Racial and ethnic determinants of psoriatic arthritis phenotypes and disease activity.

OBJECTIVE: Individuals of racially and ethnically diverse backgrounds are underrepresented in psoriatic arthritis (PsA) research/clinical trials, despite evidence that their disease presentation, severity and course may be distinct. Here we aim to describe how race, ethnicity and other socioeconomic factors inform disease characteristics in PsA. METHODS: 817 consecutive patients with PsA from a large, diverse metropolitan area, were enrolled in an observational, longitudinal registry. Demographics, medical history, medication use, and psoriatic disease phenotype and activity were all recorded and analyzed. RESULTS: The population was 77.4% non-Hispanic White, 2.2% Black, 7.1% Asian, and 9.9% identified as other races or multiracial, and 11.8% identified as Hispanic. Hispanic and non-White individuals had higher tender joint counts (p= 0.033) with similar swollen joint counts (p= 0.308) and medication use (p= 0.171). They also had high rates of radiographic axial disease. Hispanic individuals were significantly more likely to have higher tender joint counts (p= 0.029), higher RAPID3 scores (p= 0.004), and moderate-severe psoriasis (p= 0.010) compared with non-Hispanic White individuals. CONCLUSION: In this diverse cohort, 22.6% of patients identified as underrepresented racial and/or ethnic groups, mostly Asian or Hispanic. Despite similar swollen joint counts and medication use, non-white individuals have higher tender joint counts compared with white individuals. Phenotypically, they also were more likely to have radiographic axial involvement. These findings may reflect differences in PsA presentation, experience and outcomes in individuals of various racial and ethnic groups, which need to be taken into consideration in clinical care and research design.

Promoting and supporting breastfeeding in a protracted emergency setting-Caregivers' and health workers' perceptions from North-East Nigeria.

Background: Breastfeeding (BF) should be protected, promoted, and supported for all infants in humanitarian settings. The re-establishment of exclusive BF is also a central part of the management of acutely malnourished infants under 6 months (<6 m). Médecins Sans Frontières (MSF) runs a nutrition project in Maiduguri, a protracted emergency setting in North-East Nigeria. This study aimed to explore caregivers' (CGs) and health workers' (HWs) perceptions of BF practice, promotion, and support among CGs with infants <6 m in this setting. Methods: We conducted a qualitative study using in-depth interviews and focus group discussions combined with non-participant observations. Participants included CGs of young infants enrolled in MSF nutritional programs or who attended health promotion activities in a displacement camp. MSF HWs were involved at different levels in BF promotion and support. Data were collected involving a local translator and analyzed using reflexive thematic analysis directly from audio recordings. Results: Participants described how feeding practices are shaped by family, community, and traditional beliefs. The perception of breastmilk insufficiency was common and led to early supplementary feeding with inexpensive but unsuitable products. Participants often linked insufficient breastmilk production with poor maternal nutrition and stress, in a context shaped by conflict and food insecurity. BF promotion was generally well received but could be improved if tailored to address specific barriers to exclusive BF. Interviewed CGs positively valued BF support received as part of the comprehensive treatment for infant malnutrition. One of the main challenges identified was the length of stay at the facility. Some participants perceived that improvements in BF were at risk of being lost after discharge if CGs lacked an enabling environment for BF. Conclusion: This study corroborates the strong influence of household and contextual factors on the practice, promotion, and support of BF. Despite identified challenges, the provision of BF support contributes to improvements in BF practice and was positively perceived by CGs in the studied setting. Greater attention should be directed toward providing support and follow-up for infants <6 m and their CGs in the community.

Low-Cost Sensors for Monitoring Coastal Climate Hazards: A Systematic Review and Meta-Analysis.

