A Case of Poorly Differentiated Synovial Sarcoma Arising in a Nasal Cavity Radiation Field: An Unusual Tumor in an Unusual Location.

Synovial sarcomas are high-grade soft tissue sarcomas of primitive mesenchymal origin which are defined by a pathognomonic t(X;18)(p11,q11) translocation, and which occur in pediatric and adult populations. Herein we report a case of a 33-year-old female with a history of nasopharyngeal carcinoma status post radiotherapy, presenting with a poorly differentiated synovial sarcoma of the nasal cavity arising in the radiation field. While the development of radiation-associated sarcoma is a known complication of radiotherapy, to date only 10 cases of synovial sarcoma have been reported to occur in previously irradiated tissues. Moreover, only 1 case of poorly differentiated synovial sarcoma involving the nasopharynx has been described.

Relation of masking policy to COVID-19 positivity rate in Texas school districts.

Understanding of the impact of masking in schools to prevent COVID transmission is limited since much of the data considers factors in addition to masking. We collected data from 30 school districts in Texas, contrasting districts where masks were mandated with those where masks were optional. Results showed that mandatory masking was associated with a reduction in COVID-19 positivity among student populations, but not in staff populations.

When Harry Met Sally: Older Adult Spouses' First Encounter Reminiscing and Well-Being.

BACKGROUND AND OBJECTIVES: Interest in reminiscence activities for older adults has grown in recent years, but the benefits of co-reminiscence are not well-known. Drawing from a narrative identity framework, this study examined older adult spouses' co-reminiscence about their first encounters. We hypothesized that perceived closeness and support increase when spouses co-reminisce and that greater perceptions of closeness and support after reminiscing relate to lower depressive symptoms and greater marital satisfaction in daily life. RESEARCH DESIGN AND METHODS: One hundred and one couples completed questionnaires measuring marital satisfaction and depressive symptoms at home and then participated in a laboratory session in which they co-reminisced about their first encounters. Self-reported perceived support and relationship closeness were obtained before and after reminiscence. t Tests and the Actor Partner Interdependence Model were used to examine hypotheses. RESULTS: As hypothesized, closeness and perceived support increased from pre- to postreminiscence for husbands and wives. In addition, one's own relationship closeness after reminiscence was positively associated with own marital satisfaction (actor effect). One's perceived support after reminiscence was positively related to spouse's marital satisfaction and negatively associated with their spouse's depressive symptoms (partner effects). DISCUSSION AND IMPLICATIONS: Findings suggest that co-reminiscence about early relationship development can boost feelings of closeness and support for older adults. Benefiting from co-reminiscence in this way also appears to indicate broader relationship and individual well-being. Brief co-reminiscence activities may nurture late-life relational well-being.

Vitamin D, vitamin D-binding protein, free vitamin D and COVID-19 mortality in hospitalized patients.

BACKGROUND: Vitamin D deficiency has been associated with worse coronavirus disease 2019 (COVID-19) outcomes, but circulating 25-hydroxyvitamin D [25(OH)D] is largely bound to vitamin D-binding protein (DBP) or albumin, both of which tend to fall in illness, making the 25(OH)D status hard to interpret. Because of this, measurements of unbound ("free") and albumin-bound ("bioavailable") 25(OH)D have been proposed. OBJECTIVES: We aimed to examine the relationship between vitamin D status and mortality from COVID-19. METHODS: In this observational study conducted in Liverpool, UK, hospitalized COVID-19 patients with surplus sera available for 25(OH)D analysis were studied. Clinical data, including age, ethnicity, and comorbidities, were extracted from case notes. Serum 25(OH)D, DBP, and albumin concentrations were measured. Free and bioavailable 25(OH)D were calculated. Relationships between total, free, and bioavailable 25(OH)D and 28-day mortality were analyzed by logistic regression. RESULTS: There were 472 patients with COVID-19 included, of whom 112 (23.7%) died within 28 days. Nonsurvivors were older (mean age, 73 years; range, 34-98 years) than survivors (mean age, 65 years; range, 19-95 years; P = 0.003) and were more likely to be male (67%; P = 0.02). The frequency of vitamin D deficiency [25(OH)D < 50 nmol/L] was similar between nonsurvivors (71/112; 63.4%) and survivors (204/360; 56.7%; P = 0.15) but, after adjustments for age, sex, and comorbidities, increased odds for mortality were present in those with severe deficiency [25(OH)D < 25 nmol/L: OR, 2.37; 95% CI, 1.17-4.78] or a high 25(OH)D (≥100 nmol/L; OR, 4.65; 95% CI, 1.51-14.34) compared with a 25(OH)D value of 50-74 nmol/L (reference). Serum DBP levels were not associated with mortality after adjustments for 25(OH)D, age, sex, and comorbidities. Neither free nor bioavailable 25(OH)D values were associated with mortality. CONCLUSIONS: Vitamin D deficiency, as commonly defined by serum 25(OH)D levels (<50 nmol/L), is not associated with increased mortality from COVID-19, but extremely low (<25 nmol/L) and high (>100 nmol/L) levels may be associated with mortality risks. Neither free nor bioavailable 25(OH)D values are associated with mortality risk. The study protocol was approved by the London-Surrey Research Ethics Committee (20/HRA/2282).

