Health budget cuts will be paid for by the most vulnerable.

No abstract available.

The family physician's guide to the private sector galaxy.

No abstract available.

Microbiota Dysbiosis a Cause of Colorectal Cancer or Not? A Systematic Review.

Deaths from colorectal cancer (CRC) are still rising, and various links to etiology have been proposed. However, a direct link between microbial dysbiosis and colorectal cancer has not been postulated. This study aimed to identify the role of microbes in the pathogenesis of colorectal cancer. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was done considering papers published over the past 12 years, using PubMed, PubMed Central, Cochrane, Google Scholar, and ScienceDirect databases. Studies were selected based on the following predefined eligibility criteria: English-language systematic reviews, meta-analysis, randomized controlled trials (RCTs), and clinical trials, which included papers on microbes playing roles in colorectal cancer with the derived data transferred to a template. Following this, quality assessment was done using each study's relevant assessment tool. The initial search generated 128 studies. From the study, we found the ratio of Fusobacterium, when compared between healthy and colorectal cancer patients' guts, was the highest, although it was not the most predominant gut organism. Enterotoxigenic Bacteroides fragilis (ETBF), Clostridium and Salmonella, and Peptostreptococcus showed links with colorectal cancer and described pathways that could explain its implication in colorectal cancer. However, overt conclusions cannot be drawn because further research needs to be conducted.

Risk of Liver Fibrosis in Methotrexate-Treated Patients: A Systematic Review.

Methotrexate (MTX), an antifolate agent, is recommended as the first-line disease-modifying antirheumatic drug (DMARD). In this systematic review, our goals were to assess liver fibrosis in methotrexate-treated patients, evaluate liver fibrosis in relation to treatment duration and cumulative dose, and identify differences based on the underlying disease. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform the systematic review. We thoroughly searched PubMed, PubMed Central (PMC), and Cochrane library databases to identify relevant articles based on predefined selection criteria. Studies were selected based on the following predefined eligibility criteria: English language, papers from the last 20 years, systematic reviews, observational studies, randomized controlled trials (RCTs), and clinical trials, which included papers on MTX playing roles in the development of liver fibrosis with the derived data transferred to a template. Following that, quality was assessed using the appropriate assessment tool for each study. The initial search yielded 512 results. Following a thorough review, 10 studies were chosen for final consideration: eight observational studies and two systematic reviews. Liver enzyme (LE) elevations during MTX therapy are a common but transient problem. Serial abnormal LE tests may be associated with liver pathology, but fibrosis development is uncommon. However, it is unclear from the literature how therapy should be adjusted in the case of elevated LE and to what extent MTX is linked to liver toxicity; definitive conclusions cannot be drawn because more research is needed.

Comparison of Rehabilitative Interventions That Ameliorate Post-stroke Working Memory Deficit: A Systematic Review.

Stroke is one of the most common causes of disability in the world. It has sensory, motor, and cognitive symptoms. Many cognitive domains might get involved in a stroke. This systematic review focuses on working memory domain deficits after stroke and their various rehabilitation methods. This review is based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) guidelines. For this review, we have searched PubMed, Google Scholar, and Science Direct databases and screened thoroughly with the inclusion criteria of free full-text English papers in the last 10 years that have exclusively studied humans. The articles included in the search are randomized control trials (RCTs), observational studies, meta-analysis studies, systematic reviews, and traditional reviews. Consequent quality assessment was done using the most commonly used tools for each type of study and eight papers were selected. From these papers, full-text articles were studied, analyzed, and tabulated. We found five different rehabilitation methods: transcranial direct-current stimulation, computer-assisted cognitive rehabilitation, physical activity, goal setting, and multimodal rehabilitation. We found that goal setting, computer-assisted cognitive rehabilitation, and multimodal rehabilitation can improve working memory deficits. While transcranial direct current stimulation and physical activity were inconsistent, further studies are needed. The small sample size, no follow-up, the inclusion of only a few studies, the size of the stroke, and comorbid conditions like mild cognitive impairment, dementia, and depression were the main limitations of this study. Future reviews must include a larger number of studies with large sample sizes, including follow-up as an inclusion criterion. We need more clinical trials on these methods for better knowledge.