Unequivocal change in the climate system has put coastal regions around the world at increasing risk from climate-related hazards. Monitoring the coast is often difficult and expensive, resulting in sparse monitoring equipment lacking in sufficient temporal and spatial coverage. Thus, low-cost methods to monitor the coast at finer temporal and spatial resolution are imperative for climate resilience along the world's coasts. Exploiting such low-cost methods for the development of early warning support could be invaluable to coastal settlements. This paper aims to provide the most up-to-date low-cost techniques developed and used in the last decade for monitoring coastal hazards and their forcing agents via systematic review of the peer-reviewed literature in three scientific databases: Scopus, Web of Science and ScienceDirect. A total of 60 papers retrieved from these databases through the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol were analysed in detail to yield different categories of low-cost sensors. These sensors span the entire domain for monitoring coastal hazards, as they focus on monitoring coastal zone characteristics (e.g., topography), forcing agents (e.g., water levels), and the hazards themselves (e.g., coastal flooding). It was found from the meta-analysis of the retrieved papers that terrestrial photogrammetry, followed by aerial photogrammetry, was the most widely used technique for monitoring different coastal hazards, mainly coastal erosion and shoreline change. Different monitoring techniques are available to monitor the same hazard/forcing agent, for instance, unmanned aerial vehicles (UAVs), time-lapse cameras, and wireless sensor networks (WSNs) for monitoring coastal morphological changes such as beach erosion, creating opportunities to not only select but also combine different techniques to meet specific monitoring objectives. The sensors considered in this paper are useful for monitoring the most pressing challenges in coastal zones due to the changing climate. Such a review could be extended to encompass more sensors and variables in the future due to the systematic approach of this review. This study is the first to systematically review a wide range of low-cost sensors available for the monitoring of coastal zones in the context of changing climate and is expected to benefit coastal researchers and managers to choose suitable low-cost sensors to meet their desired objectives for the regular monitoring of the coast to increase climate resilience.

Ruptured angiomyolipoma, a novel entity for emergency physicians in the differential diagnosis of haemorrhagic shock in a female patient of reproductive age.

A woman in her 30s presented to the emergency department with acute onset, progressively worsening left-sided abdominal pain after exercise. She was found to be hypotensive and diaphoretic, with free intraperitoneal fluid detected on bedside point-of-care ultrasound. Resuscitation was initiated, a presumptive diagnosis of ruptured ectopic pregnancy was made, and obstetrics and gynaecology were consulted. Point-of-care urine pregnancy testing, however, was negative, and subsequent CT angiography of the patient's abdomen revealed an angiomyolipoma (AML) with active haemorrhage. Ultimately, embolisation was performed in the interventional radiology suite, with improvement of patient haemodynamics. Ruptured AML is a rare, life-threatening condition that needs to be included in the differential diagnosis of haemorrhagic shock in female patients of reproductive age presenting to the emergency department.

Evaluation of Thyroid Nodule: Thyroid Imaging Reporting and Data System (TIRADS) and Clinicopathological Correlation.

Ultrasound is one of the accepted modality for the initial assessment of thyroid nodules. Thyroid image reporting and data system (TIRADS) classification system is the most useful of the risk stratification systems of thyroid imaging in predicting malignancy. The purpose of this study is to assess the clinical usefulness of TIRADS in the evaluation of thyroid nodule and compare it with final histopathological results. This was a prospective observational study conducted in a tertiary care hospital over a period of one year. Preoperative ultrasound was performed in 85 patients admitted for thyroid surgery. Thyroid nodules were classified according to TIRADS into five groups. The TIRADS category was compared with the final histopathological diagnosis following surgery. Sensitivity, specificity, positive as well as negative predictive value and risk of malignancy for each TIRADS category was assessed. The risk of malignancy for TIRADS 2, TIRADS 3, TIRADS 4, and TIRADS 5 was 4.2%, 13.3%, 57.9% and 100%, respectively. The usefulness of TIRADS classification in prediction of malignancy was 77.8% sensitive, 89.6% specific, had a positive predictive value of 66.6% and negative predictive value of 93.8%. The probability of a particular nodule being malignant can be inferred from ultrasound based TIRADS system. Hence ACR TIRADS classification is a valuable tool for diagnosis of thyroid nodule and should be adopted in our routine clinical practice.

The impact of different plant extracts on biological parameters of Housefly [Musca domestica (Diptera: Muscidae)]: Implications for management.

