The possible association of proton pump inhibitor use with acute cholangitis in patients with choledocholithiasis: a multi-center study.

BACKGROUND: Gallstone disease is common worldwide and can lead to severe complications, including cholangitis; thus, it is important to identify modifiable risk factors for cholangitis. Proton pump inhibitors (PPIs) are commonly prescribed to treat gastroenterological disorders. We aimed to explore whether PPI use is associated with an increased risk of acute cholangitis in patients with gallstone disease. METHODS: This retrospective multicenter study included all patients arriving to the hospital over a 10-year period with various presentations of choledocholithiasis. We compared active PPI use in two groups: those with cholangitis (group A) vs. without cholangitis (group B). RESULTS: Overall, 811 patients were included, 161 in group A and 650 in group B. The average age ± standard deviation (SD) in groups A and B was 74.5 ± 20.6 vs. 61.6 ± 20.9 years, respectively. PPI use in group A was higher vs. group B (42.9% vs. 29.1%, p = 0.001). On univariate analysis, male gender (OR 1.47, 95% confidence interval (CI) 1.04-2.08), age (OR 1.04, 95% CI 1.03-1.05), ischemic heart disease (IHD) (OR 1.68, 95% CI 1.07-2.64), hyperlipidemia (OR 1.59, 95% CI 1.11-2.29), hypertension (OR 1.81, 95% CI 1.28-2.57) and PPI use (OR 1.83, 95% CI 1.28-2.61), all were associated with acute cholangitis. On multivariate analysis, only PPI use kept its association after adjustment for age (OR 1.64, 95% CI 1.2-3.7). CONCLUSIONS: Active PPI use was associated with a higher rate of cholangitis among patients with choledocholithiasis. We advocate considering this risk before prescribing PPIs to patients with gallstones. TRIAL REGISTRATION NUMBER: NHR-0263-20 received on 14/01/2021 date 'retrospectively registered'.

Ethnic Differences in Clinical Presentations and Esophageal High-Resolution Manometry Findings in Patients with Achalasia.

BACKGROUND: Ethnic differences in achalasia presentations have scarcely been described. The association between achalasia and immunologic HLA haplotypes suggests that there may be a genetic predisposition. We aimed to evaluate differences in demographic, clinical, endoscopic, and manometric findings between two distinct ethnic groups with achalasia-Israeli Arabs (IA) and Israeli Jews (IJ). METHODS: A retrospective study was performed at two medical centers. High-resolution manometry (HRM) reports were reviewed for newly-diagnosed achalasia patients. Demographic data, clinical presentations, endoscopy reports, and HRM metrics including the integrated relaxation pressure (IRP) were all reviewed. RESULTS: Overall, 94 achalasia patients were included (53.2% male; mean age 54.5 ± 18.0). 43 patients were IA (45.7%). Body mass index (BMI) was similar in both groups. Compared to IJ, the IA patients had more esophageal dysphagia (100% vs. 88.2%; P = 0.022), chest pain (46.5% vs. 25.5%; P = 0.033), and a tortuous esophagus on endoscopy (23.3% vs. 3.9%; p = 0.005). IA patients were also diagnosed at a younger age than IJ patients (50.9 ± 17.5 vs. 57.5 ± 18.0; p = 0.039). Furthermore, IRP values were higher among IA patients than IJ patients (32.2 ± 13.8 vs. 23.3 ± 8.4; p < 0.001). A regression model analysis found that ethnicity significantly predicted IRP (ß = - 10, p < .001). CONCLUSION: Ethnicity appears to affect achalasia clinical presentation and HRM findings. IA achalasia patients are diagnosed at a younger age, present with more severe esophageal symptoms, and have a higher IRP compared to IJ patients. Additional studies of diverse, multiethnic populations, especially with genetic evaluations, are required to further assess the role of ethnicity in achalasia.

