having an infant with a more severe CL/P phenotype., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Discovering alternative protein sources that are both nutritious and environmentally friendly is essential to meet the growing global population's needs. Duckweed offers promise due to its cosmopolitan distribution, rapid growth, high protein content, and scalability from household tanks to large lagoons without requiring arable land that competes for the major crops. Rich in essential amino acids, particularly branched-chain amino acids, duckweed supports human health. Extraction methods, such as ultrasound and enzymatic techniques, enhance protein yield compared to traditional methods. However, low protein solubility remains a challenge, addressed by protein modification techniques (physical, chemical, and biological) to broaden its applications. Duckweed proteins hold potential as functional food ingredients due to their unique physicochemical properties. This review also includes patents and regulations related to duckweed protein, filling a gap in current literature. Overall, duckweed presents a sustainable protein source with a lower environmental impact compared to conventional crops., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. All authors declared that they do not have any conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction and Importance: Meniscal root tears are defined as soft-tissue and/or osseous injuries that rip or avulse within one centimeter of the meniscal insertion to the tibial plateau. These injuries impact around 100,000 patients a year and make up 10 % to 21 % of all meniscal tears. Meniscal extrusion frequently happens when there are root rips, and the transmission of circumferential hoop loads is hampered., Case Presentation: We present one case of a 28-year-old male who complained of pain and stiffness in his left knee since 2 years after undergoing ACL reconstruction using a hamstring autograft. His examination revealed joint line tenderness on both the medial and lateral sides of the left knee. Further investigations involving X-ray and MRI established the diagnosis of both medial and lateral meniscal root tears, which were surgically managed using the transtibial pullout technique., Discussion: The biomechanical implications of meniscal root tears, such as loss of hoop forces and increased tibiofemoral contact pressures, underscore the importance of timely diagnosis and management. The literature advocates surgical treatment for managing root tears, as leaving them without surgical intervention can lead to functional outcomes similar to those of total meniscectomy., Conclusion: This case report presents both menisci posterior root tears with an intact ACL graft which is unique in that they commonly tear in conjuction with ACL. These kind of injuries necessitates prompt diagnosis and surgical intervention to protect the knee from early arthritic changes., Competing Interests: Conflict of interest statement We (the authors) declare that we don't have any financial or personal relationships with other people or organisations that could inappropriately influence (bias) our work., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Inter-professional learning (IPL) or more broadly Inter-professional Education (IPE) refer to a pedagogical approach that involves creating a learning experience where students from different professions learn about, from, and with each other. IPE is crucial for preparing health professionals to offer patient-centered care as part of an interdisciplinary team. This study aims to assess the readiness for IPL among students from different health professions colleges at King Saud bin Abdulaziz University for Health Sciences., Methods: A cross-sectional design was conducted for this study, with a total of 476 undergraduate students from College of Medicine, College of Nursing, and College of Applied Medical Sciences. By using quota sampling, the readiness for interprofessional learning scale (RIPLS) was used to assess the student's readiness for interprofessional learning., Results: The overall mean score of RIPLS for the students participating was 76.20, with the highest mean score in teamwork and collaboration at 39.73. The lowest mean score was in roles and responsibility at 8.45. The professional identity subscale had a mean score of 26.85. A significant difference in professional identity was found between students in applied medical sciences, nursing, and medicine colleges., Conclusion: The study reveals that undergraduate students have positive attitudes towards interprofessional education, which can enhance their engagement in developing competencies necessary for effective contribution to interprofessional healthcare teams. High readiness among medical, nursing, and applied medical sciences students allows for the Introduction of IPL., Competing Interests: The authors declare that they have no competing interests in this work., (© 2024 Alharbi et al.)

Objectives: Risk factors for non-syndromic orofacial cleft (NSOFCs) include genetic profile and environmental exposure to medication and illnesses during pregnancy. We assessed the association between the COVID-19 vaccination and the incidence of NSOFC across five Middle Eastern countries., Materials and Methods: This multi-country, hospital-based, case-control study included infants with NSOFCs whose first 3 intrauterine months coincided with the time when pregnant women were allowed to receive COVID-19 vaccination in the countries participating in the study. Newborns with NSOFCs were examined for cleft type and their parents were interviewed for maternal exposures and COVID-19 vaccination. Controls were newborns matched to cases in gender and setting., Results: The study recruited 977 (348 children with NSOFCs and 629 controls). Maternal use of nicotine (Adjusted Odds Ratio (AOR): 2.437; P = 0.044) and family history of NSOFC (AOR: 11.059; P < 0.001) increased significantly the AOR of having a child with NSOFC. On the other hand, COVID-19 vaccine administration to pregnant mothers have significantly decreased the AOR of having a child with NSOFC (AOR: 0.337; P = 0.006)., Conclusion: This study suggests that COVID-19 vaccination is not related to NSOFC and might protect against having a child affected with such a congenital anomaly., Clinical Relevance: The finding of this study is important for healthcare providers for considering COVID-19 vaccination for pregnant woman. Clear communication and education about the potential risks and benefits would be crucial for informed decision-making. The study's results would directly impact pregnant individuals, as they would need accurate information to make informed decisions about their health and the health of their infants., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Few published articles provide a comprehensive overview of the available evidence on the topic of evaluating competency-based medical education (CBME) curricula. The purpose of this review is therefore to synthesize the available evidence on the evaluation practices for competency-based curricula employed in schools and programs for undergraduate and postgraduate health professionals., Method: This systematized review was conducted following the systematic reviews approach with minor modifications to synthesize the findings of published studies that examined the evaluation of CBME undergraduate and postgraduate programs for health professionals., Results: Thirty-eight articles met the inclusion criteria and reported evaluation practices in CBME curricula from various countries and regions worldwide, such as Canada, China, Turkey, and West Africa. 57% of the evaluated programs were at the postgraduate level, and 71% were in the field of medicine. The results revealed variation in reporting evaluation practices, with numerous studies failing to clarify evaluations' objectives, approaches, tools, and standards as well as how evaluations were reported and communicated. It was noted that questionnaires were the primary tool employed for evaluating programs, often combined with interviews or focus groups. Furthermore, the utilized evaluation standards considered the well-known competencies framework, specialized association guidelines, and accreditation criteria., Conclusion: This review calls attention to the importance of ensuring that reports of evaluation experiences include certain essential elements of evaluation to better inform theory and practice., (© 2024. The Author(s).)

Microplastics and nanoplastics are emerging pollutants of concern in the aquatic environment that are causing increasing global environmental and human health problems. Although there has been extensive research on microplastics and nanoplastics, little has been said about the differences in their behavior in the aquatic environment, and many studies have considered them as the same class of hazardous materials; but in fact, microplastics and nanoplastics should be considered as two different types of environmentally hazardous materials. In this review, we propose that microplastics and nanoplastics behave in the aquatic environment in a size-dependent manner and should be distinguished. And we systematically analyzed the differences in the behavior of microplastics and nanoplastics in the aquatic environment in terms of five aspects: 1) distribution behavior; 2) adsorption behavior; 3) reaction with natural colloids; 4) aging and leaching behavior; 5) interaction with organisms. This paper has been written to draw academic attention to the different behaviors of microplastics and nanoplastics in the aquatic environment in order to distinguish between their effects on humans and the environment., Competing Interests: The authors declare no competing financial interest., (© 2024 The Authors. Co-published by Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, and American Chemical Society.)