Housefly is a significant domestic pest, which causes nuisance. The use of insecticides is discouraged to manage housefly; therefore, alternative management strategies are inevitable. The current study investigated the impact of different plant extracts, i.e., Moringa oleifera (moringa), Allium sativum (garlic) and Piper nigrum (black pepper) on biological parameters of house fly. Two different concentrations (i.e., 25 and 50%) of the extracts were blended in larval diet made through mixing of wheat bran, yeast and dried milk powder. The results indicated significant differences for larval duration. Maximum larval duration was recorded for garlic followed by black pepper and moringa, respectively. In case of pupal duration, non-significant differences were observed among plant extracts. Increase rate of oviposition was noticed with moringa at 25% concentration, while decreased oviposition rate was noted for garlic with 50% concentration. Egg hatching percentage remained non-significant for the botanical extracts. The highest survival was observed with moringa, while garlic resulted in the lowest survival. The highest repellency was noticed for garlic followed by black pepper, whereas moringa resulted in the lowest repellency after 30, 60 and 90 min. Prolonged developmental time was observed for bot concentrations of garlic, whereas moringa noted the shortest developmental time. Thus moringa was found to be a promoter of housefly development. Minimum adult emergence was found with both concentrations of garlic followed by 50% concentration of black pepper. The 50% concentration of black pepper promoted the population of adult males, while both concentrations of moringa and 25% concentration of black pepper encouraged the population of female adults. Study outcomes depicted that tested botanical extracts had significant potential for disturbing biological parameters of housefly. The garlic extracts can potentially be used to manage housefly. However, further investigations on the larval and adult mortality are needed.

Apolipoprotein L1 risk genotypes in Ghanaian patients with systemic lupus erythematosus: a prospective cohort study.

OBJECTIVE: Two apolipoprotein L1 (APOL1) risk variants (RV) are enriched in sub-Saharan African populations due to conferred resistance to Trypanosoma brucei. These variants associate with adverse renal outcomes by multiple causes including SLE. Despite emerging reports that SLE is common in Ghana, where APOL1 variant allelic frequencies are high, the regional contribution to SLE outcomes has not been described. Accordingly, this prospective longitudinal cohort study tested the associations between APOL1 high-risk genotypes and kidney outcomes, organ damage accrual and death in 100 Ghanaian patients with SLE. METHODS: This was a prospective cohort study of 100 SLE outpatients who sought care at Korle bu Teaching Hospital in Accra, Ghana. Adult patients who met 4 American College of Rheumatology criteria for SLE were genotyped for APOL1 and followed longitudinally for SLE activity as measured by the Safety of Estrogens in Lupus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) hybrid and organ injury as measured by the Systemic Lupus International Collaborating Clinics Damage Index (SDI) at baseline and every 6 months for 1 year. Outcomes of interest were kidney function, SDI and case fatality. RESULTS: Assuming a recessive inheritance, the APOL1 high-risk genotype (2RV) associated with end-stage renal disease (ESRD) at an OR of 14 (p=0.008). These patients accrued more SDI points particularly in renal and neurological domains. The SDI was 81.3% higher in 2RV patients compared with 0RV or 1RV patients despite no difference in SLE activity (p=0.01). After a 12-month period of observation, 3/12 (25%) of the 2RV patients died compared with 2/88 (2.3%) of the 0RV or 1RV carriers (OR=13.6, p=0.01). Deaths were due to end-stage kidney disease and heart failure. CONCLUSION: APOL1 RVs were heritable risk factors for morbidity and mortality in this Ghanaian SLE cohort. Despite no appreciable differences in SLE activity, APOL1 high-risk patients exhibited progressive renal disease, organ damage accrual and a 13-fold higher case fatality.

Patient Perception and Clinical Impact of Direct-to-Consumer Advertising in Inflammatory Bowel Disease.