Heat-stability study of various insulin types in tropical temperature conditions: New insights towards improving diabetes care.

Strict storage recommendations for insulin are difficult to follow in hot tropical regions and even more challenging in conflict and humanitarian emergency settings, adding an extra burden to the management of people with diabetes. According to pharmacopeia unopened insulin vials must be stored in a refrigerator (2-8°C), while storage at ambient temperature (25-30°C) is usually permitted for the 4-week usage period during treatment. In the present work we address a critical question towards improving diabetes care in resource poor settings, namely whether insulin is stable and retains biological activity in tropical temperatures during a 4-week treatment period. To answer this question, temperature fluctuations were measured in Dagahaley refugee camp (Northern Kenya) using log tag recorders. Oscillating temperatures between 25 and 37°C were observed. Insulin heat stability was assessed under these specific temperatures which were precisely reproduced in the laboratory. Different commercialized formulations of insulin were quantified weekly by high performance liquid chromatography and the results showed perfect conformity to pharmacopeia guidelines, thus confirming stability over the assessment period (four weeks). Monitoring the 3D-structure of the tested insulin by circular dichroism confirmed that insulin monomer conformation did not undergo significant modifications. The measure of insulin efficiency on insulin receptor (IR) and Akt phosphorylation in hepatic cells indicated that insulin bioactivity of the samples stored at oscillating temperature during the usage period is identical to that of the samples maintained at 2-8°C. Taken together, these results indicate that insulin can be stored at such oscillating ambient temperatures for the usual four-week period of use. This enables the barrier of cold storage during use to be removed, thereby opening up the perspective for easier management of diabetes in humanitarian contexts and resource poor settings.

SMS-based smartphone application for disease surveillance has doubled completeness and timeliness in a limited-resource setting - evaluation of a 15-week pilot program in Central African Republic (CAR).

BACKGROUND: It is a challenge in low-resource settings to ensure the availability of complete, timely disease surveillance information. Smartphone applications (apps) have the potential to enhance surveillance data transmission. METHODS: The Central African Republic (CAR) Ministry of Health and Médecins Sans Frontières (MSF) conducted a 15-week pilot project to test a disease surveillance app, Argus, for 20 conditions in 21 health centers in Mambéré Kadéi district (MK 2016). Results were compared to the usual paper-based surveillance in MK the year prior (MK 2015) and simultaneously in an adjacent health district, Nana-Mambére (NM 2016). Wilcoxon rank sum and Kaplan-Meier analyses compared report completeness and timeliness; the cost of the app, and users' perceptions of its usability were assessed. RESULTS: Two hundred seventy-one weekly reports sent by app identified 3403 cases and 63 deaths; 15 alerts identified 28 cases and 4 deaths. Median completeness (IQR) for MK 2016, 81% (81-86%), was significantly higher than in MK 2015 (31% (24-36%)), and NM 2016 (52% (48-57)) (p < 0.01). Median timeliness (IQR) for MK 2016, 50% (39-57%) was also higher than in MK 2015, 19% (19-24%), and NM 2016 29% (24-36%) (p < 0.01). Kaplan-Meier Survival Analysis showed a significant progressive reduction in the time taken to transmit reports over the 15-week period (p < 0.01). Users ranked the app's usability as greater than 4/5 on all dimensions. The total cost of the 15-week pilot project was US$40,575. It is estimated that to maintain the app in the 21 health facilities of MK will cost approximately US$18,800 in communication fees per year. CONCLUSIONS: The app-based data transmission system more than doubled the completeness and timeliness of disease surveillance reports. This simple, low-cost intervention may permit the early detection of disease outbreaks in similar low-resource settings elsewhere.

