Visit In March Research Articles

Preventing Hospitalisation- Providing Specialist Geriatric Services To Nursing Home Patients

Abstract Background Nursing home (NH) residents often require acute hospital care in unexpected deterioration and may have repeated Emergency Department (ED) attendances. Grunier et al (2018) reported 48% of NH residents reattend ED within 1 year. Our aim is to determine if those who require acute hospital admission are more likely to reattend ED or require NH outreach services. Methods Nursing home residents who attended Mater ED in March 2023 were identified through Electronic Patient Record. Their age, gender, reattendance of ED within 28 days and 6 months, visit by NH outreach team within 28 days then 6 months and 6-month mortality were recorded. The residents were categorised as admitted or discharged from their sentinel visit in March 2023. Chi-square test was used, and statistical significance was set at p<0.05. Results Sixty-three nursing home residents attended within 1-month, median age 85 years (range 67-95), 43 were women. Forty-five (71%) required admission, 6 (9.5%) and 24 (38.1%) reattended ED within 28 days and 6 months respectively. There was no difference in 28-day or 6-month ED reattendance between those who were admitted or discharged in the sentinel visit to ED. Those discharged from ED were more likely to receive NH outreach visit within 28 days (84% vs 6.8%) and 6 months (84% vs 11%) than those who were admitted, p<0.0001. There was no difference in 6 months mortality between the groups. Conclusion Our study found that 71% of NH residents who attend ED require admissions showing that the transfer was warranted. More than one-third of NH residents reattend ED within 6 months. Those discharged from ED were more likely to be reviewed by NH outreach team as per service delivery. Working closely with the resident’s General Practitioner, NH and ED staff may help to manage these complex patients to coordinate their treatment and prevent ED reattendance.

Understanding rural-urban differences in veterans' internet access, use and patient preferences for telemedicine.

The expansion of telemedicine (e.g., telephone or video) in the Veterans Health Administration (VA) raises concerns for health care disparities between rural and urban veterans. Factors impeding telemedicine use (e.g., broadband, digital literacy, age) disproportionally affect rural veterans. To examine veteran-reported broadband access, internet use, familiarity with, and preferences for telemedicine stratified by residential rurality. Three hundred fifty veterans with a VA primary care visit in March 2022 completed a 30-min computer-assisted telephone interview. The sampling design stratified veterans by residential rurality (i.e., rural or urban) and how primary care was delivered (i.e., in-person or by video). Counts and weighted percentages are reported. After accounting for survey weights, 96.2% of respondents had in-home internet access and 89.5% reported functional connection speeds. However, rural- compared to urban-residing veterans were less likely to experience a telemedicine visit in the past year (74.1%vs. 85.2%; p = 0.02). When comparing telemedicine to in-person visits, rural versus urban-residing veterans rated them not as good (45.3%vs. 36.8%), just as good (51.1%vs. 53.1%), or better (3.5%vs. 10.0%) (p = 0.05). To make telemedicine visits easier, veterans, regardless of where they lived, recommended technology training (46.4%), help accessing the internet (26.1%), or provision of an internet-enabled device (25.9%). Though rural-residing veterans were less likely to experience a telemedicine visit, the same actionable facilitators to improve telemedicine access were reported regardless of residential rurality. Importantly, technology training was most often recommended. Policy makers, patient advocates, and other stakeholders should consider novel initiatives to provide training resources.

Interest and Satisfaction of Telemedicine Use Among Ambulatory Neurology Patients in Western North Carolina During the COVID-19 Pandemic.