INTRODUCTION: With an increasing number of available therapies for inflammatory bowel disease (IBD), little is known about patients' attitudes regarding IBD-related direct-to-consumer advertising (IBD-DTCA) and its impact on treatment decisions in clinical practice. METHODS: We administered a 58-item, mailed questionnaire to patients with IBD receiving Gastroenterology subspecialty care at a large academic health system. The survey assessed patient awareness and perception of IBD-DTCA and its effect on IBD treatment discussions and decisions. We used bivariate analysis to evaluate patient-level factors associated with awareness and favorable perception of IBD-DTCA. RESULTS: We achieved a response rate of 15.2% (n = 226 of 1486). Most patients (93.3%) reported awareness of IBD-DTCA, with adalimumab receiving the most exposure. A majority of respondents reported IBD-DTCA made them more aware of treatments they otherwise would not know about (53.6%), provided information in a balanced manner (63.5%), and taught them about new potential risks and side effects (64.5%). Patients without a college degree and those with a household income less than $75 k per year perceived IBD-DTCA more favorably. However, IBD-DTCA rarely changed IBD management, with only 7.6% of respondents having a discussion with their provider about the advertised drug and only two (0.9%) being initiated on the advertised drug. CONCLUSION: IBD patients were aware of IBD-DTCA and perceived it favorably; however, IBD-DTCA rarely led to patient-provider discussions or changes in treatment regimen.

A Case Report of Neonatal Supraventricular Tachycardia Resolved with Single-Syringe Adenosine.

INTRODUCTION: Supraventricular tachycardia (SVT) is a condition requiring emergency care in neonates. CASE REPORT: We describe a successfully treated case of neonatal SVT in a four-week-old neonate using the novel adenosine administration method. This technique is potentially easier to facilitate and does not require equipment such as a stopcock. Adenosine 0.2 milligrams per kilogram was drawn up into a syringe containing 0.9% sodium chloride to a total volume of 3 milliliters. Once administered, the patient had near-immediate return to normal sinus rhythm without sequelae. CONCLUSION: This case demonstrates that the single-syringe method appears potentially safe and effective in neonates.

A phase 2B randomised trial of hyperbaric oxygen therapy for ulcerative colitis patients hospitalised for moderate to severe flares.

BACKGROUND: Hyperbaric oxygen has been reported to improve disease activity in hospitalised ulcerative colitis (UC) patients. AIM: To evaluate dosing strategies with hyperbaric oxygen for hospitalised UC patients. METHODS: We enrolled UC patients hospitalised for acute flares (Mayo score 6-12). Initially, all patients received 3 days of hyperbaric oxygen at 2.4 atmospheres (90 minutes with two air breaks) in addition to intravenous steroids. Day 3 responders (reduction of partial Mayo score ≥ 2 points and rectal bleeding score ≥ 1 point) were randomised to receive a total of 5 days vs 3 days of hyperbaric oxygen. RESULTS: We treated 20 patients with hyperbaric oxygen (75% prior biologic failure). Day 3 response was achieved in 55% (n = 11/20), with significant reductions in stool frequency, rectal bleeding and CRP (P < 0.01). A more significant reduction in disease activity was observed with 5 days vs 3 days of hyperbaric oxygen (P = 0.03). Infliximab or colectomy was required in only three patients (15%) despite a predicted probability of 80% for second-line therapy. Day 3 hyperbaric oxygen responders were less likely to require re-hospitalisation or colectomy by 3 months vs non-responders (0% vs 66%, P = 0.002). No treatment-related adverse events were observed. CONCLUSION: Hyperbaric oxygen appears to be effective for optimising response to intravenous steroids in UC patients hospitalised for acute flares, with low rates of re-hospitalisation or colectomy at 3 months. An optimal clinical response is achieved with 5 days of hyperbaric oxygen. Larger phase 3 trials are needed to confirm efficacy and obtain labelled approval.

The Clinical Significance of Crohn Disease Activity at Resection Margins.