The Impact of Ramadan Fasting on Fatty Liver Disease Severity: A Retrospective Case Control Study from Israel.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is emerging as an important public health condition. The effect of Ramadan fasting on several metabolic conditions has been previously assessed. OBJECTIVES: To assess the impact of Ramadan fasting on non-alcoholic steatohepatitis (NASH) severity scores. METHODS: A retrospective, case control study was conducted in Nazareth Hospital between 2017 and 2019. We included NAFLD patients who had been diagnosed by abdominal ultrasonography. The study population was divided in two matched groups: NASH subjects who fasted all of Ramadan and NAFLD/NASH subjects who did not fast (control). Metabolic/NASH severity scores, homeostatic model assessment of ß-cell function and insulin resistance (HOMA-IR), NAFLD Fibrosis Score (NFS), BARD scores, and fibrosis-4 (FIB4) scores were assessed in both groups before and after the Ramadan month. RESULTS: The study included 155 NASH subjects, 74 who fasted and 81 who did not. Among the fasting group, body mass index decreased from 36.7 ± 7.1 to 34.5 ± 6.8 after fasting (P < 0.003), NFS declined from 0.45 ± 0.25 to 0.23 ± 0.21 (P < 0.005), BARD scores declined from 2.3 ± 0.98 to 1.6 ± 1.01 (P < 0.005), and FIB4 scores declined from 1.93 ± 0.76 to 1.34 ± 0.871 (P < 0.005). C-reactive protein decreased from 14.2 ± 7.1 to 7.18 ± 6.45 (P < 0.005). Moreover, HOMA-IR improved from 2.92 ± 1.22 to 2.15 ± 1.13 (P < 0.005). CONCLUSIONS: Ramadan fasting improved on inflammatory markers, insulin sensitivity, and noninvasive measures for NASH severity assessment.

The Yield of Endoscopy and Histology in the Evaluation of Esophageal Dysphagia: Two Referral Centers' Experiences.

Background and Objectives: The initial diagnostic test required to evaluate esophageal dysphagia is upper endoscopy (EGD) to assess the structure of the esophagus and the esophageo-gastric junction (EGJ). Taking biopsies during EGD has become a common practice in patients with dysphagia to rule out eosinophilic esophagitis (EoE). The aims of this study were to evaluate the endoscopic findings of patients who underwent EGD for esophageal dysphagia, to assess the rate of biopsy taking from the esophagus to diagnose/exclude EoE, and to report histology outcomes of these biopsies. Materials and Methods: This was a retrospective multicenter study that included individuals ≥18 years who underwent EGD due to esophageal dysphagia between the years 2015 and2020, (with no other alarm signs, such as weight loss, new iron deficiency anemia, and lymphadenopathy). We obtained data from patients' electronic files. The endoscopy and histology findings were obtained from endoscopy reports saved in our electronic files. Results: A total of 209 patients were included in the study. The average age was 57.1 ± 17.1 years. The most common endoscopic findings were normal endoscopy in 76 patients (36.4%) and erosive esophagitis in 75 patients (35.9%). Barrett's esophagus and esophageal malignancy were encountered in 11 patients (5.3%) and 2 patients (0.95%), respectively. Esophageal biopsies were taken in 50.2% of patients, and one patient had histological evidence of EoE (0.5%). On univariate analysis, there was a trend for association between proton pump inhibitors (PPIs) use and a normal EGD, but it was not statistically significant (OR 0.28, 95% CI 0.07-1.11, p = 0.07). Conclusions: Endoscopic findings were prevalent in dysphagia patients even when no other alarm symptoms exist. Neoplastic lesions and EOE were rare in our study.

Adaption of distance learning to continue the academic year amid COVID-19 lockdown.