A Systematic Review Exploring the Effect of Human Immunodeficiency Virus on Cardiac Diseases.

Human immunodeficiency virus (HIV) primarily affects the immune systems, which, if progressed, will lead to acquired immunodeficiency syndrome (AIDS). Currently, there is no effective cure for the disease, and patients are affected lifelong, but there are antiretroviral medications that can control the disease's symptoms and progression. In addition, taking precautions during sexual contact, especially in the male homosexual population, while handling the patient's bodily fluids such as blood and saliva, and during childbirth by an infected mother is necessary to prevent the transmission of the virus. We used 15 studies, including systematic reviews and meta-analyses, observation studies, randomized clinical trials, and comprehensive reviews, to determine how HIV interferes with heart disease, increasing morbidity and mortality. We have used specific inclusion and exclusion criteria, focusing on specified age groups within a particular timeline. Some of the included studies found that many side effects from antiretroviral drugs can impact heart conditions, along with HIV, while others did not show a strong correlation between HIV and some heart diseases. In conclusion, after reviewing the literature, the results are inconclusive. More extensive trials focusing on the impact HIV has on heart disease are required to establish a strong correlation between HIV and heart disease to prevent morbidity and mortality.

Role of Non-pharmacological Interventions and Weight Loss in the Management of Gastroesophageal Reflux Disease in Obese Individuals: A Systematic Review.

With the increasing prevalence of obesity, the worldwide risk of gastroesophageal reflux disease (GERD) has also increased. Abdominal obesity increases intragastric pressure, disturbing the integrity of the gastroesophageal junction, thus facilitating reflux. Other than obesity, some lifestyle factors also cause GERD, including smoking, consumption of alcohol and caffeine, late-night meals, and high fat intake. This review study aimed to assess the impact of weight loss and lifestyle modifications on GERD. In this systematic review, the databases used were PubMed, PubMed Central (PMC), Science Direct, and Google Scholar. Boolean system and Medical Subject Headings (MeSH) strategy were used to form suitable keywords. Patients from the pediatric and geriatric populations were excluded from the study and quality assessment was done using different assessment tools. A positive association between obesity and GERD was found. It was also found that the long-term use of proton pump inhibitors (PPIs) causes complications, so lifestyle interventions should be used more than PPIs for treating GERD, especially in obese patients. We concluded that weight loss could lead to the resolution of gastroesophageal reflux disease, and therefore, conservative measures, including dietary modifications such as reducing the consumption of alcohol, caffeine, and chocolate, behavioral changes such as smoking cessation and elevation of the head of the bed, and weight loss, should be used as first-line management for GERD. Although awareness has increased regarding the adverse effects of proton pump inhibitors, future studies are required to assess these negative effects.

The Role of Regorafenib in the Management of Advanced Gastrointestinal Stromal Tumors: A Systematic Review.

Regorafenib, a multi-kinase inhibitor, has been widely used to treat patients with gastrointestinal stromal tumors (GIST) who failed the initial treatment with imatinib and sunitinib. This systematic review aims to demonstrate the efficacy and safety of regorafenib for patients with metastatic and/or unresectable GIST. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform this systematic review. We searched PubMed, Science Direct, and Cochrane databases to identify relevant articles based on predefined selection criteria. The implication of the search strategy results in 776 records from all databases. We excluded conference abstracts, discussion articles, case reports, case series, systematic reviews, and other observational non-intervention studies from the study, along with the articles published in languages other than English. After the screening and quality assessment, 10 studies were selected for final review - two randomized controlled trials and eight non-randomized prospective and retrospective review articles of intervention. Regorafenib improved the survival rates of patients after the failure of imatinib and sunitinib treatment, with an acceptable safety profile. Close monitoring of the patients may be needed to detect and manage the grade 4 or higher adverse events.