The aim of the present study was to report the feasibility of proton beam reirradiation for patients with locally recurrent rectal cancer (LRRC) with prior pelvic irradiation. The study population included patients who were treated with proton beam therapy (PBT) for LRRC between 2008 and December 2019 in our institution. Those who had a history of distant metastases of LRRC, with or without treatment, before reirradiation, were excluded. Overall survival (OS), progression-free survival (PFS) and local control (LC) were estimated using the Kaplan-Meier method. Ten patients were included in the present study. The median follow-up period was 28.7 months, and the median total dose of prior radiotherapy (RT) was 50 Gy (range, 30 Gy-74.8 Gy). The median time from prior RT to reirradiation was 31.5 months (range, 8.1-96.6 months), and the median reirradiation dose was 72 Gy (relative biological effectiveness) (range, 56-77 Gy). The 1-year/2-year OS, PFS and LC rates were 100%/60.0%, 20.0%/10.0% and 70.0%/58.3%, respectively, with a median survival time of 26.0 months. Seven patients developed a Grade 1 acute radiation dermatitis, and no Grade ≥ 2 acute toxicity was recorded. Grade ≥ 3 late toxicity was recorded in only one patient, who had developed a colostomy due to radiation-related intestinal bleeding. Reirradiation using PBT for LRRC patients who had previously undergone pelvic irradiation was feasible. However, the indications for PBT reirradiation for LRRC patients need to be considered carefully due to the risk of severe late GI toxicity., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Japanese Radiation Research Society and Japanese Society for Radiation Oncology.)

Background: Adult obesity and overweight pose a substantial risk to global public health and are associated with various noncommunicable diseases. Although intermittent fasting (IF) is increasingly used as a relatively new dietary strategy for weight loss, the effectiveness of 2 days per week of dry fasting remains unknown., Objective: This study aims to evaluate the effectiveness of a combined dry IF and healthy plate (IFHP) and healthy plate (HP) intervention in improving anthropometric outcomes and body composition., Methods: This nonrandomized controlled trial involved 177 adults who were overweight and obese. Among them, 91 (51.4%) were allocated to the IFHP group and 86 (48.6%) were allocated to the HP group. The overall study duration was 6 months (October 2020 to March 2021). The intervention was divided into 2 phases: supervised (3 months) and unsupervised (3 months). The data were collected at baseline, after the supervised phase (month 3), and after the unsupervised phase (month 6). Anthropometric (weight, height, waist circumference, and hip circumference) and body composition (body fat percentage, body fat mass, skeletal muscle mass, and visceral fat area) data were measured at all 3 data collection points. Sociodemographic data were obtained using a questionnaire at baseline., Results: Most participants were female (147/177, 83.1%) and Malay (141/177, 79.7%). After 3 months, there were significant reductions in weight (difference -1.68; P<.001), BMI (difference -0.62; P<.001), body fat percentage (difference -0.921; P<.001), body fat mass (difference -1.28; P<.001), and visceral fat area (difference -4.227; P=.008) in the IFHP group, whereas no significant changes were observed in the HP group. Compared to baseline, participants in the IFHP group showed a significant decrease in weight (difference -1.428; P=.003), BMI (difference -0.522; P=.005), body fat percentage (difference -1.591; P<.001), body fat mass (difference -1.501; P<.001), visceral fat area (difference -7.130; P<.001), waist circumference (difference -2.304; P=.001), and hip circumference (difference -1.908; P=.002) at month 6. During the unsupervised phase, waist (IFHP difference -3.206; P<.001, HP difference -2.675; P=.004) and hip (IFHP difference -2.443; P<.001; HP difference -2.896; P<.001) circumferences were significantly reduced in both groups (P<.01), whereas skeletal muscle mass (difference 0.208; P=.04) and visceral fat area (difference -2.903; P=.003) were significantly improved in the IFHP group only. No significant difference in the between-group comparison was detected throughout the intervention (all P>.05)., Conclusions: A combined IFHP intervention was effective in improving anthropometric outcomes and body composition in adults with overweight and obesity., International Registered Report Identifier (irrid): RR2-10.2196/33801., (©Shazana Rifham Abdullah, Ruziana Mona Wan Mohd Zin, Nur Hayati Azizul, Nur Suffia Sulaiman, Norhayati Mustafa Khalid, Roshan Jahn Mohd Salim Mullahi Jahn, Muhamad Khairul Nazrin Khalil, Norhashimah Abu Seman, Nur Azlin Zainal Abidin, Azizan Ali, You Zhuan Tan, Azahadi Omar, Zamtira Seman, Abqariyah Yahya, Mohd Fairulnizal Md Noh. Originally published in JMIR Formative Research (https://formative.jmir.org), 10.04.2024.)

Background: Literature suggest that physicians' high level of confidence has a negative impact on medical decisions, and this may lead to medical errors. Experimental research is lacking; however, this study investigated the effects of high confidence on diagnostic accuracy., Methods: Forty internal medicine residents from different hospitals in Saudi Arabia were divided randomly into two groups: A high-confidence group as an experimental and a low-confidence group acting as a control. Both groups solved each of eight written complex clinical vignettes. Before diagnosing these cases, the high-confidence group was led to believe that the task was easy, while the low-confidence group was presented with information from which it could deduce that the diagnostic task was difficult. Level of confidence, response time, and diagnostic accuracy were recorded., Results: The participants in the high-confidence group had a significantly higher confidence level than those in the control group: 0.75 compared to 0.61 (maximum 1.00). However, neither time on task nor diagnostic accuracy significantly differed between the two groups., Conclusion: In the literature, high confidence as one of common cognitive biases has a strong association with medical error. Even though the high-confidence group spent somewhat less time on the cases, suggesting potential premature decision-making, we failed to find differences in diagnostic accuracy. It is suggested that overconfidence should be studied as a personality trait rather than as a malleable characteristic., Competing Interests: The authors declare that they have no competing interests in this work., (© 2024 Al-Maghrabi et al.)

Objective: The coronavirus (COVID-19) pandemic presents an opportunity to study stress's effect on the development of non-syndromic orofacial clefts (NSOFCs). This study was aimed at assessing maternal stress exposure during the pregestational to first trimester pregnancy periods and the development of NSOFCs during a year of the COVID-19 pandemic., Design: Cohort study of infants with NSOFCs and controls matched based on recruitment site and age., Setting: Government hospitals in Saudi Arabia between November 2020 and November 2021., Main Outcome Measures: Data collection included NSOFC clinical examination and maternal stress exposure assessment using the Modified Life Events Questionnaire, the Fear of COVID-19 Scale, and a focus on the lack of pregnancy planning and a threatened miscarriage., Results: Of the 557 infants recruited, 191 had NSOFCs. Logistic regression analysis with adjusted odds ratios (AORs) that removed the effects of confounders showed that any of the seven stressful life events (AOR:3.78, P < .001) and the family histories of relatives with NSOFCs (AOR:9.73, P < .001) increased the AOR for NSOFC development. In contrast, maternal folic acid (AOR:0.56, P.010), threatened miscarriage (AOR:0.17, P = .001), fear of COVID-19 (AOR:0.83, P = .038), and suspected COVID-19 infection (AOR:0.43, P = .008) decreased the AOR for NSOFC development., Conclusion: Along with an established risk associated with family history of birth defects, stressful life events may be a risk factor for NSOFC development. Beyond folic acid's known benefit, it may be that higher maternal health concerns contribute to increased protective health behaviors during pregnancy. Ongoing research is needed to specify the maternal risk factors for NSOFC., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: This is the first national study to investigate the incidence of non-syndromic oro-facial clefts (NSOFC) and Pierre-Robin-Sequence in Saudi Arabia over the Covid-19 pandemic period., Methods: All maternity hospitals (30-hospitals) in the major regions and cities of Saudi from November 2020-to-2021 were included in the study. Patients were evaluated for cleft phenotype using the LASHAL-classification system. The incidence of NSOFC in Saudi Arabia was calculated by comparing the number of NSOFCs cases born out of all live births during the study period at the included hospitals. Clinical examination was performed and information was gathered using a validated data collection form., Results: In one year, 140,380 live-infants were born at the selected hospitals. Of these, 177 were diagnosed with NSOFC giving an incidence of 1.26/1,000 live-births in Saudi Arabia and the highest incidence in Medina city (2.46/1000 live-births). The incidence of cleft lip-and-palate (0.67/1000 live-births) was higher than that of cleft-palate (0.37/1000 live-births) and cleft-lip (0.22/1000 live-births). Pierre-Robin Sequence incidence was (0.04/1000 live-births). There were 21(12.1) or 23(13.2%) of NSOFC's mothers exposed or vaccinated with Covid-19, respectively., Conclusion: The national incidence of NSOFC in Saudi Arabia was 1.26/1000 live births with variation between phenotypes and regions in the country. In addition, to reporting Covid-19 infection prevalence and vaccine exposure among NSOFC's mothers, this study represents the first of its type to evaluate NSOFC prevalence in Saudi Arabia on a national level., (© 2023. The Author(s).)

