Postprandial hypoglycemia caused by the combination of clarithromycin and rifampicin in a patient with nontuberculous mycobacterial pulmonary disease.

Most cases of nontuberculous mycobacterial pulmonary disease (NTM-PD) have a progressive clinical course, and initiation of treatment is recommended rather than watchful waiting. The NTM-PD medications are frequently associated with adverse reactions, occasionally serious. Optimization of the methods for monitoring and managing adverse events in NTM-PD treatment is thus an important medical issue. Here we report a first case of postprandial hypoglycemia caused by the combination of clarithromycin (CAM) and rifampicin (RFP) in a patient with NTM-PD. A 73-year-old Japanese woman with NTM-PD was hospitalized for treatment with a combination of oral CAM, RFP, and ethambutol. She took the first doses of antibiotics before breakfast, and 3 h later went into a hypoglycemic state. Postprandial hypoglycemia occurred with high reproducibility and was accompanied by relative insulin excess. Continuous glucose monitoring with or without food and in combination with various patterns of medication revealed that the combination of CAM and RFP specifically induced postprandial hypoglycemia. Shifting the timing of administration of the CAM and RFP combination from morning to before sleep corrected the hypoglycemia and enabled continuation of the antimicrobial treatment. In conclusion, our report suggests the importance of introducing NTM-PD medication under inpatient management in order to closely monitor and early detect postprandial hypoglycemia and other serious adverse events.

Guided growth for coronal lower limb deformities in skeletal dysplasia.

Coronal angular deformities of the lower limbs are common in young children with skeletal dysplasia . The guided growth technique has been applied to correct deformities in children, but there are few comprehensive reports on the effectiveness of the procedure in skeletal dysplasia. We reviewed 44 limbs of 22 patients with various types of skeletal dysplasias who underwent guided growth surgery. Fifteen varus and 29 valgus limbs were treated with 102 epiphysiodesis. The average age at surgery, at implant removal, and at the latest examination was 10.4 ± 3.6 years, 11.8 ± 3.7 years and 14.1 ± 4.4 years, respectively. The mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (mMPTA), lateral distal tibial angle (mLDTA) and mechanical axis deviation (MAD) were measured from standing anteroposterior radiographs of both lower limbs. The mLDTA, mMPTA and MAD were successfully improved after surgery. Moderate or severe deformities were observed in 100% of the varus and 83% of the valgus limbs preoperatively, whereas only 14% of the varus and 20% of the valgus limbs had residual deformities at the latest examination. Correction of deformities was limited in some older children. Fifteen limbs (34%) required repeated implantations due to recurrence or inverted deformity. The guided growth surgery is effective in correcting coronal angular deformities in children with skeletal dysplasia with a limited risk of complications. The timing of surgery and implant removal is critical in obtaining satisfactory correction and preventing recurrence or inverted deformities.

Two children with hypophosphatasia with a heterozygous c.1559delT variant in the ALPL gene, the most common variant in Japanese populations.

Hypophosphatasia (HPP), a genetic disorder characterized by decreased tissue-nonspecific alkaline phosphatase (TNSALP) activity, is caused by loss-of-function mutations in the ALPL gene, which encodes TNSALP. The most frequent pathogenic variant in Japanese patients with HPP is a frameshift mutation in the ALPL gene, c.1559delT, and its carrier frequency is reported to be one in 480 in the Japanese population. We report the cases of two Japanese children with HPP who had a heterozygous c.1559delT variant in the ALPL gene. One case (involving a neonate) exhibited respiratory insufficiency associated with vitamin B6 dependent convulsions, significant defective mineralization similar to the severe form of HPP, and extremely low ALP activity. Enzyme replacement therapy (ERT) using asfotase alfa promptly improved her respiratory insufficiency, bone mineralization, and maintained her motor development during infancy. The second case involved a 10-year-old boy who demonstrated diffuse musculoskeletal pain and weakness that progressively disturbed mobility. Although he showed no bony lesions, the clinical symptoms and biochemical abnormalities were compatible with childhood HPP. ERT successfully relieved the severe generalized pain and significantly improved motor function.

Health literacy as a key to improving weight status among Palestinian adolescents living in chronic conflict conditions: a cross-sectional study.