Role of Serotoninergic Antidepressants in the Development of Autism Spectrum Disorders: A Systematic Review.

Autism spectrum disorders (ASDs) are one of the most common, highly heritable neurodevelopmental diseases affecting 1-2% of children under the age of 3. Although studies have implicated genetic predispositions, environmental risk factors, and maternal depression as the pathophysiology of ASD, it remains unclear. The association between antidepressant (AD) usage during pregnancy and the likelihood of ASD in children is still debatable. We carried out a systematic review to determine the relation of ASD with AD in offspring exposed to ADs in utero. We used the following terms of medical subject heading (MeSH) and keywords separately and in combination: "antidepressants," "maternal/pregnancy depression," "autism spectrum disorders/autism," and "selective serotonin reuptake inhibitors (SSRI)." Our data search was conducted on PubMed, PubMed Central, Google Scholar, and Cochrane, which resulted in 28,141 articles. We identified and eliminated duplicates and then screened 9,965 articles by title and abstract. We then applied eligibility criteria over 143 relevant articles; a quality assessment was performed, and finally we included 18 selected studies. Mothers who had taken ADs during pregnancy for at least two medication prescription cycles and children detected to have ASD from two years to 18 years of age were included. We excluded articles in languages other than English, grey literature, case reports, letters to the editor, books, documents, animal studies, and studies published before 2017. Out of 18 studies, 17 evaluated ASD as the primary outcome, and for one study, the outcome was child behavioral as well as neurodevelopmental changes. Other additional outcomes studied were attention deficit hyperactivity disorder (ADHD), preterm birth, spontaneous abortion, small for gestational age, maternal mental illness, and persistent pulmonary hypertension. After adjusting for confounding factors, in six studies, the higher correlations between ASD and ADs were eliminated. Also, paternal AD use, maternal pre-conceptional AD drug use, and maternal depression itself are additional factors that raise the incidence of ASD.

Metformin for the Improvement of Comorbid Depression Symptoms in Diabetic Patients: A Systematic Review.

Diabetes mellitus and depression are chronic debilitating disorders and can occur comorbidly. They are thought to be linked not only through environmental and behavioral factors but through molecular mechanisms as well. Antidepressant medication and psychological therapy, standard treatments for depressive symptoms in Type 2 diabetes mellitus, are linked to high rates of treatment failure and non-adherence; therefore, understanding the molecular mechanisms linking diabetes and depression could lead to discovering new targets and developing novel therapeutics. Metformin is considered a first-line anti-diabetic medication for Type 2 diabetes mellitus, and several studies have discussed its antidepressant effect. Metformin is thought to promote neurogenesis, enhance spatial memory function and protect the brain against oxidative imbalance. This systematic review aims to compile information on metformin's effect on depression symptoms and assess current knowledge on the relationship between depression and diabetes. After reviewing several studies, we concluded that metformin might help treat comorbid depression in diabetic patients, but before it can be recommended as a depression medication, more extensive and better-designed trials are needed.

The Use of Atypical Antipsychotics in Treating a Pediatric Psychiatric Patient.

Approaches to enhancing mental health management entail several perspectives and efforts to promote competent treatment. In light of this, we present a case report to describe the nature of events encountered during the management of a psychiatric patient. The paper commences by providing a general introduction and background of the concept of atypical antipsychotics before adding a thesis statement that healthcare providers should be knowledgeable regarding psychopharmacotherapy to effectively design and implement safe patient care. The paper's method involved the review of a case scenario and discussion of the concepts using evidence-based guidance and perspectives. In the case scenario, a pediatric patient significantly gains weight and develops extrapyramidal effects like dystonias, and erratic, jerky neck movements as a consequence of treatment with olanzapine. The most effective care plan involves stopping the medication, reviewing treatment options, and incorporating physical exercise. Most importantly, the plan encourages achieving an adequate heart rate above 100 beats per minute to maintain sufficient perfusion during exercise. The paper concludes by summarizing the perspectives from the studies reviewed.