Bacterial and fungal secondary and co-infections are commonly identified with viral respiratory infections. This study was undertaken to determine the incidence and factors associated with bacterial and fungal infections in patients with COVID-19 as well as antibiotics prescription patterns within the first and second waves of the outbreak in Malaysia. Clinical records of 3532 COVID-19 patients admitted to hospitals in Malaysia between 4 February and 4 August 2020 were analyzed. Co-morbidities, clinical features, investigations, treatment, and complications were captured using the REDCap database. Culture and sensitivity test results were retrieved from the WHONET database. Univariate and multivariate regression analyses were used to identify associated determinants. A total of 161 types of bacterial and fungal infections were found in 81 patients, i.e., 2.3%. The most common bacterial cultures were Gram-negative, i.e., Pseudomonas aeruginosa (15.3%) and Klebsiella pneumoniae (13.9%). The most common fungal isolate was Candida albicans (41.2%). Augmentin, ceftriaxone, tazocin, meropenem, and azithromycin were the five most frequently prescribed antibiotics. The latter four were classified under the "Watch" category in the WHO AwaRe list. Our data showed that bacterial and fungal secondary and co-infections were frequently found in severely ill COVID-19 patients and were associated with a higher mortality rate.

Bananas are among the most produced and consumed fruit all over the world. However, a vast amount of banana biomass is generated because banana trees bear fruit only once in their lifetime. This massive amount of biomass waste is either disposed of in agricultural fields, combusted, or dumped at plantations, thus posing environmental concerns. Nanocellulose (NC) extraction from this source can be one approach to improve the value of banana biomass. Owing to its superb properties, such as high surface area and aspect ratio, good tensile strength, and high thermal stability, this has facilitated nanocellulose application in the food industry either as a functional ingredient, an additive or in food packaging. In this review, two different applications of banana biomass NC were identified: (i) food packaging and (ii) food stabilizers. Relevant publications were reviewed, focusing on the nanocellulose extraction from several banana biomass applications as food additives, as well as on the safety and regulatory aspects. Ultimately, further research is required to prompt a perspicuous conclusion about banana biomass NC safety, its potential hazards in food applications, as well as its validated standards for future commercialization., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Universiti Malaysia Sabah. Published by Elsevier Ltd.)

Background: The environmental etiology of non-syndromic orofacial clefts (NSOFCs) is still under research. The aim of this case-control study is to assess COVID-19 associated factors that may be related to the risk of NSOFC in five Arab countries. These factors include COVID-19 infection, COVID-19 symptoms, family member or friends infected with COVID-19, stress, smoking, socioeconomic status and fear of COVID-19., Methods: The study took place in governmental hospitals in five Arab countries from November 2020 to November 2021. Controls are matched in the month of delivery and site of recruitment. A clinical examination was carried out using LASHAL classification. Maternal exposure to medication, illnesses, supplementation, COVID-19 infection during their pregestation and 1st trimester periods were evaluated using a validated questionnaire. Maternal exposure to stress was assessed using the Life Events scale, fear of covid-19 scale, family member or friend affected with covid-19 infection, pregnancy planning and threatened abortion., Results: The study recruited 1135 infants (386 NSOFC and 749 controls). Living in urban areas, maternal exposure to medications 3-months pregestation, maternal exposure to any of the prenatal life events and maternal fear of COVID-19 significantly increased the risk of having a child with NSOFC. On the other hand, mothers exposed to supplementation 3-months pregestation, mothers suspected of having COVID-19 infection, family members or friends testing positive with COVID-19 significantly decreased the risk of having a child with NSOFC., Conclusions: This study suggests that NSOFC may be associated with maternal exposure to lifetime stress and COVID-19 fear in particular, with no direct effect of the COVID-19 infection itself. This highlights the importance of providing psychological support for expecting mothers during stressful events that affect populations such as the COVID-19 pandemic, in addition to the usual antenatal care., (© 2023. The Author(s).)

Background: Satisfaction of women with breast cancer screening programs is important to ensure the program effectiveness., Objective: To assess the experience and satisfaction of women with breast cancer screening services., Methods: This was a descriptive study targeting 312 women undergoing mammography screening in Riyadh Region in Saudi Arabia. The data were collected through telephone interviews using a structured questionnaire covering eight domains. Weighted means were calculated by dividing the average scores for each item and domain by their maximum scores. Multiple regression was performed to identify the factors related to general satisfaction., Results: Overall satisfaction weighted mean was 0.879. Experiences were best for physical surroundings and perceived competency of staff domains with weighted means of 0.929 and 0.914 respectively. Accessibility and waiting time, and staff interpersonal skills domains came next with weighted means of 0.901 and 0.876 respectively. Information transfer, physical discomfort and psychological discomfort domains came last with weighted means of 0.783, 0.736 and 0.673 respectively. General satisfaction was related to waiting time and access domain (Exp(B) =.709 (95% CI: .595-.843, p value: .000), staff interpersonal skills domain (Exp(B) = .815 (95% CI: .686- .968, p value: .020) and perceived competency of the staff domain (Exp(B) = .660 (95% CI: .458- .951, p value: .026)., Conclusions: Overall satisfaction with breast cancer screening was high and the experience of women was highly positive for most of the domains. More efforts are needed to improve the information transfer by addressing the language barriers and to enhance the physical and psychological experiences., Competing Interests: The authors declare no conflict of interest., (© 2023 Ameerah Abdulmohsen Alrossais, Mustafa Ahmed Alshihri, Nasser Sulaiman Alsubaihi, Lolowh Mohammed Almoheteb, Hagir Mohammed Bakhiet, Muna Hassan Hassanein.)

Palm oil (PO) is widely utilised in the food industry and consumed in large quantities by humans. Owing to its bioactive components, such as fatty acids, carotenoids, vitamin E, and phenolic compounds, PO has been utilised for generations. However, public concern about their adverse effects on human health is growing. A literature search was conducted to identify fractionated palm oil processing techniques, proof of their health advantages, and potential food applications. Refined palm oil (RPO) is made from crude palm oil (CPO) and can be fractionated into palm olein (POl) and palm stearin (PS). Fractional crystallisation, dry fractionation, and solvent fractionation are the three basic fractionation procedures used in the PO industry. The composition of triacylglycerols and fatty acids in refined and fractionated palm oil and other vegetable oils is compared to elucidate the triacylglycerols and fatty acids that may be important in product development. It is well proven that RPO, POl, and PS extends the oil's shelf life in the food business. These oils have a more significant saturated fat content and antioxidant compounds than some vegetable oils, such as olive and coconut oils, making them more stable. Palm olein and stearin are also superior shortening agents and frying mediums for baking goods and meals. Furthermore, when ingested modestly daily, palm oils, especially RPO and POl, provide health benefits such as cardioprotective, antidiabetic, anti-inflammatory, and antithrombotic effects. Opportunities exist for fractionated palm oil to become a fat substitute; however, nutrition aspects need to be considered in further developing the market., Competing Interests: The authors declare no conflict of interest., (© 2022 Universiti Malaysia Sabah.)