OBJECTIVE: To examine the moderating role of health literacy in the association between direct exposure to violence and weight status among Palestinian adolescents. DESIGN: A household cross-sectional study conducted in 2017. SETTING: A Palestinian district of the West Bank. PARTICIPANTS: Palestinian adolescents aged 11-16 years. RESULTS: After excluding underweight adolescents from the 1200 who were initially recruited, the data of 1173 adolescents were analysed. A high proportion (62%) of adolescents were directly exposed to violence. The prevalence of obesity and overweight was 6.5% and 17.1%, respectively. The odds of obesity and overweight were 2.8 and 1.8 times higher among adolescents who were not exposed to domestic and school violence when they had low health literacy in the communication subscale. The odds of obesity were 62% and 57% lower among adolescents with high functional health literacy when exposed to domestic and school violence and to any form of violence, respectively. Among adolescents who were not exposed to any form of violence, those who had high health literacy in the communication subscale were 72% less likely to be obese compared with those who had low health literacy. CONCLUSIONS: Health literacy moderated the association between direct exposure to violence and weight status. When health literacy levels were higher, lower obesity rates were observed among adolescents who were directly exposed to any form of violence or exposed either to political violence only or domestic and school violence only. The results warrant further investigation of the role of health literacy in adolescent health. It is recommended that policy-makers integrate the health literacy concept into both education and health systems.

Prognostic factors for mobility in children with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a connective tissue disorder characterized by bone fragility. Although the disease severity is known to influence the ability to walk, little is known about how children with severe OI can achieve practical ambulation (PA). This study aimed to determine the early predictors of future mobility in children with OI. Thirty OI patients with an average age of 12.1 years were classified into the PA group (22 patients) and nonambulator group (NA group: 8 patients) on the basis of the Hoffer classification. Various clinical parameters related to mobility were compared between the PA and NA groups. Therapeutic interventions were also compared between the 2 groups. The mean age at diagnosis and initial fracture were significantly lower in the NA group than in the PA group. The height was significantly smaller in the NA group than in the PA group at all ages examined (at birth, 3 years, and 6 years). The number of patients with respiratory failure was significantly higher in the NA group than in the PA group. The age at initial corrective osteotomy of the lower extremities in the PA group was significantly lower than that in the NA group, although there was no significant difference in the disease severity in infancy between the groups. Height during infancy, age at initial fracture, and neonatal respiratory status could be prognostic factors for mobility in OI. Surgical interventions at an early age may influence walking ability in children with moderate OI.

Appropriate Surgical Timing of Salter Innominate Osteotomy for Residual Acetabular Dysplasia in Children.

BACKGROUND: Salter innominate osteotomy (SIO) provides favorable results for treating residual acetabular dysplasia in young children. In this study, we examined the midterm results of SIO according to the age at surgery to determine the optimal timing of this procedure. METHODS: We retrospectively examined 50 hips of 42 patients (8 boys and 34 girls) with acetabular dysplasia who underwent SIO and were followed up until skeletal maturity. The center-edge angle (CEA) was measured based on the anteroposterior radiographs of the hip obtained before surgery, 5 weeks after surgery, and at the latest follow-up. Severin classification was evaluated at the latest follow-up. Patients were categorized into 3 groups according to age at surgery: younger than 7 years of age (group A), 7 to 8 years of age (group B), and 9 years of age or older (group C). RESULTS: The mean preoperative CEA level of 0.9 degrees improved to 17.1 degrees postoperatively, which was increased to 28.1 degrees at the latest examination. Overall, 45 hips (90%) were classified as Severin I or II, with 96% in group A, 94% in group B, and 57% in group C. In group C, postoperative acetabular coverage was similar to that in the other groups (16.6 degrees in group A, 14.8 degrees in group B, and 18.1 degrees in group C), although the final outcome was unsatisfactory. The average improvement in CEA from postoperative to skeletal maturity was significantly smaller in group C than in the other groups (12.7 degrees in group A, 11.3 degrees in group B, and 3.0 degrees in group C). CONCLUSIONS: SIO showed favorable outcomes with satisfactory acetabular coverage at skeletal maturity. However, satisfactory acetabular coverage could not be obtained in some older patients because of limited postoperative remodeling capacity and smaller secondary improvement of CEA. We recommend that SIO should be performed in patients aged 8 years or younger. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

A case of Gross E esophageal atresia discovered following a unique clinical course.