An efficient multilevel security architecture for blockchain-based IoT networks using principles of cellular automata.

The tremendous increase in the use of Internet of Things (IoT) has made an impact worldwide by changing the mode of day-to-day life. Like any other application, IoT based networks also have to be protected since the data produced consist of sensitive information. Existing algorithms for providing security in such networks do not consider all the security objectives. Starting from the sensing of data from IoT environment, the data have to be protected from several types of attacks. Also, the authentication of involved entities, integrity of data, access control and confidentiality are to be achieved. This work proposes a novel security architecture for IoT based distributed applications. The architecture uses the best known lightweight cipher ChaCha20. Principles of cellular automata are applied for random number generation to attain more security and randomness. Double encryption ensures multilevel protection of data during the data uploading and storing phases. Providing encryption based on dynamic session keys guarantees the security of the method. It also ensures secure data sharing, mutual authentication between communicating entities, fast execution, user authentication and message integrity. The IoT device connected to a gateway node has to complete registration phase successfully. Subsequently, each time a data transfer between the device and gateway node takes place, mutual authentication phase is executed. Blockchain network used at the edge level ensures authentication of participating nodes and hence, unintended modification of data is prevented. The proposed architecture proves to be efficient in terms of throughput, execution time and resistance to various security attacks.

A Novel Secure and Robust Encryption Scheme for Medical Images.

BACKGROUND: Medical imaging encloses different imaging techniques and processes to image the human body for medical diagnostic and treatment purposes. Hence it plays an important role to improve public health. The technological development in biomedical imaging specifically in X-ray, Computed Tomography (CT), nuclear ultrasound including Positron Emission Tomography (PET), optical and Magnetic Resonance Imaging (MRI) can provide valuable information unique to a person. OBJECTIVE: In health care applications, the images are needed to be exchanged mostly over a wireless medium. The diagnostic images with confidential information of a patient need to be protected from unauthorized access during transmission. In this paper, a novel encryption method is proposed to improve the security and integrity of medical images. METHODS: Chaotic map along with DNA cryptography is used for encryption. The proposed method describes a two-phase encryption of medical images. RESULTS: The performance of the proposed method is also tested by various analysis metrics. The robustness of the method against different noises and attacks is analyzed. CONCLUSION: The results show that the method is efficient and well suitable for medical images.

Therapeutic metamorphosis: Findings from a grounded theory study of the impact of low-dose prophylaxis in children living with haemophilia in India.

INTRODUCTION: The clinical benefits of administering low-dose prophylaxis in children with haemophilia are well established. Qualitative research describing the impact of prophylaxis on quality of life is comparatively rare in this area. AIM: The aim of this study was to investigate in children the experiences of living and becoming adjusted to haemophilia before prophylaxis, by collecting information directly from children and their parents or guardians. A further goal was to evaluate whether and how the use of low-dose prophylaxis impacts the disease experience. METHODS: A grounded theory design according to Strauss and Corbin was chosen for this study. The study was conducted in the Haemophilia Treatment Centre at Aluva, Kerala, India and involved nineteen participants (children, mothers, father and grandmothers) who were selected by theoretical sampling. Data were collected through audiotaped interviews, which included demographic and semi-structured interview questions. Data were coded and evolved into concepts and categories that lead to the emergence of theory. RESULTS: The study resulted in the construction of 'Theory of Therapeutic Metamorphosis'. It comprised two stages: stage of bondage (enduring hardships), experienced during the absence of prophylaxis or on-demand treatment and stage of freedom (deliverance/reductions, energized life/improvements and behaviour to seek prophylaxis) experienced during low-dose prophylaxis. CONCLUSION: This study illustrates the challenges faced by children with haemophilia and their families and the positive impact of low-dose prophylaxis. Further prospective research studies are required to add to the growing knowledge in this area.

Exploring the beliefs and attitudes of private general practitioners towards national health insurance in Cape Town, South Africa.