Natural plant pigments have attracted researchers to investigate the application of these dyes in food products. Besides, public awareness of the adverse effects of synthetic dye also increased the demand for natural pigments. Various colours can be obtained from different plants. Interestingly, these pigments are not only beneficial in the appearance of final food products, but they are very advantageous to the plant itself, food and human nutrition. Hence, this article reviews the state-of-the-art establishment of plant pigment application in food products. This review starts with a brief explanation of plant pigment usage in food, followed by clarifications on the functions of six primary plant dyes and the extraction of the natural pigments. The importance of natural pigments is shared. A highlight of future challenges facing the food industry in utilizing natural pigment is also discussed., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Overweight and obesity among adults are a growing global public health threat and an essential risk factor for various noncommunicable diseases. Although intermittent fasting is a generally new dietary approach to weight management that has been increasingly practiced worldwide, the effectiveness of 2 days per week dry fasting remains unclear., Objective: The Cardiometabolic and Anthropometric Outcomes of Intermittent Fasting study aims to determine the cardiometabolic, anthropometric, dietary intake, and quality of life changes among civil servants with overweight and obesity, following combined intermittent fasting and healthy plate (IFHP) and healthy plate (HP) and explore the participants' experiences., Methods: We designed a mixed methods quasi-experimental study to evaluate the effectiveness of the IFHP and HP methods among adults with overweight and obesity. A total of 177 participants were recruited for this study, of which 91 (51.4%) were allocated to the IFHP group and 86 (48.6%) to the HP group. The intervention comprised 2 phases: supervised (12 weeks) and unsupervised (12 weeks). Data collection was conducted at baseline, after the supervised phase (week 12), and after the unsupervised phase (week 24). Serum and whole blood samples were collected from each participant for analysis. Data on sociodemographic factors, quality of life, physical activity, and dietary intake were also obtained using questionnaires during data collection., Results: Most of the participants were female (147/177, 83.1%) and Malay (141/177, 79.7%). The expected outcomes of this study are changes in body weight, body composition, quality of life, physical activity, dietary intake, and cardiometabolic parameters such as fasting blood glucose, 2-hour postprandial blood glucose, hemoglobin A1c, fasting insulin, and lipid profile., Conclusions: The Cardiometabolic and Anthropometric Outcomes of Intermittent Fasting study is a mixed methods study to evaluate the effectiveness of combined IFHP and HP interventions on cardiometabolic and anthropometric parameters and explore participants' experiences throughout the study., Trial Registration: ClinicalTrials.gov NCT05034653; https://clinicaltrials.gov/ct2/show/NCT05034653., International Registered Report Identifier (irrid): RR1-10.2196/33801., (©Shazana Rifham Abdullah, Nur Hayati Azizul, Ruziana Mona Wan Mohd Zin, Nur Suffia Sulaiman, Norhayati Mustafa Khalid, Roshan Jahn Mohd Salim Mullahi Jahn, Muhamad Khairul Nazrin Khalil, Norhashimah Abu Seman, Nur Azlin Zainal Abidin, Azizan Ali, You Zhuan Tan, Azahadi Omar, Mohammad Zabri Johari, Nur Shahida Abdul Aziz, Azli Baharudin, Zamtira Seman, Norazizah Ibrahim Wong, Mona Lisa Md Rasip, Hayati Mohd Yusof, Mohd Fairulnizal Md Noh. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 05.08.2022.)

Cassava is a type of crop popular in Asian countries. It can be easily cultivated and grows to a mature plant in 9 months. Considering its availability, this work studied activated carbon based on cassava stem. Ofloxacin was chosen as the adsorbate, simulating the wastewater from the pharmaceutical industry. Cassava stem was ground into particles and heated to the activated state, 787 °C. The cassava-stem-activated carbon was further treated with the surface modifier, namely sodium hydroxide and zinc chloride, to study the improvement in ofloxacin adsorption. Prepared adsorbents were characterised using the SEM, FT-IR, XRD, DSC and TGA methods before being evaluated through batch adsorption, thermodynamic, and kinetic studies. The surface area analysis indicates that treatment of the activated carbon with NaOH and ZnCl 2 increases the surface area due to the removal of organic content by the chemicals. Better ofloxacin adsorption of all activated carbon samples can be obtained with solutions at pH 8. An endothermic reaction was predicted, shown by higher ofloxacin adsorption at a higher temperature, supported by a positive value of ΔH° in the thermodynamic studies. The negative values of ΔG° revealed that adsorptions were spontaneous. The higher R 2 values indicate that the adsorption process follows the pseudo-second-order equation of kinetic study. The maximum adsorption capacities are 42.37, 62.11, 62.89 and 58.82 mg/g for raw cassava stem (RC), cassava-stem-activated carbon (AC), NaOH-modified cassava-stem-activated carbon (NAC), and ZnCl 2 modified cassava-stem-activated carbon (ZAC). The adsorption capacity is good compared to previous works by other researchers, making it a possible alternative material for the pharmaceutical industry's wastewater treatment.

Background: Although the burden of premature myocardial infarction (MI) is high in Malaysia, direct evidence on the determinants of MI in this multi-ethnic population remains sparse., Objective: The Malaysian Acute Vascular Events Risk (MAVERIK) study is a retrospective case-control study established to investigate the genomic, lipid-related, and other determinants of acute MI in Malaysia. In this paper, we report the study protocol and early results., Methods: By June 2019, we had enrolled approximately 2500 patients with their first MI and 2500 controls without cardiovascular disease, who were frequency-matched by age, sex, and ethnicity, from 17 hospitals in Malaysia. For each participant, serum and whole blood have been collected and stored. Clinical, demographic, and behavioral information has been obtained using a 200-item questionnaire., Results: Tobacco consumption, a history of diabetes, hypertension, markers of visceral adiposity, indicators of lower socioeconomic status, and a family history of coronary disease were more prevalent in cases than in controls. Adjusted (age and sex) logistic regression models for traditional risk factors indicated that current smoking (odds ratio [OR] 4.11, 95% CI 3.56-4.75; P<.001), previous smoking (OR 1.34, 95% CI 1.12-1.60; P=.001), a history of high blood pressure (OR 2.13, 95% CI 1.86-2.44; P<.001), a history of diabetes mellitus (OR 2.72, 95% CI 2.34-3.17; P<.001), a family history of coronary heart disease (OR 1.28, 95% CI 1.07-1.55; P=.009), and obesity (BMI >30 kg/m 2 ; OR 1.19, 95% CI 1.05-1.34; P=.009) were associated with MI in age- and sex-adjusted models., Conclusions: The MAVERIK study can serve as a useful platform to investigate genetic and other risk factors for MI in an understudied Southeast Asian population. It should help to hasten the discovery of disease-causing pathways and inform regionally appropriate strategies that optimize public health action., International Registered Report Identifier (irrid): RR1-10.2196/31885., (©Rajiv Chowdhury, Mohd Fairulnizal Md Noh, Sophia Rasheeqa Ismail, Kim Robin van Daalen, Puteri Sofia Nadira Megat Kamaruddin, Siti Hafizah Zulkiply, Nur Hayati Azizul, Norhayati Mustafa Khalid, Azizan Ali, Izyan Mohd Idris, Yong Shih Mei, Shazana Rifham Abdullah, Norfashihah Faridus, Nur Azirah Md Yusof, Nur Najwa Farahin M Yusoff, Rahman Jamal, Aizai Azan Abdul Rahim, Abdul Kahar Abdul Ghapar, Ammu Kutty Radhakrishnan, Alan Yean Yip Fong, Omar Ismail, Saravanan Krishinan, Chuey Yan Lee, Liew Houng Bang, Eashwary Mageswaren, Kauthaman Mahendran, Nor Hanim Mohd Amin, Gunavathy Muthusamy, Aaron Ong Hean Jin, Ahmad Wazi Ramli, Noel Thomas Ross, Anwar Irawan Ruhani, Mansor Yahya, Yusniza Yusoff, Siti Khairani Zainal Abidin, Laryssa Amado, Thomas Bolton, Sophie Weston, Jason Crawte, Niko Ovenden, Ank Michielsen, Md Mostafa Monower, Wan Rozita Wan Mahiyuddin, Angela Wood, Emanuele Di Angelantonio, Nur Suffia Sulaiman, John Danesh, Adam S Butterworth. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 10.02.2022.)