Introduction: During the COVID-19 pandemic, care shifted from exclusively telemedicine to hybrid models with in-person, video, and telephone visits. We explored how patient satisfaction and visit preferences have changed by comparing in-person versus virtual visits (telephone and video) in an ambulatory neurology practice across three time points. Methods: Patients who completed a virtual visit in March 2020 (early-pandemic), May 2020 (mid-pandemic), and March 2021 (later-pandemic) were contacted. Patients were assessed for visit satisfaction and desire for future telemedicine. Univariate and multivariable logistic regression analysis was conducted to determine factors independently associated with video visit completion. Results: Four thousand seven hundred seventy-eight the number of ambulatory visits (n = 4,778) were performed (1,004 early; 1,265 mid; and 2,509 later); 1,724 patients (36%) assented to postvisit feedback; mean age 45.8 ± 24.4 years, 58% female, 79% white, and 56% with Medicare/Medicaid insurance. Patient satisfaction significantly increased (73% early, 79% mid, 81% later-pandemic, p = 0.008). Interest in telemedicine also increased for patients completing telephone visits (40% early, 50% mid, 59% later, p = 0.027) and video visits (52% early, 59% mid, 62% later, p = 0.035). Patients satisfied with telemedicine visits were younger (p < 0.001). White patients were more interested in future telemedicine (p = 0.037). Multivariable analysis showed that older patients (for each 1 year older), Black patients, and patients with Medicare/Medicaid were 2%, 45%, and 54% less likely to complete a video visit than telephone, respectively. Discussion: Patients, especially younger ones, have become more satisfied and more interested in hybrid care models during the COVID-19 pandemic. Barriers to conducting video visits persist for older, Black patients with Medicare or Medicaid insurance.

17th International Conference on Malignant Lymphoma, Palazzo dei Congressi, Lugano, Switzerland, 13 - 17 June, 2023.

Introduction: Circulating tumor DNA (ctDNA) has been proven to be a promising tumor-specific biomarker in tumors, but its clinical utility in risk stratification and early prediction of relapse for peripheral T cell lymphoma (PTCL) has not been well explored. Methods: Using a lymphoma-specific sequencing panel, we assessed the prognostic and predictive utilities of ctDNA measurements before and after first-line therapy in 41 PTCL patients. Results: For the 41 patients, we obtained a total of 36 primary tumor specimens, 41 pretreatment blood samples and 21 serial blood samples before and after first-line therapy. By the last visit in March 2023, the median follow-up duration was 10.0 (range, 2.5–18.8) months. The clinical characteristics of the 41 patients were shown in Figure 1A. All patients received CHOP-like regimen. The top 30 somatic mutations of tissues were shown in Figure 1B. Pretreatment ctDNA (Pre-ctDNA) achieved an overall sensitivity of 81.3% (159/196) in detecting variants verified in tumor, indicating that ctDNA is a reliable source for PTCL genotyping. In addition, ctDNA allowed for the identification of additional 98 somatic mutations that were undetectable in tumor gDNA, which demonstrated that ctDNA could overcome tumor spatial heterogeneity (Figure 1C). Pre-ctDNA burden was significantly associated with clinical characteristics, including extranodal involvement (P < 0.001), lactate dehydrogenase (LDH) levels (P < 0.001), age (P = 0.047), B symptoms (P = 0.038), stage (P = 0.008) and international prognosis index (IPI) score (P < 0.001) (Figure 1D). The cell-free (cfDNA) fragments profoundly reflects both genomic and chromatin characteristics. Our results suggested that all samples had a more prominent mono-nucleosomal fragments abundance (167 bp), whereas the samples of angioimmunoblastic T-cell lymphom (AITL) and the samples with high IPI scores or non-complete response (CR) in the mid-stage of treatment had a more prominent shift towards shorter cfDNA size (Figure 1E). Similarly, when we analyzed the response to treatment, significant decline in ctDNA levels was observed at end of treatment (EOT) in patients with CR compared with those who did not achieved CR. The 4 patients with CR and EOT ctDNA negative achieved continuous CR until now (Figure 1F). Furthermore, high pre-ctDNA levels presented unfavourable PFS (P = 0.002) and OS (P = 0.020) (Figure 1G). Multivariate cox regression analysis showed that high pre-ctDNA burden (P = 0.029) and TP53 mutation (P = 0.005) (Figure 1H). Subgroup analysis showed that patients without these 2 risk factors (Type 1) had longer PFS than the other patients with more than 0 risk factor (Type 2) (P < 0.001) (Figure 1I). Keywords: Aggressive T-cell non-Hodgkin lymphoma, Diagnostic and Prognostic Biomarkers No conflicts of interests pertinent to the abstract.

A comparison of telemedicine and in-person neurology visits: what are the factors that patients consider when selecting future visit type?