The patient was a 15 months-old boy who had been diagnosed CHARGE syndrome, which is a multiple congenital anomaly syndrome caused by mutations in the CHD7 gene. Mechanical ventilation management was initiated 2 hours after birth for dysphagia and respiratory failure, and tracheotomy was performed 3 months after birth for dysphagia and failed extubation. He was repeatedly hospitalized due to pneuomoniae. Approximately 1 year after birth, the boy had two consecutive episodes of sudden ventilatory insufficiency while replacing the tracheotomy cannula. A bronchoscopic examination under general anesthesia revealed a tracheoesophageal fistula directly below the tracheostomy. The patient was diagnosed with Gross E esophageal atresia, and we speculated that the cannula migrated to the esophagus via the fistula during tracheostomy cannula replacement. Gross E esophageal atresia is a rare disease. Its diagnosis is often delayed, and it is discovered by recurrent pneumonia in many cases. A tracheoesophageal fistula may also be found in children with deformities of the respiratory system. Furthermore, tracheoesophageal fistulae are often found in the neck. Therefore, when sudden ventilatory insufficiency occurs in a child with a tracheostomy after replacing the tracheostomy cannula, caution must be exercised since the cannula may have migrated to the esophagus via a fistula. J. Med. Invest. 69 : 141-144, February, 2022.

Prevalence and characteristics of Palestine refugee mothers at risk of postpartum depression in Amman, Jordan: a cross-sectional study.

BACKGROUND: Postpartum depression (PPD) is a major public health concern because it adversely affects maternal health and children's physical and mental development. The prevalence of PPD in Arab countries is higher than the worldwide prevalence. Additionally, refugee women are more likely to develop PPD than women in the general population, but little research of refugee women in Arab countries is available. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) have provided primary health care to Palestine refugees since 1950 and began the Mental Health and Psychosocial (MHPSS) programme in Jordan in 2017 to enhance the psychosocial and social wellbeing of Palestine refugees. We assessed the prevalence of PPD and examined associated factors among Palestine refugee women living in Amman, Jordan. METHODS: This cross-sectional descriptive study was done between April 21 and May 21, 2018. Eligible participants were Palestine refugee mothers who had given birth 3-16 weeks previously and were attending any of five UNRWA health centres in Amman that were launching the MHPSS programme. Data were gathered in face-to-face structured interviews that included the Edinburgh Postpartum Depression Scale (EPDS) to assess PPD, the Maternal Social Support Scale to assess levels of perceived social support, and a structured questionnaire about sociodemographic, obstetric or paediatric, psychological, and social factors. Participants with scores greater than 12 in the EPDS were classified as having depressive symptoms. Logistic regression was used to identify factors associated with depressive symptoms. The study protocol was approved by the Department of Health, UNRWA Headquarters, Amman, Jordan, and Nagasaki University. Each participant provided written informed consent. FINDINGS: 251 women participated in the study, with a mean age of 27·2 years (range 18-42, SD 5·43). 123 (49%) women were classified as having PPD. Logistic regression showed that factors associated with PPD were perceived low levels of social support (adjusted odds ratio 3·76, 95% CI 1·92-10·93) and experiencing stressful life events (one event 3·92, 1·51-9·91; two events 5·77, 2·33-14·27; and three or more events 14·8, 5·23-41·89). INTERPRETATION: The prevalence of PPD among Palestine refugee women in Amman was higher than that reported in a previous study of the general childbearing population (women aged 18-45 years) in Irbid in Jordan (22%, Mohammad et al. Midwifery 2011; 27: e238-45) but similar to findings in the West Bank (47%, Quandil et al. BMC Pregnancy Childbirth 2016; 16: 375) and in Syrian refugee women in Jordan (49·6%, Mohammad et al. Res Nurs Health 2011; 41: 519-245). Our findings highlight the need to address this disorder in Palestine refugee mothers. Periodical PPD screening, raising awareness about PPD, providing information to husbands and families, and building a support system for mothers could alleviate the risk of PPD. Future studies should examine whether factors of antenatal depression, which were not assessed in this study, correlate with having PPD to clarify the need for early intervention in mothers. FUNDING: Nagasaki University.

Morbidity patterns among hospitalised Palestine refugees from Syria in Jordan: a population-based study.