This work investigates the use of distance learning in saving students' academic year amid COVID-19 lockdown. It assesses the adoption of distance learning using various online application tools that have gained widespread attention during the coronavirus infectious disease 2019 (COVID-19) pandemic. Distance learning thrives as a legitimate alternative to classroom instructions, as major cities around the globe are locked down amid the COVID-19 pandemic. To save the academic year, educational institutions have reacted to the situation impulsively and adopted distance learning platforms using online resources. This study surveyed random undergraduate students to identify the impact of trust in formal and informal information sources, awareness and the readiness to adopt distance learning. In this study, we have hypothesized that adopting distance learning is an outcome of situational awareness and readiness, which is achieved by the trust in the information sources related to distance learning. The findings indicate that trust in information sources such as institute and media information or interpersonal communication related to distance learning programs is correlated with awareness (ß = 0.423, t = 12.296, p = 0.000) and contribute to readiness (ß = 0.593, t = 28.762, p = 0.001). The structural model path coefficient indicates that readiness strongly influences the adoption of distance learning (ß = 0.660, t = 12.798, p = 0.000) amid the COVID-19 pandemic. Our proposed model recorded a predictive relevance (Q2) of 0.377 for awareness, 0.559 for readiness, and 0.309 for the adoption of distance learning, which explains how well the model and its parameter estimates reconstruct the values. This study concludes with implications for further research in this area.

Clinical evaluation of pregnant women with SARS-COV2 pneumonia: a real-life study from Egypt.

BACKGROUND: Knowledge about the outcome of COVID-19 on pregnant women is so important. The published literature on the outcomes of pregnant women with COVID-19 is confusing. The aim of this study was to report our clinical experience about the effect of COVID-19 on pregnant women and to determine whether it was associated with increased mortality or an increase in the need for mechanical ventilation in this special category of patients. METHODS: This was a cohort study from some isolation hospitals of the Ministry of Health and Population, in eleven governorates, Egypt. The clinical data from the first 64 pregnant women with COVID-19 whose care was managed at some of the Egyptian hospitals from 14 March to 14 June 2020 as well as 114 non-pregnant women with COVID-19 was reviewed. RESULTS: The two groups did not show any significant difference regarding the main outcomes of the disease. Two cases in each group needed mechanical ventilation (p 0.617). Three cases (4.7%) died among the pregnant women and two (1.8%) died among the non-pregnant women (p 0.352). CONCLUSIONS: The main clinical outcomes of COVID-19 were not different between pregnant and non-pregnant women with COVID-19. Based on our findings, pregnancy did not exacerbate the course or mortality of COVID-19 pneumonia.

Concomitant use of direct oral anticoagulants and aspirin versus direct oral anticoagulants alone in atrial fibrillation and flutter: a retrospective cohort.

BACKGROUND: The benefit of combining aspirin and direct oral anticoagulants on the reduction of cardiovascular events in atrial fibrillation or flutter is not well studied. We aimed to assess whether concurrent aspirin and direct oral anticoagulant therapy for atrial fibrillation or flutter will result in less coronary, cerebrovascular and systemic ischemic events compared to direct oral anticoagulant therapy alone. METHODS: Retrospective study of adult patients between 18 and 100 years old who have nonvalvular atrial fibrillation or flutter and were started on a direct oral anticoagulant (apixaban, rivaroxaban, or dabigatran), between January 1, 2010 and September 1, 2015 within the Beaumont Health System. Exclusions were history of venous thromboembolic disease and use of other antiplatelet therapies such as P2Y12 inhibitors. Patients were classified into two groups based on concurrent aspirin use and observed for a minimum of 2 years. Primary outcome was major adverse cardiac events, defined as acute coronary syndromes, ischemic strokes, and embolic events. Secondary outcomes were bleeding and death. RESULTS: Six thousand four patients were in the final analysis, 57% males and 80% Caucasians, median age 71, interquartile range (63-80). The group exposed to aspirin contained 2908 subjects, and the group unexposed to aspirin contained 3096 subjects. After using propensity scores to balance the baseline characteristics in both groups, the analysis revealed higher rate of major adverse cardiac events in the exposed group compared to the unexposed group, (HR 2.11, 95% CI (1.74-2.56)) with a number needed to harm of 11 (95% CI [9-11]). The rate of bleeding was also higher in the exposed group, (HR 1.30, 95% CI (1.11-1.52)). The rate of death was not statistically different between the groups, (HR 0.87, 95% CI (0.61-1.25)). CONCLUSIONS: In this observational analysis of patients with atrial fibrillation and flutter, the concomitant use of direct oral anticoagulants and aspirin was associated with an increased risk of both major adverse cardiac and bleeding events when compared to the use of direct oral anticoagulants alone. These findings underscore the potential harm of this combination therapy when used without a clear indication.