ObjectiveTo identify factors that patients consider when choosing between future in-person, video, or telephone visits.BackgroundTelemedicine has been rapidly integrated into ambulatory neurology in response to the COVID-19 pandemic.MethodsAmbulatory neurology patients at a single center were contacted via telephone to complete: (1) a survey quantifying likelihood of scheduling a future telemedicine visit, and (2) a semi-structured qualitative interview following their visit in March 2021. Data were processed using the principles of thematic analysis.ResultsOf 2493 visits, 39% assented to post-visit feedback; 74% were in-person visits and 13% video and telephone. Patients with in-person visits were less likely than those with video and telephone visits to “definitely” consider a future telemedicine visit (36 vs. 59 and 62%, respectively; p < 0.001). Patients considered five key factors when scheduling future visits: “Pros of Visit Type,” “Barriers to Telemedicine,” “Situational Context,” “Inherent Beliefs,” and “Extrinsic Variables.” Patients with telemedicine visits considered convenience as a pro, while those with in-person visits cited improved quality of care. Accessibility and user familiarity were considered barriers to telemedicine by patients with in-person and telephone visits, whereas system limitations were prevalent among patients with video visits. Patients agreed that stable conditions can be monitored via telemedicine, whereas physical examination warrants an in-person visit. Telemedicine was inherently considered equivalent to in-person care by patients with telephone visits. Awareness of telemedicine must be improved for patients with in-person visits.ConclusionAcross visit types, patients agree that telemedicine is convenient and effective in many circumstances. Future care delivery models should incorporate the patient perspective to implement hybrid models where telemedicine is an adjunct to in-person visits in ambulatory neurology.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00415-022-11149-0.

Dampak Ekonomi dalam Pengelolaan Homestay di Desa Terong Kabupaten Belitung

Desa Wisata Terong has a high unique selling point. The uniqueness of the Desa Wisata Terong is also equipped with supporting facilities including homestay, Belitung Regency. The number of visits to Desa Wisata Terong January-August 2019 experienced a peak visit in March, May and June with the largest number of visits in June (238) tourists. The number of visits to Desa Wisata Terong in January-August 2019 was as large as 844. Of the number of visits only 0.02% (22) included visitors staying overnight, while the remainder were one day visitors.The longer visitors stay at Homestay the more meaningful the economic contribution of tourism is generated,this underlies the necessary strategy to increase the length of stay of visitors in Desa Wisata Terong. This strategy has implications for the development in accordance with the potential and tourism products such as homestays, food and drinks, souvenirs and transport in Desa Wisata Terong of Belitung Regency. Spending on Homestay visitors from Pancasila University where the composition of the largest expenditure is the culinary business component, which is 55% of the total visitor expenditure

Analysis of Key factors in Arms Export and Arms Export Strategy of Middle East Countries

&#x0D; President Moon has visited to UAE as a National Visit in March, 2018 and express to support co-develop, co-produce and co-export to the third countries of weapon system. Therefore, the paper analyzes the recent arms market in the Middle East, as one of the three major arms export market to Korea, and present an arms export strategy to customize the Middle East countries.Concerning a recent 10 year arms export by region, the ratio of Middle East countries arms export was highly increased by 12%p(17%→29%). And arms acquisition budget in 5 years(2018∼22) will be over 130 billion dollars. UAE has a highly interested in missiles, warship building, surveilance system, RWCS etc after Summit meeting. Iraq has focus on his post war rebuilding to include relevant weapon system and facilities. Also, Saudi Arabia is necessary to fulfill his Saudization policy to enter his arms market.For expanding of Middle East arms market, it is necessary to provide customized defense industry total solution for the whole weapon system lifecycles, dispatch defense cooperation director, find out co-development program between Korea and Middle East countries, and diversify cooperation system in the near future.

Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties

ObjectivesLockdown measures in response to the coronavirus disease 2019 (COVID-19) pandemic can have serious mental health effects on the population, especially in vulnerable groups, such as those living in poor socio-economic conditions, those who are homeless, migrant workers and asylum seekers/refugees. In addition, these vulnerable groups frequently have greater difficulty accessing health services and in treatment adherence. The aim of this study is to estimate the impact of the COVID-19–related lockdown on service utilisation and follow-up adherence in an Italian mental health outpatient service for migrants and individuals in socio-economic difficulties. Study designThe design of this study is a retrospective cross-sectional study. MethodsAll patients who visited the mental health outpatient service in the months of February and March in the years 2017–2020 were included in the study. To compare service utilisation before and after the lockdown, the number of patients who visited the mental health outpatient service for psychiatric interview were recorded. Follow-up adherence was calculated as the percentage of patients who visited in February and subsequently attended a follow-up visit in March of the same year. ResultsThe number of patients who visited the outpatient service between February 2017 and February 2020 was continuously increasing. In March 2020, fewer patients visited the service for psychiatric interview, in line with the introduction of lockdown measures. In addition, the number of the patients who visited in February 2020 and returned for their follow-up visits in March 2020 declined from approximately 30% over the same months in 2017–2019 to 17.53% in March 2020. ConclusionsThe lockdown-related reduction in numbers of patients accessing the mental health service makes it difficult to help vulnerable populations during a period of time in which their mental health needs are expected to increase. Moreover, the reduction seen in follow-up compliance increases the risk of treatment discontinuation and possible relapse. Proactive alternative strategies need to be developed to reach these vulnerable populations.

SAT-640 Glycemic Profile of Intravenous Glucocorticoid Induced Hyperglycemia Using Continuous Glucose Monitoring

Background: Intravenous (IV) steroids are widely used in critically ill patients and with chemotherapy. It is well known that glucocorticoid-induced hyperglycemia (GCIH) occurs within 3 hours following oral administration of steroids with typical postprandial glycemic excursions lasting 24-36 hours. The recent increased availability of Continuous Glucose Monitoring (CGM) has allowed a detailed description of glycemic fluctuations in patients receiving steroids in different settings, however there is no reported observation of CGM findings following a single dose of IV Dexamethasone in a patient with diabetes. We present a case of glycemic pattern documented on CGM of a patient with type 2 diabetes, who had received 11 cycles of a single dose Dexamethasone-containing chemotherapy. Clinical Case: The patent is 70 years old female with history of type 2 DM of 19 years duration and metastatic pancreatic adenocarcinoma, diagnosed in November 2018, and treated with Fluorouracil and Dexamethasone 6mg IV on every other Wednesday since December 2018. Her diabetes was fairly controlled on Metformin, Repaglinide, Pioglitazone and Detemir insulin. Premeal Lispro was added while Metformin and Repaglinide were discontinued with the beginning of chemotherapy. She started using Freestyle Libre CGM in January 2019. During her visit in March 2019, the patient was taking Detemir Insulin 50 units in AM and 30 units at night, and Lispro 15 units before meals, in addition to correction insulin based on an Insulin Sensitivity Factor (ISF) of 1:25 for Blood Glucose (BG) above 200mg/dl. Unlike the reported postprandial hyperglycemic excursions associated with oral steroids, the patient’s CGM data showed a reproducible triphasic glycemic pattern following IV Dexamethasone, consisting of a steady state of hyperglycemia reached within 3 hours and lasting around 18-30 hours, followed by a transient BG improvement for 18-20 hours, and ending with another hyperglycemic plateau of 10-16 hours on day 3 post chemotherapy, with no association to meal intake. Given this recurrent pattern, the patient was advised to increase her bedtime Detemir insulin from 30 to 45 units and her correction ISF from 1:25 to 1:18 on days 1 and 2 after chemotherapy, with subsequent attenuation and shortening of GCIH. Conclusion: Our case report is the first one to describe CGM documented glycemic profile following a single dose of IV Dexamethasone in a patient with type 2 diabetes treated with insulin. The CGM data reveals a consistent steady GCIH, lasting around 48 hours, and reflecting the prolonged action of Dexamethasone. The transient BG improvement seen on day 2 is likely due to the Detemir dose self-increase and the carbohydrates intake decrease in response to day 1 hyperglycemia. A 48 hours modified insulin regimen based on higher dose of long acting and correction insulin improved Dexamethasone induced hyperglycemia.

Patient experience with clinical pharmacist services in Travis County Federally Qualified Health Centers.