Background: Factors associated with long-term survival in gemcitabine-concurrent proton radiotherapy (GPT) for non-metastatic, locally advanced pancreatic cancer (LAPC) remain unclear. This study aimed to determine the factors associated with long-term survival in GPT for non-metastatic LAPC., Methods: The medical records of 123 patients with LAPC treated with GPT between February 2009 and December 2019 at Hyogo Ion Beam Medical Center were retrospectively reviewed to assess the factors associated with long-term survival outcomes., Results: The median overall survival of the total cohort treated with GPT was 18.7 months. The 1- and 2-year overall, local progression-free, and progression-free survival rates were 70.4% and 35.7%, 78.2% and 59.0%, and 38.6% and 20.8%, respectively. Multivariate analysis revealed that LAPCs at the pancreatic body-tail and those without anterior peripancreatic invasion were independently associated with longer overall survival (P = 0.040 and P = 0.015, respectively). The median overall survival of patients with LAPC at the pancreatic body-tail and those with LAPC without anterior peripancreatic invasion were 24.1 and 28.1 months, respectively. LAPCs at the pancreatic body-tail had a higher volume ratio irradiated over 60 Gy equivalents at gross tumor volume than those at the pancreatic head (P < 0.001). LAPCs with anterior peripancreatic invasion had more peritoneal recurrence within 6 months after GTP than those without anterior peripancreatic invasion (P = 0.039)., Conclusions: GPT is a promising treatment option for patients with LAPC at the pancreatic body-tail and those with LAPC without anterior peripancreatic invasion., (© 2022. The Author(s).)

Background: Although most systematic reviews of interprofessional education (IPE) evaluated the impact of IPE on the students' acquisition of knowledge in relation to other professions, the development of teamwork skills, and the changes in collaborative behaviour, the processes involved in IPE (i.e., approaches to teaching and learning) are under-researched. The purpose of the study was to conduct a systematic review to establish how IPE has been implemented in university-based undergraduate curricula, focusing on the teaching and learning approaches., Methods: The systematic review was performed in 2020 with three databases: PubMed, Science Direct, and the Cochrane Library. Titles and abstracts were included based on pre-identified eligibility criteria. We used the article entitled 'Systematic reviews in medical education: a practical approach: AMEE guide 94' as the basis to establish the aim and methods of the current systematic review from 2010 to 2019., Results: We found 16 articles that met the inclusion criteria and reported the implementation process of IPE in universities from Western, Asian, and African countries. A combination of at least two teaching and learning approaches was used to deliver IPE. The findings indicated that of all the teaching and learning approaches, simulation-based education, e-learning, and problem-based learning were the most prevalent approaches used to deliver IPE. This systematic review also revealed a lack of IPE programmes in the Middle East region., Conclusions: The evidence synthesised in the current systematic review could support IPE curriculum planners and educators when planning an IPE programme. More global IPE initiatives are required to meet the global health workforce needs. Further studies are required to identify the effectiveness of the different teaching and learning approaches in the development of IPE competencies., (© 2021. The Author(s).)

Background and Purpose: We aimed to determine the risk factors for radiation-induced brain injury (RIBI 1 ) after carbon ion radiotherapy (CIRT) to predict their probabilities in long-term survivors., Materials and Methods: We evaluated 104 patients with head, neck, and skull base tumors who underwent CIRT in a regimen of 32 fractions and were followed up for at least 24 months. RIBI was assessed using the Common Terminology Criteria for Adverse Events., Results: The median follow-up period was 45.5 months; 19 (18.3 %) patients developed grade ≥2 RIBI. The maximal absolute dose covering 5 mL of the brain (D5ml) was the only significant risk factor for grade ≥2 RIBI in the multivariate logistic regression analysis (p = 0.001). The tolerance doses of D5ml for the 5% and 50% probabilities of developing grade ≥2 RIBI were estimated to be 55.4 Gy (relative biological effectiveness [RBE]) and 68.4 Gy (RBE) by a logistic model, respectively., Conclusion: D5ml was most significantly associated with grade ≥2 RIBI and may enable the prediction of its probability., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

We attempted to re-evaluate the efficacy of prophylactic cranial irradiation (PCI) in limited-stage small cell lung cancer (LS-SCLC) with more recent data. A total of 179 patients with LS-SCLC received radical thoracic radiotherapy and chemotherapy at our institution between 1998 and 2018. One hundred twenty-eight patients who achieved complete response (CR), good partial response (PR), and PR without progression for at least for one year after initial therapy were enrolled in this study. These patients were divided into a PCI group (group A, n = 43), and a non-PCI group (group B, n = 85). Survival outcomes were retrospectively evaluated. Because several background factors differed significantly between groups A and B, propensity score (PS) matching was performed as 1:1 match of the two groups. Finally, we analyzed 64 patients (group A/B = 32/32). Median follow-up periods were 53 and 31 months in groups A and B, respectively. There were no significant differences between the groups' backgrounds. Two-year overall survival (OS) rates were 77% in group A and 62% in group B (p = 0.224). Two-year brain metastasis free survival (BMFS) rates were 85% in group A and 57% in group B (p = 0.008). The number of patients who underwent a brain imaging test for confirmation of no brain metastasis (BM) after radical thoracic radiotherapy and chemotherapy (before PCI) was 84 (group A/B = 32/52). A PS matched analysis for cases of pre-PCI brain imaging group, two-year OS rates for group A/B were 73/59% (p = 0.446). Two-year BMFS rates for group A/B were 91/52% (p = 0.021). Retrospectively, PS matched analysis revealed that adding PCI to LS-SCLC patients who achieved good thoracic control significantly improved BMFS, but OS did not improve., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Japanese Radiation Research Society and Japanese Society for Radiation Oncology.)

This paper aims to describe how healthcare providers perceived spirituality and spiritual care while caring for dying patients and their families in a hospice setting in Karachi, Pakistan. Using a qualitative interpretive description design, individual in-depth interviews were conducted among healthcare providers. Thematic analysis approach was used for data analysis. Spirituality and spiritual care were perceived as shared human connections, relating to each other, acts of compassion, showing mutual respect while maintaining dignity in care and empowering patients and families. Developing spiritual competency, self-awareness, training and education, and self-care strategies for healthcare providers are essential components promoting spiritual care in a hospice setting., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Human saphenous vein (hSV) and synthetic grafts are commonly used conduits in vascular grafting, despite high failure rates. Decellularising hSVs (D-hSVs) to produce vascular scaffolds might be an effective alternative. We assessed the effectiveness of a detergent-based method using 0% to 1% sodium dodecyl sulphate (SDS) to decellularise hSV. Decellularisation effectiveness was measured in vitro by nuclear counting, DNA content, residual cell viability, extracellular matrix integrity and mechanical strength. Cytotoxicity was assessed on human and porcine cells. The most effective SDS concentration was used to prepare D-hSV grafts that underwent preliminary in vivo testing using a porcine carotid artery replacement model. Effective decellularisation was achieved with 0.01% SDS, and D-hSVs were biocompatible after seeding. In vivo xeno-transplantation confirmed excellent mechanical strength and biocompatibility with recruitment of host cells without mechanical failure, and a 50% patency rate at 4-weeks. We have developed a simple biocompatible methodology to effectively decellularise hSVs. This could enhance vascular tissue engineering toward future clinical applications., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

This study aimed to determine the maximum tolerance dose (MTD) and to estimate the recommended dose (RD) of concomitant S-1 with carbon-ion radiotherapy (RT) for sinonasal squamous cell carcinoma (SCC). Nine patients with sinonasal SCC received carbon-ion RT with escalating doses of S-1 according to phase I methods. Doses of 40, 60 and 80 mg/m2/day were administered twice daily in dose levels 1, 2 and 3, respectively, from days 1 to 14 and 22 to 35. Carbon-ion RT was administered at a dose of 70.4 Gy (relative biological effectiveness) in 32 fractions, 5 days a week. Two patients developed grade 3 acute dermatitis. However, none developed dose-limiting toxicities. Therefore, the MTD of S-1 could not be determined; the RD was estimated to be 80 mg/m2/day with concurrent carbon-ion RT. Partial response and stable disease were noted in 5 and 4 patients, respectively. The 2-year overall survival and local control rates were 56 and 74%, respectively. Overall, 2 patients developed ≥grade 3 late toxicities; among them, 1 patient developed grade 3 cataract and the other developed grade 4 cataract, optic nerve disorder and hearing impairment. To the best of our knowledge, this phase I study is the first clinical trial to evaluate concomitant S-1 with carbon-ion RT for sinonasal SCC. The MTD of S-1 could not be determined, and the RD was estimated to be 80 mg/m2/day. This study demonstrated a manageable safety profile for this combination. The observed outcomes may facilitate further evaluation of this novel therapy., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Japanese Radiation Research Society and Japanese Society for Radiation Oncology.)