CONTEXT.­: Conflicting data about the clinical significance of microscopic Crohn disease (CD) activity at resection margins have led to varying practice patterns for routine reporting by pathologists. OBJECTIVE.­: To characterize the association between active disease at resection margins with postoperative CD recurrence and time-to-recurrence in the era of anti-tumor necrosis factor therapy. DESIGN.­: We performed a multicenter retrospective cohort study of 101 consecutive CD bowel resections during 10 years. Margin slides were reviewed, and CD activity at the margins was graded as none, mild, moderate, or severe. The association between microscopic CD activity at the margin with postoperative recurrence and time-to-recurrence were evaluated with logistic regression and Cox regression analyses, respectively. RESULTS.­: Crohn disease activity at resection margins was reported in 43% of pathology reports. Resection margins had CD involvement in 39.6% of cases, 20 of which were classified as mild, 6 as moderate, and 12 with severe CD activity. Although patients with mild (odds ratio, 1.14; 95% CI, 0.40-3.20) and moderate to severe (odds ratio, 1.97; 95% CI, 0.62-6.35) activity were at increased risk of disease recurrence, the differences were not statistically significant. Patients with mild (hazard ratio, 0.97; 95% CI, 0.50-1.91) and moderate to severe (hazard ratio, 1.29; 95% CI, 0.65-2.55) disease activity at margins did not have significantly different time-to-recurrence compared with those without disease activity. CONCLUSIONS.­: Our study suggests CD activity at resection margins is not significantly associated with postoperative CD recurrence.

Inflammatory Bowel Disease: Pathophysiology and Current Therapeutic Approaches.

Inflammatory bowel diseases, most commonly categorized as Crohn's disease and ulcerative colitis, are immune mediated chronic inflammatory disorders of the gastrointestinal tract. The etiopathogenesis is multifactorial with different environmental, genetic, immune mediated, and gut microbial factors playing important role. The current goals of therapy are to improve clinical symptoms, control inflammation, prevent complications, and improve quality of life. Different therapeutic agents, with their indications, mechanisms of action, and side effects are discussed in this chapter. Anti-integrin therapy, a newer therapeutic class, with its potential beneficial role in both Crohn's disease and ulcerative colitis is also mentioned. In the end, therapeutic algorithms for both diseases are reviewed.

Impella induced massive hemolysis: reemphasizing echocardiographic guidance for correct placement.

The Impella LP 2.5 (Abiomed, Danvers, MA) has been a tool of use for high risk coronary procedures and for cardiogenic shock. As with any invasive or intracardiac device, improper placement can result in disastrous complications. Hemolytic anemia secondary to Impella implantation is one of the documented complications. However, cases of severe hemolytic anemia are rare in the literature. Proven imaging modalities like ultrasound need to be used to guide proper placement. We present a case of device induced severe hemolysis due to Impella insertion and the need to use ultrasound guidance to avoid such an unnecessary complication.

Pathogenesis of postoperative recurrence in Crohn's disease.

The majority of patients with Crohn's disease (CD) require surgery during the course of their disease, but such surgery is typically not curative. Although some studies suggest that the disease state is theoretically reset to its earliest phase following surgery, disease phenotype and natural history of CD do not change significantly after surgery, leading to high rates of recurrence. Factors predisposing to this recurrence are not well defined, so there is a need for and a unique opportunity to develop a better understanding of the pathogenesis of recurrent inflammation and associated risk factors after an ileocolic resection. This paper reviews the postoperative disease outcome and evolution based on defining the combination of the patient's microbial flora, environmental exposure history, immune response and genetic make-up.

Random versus targeted biopsies for colorectal cancer surveillance in inflammatory bowel disease.

For many years, cancer surveillance colonoscopy in ulcerative colitis patients has involved obtaining at least 30 biopsies of flat and abnormal-appearing mucosa. With the advent of better imaging techniques, biopsies can be better targeted to abnormal-appearing mucosa, thereby increasing the sensitivity of testing. Use of chromoendoscopy, narrow-band imaging, autofluorescence, or confocal endomicroscopy to target biopsies is likely to improve detection of dysplasia and identification of patients at high risk for developing cancer.

A PAK4-LIMK1 pathway drives prostate cancer cell migration downstream of HGF.