HRH dimensions of community health workers: a case study of rural Afghanistan.

INTRODUCTION: There is ample evidence to indicate that community health workers (CHW) are valuable human resources for health in many countries across the globe, helping to fill the gap created by a chronic health workforce shortage. This shortage is not only in number but also in workforce distribution and skill mix. There remains a lack of evidence, however, concerning the size and distribution of CHWs and their relationship to the professionally regulated and recognized health workforce, such as physicians and nurses, and the unregulated and unrecognized health workforce, such as traditional birth attendants and traditional healers. This is particularly the case in low-income, under-resourced countries, such as Afghanistan. METHOD: We conducted a descriptive qualitative analysis involving fieldwork in Afghanistan between 2013 and 2014. We undertook participant observation and in-depth interviews with community members, CHWs, health managers, and policymakers, in an attempt to add more depth to our knowledge of how CHWs function, or could function better, as a recognized health worker. RESULTS: We found that the number of CHWs has increased dramatically in recent years and that CHWs play a variety of roles, including work generally associated with professional providers, such as referral, education, and counseling. Although not a replacement for professional health providers, CHWs, in places where the number of and access to such providers is low, become the only option to meet basic health needs of the population. In places where professional providers are available, CHWs have the potential to extend the services to marginalized populations, provide community health services, and become a recognized member of the health provider team. A limitation of their role in health system strengthening is their lack of integration and a clear career path including into more recognized professional roles. CONCLUSION: CHWs provide a critical human resources for health role in Afghanistan, but there are opportunities for improved integration with other providers which can increase their potential to improve service delivery.

Compound-Specific Sulfur Isotope Analysis of Petroleum Gases.

We describe a simple, sensitive, and robust method for sulfur isotope ratio (34S/32S) analysis of ppm-level organic sulfur compounds (OSCs) in the presence of percent-level H2S. The method uses a gas chromatograph (GC) coupled with a multicollector inductively coupled plasma mass spectrometer (MC-ICPMS). The GC, equipped with a gas inlet and a valve that transfers the H2S to a thermal conductivity detector (TCD), enables a precise heart cut and prevents the saturation of the MC-ICPMS. The sensitivity and accuracy of the method are better than 0.3‰ for OSCs at a concentration of 25 pmol or 1.4 ppm, and better than 0.5‰ for concentrations ≥0.7 ppm of OSCs. An order of magnitude increase in sensitivity, with no effect on accuracy, can be achieved if the loop volume (0.5 mL) is changed to 5 mL. High concentrations of methane (95% v/v) and/or H2S (20% v/v) had no effect (within 0.5‰) on the precision and accuracy of the gas sample containing 2 ppm of OSCs after heart cut. The applicability and robustness of this method are demonstrated on a gas sample (10% v/v H2S) that was produced by pyrolysis of sulfur-rich kerogen. The results show good precision and reveal sulfur isotope variability between individual OSCs that may represent key processes during formation and degradation of OSCs.

Interleukin-33 induces mucin gene expression and goblet cell hyperplasia in human nasal epithelial cells.

We investigated whether IL-33 is involved in mucus overproduction and goblet cell hyperplasia in eosinophilic chronic rhinosinusitis (ECRS). IL-33 mRNA was significantly higher in the eosinophilic CRS group than in the non-eosinophilic CRS group from human nasal polyps. IL-33 induced MUC5AC mRNA and MUC5AC protein, and also goblet cell hyperplasia at air liquid interface culture in human nasal epithelial cells. In addition to that, IL-33 induced MUC5B and FOXA3, and reduces FOXJmRNA. In conclusion, our present study demonstrated that the direct evidence of IL-33 which lead to increase mucin gene and protein expression, as well as goblet cell hyperplasia. This study provides novel insights into the role of IL-33 on mucus overproduction in eosinophilic inflammation of human airways.

Oxytetracycline Inhibits Mucus Secretion and Inflammation in Human Airway Epithelial Cells.