Background: The primary definitive treatment for abdominopelvic sarcomas (APSs) is resection, although incomplete resection has a negative prognostic impact. Although the effectiveness of particle therapy (PT) as a treatment for APS has already been demonstrated, its application for tumors adjacent to the gastrointestinal tract is frequently restricted, due to extremely low tolerance. Space-making PT, consisting of surgical spacer placement and subsequent PT, has been developed to overcome this limitation., Materials and Methods: Between June 2006 and June 2018, a total of 75 patients with 12 types of APS underwent space-making PT., Results: The 3-year local control rate of all patients was 90.3%. Fourteen surgery-related complications were observed in 12 patients (16%), and complications of Grade 3b or higher were observed in 3 patients. Ninety-five PT-related complications were seen in 66 patients (88.0%), and 13 patients (17.3%) had complications of Grade 3 or higher. The median V95% (volume irradiated with 95% of the treatment planning dose) of the gross tumor volume and clinical target volume were 99.9% and 99.5%, respectively. The median D95% (dose intensity covering 95% of the target volume) of the gross tumor volume/planned dose and clinical target volume/planned dose were 99.4%, and 99.1%, respectively., Conclusion: The feasibility and effectiveness of space-making PT have been demonstrated via dosimetric evaluation, and our results indicate that this new strategy may potentially provide an effective and innovative treatment option for advanced APS., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Sacral chordomas are rare malignant bone tumors and are often very large for complete resection. Particle therapy for these tumors, which are adjacent to the gastrointestinal tract, is restricted because the tolerance dose of the intestine is low. This study aimed to demonstrate the technical aspects and treatment results of space-making particle therapy with surgical spacer placement for sacral chordoma. We aimed to investigate the dosimetric change in the particle therapy before and after spacer placement and the safety, efficacy, and long-term outcomes of space-making particle therapy., Study Design: Twenty-one patients with sacral chordomas who were excluded from typical particle therapy were enrolled between 2007 and 2015. Gore-Tex sheets (WL Gore & Assoc) were folded and placed between the sacral and rectum. Particle therapy with 70.4 Gy (relative biologic effectiveness) was then performed., Results: The mean volume that allows 95% of the treatment plan dose of the gross tumor volume and clinical tumor volume after spacer placement was improved to 97.7% and 96.4% from preoperative values of 91.0% and 89.5%, respectively. The recurrence rate within the gross tumor volume was only 4.8%. The 4-year local progression-free survival rate was 68.4%. The 5-year overall survival rate was 100% and the adverse events were acceptable., Conclusions: Considering improvements in the dose-volume histogram after spacer placement, low recurrence rates within the gross tumor volume, good survival rates, and low incidences of side effects, treatment of sacral chordoma with space-making particle therapy shows promise., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Some studies have demonstrated that concurrent chemo-radiotherapy is an effective salvage treatment for isolated para-aortic lymph node (PALN) recurrence. However, no studies have compared multi-treatment modalities, such as radiation therapy (RT), concurrent chemoradiotherapy (CCRT), surgery, chemotherapy, and best supportive care (BSC), across a sufficient number of patients with PALN recurrence. We thus aimed to evaluate the clinical outcomes of multi-treatment modalities for isolated PALN recurrence in uterine cervical cancer., Methods: Records of 50 patients who were first diagnosed with isolated PALN recurrence after definitive cervical cancer treatment from 2002 to 2016 at our institution were reviewed retrospectively. The initial definitive cervical cancer therapies included RT alone, CCRT, or surgery with or without post-operative RT. The median follow-up time was 33 months. The median age at recurrence diagnosis was 57 years (range, 26-84 years). The median duration between the end of initial treatment and recurrence was 10 months (range, 1-91 months). The median maximum metastatic lesion size was 17 mm (range, 8-60 mm). Twenty-four patients had one or two PALN metastases, while 26 had 3 or more. Eighteen patients were treated for recurrence with RT alone, seven with CCRT, three with surgery, 17 with chemotherapy, and five with BSC. Potential prognostic factors included histopathology, initial FIGO stage, initial treatment, age at recurrence, tumor markers (serum SCC-Ag and CEA) at recurrence, time to recurrence, maximum size of the metastatic lesion, number of metastases, and the recurrence treatment method., Results: The 3-year overall survival (OS) rates of all patients were 47.0%. The 3-year OS rate of patients who underwent CCRT for recurrence was 85.7%; surgery, 66.7%; chemotherapy, 48.8%; RT, 41.3%; and BSC, 0% (p = 0.014). Univariate analysis revealed that only the recurrence treatment method was significantly associated with OS. The 3-year local control rate (LCR) and progression free survival (PFS) rate for CCRT were 100 and 71.4%; for surgery, 100 and 66.7%; for chemotherapy, 33.6 and 13.7%; and for RT, 55.5 and 14.1%, respectively (LCR: p = 0.028, PFS: p = 0.059). The number of metastatic lesions, SCC-Ag levels and recurrence treatment method were significantly associated with LCR. Age at recurrence, SCC-Ag levels, and number of metastatic lesions were significantly associated with PFS., Conclusions: Although our patient cohort size was small, our results suggest that CCRT may be effective in preventing local disease recurrence in the PALN and may improve OS.

Our observational study aimed to verify the safety of our original titanium fiducial markers in gynecological cancer by using a simple insertion method. We prospectively evaluated the safety in patients with gynecological cancer who had undergone our insertion procedure of the titanium markers. The decision to implant a titanium marker was at the discretion of each radiation oncologist. The fiducial markers were manufactured by severing ligating clips for surgery into 3-6 mm pieces and were sterilized thereafter. We inserted an 18-gauge injection needle containing the marker before the marker was extruded by a 22-gauge Cattelan needle or shape memory alloy wire into the tumor or tissues close to the tumor. Severe complications within 3 months after implantation were scored according to the National Cancer Institute's Common Terminology Criteria for Adverse Events version 4.0. Between August 2016 and December 2018, we enrolled 46 patients. Of 46, 44 underwent implantation. The median age was 58.5 years. The most common primary site was the cervix. Two patients experienced detachment of the markers after implantation. No Grade 3 or higher level of complications was observed. Our simple insertion technique for original titanium fiducial markers was well-tolerated., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Japan Radiation Research Society and Japanese Society for Radiation Oncology.)

Background: The optimal treatment for isolated local recurrence (ILR) of pancreatic adenocarcinoma (PDAC) after surgical resection remains unclear. This study aimed to evaluate the safety and efficacy of proton radiotherapy (PRT) for ILR of PDAC after surgery., Methods: The medical records of patients with ILR of PDAC after surgery who underwent proton beam therapy between 2011 and 2015 at Hyogo Ion Beam Medical Center were retrospectively studied., Results: The study analyzed 30 patients (14 women and 16 men) with a median age of 65 years (range 38-81 years) who had initially undergone pancreatoduodenectomy (n = 23) or distal pancreatectomy (n = 7) for their primary tumors. Upon ILR, PRT was administered with a median total cumulative dose of 67.5 gray equivalent (GyE) (range 50-67.5 GyE) using 19 to 25 fractions. For 25 patients, concurrent chemotherapy was administered using gemcitabine (n = 18) or S-1 (n = 7). Four patients (13.3%) experienced acute grade ≥ 3 gastrointestinal toxicities. After a median follow-up period of 17.6 months (range 2.1-50.4 months), 23 patients had experienced tumor progression and 10 had died. Nine patients (30%) experienced local tumor progression. The median overall, progression-free, and local progression-free survival rates were 26.1, 12.3, and 41.2 months, respectively. Pre-PRT serum levels of cancer antigen 19-9 higher than 100 U/mL and duke pancreatic monoclonal antigen type 2 higher than 150 U/mL were significantly associated with shorter progression-free survival rates., Conclusions: Proton radiotherapy for ILR of PDAC after surgery is well tolerated and produces good locoregional control and should be considered for eligible patients.