Hepatocyte growth factor (HGF) is associated with tumour progression and increases the invasiveness of prostate carcinoma cells. Cell migration and invasion requires reorganisation of the actin cytoskeleton; processes mediated by the Rho family GTPases. p21 activated kinase 4 (PAK4), an effector of the Rho family protein Cdc42, is activated downstream of HGF. We report here the novel finding that in prostate cancer cells PAK4 binds to and phosphorylates LIM kinase 1 (LIMK1) in an HGF-dependent manner. We show for the first time that variations in the level of PAK4 expression change the level of cofilin phosphorylation in cells, a change we correlate with LIMK1 activity, cell morphology and migratory behaviour. We identify for the first time a direct and localised interaction between PAK4 and LIMK1 within cells using FRET: FLIM. Moreover we show here that HGF mediates this interaction which is concentrated in small foci at the cell periphery. PAK4 and LIMK1 act synergistically to increase cell migration speed, whilst a reduction in PAK4 expression decreases cell speed. It is well established that unphosphorylated (active) cofilin is a required to drive cell migration. Our results support a model whereby HGF-stimulated cell migration also requires a cofilin phosphorylation step that is mediated by PAK4.

Chronic laryngitis associated with gastroesophageal reflux: prospective assessment of differences in practice patterns between gastroenterologists and ENT physicians.

OBJECTIVES: Ear, nose, and throat (ENT) physicians often diagnose gastroesophageal reflux disease (GERD)-related laryngitis on the basis of symptoms and laryngeal signs; and may refer patients to gastroenterologists who contend that many such patients do not have reflux. Because of this dichotomy we designed this study to assess the practice pattern differences among ENT physicians and gastroenterologists in relation to the diagnosis and treatment of patients with GERD-related laryngitis. METHODS: Separate surveys were specifically designed for ENT physicians and gastroenterologists to assess the following: the percentage of patients diagnosed with GERD-related laryngitis, dose and duration of therapy, treatment response, and other diagnostic options in nonresponders. A total of 2000 surveys were mailed randomly to members of both the American Academy of Otolaryngology Head and Neck Surgery and the American Gastroenterological Association. RESULTS: Of the total 4,000 surveys sent, 782 (39%) ENT physicians and 565 (28%) gastroenterologists responded. Most respondents (both specialties) were private practitioners (82% and 74%, respectively). From the ENT survey, the diagnosis was most commonly suspected based on the following symptoms: globus = throat clearing > cough > hoarseness. The most useful signs were laryngeal erythema and edema reported by 70% of respondents. Seventy-four percent of ENT physicians reported they made the diagnosis more on symptoms than on laryngeal signs, and initiated therapy most often with proton pump inhibitor (PPI) once daily for 2 months. Gastroenterologists were divided on pre-therapy testing, 50% reporting testing with esophagogastro-duodenoscopy followed by pH monitoring (distal > proximal) prior to therapy, while the remaining 50% reported treating empirically with PPI twice daily for 3 months. Seventy percent of gastroenterologists reported treatment response of less than 60%, while 62% of ENT physicians reported response rate of greater than 60% (p < 0.05). CONCLUSIONS: (1) Globus and throat clearing were considered the most useful symptoms in diagnosing GERD-related laryngitis, while laryngeal erythema and edema were considered the most useful signs for diagnosis and treatment of this condition by ENT physicians. However, these symptoms and signs may represent the least specific markers for reflux. (2) Many gastroenterologists perform pre-therapy testing which has low sensitivity in GERD-related laryngitis. (3) There is a dichotomy in treatment dose, duration, and perceived patient response to therapy between the two specialists. (4) Our study highlights a need for cross communication and education between these two disciplines in understanding and treating GERD-related laryngitis better.

The role of pH monitoring in extraesophageal gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is linked to several extraesophageal disease states including laryngitis, asthma, chronic cough, and noncardiac chest pain (NCCP). Although 24-hour pH monitoring is considered the "gold standard" in the diagnosis of typical GERD, it is also increasingly used in establishing the diagnosis of GERD in patients with extraesophageal symptoms. The clinical utility of pH monitoring in this patient population, however, remains controversial. In this article, the authors examine the role of pH monitoring in laryngitis, asthma, chronic cough, and NCCP.