Oxytetracycline is a broad-spectrum antibiotic, but its nonantibacterial effects in the human respiratory tract are unknown. In this study, the effects of oxytetracycline on mucus secretion and inflammation were examined by PCR and ELISA in the human airway epithelial cell line NCI-H292. Oxytetracycline (10 µg/mL) significantly inhibited TNF-α-induced MUC5AC gene expression and MUC5AC protein levels in NCI-H292 cells. It also downregulated IL-8 and IL-1ß gene expression and IL-1ß protein levels. Our findings demonstrated that oxytetracycline suppressed mucus production and inflammation in human respiratory epithelial cells, providing further evidence for the usefulness of oxytetracycline for human airway inflammatory diseases.

Sulfur isotope homogeneity of oceanic DMSP and DMS.

Oceanic emissions of volatile dimethyl sulfide (DMS) represent the largest natural source of biogenic sulfur to the global atmosphere, where it mediates aerosol dynamics. To constrain the contribution of oceanic DMS to aerosols we established the sulfur isotope ratios ((34)S/(32)S ratio, δ(34)S) of DMS and its precursor, dimethylsulfoniopropionate (DMSP), in a range of marine environments. In view of the low oceanic concentrations of DMS/P, we applied a unique method for the analysis of δ(34)S at the picomole level in individual compounds. Surface water DMSP collected from six different ocean provinces revealed a remarkable consistency in δ(34)S values ranging between +18.9 and +20.3‰. Sulfur isotope composition of DMS analyzed in freshly collected seawater was similar to δ(34)S of DMSP, showing that the in situ fractionation between these species is small (<+1‰). Based on volatilization experiments, emission of DMS to the atmosphere results in a relatively small fractionation (-0.5 ± 0.2‰) compared with the seawater DMS pool. Because δ(34)S values of oceanic DMS closely reflect that of DMSP, we conclude that the homogenous δ(34)S of DMSP at the ocean surface represents the δ(34)S of DMS emitted to the atmosphere, within +1‰. The δ(34)S of oceanic DMS flux to the atmosphere is thus relatively constant and distinct from anthropogenic sources of atmospheric sulfate, thereby enabling estimation of the DMS contribution to aerosols.

Factors influencing non-institutional deliveries in afghanistan: secondary analysis of the afghanistan mortality survey 2010.

Home delivery in unhygienic environments is common among Afghan women; only one third of births are delivered at health facilities. Institutional delivery is central to reducing maternal mortality. The factors associated with place of delivery among women in Afghanistan were examined using the Afghanistan Mortality Survey 2010 (AMS 2010), which was open to researchers. The AMS 2010 data were collected through an interviewer-led questionnaire from 18,250 women. Odds ratio (OR) and 95% confidence interval (CI) of non-institutional delivery were estimated by logistic regression analysis. When age at survey, education, parity, residency, antenatal care frequency, remoteness, wealth and regions were adjusted, the OR of non-institutional delivery was 8.37 (95% CI, 7.47-9.39) for no antenatal care relative to four or more antenatal care visits, 4.07 (95% CI, 3.45-4.80) for poorest household relative to women from richest household, 2.02 (95% CI, 1.43-2.84) for no education relative to higher education, 1.78 (95% CI, 1.52-2.09) for six or more deliveries relative to one delivery, and 1.50 (95% CI, 1.36-1.67) for rural relative to urban residency. Since antenatal care was strongly associated with non-institutional delivery after adjustment of the other factors, antenatal care service may promote institutional deliveries, which can reduce maternal mortality ratio in Afghanistan.

Immunological parameters in prophylactic sublingual immunotherapy in asymptomatic subjects sensitized to Japanese cedar pollen.