Background: The selection of radiation therapy dose fractionation schedules for bone metastases is often based on the estimation of life expectancy. Therefore, accurate prognosis prediction is an important issue. It is reported that the Katagiri scoring system can be used to predict the survival of patients with bone metastases. We aimed to assess prognostic factors and validate the Katagiri scoring system in patients who were treated with radiation therapy for bone metastases., Materials/methods: We retrospectively reviewed data of all patients who were treated with radiation therapy for bone metastases between 2004 and 2013. Age, sex, Karnofsky performance status (KPS), Eastern Cooperative Oncology Group performance status (ECOG PS), primary site (lesions and characteristics), visceral metastases, laboratory data, previous chemotherapy, and multiple bone metastases were analyzed for associations with overall survival (OS). Katagiri scores were calculated for each patient and were used to compare OS., Results: Out of the 616 patients included in this analysis, 574 had died and 42 remained alive. The median follow-up time for survivors was 42 months. Univariate analysis revealed that age (P = 0.604) and multiple bone metastases (P = 0.691) were not significantly associated with OS. Multivariate analysis revealed that sex, ECOG PS, KPS, primary characteristics, visceral metastases, laboratory data, and previous chemotherapy were significantly associated with OS. The survival rates at 3, 6, 12, and 24 months, categorized by Katagiri score, were as follows: score 0-3, 94.4, 77.8, and 61.1%, respectively; score 4-6, 67.7, 48.7, and 31.2%, respectively; and score 7-10, 39.1, 22.1, and 9.0%, respectively (P < 0.001)., Conclusion: Sex, ECOG PS, KPS, primary characteristics, visceral metastases, laboratory data, and previous chemotherapy were significant predictors of survival in patients with bone metastases. The Katagiri scoring system was significantly correlated with OS and can help us select the optimal dose-fractionation.

Background: Currently, there is a lack of guidelines for the use of short-acting bronchodilators (SABD) in people admitted to hospital for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), despite routine use in practice and risk of cardiac adverse events., Aim: To review the evidence that underpins use and optimal dose, in terms of risk versus benefit, of SABD for inpatient management of AECOPD and collate the results for future guidelines., Methods: Medline, Embase, the Cochrane Central Register of Controlled Trials, clinicaltrials.gov and International Clinical Trials Registry Platform were searched (inception to November 2017) for published and ongoing studies. Included studies were randomised controlled trials or controlled clinical trials investigating the effect of SABD (β2-agonist and/or ipratropium) on inpatients with a diagnosis of AECOPD. This review was undertaken in accordance with PRISMA guidelines and a pre-defined protocol. Due to heterogeneous methodologies, meta-analysis was not possible so the results were synthesised qualitatively., Results: Of 1378 studies identified, 10 met inclusion criteria. Narrative synthesis of 10 studies revealed no significant differences in most outcomes of interest relative to dose, delivery via inhaler or nebuliser, and type of β2-agonist used. However, some evidence demonstrated significantly increased cardiac side effects with increased dosage of β2-agonist (45% versus 24%), P<0.05)., Conclusion: This review identified a paucity of methodologically rigorous evidence evaluating use of SABD among AECOPD. The available evidence did not identify any additional benefits for participants receiving higher doses of short-acting β2-agonists compared to lower doses, or based on type of delivery method or β2-agonists used. However, there was a small increase in some adverse events for participants using higher doses of β2-agonists.