Background:Positive patient experiences with care have been linked to improved health outcomes. Patient experience surveys can provide feedback about the level of patient-centered care provided by clinical pharmacists and information about how to improve services.Objectives:Study objectives are: 1) To describe patient experience with clinical pharmacist services in a federally qualified health center (FQHC). 2) To determine if demographic or health-related factors were associated with patient experience.Methods:This cross-sectional survey included adult patients who were English or Spanish speaking, and completed a clinical pharmacist visit in March or April 2018. Patient experience was evaluated, on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with 10 items using four domains: pharmacist-patient interaction information provision, support for self-care, and involvement in decision making. In addition, one item was used to rate the overall experience. Demographic and health-related variables were also collected. Eligible patients completed the survey after their clinical pharmacist visit. Descriptive and inferential statistics, as well as Cronbach’s alpha for scale reliability, were employed.Results:Respondents (N=99) were 55.4 (SD=12.1) years and 53.1% were women. Overall, patients rated their experiences very high with the 10-item scale score of 4.8 (SD=0.4) out of 5 points and the overall experience rating of 4.9 (SD=0.4) out of 5 points. With the exception of race, there were no differences between patient experience and demographic and health-related variables. African Americans had significantly (p=0.0466) higher patient experience scores compared to Hispanics.Conclusions:Patients receiving care in a FQHC highly rated their experience with clinical pharmacists. This indicates that clinical pharmacists provided a high level of patient-centered care to a diverse group.

New Fiscal Package in Kosovo and Its Impact on Economy

In order to create a more flexible system for citizens and businesses in Kosovo, the Government of Kosovo made a decision by which from 1 April 2014 increased the salaries for 25% for employees receiving salaries and pensioner compensation and other social categories from the Kosovo budget. This Government decision carries some problems with regard to public finance management and impact on the country's economy by creating a new reality in the payroll and public spending. Direct impact of this document: Decision No: 01/176. 10 March 2014, are: First, the increase in wage expenditures was not planned in the Medium Term Expenditure Framework 2014-2016 and this has given an indication of macroeconomic inefficiency (Assessed by the Kosovo Finance Ministry). Secondly, this increase decreases capital investment costs, which have the greatest potential to generate economic growth. Thirdly, wage growth along with spending on the Pristina-Skopje highway is expected to increase the budget deficit over the fiscal rule. Such a situation was also present at the time of investments in the Motorway Vermicë - "Nations connection way". In order to balance the increase of budget expenditures with revenues, the International Monetary Fund (IMF), at the conclusion of the Kosovo visit in March 2015, suggested to the Government of Kosovo that in the continuation of the increase of the various excise duties to see the possibilities for growth Value Added Tax (VAT) which would bring a substantial increase in budget revenues. At the 20th meeting of the Government of Kosovo, dated 24 March 2015, during this IMF visit, the Government took a series of decisions on fiscal changes. Among other things, these decisions have to do with the approval of new draft laws: 1. Changes in Value Added Tax (VAT); 2. Changes in Corporate Income Tax; 3. Changes in Personal Income Tax; and 4. Changes in excises duties of cars, tobacco, and alcoholic beverages etc. Based on the analysis of these changes and their effects, one can make an assessment of the economic and fiscal effects of the aforementioned laws. Some of the key findings of this study-analysis section show that small businesses will be negatively impacted by lowering the VAT threshold, while the abolition of VAT on machinery and raw materials will lower the cost of production and potentially increase investments in manufacturing sectors. Reform in fiscal policy encourages greater investment in production and at the same time improves business liquidity. According to an estimate by the Ministry of Finance, businesses will have about 27.6% cheaper start of production process. Keywords: Kosovo budget.,VAT, Tax, IMF, Ministry of Finance, fiscal

The great paradox: how Obama’s opening to Cuba may imperil the country’s reform process

This article examines the kind of development and political model most likely to emerge in Cuba, particularly in the wake of the gradual US–Cuban normalisation currently taking place. The rapprochement process, culminating with President Obama’s historic visit in March 2016, has unleashed stiff resistance in both countries. The liberal democratisation paradigm is held up against what we have termed ‘socialist neo-patrimonialism’, with both seen as alternative tools for assessing the direction of social transformations underway in Cuba, focusing on the debate about the role of the national private sector. Paradoxically, normalisation with the USA may so far have had the contrary effect of what President Obama had in mind in this respect: judging from the 7th Congress of the Communist Party in April 2016, it seems that resistance against economic reforms has hardened, caused by a fear that Obama’s charm offensive, combined with a strengthened entrepreneurial sector, will undermine the entire revolutionary project. The article concludes with a discussion of four development scenarios.