BACKGROUND: This study aims to examine the immunological parameters, focusing IL-10 productivity, in prophylactic sublingual immunotherapy (SLIT) in asymptomatic subjects sensitized to Japanese cedar pollen (JCP). METHODS: This study was conducted as part of a randomized, double-blind, placebo-controlled, multiple center trial, and was performed for two consecutive pollen seasons in 2012 and 2013. The present results were based only on our institution. We recruited 29 participants with specific IgE against JCP of at class 2 and higher levels without history of the pollinosis symptoms at the time of JCP scattering. The SLIT group received standardized JCP extract for five months over the pollen season. We observed and judged development of the symptoms in the pollen season. The percentage of IL-10 producing CD4(+) T (Trl) cells, B cells and monocytes were analyzed by flow cytometry. JCP specific IgE and total IgE were also measured. RESULTS: The ratio of development of cedar pollinosis was significantly lower in the SLIT group compared to the placebo group in 2013. In 2012, the percentage of circulating Tr1 cells and IL-10 producing monocytes significantly increased in the SLIT group. In 2013, the percentage of circulating Tr1 cells and IL-10 producing B cells increased significantly in the SLIT group. The percentage of circulating IL-10 producing monocytes significantly decreased in the placebo group. CONCLUSIONS: Prophylactic SLIT is effective for prevention of the development of pollinosis. Induction of IL-10 producing T cells, B cells and monocytes is an important mechanism of SLIT for prevention of pollinosis in asymptomatic but sensitized subjects.

A sensitive method for the sulfur isotope analysis of dimethyl sulfide and dimethylsulfoniopropionate in seawater.

RATIONALE: Dimethyl sulfide (DMS) is the major volatile sulfur species emitted to the atmosphere from the oceans. The sulfur isotope ratio ((34)S/(32)S) of DMS may offer a way to calculate the contribution of marine DMS to global sulfur cycling. The S-isotopic analysis of DMS is difficult due to its low concentrations in natural seawater and high chemical reactivity. Here we present a sensitive, precise and accurate method for determining the S-isotopic composition of natural DMS and its precursor, dimethylsulfoniopropionate (DMSP), in seawater. METHODS: The method was based on a purge of DMS from aqueous solutions or natural seawater to a cryogenic trap and subsequent separation of DMS by gas chromatography. The separated DMS was then transferred from the gas chromatograph to a multicollector inductively coupled plasma mass spectrometer (GC/MC-ICPMS system) for measurement of (34)S/(32)S ratios. Correction for mass bias was accomplished using standard-sample bracketing with peaks of SF6 as a reference gas. RESULTS: Results obtained from synthetic DMS and DMSP dissolved in artificial seawater show >98% recovery of DMS and very good precision (0.1 to 0.3‰), accuracy and linearity (0.2‰) for the 26-179 picomoles (pmol) of DMS or DMSP injected. The system was tested with natural seawater from Eilat (Red Sea, Israel) and similar precision and accuracy for both DMS and DMSP were obtained. The δ(34)S values of DMS and DMSP from Eilat seawater were 19.2 ± 0.2‰ and 19.7 ± 0.2‰, respectively. CONCLUSIONS: The coupling of a purge-and-trap system with a GC/MC-ICPMS system was shown to be a sensitive, accurate and robust approach for the S-isotope analysis of nanomolar (nM) concentrations of DMS and DMSP from aqueous solutions and natural seawater.

Effects of interleukin-31 on MUC5AC gene expression in nasal allergic inflammation.

BACKGROUND: Interleukin-31 (IL-31) is a newly discovered T helper lymphocyte-derived cytokine that plays an important role in allergic inflammation. However, the effects of IL-31 on mucus production in nasal allergic inflammation are completely unknown. OBJECTIVE: To investigate the effects of IL-31 on mucin gene expression (MUC5AC) in patients with allergic rhinitis and in human airway epithelial cells. METHODS: Expression levels of IL-31 and IL-31 receptor A (IL-31RA) were evaluated in the inferior turbinate of patients with allergic rhinitis and non-allergic rhinitis with immunohistochemistry. IL-31-induced MUC5AC gene expression was measured with a MUC5AC luciferase reporter assay in human epithelial HM3-MUC5AC cells and quantified by quantitative real-time polymerase chain reaction in human airway epithelial A549 cells. RESULTS: IL-31RA was primarily localized in submucosal glands and upregulated in allergic rhinitis. IL-31 was detected in submucosal tissue and increased in allergic inflammation. MUC5AC gene expression was induced by IL-31 stimulation both in HM3-MUC5AC and A549 cells. Additionally, IL-31 cooperated with Th2 cytokines on MUC5AC gene expression in HM3-MUC5AC cells. CONCLUSION: IL-31 and IL-31RA are upregulated in patients with allergic rhinitis, and induce MUC5AC gene expression in human airway epithelial cells. These findings suggest that IL-31 plays an important role in mucus overproduction in nasal allergic inflammation.

