Skeletal Fluorosis in a Patient With Computer Cleaner Inhalant Abuse.

Skeletal fluorosis is a metabolic bone disease caused by excessive consumption of fluoride from fluoride-contaminated water or foods. Such a condition often takes place in developing countries without proper handling of drinking water or food. However, in recent years, multiple cases of skeletal fluorosis have been observed in the United States due to the increasing frequency of recreational substance abuse. In this case report, a 26-year-old male with a history of polysubstance use disorder presented to the emergency department after being assaulted by store employees when attempting to steal computer cleaner inhalants. On evaluation for acute traumatic injury, he was incidentally found to have diffuse sclerosis of all visualized bones on knee, femur, and hip X-rays. Labs were significant for elevated serum alkaline phosphatase levels, secondary hyperparathyroidism, and hypovitaminosis D. Given the patient's history of computer cleaner inhalant misuse and imaging findings, serum and urine fluoride levels were obtained and supported the diagnosis of skeletal fluorosis. Skeletal pain and diffuse sclerosis on imaging should prompt clinicians to include skeletal fluorosis in the differential diagnosis. Cessation of substance use is the primary treatment of fluorosis in the setting of computer cleaner inhalant abuse. However, clinical symptoms and laboratory and imaging abnormalities may take decades to resolve due to the prolonged half-life of fluoride in bone. Proper hydration is crucial, as nephrolithiasis and hypercalciuria have been described during the skeletal unloading of fluoride.

Impact of supplemental training programs on improving medical students' confidence in providing diabetes self-management education and support.

BACKGROUND/PURPOSE: The purpose of this study was to evaluate the effectiveness of supplemental diabetes-related training modalities and volunteer activities in increasing first-year medical students' knowledge/comfort in providing diabetes self-management education and support (DSMES) to patients. METHODS: A group of medical students developed supplemental diabetes-related training/volunteer programs. The training modalities included an optional 7-session interprofessionally taught Diabetes Enrichment Elective and a 3-hour endocrinologist-led training session intended to prepare students for involvement in an inpatient DSMES volunteer program. The volunteer program provided the students with the opportunity to provide DSMES to patients with diabetes admitted to an academic medical center. Those participating in any of the stated programs were compared to those with no such training regarding confidence in providing DSMES using an optional online survey. The results were analyzed by using Mann-Whitney U test and descriptive analyses. RESULTS: A total of 18 first-year medical students responded to the optional survey with a response rate of ~30% (10 of 33) among participants in any training/volunteer program. First-year medical students who attended any of the offered optional programs had statistically significant higher comfort level in 4 of the 6 areas assessed regarding providing DSMES compared with those with no such training (p<0.05), with medium to large effect size (r=0.48-0.59). CONCLUSION: This study suggests that the supplemental preclerkship diabetes-specific training modalities/volunteer programs can provide benefit in providing medical students with practical knowledge while improving their confidence in providing DSMES to patients with diabetes.

Expression of Five Neuroblastoma Genes in Bone Marrow or Blood of Patients with Relapsed/Refractory Neuroblastoma Provides a New Biomarker for Disease and Prognosis.