BACKGROUND: Palestine refugees from Syria (PRS) are among the most vulnerable refugee groups for adverse health outcomes and require assistance from humanitarian agencies. As the armed conflict in Syria has continued, most Palestinians have been displaced from that country to neighbouring countries, where they have experienced difficulties in accessing essential services. More than 17 000 PRS are in Jordan as of 2018 and have received assistance from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), including free primary care and subsidised secondary and tertiary care through contracted governmental hospitals. In this study, we investigated the morbidity patterns among PRS in Jordan receiving UNRWA-supported hospital care. METHODS: We assessed cross-sectional data extracted from the UNRWA Hospitalization Database in Jordan on Oct 18, 2018, for PRS who used UNRWA hospitalisation support between May 31, 2012, and Dec 9, 2017. The database records demographic and medical characteristics of patients and financial information for the care sought. We used descriptive statistics to reveal morbidity patterns. Analyses were done with Microsoft Excel 2016 and Stata/IC (version 15). No ethics approval was required for this study as it was conducted as a part of routine internal monitoring by UNRWA. FINDINGS: 889 PRS were included in analysis, among whom 637 (72%) were girls or women and 252 (28%) were boys or men. The age range was 1-78 years, with girls and women being younger than boys and men (28·1 years [SD 15·1] vs 31·0 years [SD 21·3], p=0·02). The most common reasons for seeking care were pregnancy, childbirth, and the puerperium (381 [60%] of 637 girls and women). Diseases of the circulatory system, digestive system, and musculoskeletal system and connective tissue were the most common diagnoses among boys and men (34 cases [14%] of 252 for each diagnosis). The mean length of stay for women (1·8 days [SD 2·0]) was slightly shorter than that for men (2·0 days [SD 2·2]) but the difference was not significant. The cost was significantly higher for boys and men (mean US$729·7 [SD 557·4] per person) than for girls and women ($326·0 [SD 1190·4], p<0·001). Of all, 886 (>99%) patients were discharged from hospital, two died, and one was transferred to another hospital. INTERPRETATION: More girls and women than boys and men sought care through the UNRWA support programme during the study period, mostly for pregnancy, childbirth, and the puerperium. However, the conditions seen in boys and men led to longer stays in hospitals and significantly higher costs. Diagnoses based on International Classification of Diseases standards should be investigated further, but this study highlights the demand for health-care services and types of care required by the PRS population. Future research should focus on identifying similarities and differences in hospital admissions for PRS compared with other Palestine refugees to inform future preventive public health efforts by UNRWA. The study examined PRS who accessed to UNRWA services only, thus the findings are not representative of PRS in general. However, this is to our knowledge the first study to present morbidity patters and differences in female and male PRS patients receiving care at UNRWA in Jordan. FUNDING: None.

Docking phenomenon and subsequent acetabular development after gradual reduction using overhead traction for developmental dysplasia of the hip over six months of age.

PURPOSE: This study aimed to explore the docking of the femoral head into the acetabulum after gradual reduction (GR) using traction for developmental dysplasia of the hip (DDH) and the impact on subsequent acetabular development. METHODS: A total of 40 patients with DDH (42 hips) undergoing GR using overhead traction and spica casting were retrospectively reviewed. The presence of inverted labrum and the coronal and axial femoral-acetabular distances (FADs) were compared between MRI immediately and five weeks after spica casting. The change in the acetabular index on anteroposterior pelvic radiographs were compared between hips with inverted labrum (residual group) and with normally-shaped labrum (normalized group) on follow-up MRI. RESULTS: The mean age at reduction was 13.1 months (7 to 33) and the mean follow-up duration was 7.7 years (4 to 11). The rate of inverted labrum and the FADs significantly decreased between the MRI scans (all p-values < 0.001), and previous Pavlik harness failure had no negative effect on these decreases. The acetabular indices at the ages of three and five years in the residual group were significantly larger than those in the normalized group (both p-values < 0.001). Residual acetabular dysplasia was seen in 84.2% of the residual group compared with 34.8% of the normalized group (p = 0.002). CONCLUSION: The docking phenomenon can occur during spica casting following GR using traction in children with DDH between the ages of six months and three years. The remaining inverted labrum at the cast removal may negatively affect subsequent acetabular development. LEVEL OF EVIDENCE: III - retrospective comparative study.

Exploring health literacy and its associated factors among Palestinian university students: a cross-sectional study.