Pathogenesis of chronic rhinosinusitis with nasal polyp and a prominent T2 endotype.

Chronic rhinosinusitis is a heterogenous and multifactorial disease, characterized by persistent inflammation of the nose and paranasal sinuses, which causes nasal obstruction, nasal discharge, facial pain, and smell disturbance. Chronic rhinosinusitis is divided into two phenotypes: chronic rhinosinusitis with nasal polyp and chronic rhinosinusitis without nasal polyp. Nasal polyps can be associated with many inflammatory cells including eosinophil cells, neutrophil cells, plasma cells, and lymphocytes. T2 endotype is characterized by the type-2 immune response and nasal polyps are associated with eosinophilic dominant infiltration. In contrast, in the T1 and T3 endotypes, chronic rhinosinusitis can be associated with neutrophilic dominant infiltration. In addition, there are mixed types of inflammation with different proportions of eosinophils-neutrophils in chronic rhinosinusitis. In the T2 endotype, there is an increase in the production of Th2 cytokines, including interleukin-4, interleukin-5, and interleukin-13, high levels of immunoglobulin-E in polyp tissue, and eosinophilia. Stimulation of Th2 cells, type-2 innate lymphoid cells, epithelial cell damage, Staphylococcus aureus enterotoxins, and autoimmune antibodies have important roles in the enhancement of Th2 cytokines and pathogenesis of chronic rhinosinusitis with nasal polyp. Monoclonal antibodies target type-2 inflammation, decrease nasal polyp size, and improve the clinical symptoms of CRSwNP patients. The present review will focus on factors involved in the pathogenesis of chronic rhinosinusitis and its treatment.

The attitude and knowledge of pediatricians and family physicians toward COVID-19 vaccination in children: A cross-sectional study.

COVID-19 vaccines to children are expected to reduce the transmission of the disease to high-risk groups and achieve herd immunity in younger populations. A positive attitude toward COVID-19 vaccination in children among healthcare workers (HCWs) is predicted to reduce parents' hesitancy to vaccinate their children. This study aimed to assess the knowledge and attitude of pediatricians and family physicians toward COVID-19 vaccination in children. A total of 112 pediatricians and 96 family physicians (specialists and residents) were interviewed to assess the level of knowledge, attitude, and perceived safety of COVID-19 vaccines for children. Physicians willing to receive regular COVID-19 vaccination (analogous to the influenza vaccine) had significantly higher knowledge and attitude scores (P < .05). Multivariate analysis indicated that a higher knowledge score and having at least five years of experience as a specialist were significantly associated with a positive attitude among pediatricians or family physicians (P < .05). Pfizer/BioNTech was the preferred COVID-19 vaccine in children among physicians of both groups (>67%). Around 71% of physicians believed COVID-19 vaccines for children do not cause or worsen any health condition. Educational and training programs that increase the knowledge of physicians about COVID-19 vaccines and their safety in children are recommended to inform a more positive attitude.

Hemofiltration as an Alternative for IL-6 Inhibitors in COVID-19 Cytokines Storm Associated with Underlaying Bacterial Infections: A Review Article.

SARS-CoV-2 causes mostly mild cases. However, a considerable number of patients develop fatal acute respiratory distress syndrome due to the cytokine storm and imbalanced immune response. Several therapies depending on immunomodulation have been used, including glucocorticoids and IL-6 blockers. However, their efficacy is not perfect with all patients and patients with concomitant bacterial infections and sepsis. Accordingly, studies on different immunomodulators, including extracorporeal techniques, are crucial to save this category of patients. In this review, we overviewed the different immunomodulation techniques shortly, with a brief review of extracorporeal methods.