Purpose: We determined whether quantifying neuroblastoma-associated mRNAs (NB-mRNAs) in bone marrow and blood improves assessment of disease and prediction of disease progression in patients with relapsed/refractory neuroblastoma.Experimental Design: mRNA for CHGA, DCX, DDC, PHOX2B, and TH was quantified in bone marrow and blood from 101 patients concurrently with clinical disease evaluations. Correlation between NB-mRNA (delta cycle threshold, ΔCt, for the geometric mean of genes from the TaqMan Low Density Array NB5 assay) and morphologically defined tumor cell percentage in bone marrow, 123I-meta-iodobenzylguanidine (MIBG) Curie score, and CT/MRI-defined tumor longest diameter was determined. Time-dependent covariate Cox regression was used to analyze the relationship between ΔCt and progression-free survival (PFS).Results: NB-mRNA was detectable in 83% of bone marrow (185/223) and 63% (89/142) of blood specimens, and their ΔCt values were correlated (Spearman r = 0.67, P < 0.0001), although bone marrow Ct was 7.9 ± 0.5 Ct stronger than blood Ct When bone marrow morphology, MIBG, or CT/MRI were positive, NB-mRNA was detected in 99% (99/100), 88% (100/113), and 81% (82/101) of bone marrow samples. When all three were negative, NB-mRNA was detected in 55% (11/20) of bone marrow samples. Bone marrow NB-mRNA correlated with bone marrow morphology or MIBG positivity (P < 0.0001 and P = 0.007). Bone marrow and blood ΔCt values correlated with PFS (P < 0.001; P = 0.001) even when bone marrow was morphologically negative (P = 0.001; P = 0.014). Multivariate analysis showed that bone marrow and blood ΔCt values were associated with PFS independently of clinical disease and MYCN gene status (P < 0.001; P = 0.055).Conclusions: This five-gene NB5 assay for NB-mRNA improves definition of disease status and correlates independently with PFS in relapsed/refractory neuroblastoma. Clin Cancer Res; 23(18); 5374-83. ©2017 AACR.

A student-implemented elective to improve medical student confidence in providing diabetes self-management support.

BACKGROUND: The purpose of this study was to develop a preclerkship elective and assess its effectiveness in supplementing medical students' education. METHODS: A group of medical students under the guidance of two faculty advisors developed an elective consisting of six sessions covering a variety of practical aspects of diabetes care/education taught by an interprofessional team. Following the course completion, a survey was emailed to the enrollees who attended at least one session. The results were analyzed using Wilcoxon signed-rank and descriptive analyses. RESULTS: A total of 14 medical students were enrolled (nine first year and five second year). An average of 4.4 sessions/student was attended. Thirteen students attended at least one session and were surveyed. The survey response rate was ~62% (8/13). All eight students indicated that the course was valuable and would recommend it to their colleagues. A Wilcoxon signed-rank test revealed a statistically significant increase in students' confidence in all five areas assessed following participation in the course, P<0.05 with a large effect (r>0.5). CONCLUSION: This study suggests the feasibility of developing disease state-specific preclerkship elective courses and that such courses can be beneficial in supplementing medical student education with practical knowledge.

Inflammation and Elevation of Interleukin-12p40 in Patients with Schizophrenia.

Schizophrenia is a serious mental illness with chronic symptoms and significant impairment in psychosocial functioning, which suggests that it likely has neurodegenerative characteristics. Inflammatory markers such as pro-inflammatory cytokines are well-known etiological contributors for psychiatric disorders, including schizophrenia. Although, the role of inflammation in schizophrenia is becoming evident, the number of studies in this area is relatively scarce, especially in Lebanon, and increased procedural thoroughness is needed. Cytokines play a key role in the activation of the immune system and strongly influence neurotransmission. Previous investigation of plasma levels showed dysregulation of interleukin (IL)-12. However, genotypical variations of this interleukin have not been investigated for patients with schizophrenia yet. Thus, in this paper, we aimed to compute and assess IL-12p40 levels in the sera of individuals with schizophrenia from different provinces in Lebanon and compare it to controls. Healthy subjects comprised 60 individuals with a male/female (M/F) ratio of 31/29, whereas patients with schizophrenia consisted of 63 subjects with an M/F ratio of 30/33. The mean age for healthy controls was 30 years, whereas that for patients with schizophrenia was 35 years. A standardized enzyme-linked immunosorbent assay (ELISA) technique was used to measure the concentration of IL-12p40 in all collected sera (n = 123). The mean IL-12p40 levels in patients with schizophrenia were significantly higher than in healthy controls (p = 0.002). Healthy females had a significantly higher concentration of IL-12p40 than healthy males (p = 0.009). Female patients with schizophrenia had significantly higher concentrations of IL-12p40 than their male counterparts (p < 0.001), healthy females (p = 0.018), and healthy males (p < 0.001), respectively. Male patients with schizophrenia had significantly higher concentrations of IL-12p40 than healthy males (p = 0.023). The study's results suggest that IL-12p40 has a putative role as a potential marker in schizophrenia and that its elevation may participate in its pathogenesis. IL-12p40 may be included in a panel to be evaluated in the sera of patients with schizophrenia and an appreciation of its independent function is important for improving our understanding of both protective and pathogenic immune responses. Future research should aim to assess this interleukin and understand its role in other mental illnesses that share a similar etiology to schizophrenia.