Health literacy plays an important role in personal and community health. Since university is a turning point when young adults begin to take responsibility for their own health, understanding university students' health literacy levels is crucial. To this end, we aimed to explore health literacy and its associated factors among Palestinian university students. We conducted a cross-sectional study at Birzeit University in the Ramallah district. We recruited 472 students using convenience sampling at six on-campus cafeterias. The 44-item Arabic version of the Health Literacy Questionnaire was used to measure students' health literacy levels, while a locally developed distress scale was used to measure students' distress levels. We stratified the multiple regression model for the health literacy score by gender. Students' average total health literacy score was 135.3 (SD 20.9), with male students scoring significantly higher than female students. A higher health literacy score was significantly associated with having a father with a higher level of education, a higher frequency of medical checkups, higher self-reported health status, and consulting a higher number of sources for health-related information. High distress levels were associated with lower levels of health literacy, especially among female students. This study provides the first evidence on Palestinian university students' health literacy levels. Tailored health education and promotion are required for students with low parental education and moderate to high distress. Future research is required to explain the gender differences in health literacy and distress among university students.

Dissemination and implementation of the e-MCHHandbook, UNRWA's newly released maternal and child health mobile application: a cross-sectional study.

OBJECTIVES: In April 2017, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) released the electronic Maternal andChildHealth Handbook, the e-MCH Handbook application. One of the first mobile health (m-Health) interventions in a refugee setting, the application gives pregnant women and mothers access to educational information and health records on smartphones. This study investigated factors associated with the dissemination and implementation of m-Health in the refugee setting. SETTING AND PARTICIPANTS: A cross-sectional study was conducted in 9 of 25 UNRWA health centres for Palestine refugees in Jordan. Self-administered questionnaires were distributed for 1 week to pregnant women and mothers with children aged 0-5 years. OUTCOME MEASURES: The outcomes were whether participants knew about, downloaded or used the application. Multiple regression analyses were conducted to determine factors associated with application download and usage. RESULTS: 1042 participants were included in the analysis. 979 (95.5%) had a mobile phone and 862 (86.9%) had a smartphone. 499 (51.3%) knew about, 235 (23.8%) downloaded and 172 (17.4%) used the application. Having other mobile applications (OR 6.17, p<0.01), staff knowledge of the application (OR 11.82, p<0.01), using the internet as a source of medical information (OR 1.63, p=0.01) and having internet access at home (OR 1.46, p=0.05) were associated with application download. The age of the husband was associated with application usage (OR 1.04, p=0.11). CONCLUSIONS: Though m-Health may be a promising means of promoting health in refugees, multiple barriers may exist to its dissemination and implementation. Those who regularly use mobile applications and get medical information from the internet are potential targets of m-Health dissemination. For successful implementation of a m-Health intervention, health staff should have thorough knowledge of the application and users should have access to the internet. Husband-related factors may also play a role.

Delivering and evaluating a scalable training model for strengthening family medicine in resource-limited environments: the Gaza experience. A mixed-methods evaluation.

BACKGROUND: Since 2007, Gaza Palestine has been subject to blockade affecting over 1.9 million people. This denies health professionals access to continuing professional development (CPD). In Gaza, family physicians are scarce, and their level of training does not meet the needs of United Nations Relief and Works Agency's (UNRWA) Family Health Team (FHT) model for better population health. AIM: This study sought to develop a postgraduate training programme for Gazan doctors via a Diploma in Family Medicine (FM PG), and evaluate its impact on physicians and patients. DESIGN & SETTING: A mixed-methods evaluation of a postgraduate diploma in Gaza Palestine. METHOD: The programme was delivered over 1 year, to 15 primary care doctors. The impact was evaluated through focus group discussions and patient feedback questionnaire survey comparing FM PG graduate doctors and doctors without the FM PG Diploma. RESULTS: All participating doctors graduated successfully and found the experience extremely positive. Trainees felt that the Diploma helped them take more individualised approach to patients; have a better understanding of psychosocial elements affecting patient health; feel more inclined towards team-working and collaborative approaches to health care; and more insight into non-verbal communication such as active listening and tactile gestures. Statistical analysis of patients' feedback showed significantly improved patient-reported outcomes and satisfaction when treated by course diplomates compared to non-diplomates. CONCLUSION: Where there are limited training opportunities, investment in a structured postgraduate diploma training programme can improve quality of health service delivery. UNRWA's experience in Gaza demonstrates the value of a scalable model in resource-limited settings.