BACKGROUND: Private general practitioner (GP) participation in the national health insurance (NHI) is necessary to address doctor shortages and achieve universal health coverage. An in-depth understanding of GP's views on the NHI is needed to inform implementation strategies. AIM: To explore the beliefs and attitudes of GPs towards the proposed NHI system. SETTING: Cape Town, South Africa. METHODS: This was a descriptive, exploratory, qualitative study using semi-structured interviews. Eleven GPs were recruited using purposeful snowball sampling from different practices and communities. Thematic data analysis was conducted using the framework approach and Atlas.ti software. RESULTS: Although GPs saw the need for NHI, they felt that the government was antagonistic towards the private sector and had not engaged in a dialogue. They were wary of integration into a nurse-led primary care system and of being coerced. They felt that the public sector lacked the necessary financial and administrative capacity, and were concerned about the level, efficiency and sustainability of reimbursement, and the criteria to be used to accredit practices. General practitioners anticipated that the NHI would favour multidisciplinary teams and group practices. They also had mixed ideas about the impact on practice with some expecting higher workloads, stress and costs with reduced quality of care, while others saw more comprehensive care, better incomes and increased patient satisfaction. CONCLUSIONS: While GPs are essential for the success of the NHI, there are many concerns regarding government policy, plans for implementation and the consequences for GP practice. Many of the concerns expressed could be tackled by greater policy dialogue and clarification.

The National Practice Patterns of Venous Thromboembolism Prophylaxis Post-Cardiothoracic Surgery.

BACKGROUND: The rates of venous thromboembolism (VTE) post-cardiothoracic surgery are not well understood. The american college of chest physicians (CHEST) guidelines report weak recommendations for starting VTE prophylaxis post-cardiothoracic surgery. It is suspected that due to the increase in bleed risk, postsurgery initiation of pharmacologic VTE prophylaxis is limited. OBJECTIVE: The study sought to investigate the use of VTE prevention in US hospitals performing cardiac surgery and the use of mechanical/chemical prophylaxis postoperatively. METHODS: This is a multicenter survey distributed to cardiac hospitals in the United States. The survey was distributed through 3 separate listservs. Data were analyzed utilizing descriptive statistics. RESULTS: The majority of the hospitals were academic and/or community and completed coronary artery bypass graft (CABG), valve replacement (mitral/aortic/tricuspid), and aortic repair. It was common for hospitals to start mechanical and pharmacologic prophylaxis post-cardiothoracic surgery on postoperative day (POD) 1 to 2. The anticoagulation most commonly used consisted of unfractionated heparin. CONCLUSIONS: The majority of the institutions are initiating therapy POD 1 to 2 with both mechanical and chemical prophylaxis. The full impact of early initiation of VTE prophylaxis is unknown, and more studies are needed to assess the true risks/benefits of these practices.

A Pilot Randomized Controlled Trial of the Feasibility of a Multicomponent Delirium Prevention Intervention Versus Usual Care in Acute Stroke.

BACKGROUND: Delirium after acute stroke is a serious complication. Numerous studies support a benefit of multicomponent interventions in minimizing delirium-related complications in at-risk patients, but this has not been reported in acute stroke patients. The purpose of this study was to explore the feasibility of conducting a randomized (delirium care) versus usual standardized stroke care (usual care) in reducing delirium in acute stroke. OBJECTIVE: This pilot study assessed the feasibility of (1) enrollment within the 48-hour window when delirium risk is greatest, (2) measuring cognitive function using the Montreal Cognitive Assessment, (3) delivering interventions 7 days per week, and (4) determining delirium incidence in stroke-related cognitive dysfunction. METHODS: A 2-group randomized controlled trial was conducted. Patients admitted with ischemic and hemorrhagic strokes and 50 years or older, English speaking, and without delirium on admit were recruited, consented, and randomized to usual care or delirium care groups. RESULTS: Data from 125 subjects (delirium care, n = 59; usual care, n = 66) were analyzed. All Montreal Cognitive Assessment subscales were completed by 86% of subjects (delirium care, mean [SD], 18.14 [6.03]; usual care, mean [SD], 17.61 [6.29]). Subjects in the delirium care group received a mean of 6.10 therapeutic activities (range, 2-23) and daily medication review by a clinical pharmacist using anticholinergic drug calculations. Delirium incidence was 8% (10/125), 3 in the delirium care group and 7 in the usual care group. CONCLUSION: Findings support the feasibility of delivering a multicomponent delirium prevention intervention in acute stroke and warrants testing intervention effects on delirium outcomes and anticholinergic medication administration.