Myeloid Sarcoma of Orbits: Effectiveness of a Low-Dose Radiation Regimen.

Acute myeloid leukemia (AML) can present with extramedullary involvement known as myeloid sarcoma (MS). We present the case of a young woman who was diagnosed with AML and MS in bilateral orbits, brain, omentum, and retroperitoneum. She was treated with induction chemotherapy. Low-dose radiation was given to the orbits due to visual symptoms which resulted in complete response. The use of radiation therapy in orbital MS has not been studied extensively, and low dose may be adequate to achieve complete remission (CR) in selected patients.

A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon.

BACKGROUND: Patients with diabetes require knowledge and skills to self-manage their disease, a challenging aspect of treatment that is difficult to address in humanitarian settings. Due to the lack of literature and experience regarding diabetes self-management, education and support (DSMES) in refugee populations, Medecins Sans Frontieres (MSF) undertook a DSMES survey in a cohort of diabetes patients seen in their primary health care program in Lebanon. METHODS: Structured interviews were conducted with diabetes patients in three primary care clinics between January and February 2015. Scores (0-10) were calculated to measure diabetes core knowledge in each patient (the DSMES score). Awareness of long-term complications and educational preferences were also assessed. Analyses were conducted using Stata software, version 14.1 (StataCorp). Simple and multiple linear regression models were used to determine associations between various patient factors and the DSMES Score. RESULTS: A total of 292 patients were surveyed. Of these, 92% had type 2 diabetes and most (70%) had been diagnosed prior to the Syrian conflict. The mean DSMES score was 6/10. Having secondary education, previous diabetes education, a 'diabetes confidant', and insulin use were each associated with a higher DSMES Score. Lower scores were significantly more likely to be seen in participants with increasing age and in patients who were diagnosed during the Syrian conflict. Long-term complications of diabetes most commonly known by patients were vision related complications (68% of patients), foot ulcers (39%), and kidney failure (38%). When asked about the previous Ramadan, 56% of patients stated that they undertook a full fast, including patients with type 1 diabetes. Individual and group lessons were preferred by more patients than written, SMS, telephone or internet-based educational delivery models. CONCLUSIONS: DSMES should be patient and context appropriate. The variety and complexities of humanitarian settings provide particular challenges to its appropriate provision. Understanding patient baseline DSMES levels and needs provides a useful basis for humanitarian organizations seeking to provide diabetes care.

T-cell lymphoblastic leukemia/lymphoma: relapse 16 years after first remission.

Little information is available regarding late relapse in patients with T-lymphoblastic leukemia/lymphoma (T-LBL). Because of the aggressive nature of this disease, relapse is common and often happens early. Late relapses are rare and generally occur within a few years after initial remission. The relapse rate after 3 years has been reported to steadily decrease over time yet does not parallel with cure. We report a case of a 26-year-old female with T-LBL and relapse 16 years after her first remission with successful treatment with HyperCVAD and L-asparaginase.

Effect of an immunomodulator containing Mycobacterium w on sputum conversion in pulmonary tuberculosis.

Sputum conversion is an important milestone in the management of pulmonary tuberculosis. Early sputum conversion is desirable. A controlled study was done to improve sputum conversion rate of current short course chemotherapy using immunomodulator containing mycobacterium w. The immunomodulator is very potent and freely available. It shares antigens with Mycobacterium tuberculosis. In a randomised pattern 69 of 134 patients suffering from pulmonary tuberculosis received the immunomodulator intradermally every 15 days along with chemotherapy. The use of the immunomodulator results in preponement of sputum conversion. The sputum conversion rate obtained by chemotherapy at 60 days was achieved latest by 30 days when mycobacterium w containing immunomodulator was used as an adjuvant therapy. This was found irrespective of bacterial load (1 +, minimal or 3+, maximal) in sputum or category (fresh or retreatment) of disease. The therapy was well tolerated.