Assessment of mental health and psycho-social support pilot program's effect on intended stigmatizing behavior at the Saftawi Health Center, Gaza: a cross-sectional study.

Background: In the midst of a global refugee crisis, addressing mental health is critical for refugee health care delivery. Understanding efficacy of mental health interventions is more important than ever. Aims: In this study, we aim to assess the efficacy of comprehensive mental health and psychosocial support services for refugees in Gaza by comparing intended stigmatizing behavior toward mental health disorders between two health centers (HCs)(Saftawi and Nasser). Methods: One year after these services by the United Nations Relief and Works Agency (UNRWA) for Palestine Refugees in the Near East were implemented at Saftawi HC, a randomly selected sample of HC patrons (n = 205) from Saftawi, and a comparable number from a control HC (n = 203 at Nasser) completed the Reported and Intended Behavior Scale (RIBS) regarding stigma towards mental illnesses. Multivariable linear regressions were used to determine the impact of these services in the HC on attitudes against mental health. Results: Saftawi respondents endorsed significantly less intended stigmatizing behavior compared to Nasser respondents (p < 0.001). Multivariable analysis demonstrated significantly less intended stigmatizing behavior at Saftawi compared to Nasser (p < 0.01) while controlling for demographic covariables. Conclusions: UNRWA primary care services and education implemented for refugees in Gaza was associated with reduced stigmatizing behavior toward mental health, which can help guide efficacious mental health care interventions within the Palestine refugee community and in other simiilar communities.

Three species of Dendromonocotyle Hargis, 1955 (Monogenea: Monocotylidae) collected from Japanese rays.

Eighteen species of Dendromonocotyle Hargis, 1955 (Monogenea: Monocotylidae) have so far been described from elasmobranchs worldwide. In this paper, two new species are described; Dendromonocotyle tsutsumii n. sp. from the skin of the Japanese eagle ray, Myliobatis tobijei Bleeker from Tokyo Bay and the pitted stingray, Dasyatis matsubarai Miyosi, from Ooarai, Ibaraki Prefecture, Japan, and Dendromonocotyle fukushimaensis n. sp. from the skin of the cow stingray, Dasyatis ushiei (Jordan & Hubbs) reared at an aquarium in Fukushima Prefecture, Japan. Dendromonocotyle tsutsumii is distinguished from the congeners by the presence of a sclerotised duct connecting the vagina with the seminal receptacle, and De. fukushimaensis by the large body size and the presence of a donut-shaped structure encircling the male copulatory organ near its distal end. Additionally, the reproductive system of Dendromonocotyle akajeii Ho & Perkins, 1980 is redescribed, based on specimens from the skin of the whip stingray, Hemitrygon akajei (Müller & Henle) (syn. Dasyatis akajei) caught in Hamana Lake, Shizuoka Prefecture, Japan. A key to the 20 species of Dendromonocotyle including the present new species is provided.

Preoperative weight loss program involving a 20-day very low-calorie diet for obesity before laparoscopic gastrectomy for gastric cancer.

INTRODUCTION: The increased visceral fat in patients with obesity can increase the technical difficulty of surgery. This study was performed to evaluate a preoperative 20-day very low-calorie diet for obesity before laparoscopic gastrectomy for gastric cancer. METHODS: This prospective single-center study involved patients with obesity who were planning to undergo laparoscopic gastrectomy for gastric cancer. Obesity was defined according to the Japanese criteria: BMI ≥25 kg/m2 or waist circumference ≥85 cm in men and ≥90 cm in women. The patients underwent a preoperative 20-day very low-calorie diet and received nutritional counseling. Weight loss, body composition, visceral fat mass, and operative outcomes were evaluated. RESULTS: Thirty-three patients were enrolled from September 2013 to August 2015. Their median age was 71 years, and 78.8% were men. Their median bodyweight and BMI were 72.3 kg (range, 53.8-82.5 kg) and 26.0 kg/m2 (range, 23.5-31.0 kg/m2 ), respectively. The patients achieved a mean weight loss of 4.5% (95% confidence interval [CI]: 3.8-5.1), corresponding to 3.2 kg (95%CI: 2.7-3.7 kg). Body fat mass was significantly decreased by a mean of 2.5 kg (95%CI: 1.9-3.1), whereas skeletal muscle mass was unaffected (mean: -0.20 kg [95%CI: -0.55-0.15]). The visceral fat mass reduction rate was high as 16.8% (range, 11.6%-22.0%). All patients underwent laparoscopic gastrectomy as planned. Severe postoperative morbidity (Clavien-Dindo grade ≥III) was seen in only one patient (3.0%). CONCLUSION: The preoperative 20-day very low-calorie diet weight loss program is promising for the treatment of obesity before laparoscopic gastrectomy for gastric cancer.