Atypical presentation of West Nile virus in a newly diagnosed human immunodeficiency virus patient in New York City.

Central nervous system manifestations of West Nile virus (WNV) infection include meningitis, encephalitis, and poliomyelitis-like syndrome. We describe a 44-year-old man with no past medical history who presented with a meningoencephalitic syndrome and spastic paralysis bilaterally in the upper and lower extremities, hyperreflexia, and myoclonus and was ultimately diagnosed as being infected with HIV and WNV.

Establishment, characterization, and differentiation of a karyotypically normal human embryonic stem cell line from a trisomy-affected embryo.

Derivation of human embryonic stem cell (hESC) lines from chromosomally or genetically abnormal embryos obtained following preimplantation genetic diagnosis (PGD) is of immense interest to study various kinds of genetic disorders. In this study, we have established a new hESC line Relicell(®)hES4, isolated from an aneuploid embryo. Derivation of this cell line was achieved by isolation of the inner cell mass (ICM) by mechanical method. Karyotype analysis showed that the hESC line is euploid having 46 chromosomes, contrary to our expectations. The undifferentiated cells exhibited long-term proliferation capacity and expressed markers typical for hESC, such as OCT4, NANOG, and SSEA4. A comparative microarray study was carried out to analyze the transcription profile of Relicell(®)hES4 along with three other normal hESC line generated earlier in our lab. Relicell(®)hES4 manifested pluripotent differentiation potential both in vivo and in vitro. The cells were also induced to form neurons, cardiomyocytes, and pancreatic ß islets. The generation of a normal hESC line from an abnormal embryo points to the fact that even such embryos can be considered for deriving new hESC lines instead of discarding them. The data represented here are the first detailed report on characterization and differentiation of an Indian hESC line generated from a PGD analyzed embryo.

Intrinsic properties and external factors determine the differentiation bias of human embryonic stem cell lines.

A major goal of human embryonic stem cell (hESC) research is to regulate differentiation through external means to generate specific cell types with high purity for regenerative medicine applications. Although all hESC lines express pluripotency-associated genes, their differentiation ability to various lineages differs considerably. We have compared spontaneous differentiation propensity of the two hESC lines, RelicellhES1 and BG01. Spontaneous differentiation of hESC lines grown in different media conditions was followed by differentiation using two methods. Kinetic data generated by real-time gene expression studies for differentiated cell types were analyzed, and confirmed at protein levels. Both cell lines showed upregulation of genes associated with the 3 germ layers, although stark contrast was evident in the magnitude of upregulation of lineage specific genes. A distinct difference was also found in the rate at which the pluripoteny factors, Oct-4 and Nanog, were downregulated during differentiation. Once differentiation was initiated, both Oct-4 and Nanog gene expression was drastically reduced in RelicellhES1, whereas a gradual decrease was observed in BG01. A clear trend is seen in RelicellhES1 to differentiate into neuroectodermal and mesenchymal lineages, whereas BG01 cells are more prone to mesoderm and endoderm development. In addition, suspension versus plated methods of cell culture significantly influenced the outcome of differentiation of certain types of cells. Results obtained by spontaneous differentiation of hESCs were also amplified by induced differentiation. Thus, differential rates of downregulation of pluripotency markers along with culture conditions seem to play an important role in determining the developmental bias of human ES cell lines.