Mycobacterium tuberculosis spoligotypes circulating in the Syrian population: A retrospective study.

OBJECTIVES: To characterize by spoligotyping clinical isolates of Mycobacterium tuberculosis (MTB) collected between July 2003 and October 2005 from all Syrian provinces (muhafazat). METHODS: All isolates (n=96) were cultured and identified by biochemical characteristics. DNA extracts of these samples were amplified by PCR and genotyped by spoligotyping. RESULTS: Twelve patterns were identified: 46.8% of the strains belonged to T 1 family; 20.8% to LAM 9; 10.4% to CAS; 9.3% to Haarlem 3; 4.1% to Haarlem 1; 2.1% to Family 34; and 1% to each of Family 36, EAI 5, LAM 1, LAM 8, T 3, and X 3 families. The noticeable absence of the Beijing family was not consistent with the patterns reported in most neighboring countries. CONCLUSION: A more inclusive study of the Syrian population is necessary to more accurately identify most of the prevailing families in the country.

[Typhoid fever in Lebanon: epidemiological study]. / La fièvre typhoïde au Liban : étude épidémiologique.

Typhoid fever is a major public health problem, especially in developing countries. From 2000 through 2008, the infectious disease surveillance unit at the Lebanese Ministry of Public Health received 6148 reports of typhoid cases. A case is considered positive for typhoid or paratyphoid fever when fever of at least 38 degrees C persists for three days, and Salmonella enterica serovar Typhi or Paratyphi is isolated from blood, bone marrow, or stool. Statistical analysis was performed with STATA v.10 software. The most cases were recorded in 2003 (n=891), followed by 2007 (n=879), while the fewest were recorded in 2005 (n=461). The distribution of typhoid was not homogeneous between age groups: the age group most affected were those aged 20-39 years, followed by those from 10-19 years; those older than 60 years were least affected. Nor was the geographic distribution, by district (combining Nabatieh and the South together), homogeneous. The most affected individuals were in the North (n=2,192), followed by Bekaa (n=1,651) and Mount Lebanon (n= 1,094). Beirut was the least affected, with 210 cases. The results indicate that typhoid fever remains endemic in Lebanon and that the risk of epidemic episodes is still present.

Survey of antimicrobial prophylaxis for surgical procedures in Lebanese hospitals.

Antimicrobial prophylaxis (AMP) is an effective measure to prevent the surgical site infection (SSI). This prospective survey of three months describe the adequacy of AMP in 10 acute care hospitals (affiliated to the Lebanese University, Faculty of Medical Sciences) based on international guidelines for only three parameters, digestive, orthopaedic and vascular surgery. Out of 964 surgical procedures, 916 (95%) were eligible for AMP, of which 767 (84%) received one or several antibiotics. Cefazolin was frequently prescribed (49%), followed by beta-lactamase-inhibitor/penicillin (18%), cefuroxime (17%), ceftriaxone (7%) and vancomycin (0.1%). In compliance with current US guidelines on indication, choice of drug, duration and time of first dose administration, AMP was given for only 32% of the procedures. Duration of AMP was < or = 24 hours in 35% and exceeded 48 hours in 57%. A single dose of prophylaxis was given to 26%, 12% receive an additional dose and 62% receive more than 2 doses. The first dose was administered within 30 min before operation in 92% of procedures. We conclude that AMP in Lebanese hospitals was fairly adequate in terms of respecting indications for selected surgical procedures. Improvement could be made by reducing the duration of prophylaxis and avoiding the use of broad-spectrum antibiotics.