Another pandemic disaster looms: yellow fever spreading from Angola

For more than a decade, WHO has been warning that changes in demography and land use patterns in Africa have created ideal conditions for explosive outbreaks of urban yellow fever (YF). Africa's urbanization has been rapid and rampant, showing the fastest growth rates anywhere in the world. And for more than a decade, some of us in public health have been concerned about the increasing threat of the introduction of YF into Asia. But during all that time, market forces have kept the supply of YF vaccine below global demand. But nobody foresaw the emergence of urban YF in a low-risk country like Angola, nor of viremic people taking it from there to Kinshasa, capital of the Congo DR, and even China, the first time YF has ever been reported in Asia. Every country that has dengue, carried by the same Aedes mosquitoes that spread YF, is now at risk. Mosquito control has not succeeded in controlling dengue anywhere, so will be unable alone to stop a pandemic. The only immediately available preventive measure is the vaccine. But there is not enough vaccine available from manufacturers` stocks now, nor that can be produced in the coming months with current capacity. Increasing production rapidly is problematic. Figures for cases and deaths are probably underestimates by a factor of 10, according to WHO`s own expert after a visit in March, so that two months ago there were already thousands of cases and many hundreds of deaths. Angola has a population of at least 24 million, so another 16 million doses of vaccine are needed for enough coverage to bring the epidemic to an end. Now global stocks will soon be exhausted unless steps are taken immediately to conserve vaccine by authorizing the use of a lower, but still effective, 1/5th dose.

Lymphocutaneous Sporotrichosis during Treatment with Anti-TNF-Alpha Monotherapy.

Sporotrichosis is an infectious disease caused by Sporothrix schenckii, a dimorphic fungus isolated for the first time in 1896 by Benjamin Schenck from a 36-year-old male patient presenting lesions on the right hand and arm. The infection generally occurs by traumatic inoculation of soil, plants, and organic matter contaminated with the fungus. Different clinical syndromes are described as a direct consequence of S. schenckii infection, including lymphocutaneous and disseminated forms, although extracutaneous presentations are reported most frequently in AIDS patients. Here we describe the case of a 57-year-old Caucasian male diagnosed in 2004 with ankylosing spondylitis under stable treatment with adalimumab monotherapy (40 mg every other week). During a routine follow-up visit in March 2013, he presented with multiple nodular lesions arranged in a linear fashion along the left hand and forearm. After diagnostic aspiration of the lesions, lymphocutaneous sporotrichosis was diagnosed and appropriate therapy started.

The Wabar impact craters, Saudi Arabia, revisited

AbstractThe very young Wabar craters formed by impact of an iron meteorite and are known to the scientific community since 1933. We describe field observations made during a visit to the Wabar impact site, provide analytical data on the material collected, and combine these data with poorly known information discovered during the recovery of the largest meteorites. During our visit in March 2008, only two craters (Philby‐B and 11 m) were visible; Philby‐A was completely covered by sand. Mapping of the ejecta field showed that the outcrops are strongly changing over time. Combining information from different visitors with our own and satellite images, we estimate that the large seif dunes over the impact site migrate by approximately 1.0–2.0 m yr−1 southward. Shock lithification took place even at the smallest, 11 m crater, but planar fractures (PFs) and undecorated planar deformation features (PDFs), as well as coesite and stishovite, have only been found in shock‐lithified material from the two larger craters. Shock‐lithified dune sand material shows perfectly preserved sedimentary structures including cross‐bedding and animal burrows as well as postimpact structures such as open fractures perpendicular to the bedding, slickensides, and radiating striation resembling shatter cones. The composition of all impact melt glasses can be explained as mixtures of aeolian sand and iron meteorite. We observed a partial decoupling of Fe and Ni in the black impact glass, probably due to partitioning of Ni into unoxidized metal droplets. The absence of a Ca‐enriched component demonstrates that the craters did not penetrate the bedrock below the sand sheet, which has an estimated thickness of 20–30 m.