Health and dignity of Palestine refugees at stake: a need for international response to sustain crucial life services at UNRWA.

The UN Sustainable Development Goals affirm equality and dignity as essential to the enjoyment of basic human rights, including the right to the highest attainable standard of physical and mental health, which promotes global solidarity among all people, including refugees. The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has provided support to Palestine refugees in Jordan, Lebanon, Syria, the Gaza Strip, and the West Bank since the 1950s. Today, however, conflict and violence, occupation, high levels of poverty, and other social determinants of health jeopardize the wellbeing of Palestine refugees. Health concerns include non-communicable diseases, mental health conditions, and access to hospital care. Additionally, UNRWA is continuing to face a severe funding crisis. Using a historical and health policy perspective, this Health Policy examines UNRWA strategies that facilitate continuous provision of health-care services for Palestine refugees. Given the increasingly volatile environment faced by this population, a multifaceted international response is needed to enable UNRWA to deliver sustainable services to Palestine refugees and avert further loss of life, dignity, and hope, pending a just and lasting solution to their plight in accordance with applicable international law and UN General Assembly resolutions.

The Knowledge and Awareness for Radiocesium Food Monitoring after the Fukushima Daiichi Nuclear Accident in Nihonmatsu City, Fukushima Prefecture.

On 11 March 2011, Japan experienced a massive earthquake and tsunami that triggered the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident, resulting in the release of large amounts of cesium-134 and -137 into the atmosphere. In addition to the food radioactivity control in the markets throughout the country, radiocesium concentrations in locally grown foods were voluntarily inspected and the results were shown to the residents by the local government to raise their awareness of the internal radiation contamination risk from low knowledge in Nihonmatsu City, Fukushima Prefecture. In this longitudinal study, local food products for in-home consumption were evaluated by seven different food radioactivity measuring devices in Nihonmatsu City from 2011⁻2017. Radiocesium was detected in local foods in Nihonmatsu City even six years after the FDNPP accident. The highest number of products tested was in 2012, with the number steadily decreasing thereafter. Most foods had contamination levels that were within the provisional regulation limits. As edible wild plants and mushrooms continue to possess high radiocesium concentrations, new trends in radioactivity in foods like seeds were discovered. This study highlights that the increased risk of radiation exposure could possibly be due to declining radiation awareness among citizens and food distributors. We recommend the continuation of food monitoring procedures at various points in the food processing line under the responsibility of the government to raise awareness for the reduction of future risks of internal exposure.

Early radiographic risk factors for rigid relapse in idiopathic clubfoot treated with the Ponseti method.

BACKGROUND: This study aimed at identifying early risk factors for rigid relapse in idiopathic clubfoot using foot radiographs. METHODS: Thirty-four patients with 43 idiopathic clubfeet treated with the Ponseti method were retrospectively reviewed. RESULTS: There were seven rigid relapse recalcitrant to manipulation and requiring extensive soft-tissue release. Three radiograabphic measurements on the maximum dorsiflexion lateral (MD-Lat) radiograph, talocalcaneal (TaloCalc-Lat), tibiocalcaneal (TibCalc-Lat), and calcaneus-first metatarsal (CalcMT1-Lat) angles, showed significant differences between patients with and without rigid relapse. The TaloCalc-Lat and CalcMT1-Lat angles showed significant hazard ratio for rigid relapse by multivariate survival analysis. Clubfeet demonstrating TibCalc-Lat>90° and CalcMT1-Lat<5° have a 24.9-fold odds ratio to develop rigid relapse compared to those demonstrating TibCalc-Lat≤90° or CalcMT1-Lat≥5°. CONCLUSIONS: The TaloCalc-Lat, TibCalc-Lat, and CalcMT1-Lat angles on the MD-Lat radiograph immediately before the tenotomy, probably representing intrinsic tightness of the midfoot and/or hindfoot, are significant risk factors for rigid relapse in patients treated with the Ponseti method.