Background: Diabetes mellitus with comorbid complications constitute a major public health problem worldwide. The aim of this study was to evaluate the risk of comorbid complications with glycosylated hemoglobin levels and diabetes duration. Also assessed were patients' diabetic foot-care knowledge and practices., Patients and Methods: This was a quasiexperimental study. A total of 360 type 2 diabetes mellitus patients were interviewed at a government health care center in Riyadh, Saudi Arabia. Diabetic complications and HbA 1c -level data were collected from hospital records. A standard questionnaire was used to assess their diabetic foot-care knowledge and practice., Results: Of the type 2 diabetes mellitus patients, 32.5% had highly uncontrolled glycosylated hemoglobin (HbA 1c ) levels (≥8.6%) and 62.8% had had diabetes >10 years. The patients had comorbid complications, such as hypertension (61.4%), dyslipidemia (58.6%), retinopathy (23.3%), heart disease (14.4%), and severe foot complications (3.9%). The majority of highly uncontrolled HbA 1c -level patients had retinopathy (OR 8.90, P =0.0001), foot complications (OR 8.09, P =0.0001), dyslipidemia (OR 2.81, P =0.010), and hypertension (OR 2.0, P =0.028) compared to the controlled HbA 1c -level (<7%) group. Patients with diabetes >10 years also had higher prevalence of foot complications (OR 2.92, P =0.0001), retinopathy (OR 2.17, P =0.011), and hypertension (OR 1.67, P =0.033). From patient responses, physicians examined only 34.2% of patient feet and 36.7% of patients received physicians advice for foot care. About 70% of patients had knowledge of diabetic foot care; however, only 41.7% of patients always examined their feet, 41.4% washed feet with warm water, 31.4% carefully dried between the toes, and 33.1% were using foot-moisturizing substances., Conclusion: The prevalence of comorbid complications was higher in the Saudi population compared to other international studies. Also, foot-care practice was not satisfactory. Therefore, there is need of improvement and increased awareness among physicians and patients to check regularly for proper care of the diabetic foot to avoid diabetic foot-related complications., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Purpose: This retrospective study aimed to determine the clinical outcomes following particle monotherapy (ie, proton therapy [PT] or carbon ion therapy [CIT]) in patients with sinonasal squamous cell carcinoma at a single institution., Methods and Materials: Between August 2001 and March 2012, 59 patients were treated with definitive PT or CIT; none underwent chemotherapy or surgery. Of the patients, 22 (37%) had unresectable disease. PT was used in 38 patients (64%); CIT, 21 patients (36%). Almost half of the patients (n = 29, 47%) received 65.0 Gy (relative biological effectiveness) in 26 fractions., Results: The median follow-up period was 30 months (range, 8-127 months) for all patients and 65 months (range, 9-127 months) for the survivors. The 3- and 5-year overall survival rates were 56.2% and 41.6%, respectively; progression-free survival rates, 42.9% and 34.7%, respectively; and local control rates, 54.0% and 50.4%, respectively. Late toxicities of grade ≥3 occurred in 13 patients (22%)., Conclusions: To our knowledge, this is the largest retrospective study of sinonasal squamous cell carcinoma treated with particle therapy alone. The efficacy of PT and CIT indicated that particle therapy can serve an important role in treating this disease., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the efficacy and safety of definitive proton beam therapy (PBT) for primary sacral chordoma., Methods and Materials: We conducted a retrospective analysis of the clinical outcomes of eligible patients with primary sacral chordoma who had undergone definitive PBT with 70.4 Gy (relative biological effectiveness) in 32 fractions at our institution from September 2009 to October 2015. Local progression-free survival, distant metastasis-free survival, disease-free survival, cause-specific survival, and overall survival were evaluated. To explore the factors that influenced local progression, the following parameters were analyzed: sex, the presence of a spacer (Gore-Tex sheets), gross tumor volume, and extent of cranial tumor extension. Adverse events were evaluated using the Common Terminology Criteria for Adverse Events, version 4.0. To assess the impact of PBT on pain relief, the change in pain grades was investigated between the initiation of PBT and the last follow-up visit., Results: Thirty-three eligible patients were analyzed. The median follow-up period was 37 months. The 3-year estimated local progression-free survival, distant metastasis-free survival, disease-free survival, cause-specific survival, and overall survival rates were 89.6%, 88.2%, 81.9%, 95.7%, and 92.7%, respectively. No significant association was between the patients' clinicopathologic characteristics and local progression-free survival. Four patients developed grade 3 adverse events, including acute dermatitis (n = 1), ileus (n = 1), and pain due to sacral insufficiency fractures (n = 2). The pain grades had improved, were unchanged, or had deteriorated in 15, 7, and 11 patients, respectively., Conclusions: Definitive PBT with 70.4 Gy (relative biological effectiveness) in 32 fractions is an effective treatment with acceptable toxicity for primary sacral chordoma and has the potential to reduce pain., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To retrospectively analyze the treatment outcomes of carbon-ion radiation therapy for adenoid cystic carcinoma (ACC) of the head and neck at 4 active carbon-ion facilities in Japan., Methods and Materials: A total of 289 patients who underwent carbon-ion radiation therapy for histology-proven ACC of the head and neck at 4 institutions in Japan between November 2003 and December 2014 were included in this study., Results: Median patient age was 58 years (range, 12-83 years). Tumor sites included the nasal cavity and paranasal sinuses (42%), nasopharynx and oropharynx (19%), oral cavity (12%), major salivary glands (12%), and others (15%). Tumor classifications were T4 in 200 (69%) patients, T3 in 45 (16%), T2 in 22 (8%), T1 in 15 (5%), and unclassified in 7 (2%). The median total dose was 64 Gy (relative biological effectiveness [RBE]; range, 55.2-70.4 Gy [RBE]) in 16 fractions (range, 12-32 fractions). Median follow-up time was 30 months (range, 2-118 months). The 2-year overall survival, progression-free survival, and local control rates were 94%, 68%, and 88%, respectively. Estimated 5-year overall survival, progression-free survival, and local control rates were 74%, 44%, and 68%, respectively. In all, 43 patients (15%) experienced grade ≥3 late toxicity, of which osteonecrosis of the jaw bone was the most common. Two patients treated for nasopharyngeal ACC died from a bleeding ulcer at the tumor site (grade 5 toxicity)., Conclusions: Carbon-ion radiation therapy seems to be a promising treatment for ACC of the head and neck., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To retrospectively analyze the treatment outcomes of particle therapy using protons or carbon ions for unresectable or incompletely resected bone and soft tissue sarcomas (BSTSs) of the pelvis., Methods and Materials: From May 2005 to December 2014, 91 patients with nonmetastatic histologically proven unresectable or incompletely resected pelvic BSTSs underwent particle therapy with curative intent. The particle therapy used protons (52 patients) or carbon ions (39 patients). All patients received a dose of 70.4 Gy (relative biologic effectiveness) in 32 fractions (55 patients) or 16 fractions (36 patients)., Results: The median patient age was 67 years (range 18-87). The median planning target volume (PTV) was 455 cm 3 (range 108-1984). The histologic type was chordoma in 53 patients, chondrosarcoma in 14, osteosarcoma in 10, malignant fibrous histiocytoma/undifferentiated pleomorphic sarcoma in 5, and other in 9 patients. Of the 91 patients, 82 had a primary tumor and 9 a recurrent tumor. The median follow-up period was 32 months (range 3-112). The 3-year rate of overall survival (OS), progression-free survival (PFS), and local control was 83%, 72%, and 92%, respectively. A Cox proportional hazards model revealed that chordoma histologic features and a PTV of ≤500 cm 3 were significantly associated with better OS, and a primary tumor and PTV of ≤500 cm 3 were significantly associated with better PFS. Ion type and number of fractions were not significantly associated with OS, PFS, or local control. Late grade ≥3 toxicities were observed in 23 patients. Compared with the 32-fraction protocol, the 16-fraction protocol was associated with significantly more frequent late grade ≥3 toxicities (18 of 36 vs 5 of 55; P<.001)., Conclusions: Particle therapy using protons or carbon ions was effective for unresectable or incompletely resected pelvic BSTS, and the 32-fraction protocol was effective and relatively less toxic. Nevertheless, a longer follow-up period is needed to confirm these results., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Box-Behnken model of response surface methodology was used to study the effect of adsorption process parameters for Rhodamine B (RhB) removal from aqueous solution through optimized large surface area date stone activated carbon. The set experiments with three input parameters such as time (10-600min), adsorbent dosage (0.5-10g/L) and temperature (25-50°C) were considered for statistical significance. The adequate relation was found between the input variables and response (removal percentage of RhB) and Fisher values (F- values) along with P-values suggesting the significance of various term coefficients. At an optimum adsorbent dose of 0.53g/L, time 593min and temperature 46.20°C, the adsorption capacity of 210mg/g was attained with maximum desirability. The negative values of Gibb ' s free energy (ΔG) predicted spontaneity and feasibility of adsorption; whereas, positive Enthalpy change (ΔH) confirmed endothermic adsorption of RhB onto optimized large surface area date stone activated carbons (OLSADS-AC). The adsorption data were found to be the best fit on the Langmuir model supporting monolayer type of adsorption of RhB with maximum monolayer layer adsorption capacity of 196.08mg/g., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aim: To evaluate the treatment results of radiotherapy (RT) in children and adults with brainstem gliomas (BSGs) and review the previous literature., Methods: Thirty patients (14 children, 16 adults) with BSG treated using RT were retrospectively evaluated. The median ages of the children and adults were 8 years (range: 2-16 years) and 49 years (range: 19-75 years), respectively. A histological diagnosis was obtained in 11 patients. The median total radiation dose was 56 Gy (range: 50-70 Gy) with a single fraction size of 1.8-2.0 Gy. Temozolomide was administered concurrently with RT in 14 patients., Results: Tumor progression after RT occurred in 26 patients (14 children and 12 adults). Four adults survived without tumor progression. The median survival times for children and adults were 8.5 and 39 months, respectively. The 1-, 2- and 3-year overall survival rates for children/adults were 29%/75%, 14%/68% and 0%/53%, respectively (P = 0.001), and the 1-, 2- and 3-year progression-free survival rates for children/adults were 14%/69%, 0%/49% and 0%/35%, respectively (P < 0.001). Grade 3 or higher acute and late toxicities did not occur., Conclusion: In this study, the prognosis of children with BSGs was considerably poorer than that of adults, and our results are consistent with those of previous studies. Efforts should be made to improve the survival outcomes of patients with BSGs, especially children., (© 2016 The Authors. Asia-Pacific Journal of Clinical Oncology Published by John Wiley & Sons Australia, Ltd.)

Keratinocytes are central to the barrier functions of surface epithelia, such as the gingiva and epidermis. RIPK4 is a key regulator of keratinocyte differentiation; however, the signalling pathways in which it functions remain poorly defined. In this study, we identified a regulatory relationship between RIPK4 and ELF3, an ETS family transcription factor. RIPK4 was shown to be important for the upregulation of ELF3 gene expression by the PKC agonist PMA in both oral and epidermal keratinocytes. RIPK4 promotes keratinocyte differentiation in part by phosphorylating and thereby activating the IRF6 transcription factor. Significantly, silencing of IRF6 inhibited the PMA-inducible expression of ELF3. A role for the GRHL3 transcription factor, a downstream target gene of IRF6, in the regulation of ELF3 expression was similarly demonstrated. ELF3 has previously been shown to regulate the expression of SPPR1A and SPRR1B, small proline-rich proteins that contribute to the cornification of keratinocytes. Consistently, RIPK4 and IRF6 were important for the PMA-inducible expression of SPRR1A and SPRR1B. They were also important for the upregulation of TGM1, a transglutaminase that catalyses the cross-linking of proteins, including small proline-rich proteins, during keratinocyte cornification. RIPK4 was also shown to upregulate the expression of TGM2 independently of IRF6. Collectively, our findings position RIPK4 upstream of a hierarchal IRF6-GRHL3-ELF3 transcription factor pathway in keratinocytes, as well as provide insight into a potential role for RIPK4 in the regulation of keratinocyte cornification., (Copyright © 2016 Elsevier Inc. All rights reserved.)