A word of caution: do not wake sleeping dogs; micrometastases of melanoma suddenly grew after progesterone treatment

BackgroundHormonal treatment might affect the immune response to tumor antigens induced in cancer patients who are being vaccinated.Case presentationA 33 years-old woman was diagnosed with cutaneous melanoma in May 2009. Her melanoma was located in the intermammary sulcus, had a Breslow thickness of 4 mm, a Clark’s level IV, it was ulcerated and highly melanotic. The bilateral sentinel node biopsy was negative. She entered into a randomized Phase II/III clinical study comparing a vaccine composed of irradiated melanoma cells plus BCG plus GM-CSF versus IFN-alpha 2b and she was assigned to the vaccine arm. During the two years treatment she remained disease-free; the final CAT scan being performed in August 2011. Between November and December 2011, her gynecologist treated her with three cycles of 200 mg progesterone/day for ten days, every two weeks, for ovary dysfunction. In November 2011 the patient returned to the Hospital for clinical and imaging evaluation and no evidence of disease was found. At the next visit in March 2012 an ultrasound revealed multiple, large metastases in the liver. A CAT scan confirmed the presence of liver, adrenal glands and spleen metastases. A needle biopsy of a liver lesion revealed metastatic melanoma of similar characteristics to the original tumor. We suggest that progesterone treatment triggered proliferation of so far dormant micrometastases that were controlled during CSF470 vaccine treatment.ConclusionThe use of progesterone in patients with melanoma that are under immunological treatments should be carefully considered, since progesterone could modify the balance of pro-inflammatory and Th1 functions to a regulatory and anti-inflammatory profile of the immune system that could have an impact in tumor progression.

Evidence of lasting impact of the Deepwater Horizon oil spill on a deep Gulf of Mexico coral community

Abstract A coral community 11 km southwest of the site of the Deepwater Horizon blowout at 1,370 m water depth was discovered 3.5 months after the well was capped on 3 November 2010. Gorgonian corals at the site were partially covered by a brown flocculent material (floc) that contained hydrocarbons fingerprinted to the oil spill. Here we quantify the visible changes to the corals at this site during five visits over 17 months by digitizing images of individual branches of each colony and categorizing their condition. Most of the floc visible in November 2010 was absent from the corals by the third visit in March 2011, and there was a decrease in the median proportions of the colonies showing obvious signs of impact after the first visit. During our second visit in 2010, about six weeks after the first, we documented the onset of hydroid colonization (a sign of coral deterioration) on impacted coral branches that increased over the remainder of the study. Hydroid colonization of impacted portions of coral colonies by the last visit in March 2012 correlated positively with the proportion of the colony covered by floc during the first two visits in late 2010. Similarly, apparent recovery of impacted portions of the coral by March 2012 correlated negatively with the proportion of the coral covered with floc in late 2010. A notable feature of the impact was its patchy nature, both within and among colonies, suggesting that the impacting agent was not homogeneously dispersed during initial contact with the corals. While the median level of obvious visible impact decreased over time, the onset of hydroid colonization and the probability of impacts that were not visually obvious suggest that future visits may reveal additional deterioration in the condition of these normally long-lived corals.

Malnutrition levels among vaccinated and unvaccinated children between 2 and 3 years of age following enrollment in a randomized clinical trial with the pentavalent rotavirus vaccine (PRV) in Bangladesh

A double-masked, individually randomized Phase 3 clinical trial to assess the efficacy, safety and immunogenicity of the pentavalent rotavirus vaccine (PRV), RotaTeq™, was conducted in rural Matlab, Bangladesh (NCT00362648). A total of 1136 infants were enrolled and randomized to receive either vaccine or placebo in a 1:1 ratio administered with the standard EPI vaccines at a mean age of approximately 8, 12, and 16 weeks. Weight was collected at four time points (study vaccine doses 1, 2, and 3, and a close-out visit in March 2009 at 15-26 months of age), and birth weight was retrospectively collected from information contained on the mother's health card when available. Approximately one year following trial completion a separate study was conducted to collect anthropometry measurements, including weight and height. These measurements were linked with Phase 3 trial data and a post hoc analysis was conducted to assess the effects of rotavirus vaccination on malnutrition among enrolled children who could be located when they were between 27 and 38 months old. Among the 1033 (91%) children located, and measured, for this analysis height-for-age and weight-for-height Z scores were calculated and compared between vaccine and placebo recipients at the anthropometry follow-up 1-year post-trial, and weight-for-age Z scores were calculated at four trial time points in addition to the anthropometry follow-up. The data indicated that there was no effect of rotavirus vaccination on malnutrition in this population at any of the measured time points. PRV, estimated to have about 43% efficacy against severe rotavirus gastroenteritis in this population, may not reduce the overall burden of diarrheal illness sufficiently among all vaccinees to appreciably measure impact on growth compared with non-vaccinees. Regardless of the impact on malnutrition indicators, rotavirus vaccines are an important intervention for reducing morbidity and mortality in children in developing countries.

Bilateral hip pain

In October, 2008, a 40-year-old man was referred to our hospital because of pain in his right groin, which had started a few days after he fell on his back at work 10 days earlier. He had mild asthma, which was treated with an occasional dose of inhaled broncholytics. On physical examination, he had right groin tenderness, and pain that was provoked by weight-bearing. A pelvic radiograph was normal. A tendon or muscle injury was suspected, and ultrasonography suggested a partial rupture of the rectus femoris muscle. MRI was planned as an elective outpatient procedure to rule out a total rupture of the tendon. A month after the onset of symptoms, the pain on weight bearing in the right groin had decreased but not resolved. He had also started to have pain in the left groin, and on examination, pain on rotation of both hip joints. MRI showed bilateral insuffi ciency fractures of the femoral necks (fi gure). Although he denied any regular recreational sports activities, his new job as a delivery-van driver required a lot of climbing. He had no dietary restrictions. Elderly relatives of our patient had a history of osteoporosis and osteopenia. Our patient was asked to restrict weight-bearing. A dual-energy x-ray absorptiometry scan showed that his bone mineral density was osteopenic at the lumbar spine and right femoral neck. The left femoral neck showed osteoporotic values (0·706 g/cm2; T score –2·8; Z score –2·4). Biochemistry tests for parathyroid and coeliac disease excluded secondary reasons for osteoporosis. His serum 25-hydroxyvitamin D(3) concentration was 33 nmol/L (normal > 40nmol/L). He was referred for iliac crest bone biopsy after tetracycline double-labelling. Low trabecular bone volume was found by histomorphometry (BV/TV 9·0%), and confi rmed by microcomputed tomography (9·9%). The turnover rate was normal as shown by normal amounts of formation and erosion surfaces (OV/BV 1·5%, OS/BS 14·2%, ES/BS 7·0%). The osteoblast and osteoclast surfaces were normal (Ob.S/BS 1·9%, Oc.S/BS 0·0%) as was the amount of mineralising surface (MS/BS 8·0%), but the mineral apposition rate was slightly low (0·28 μm/day). The results were consistent with normal-turnover osteoporosis. In a repeat MRI 10 weeks after the beginning of the symptoms bone oedema was diminished and in the follow up visit in March 2009, the fractures had clinically healed. His osteoporosis was treated with daily calcium 1000 mg, vitamin D 800 IU supplementation and weekly alendronate 70 mg. When last seen in June, 2010, he was asymptomatic. The diagnosis of insuffi ciency fracture of the femoral neck is commonly missed in clinical practice. The diagnostic algorithm should include, but not be restricted to radiographs. A normal radiograph does not rule out insuffi ciency fractures, as our patient’s case demonstrates. Osteoporosis may in itself be an aetiological factor in the case of insuffi ciency fractures. Long term bisphosphonate therapy has been linked with insuffi ciency fracturees in the femoral shaft. However, our patient’s fractures did not show features of such atypical fractures.Although secondary osteoporosis should be considered in young male patients, primary osteoporosis remains the diagnosis for up to half of patients. In the case of insuffi ciency fractures, the possibility of bilateral injury should be considered. Early diagnosis is warranted because untreated insuffi ciency fracture of the femoral neck can lead to a displaced fracture.

Follow-up of prolapse surgery in rural Nepal

Pelvic organ prolapse (POP) is a significant problem in Nepal. Surgical treatment is scarcely available and little is known of the results of POP surgery on women living under burdensome circumstances. The aim of our study was to set up a follow-up program in rural Nepal and evaluate POP surgery. In 2004 and 2006, 74 women with a POP from remote areas around Dhulikhel Hospital underwent prolapse surgery. Together with local contacts men, a plan was made to implement a follow-up program. All the operated patients were invited to a follow-up visit in March 2007. Thirty-three (45%) patients attended the follow-up: 85% (n = 28) found the effect of the procedure an improvement. A satisfactory anatomic outcome was found in 93% (n = 32). A remarkable finding was the reduction in physical labour after the surgical procedure in 50% of the follow-up cases. Some adjustments in the follow-up program may contribute to a higher participation.