Impression Disinfection and Its Effect on Dimensional Accuracy and Surface Detail in the Times of COVID-19: An In Vitro Study.

Introduction The disinfection of impressions is crucial to eliminate the viral and other microbial loads to prevent the cross contamination of diseases. The aim of this study was to compare the effect of different virucidal disinfecting methods on the dimensional accuracy and surface detail reproduction (SDR) of impression materials. Methods A total of 160 samples were fabricated with different impression materials using zinc oxide eugenol (Group 1), alginate (Group 2), polyether (Group 3), and addition silicone (Group 4) impression materials, each containing 40 samples (n=40). These groups were further divided into Subgroups A, B, C, and D (n=10) based on the disinfecting method used. Disinfection was carried out using 0.2% peracetic acid (A), a natural polymer of glucosamine (B), ultraviolet (UV) radiation (C), and ozonated water (D). The disinfected impressions were poured in type IV gypsum, and the obtained casts were checked for dimensional accuracy and surface detail reproduction (SDR). For dimensional accuracy, a one-way analysis of variance (ANOVA) test and, for surface detail reproduction, the chi-square test were used to compare the different subgroups of each impression material separately. Results Zinc oxide eugenol samples showed the lowest mean dimensional change when disinfected with 0.2% peracetic acid (1A=154.1 µm), and alginate showed the lowest mean dimensional change when disinfected using ozonated water (2D=134.9 µm). On the other hand, the lowest mean dimensional change observed in polyether and addition silicone samples was those which were disinfected using UV radiation (3C=100.9 µm and 4C=113.5 µm). Surface detail was reproduced adequately in most of the samples. Conclusion A 0.2% peracetic acid could be used to disinfect zinc oxide eugenol impressions, ozonated water for alginate impressions, and UV radiation for polyether and addition silicone impressions.

Integrated analytical hierarchy process-grey relational analysis approach for mechanical recycling scenarios of plastics waste in India.

Mechanical recycling is an indispensable tool for plastic waste (PW) recycling and has the highest share in the PW recycling sector in India. The transition to the circular economy of plastics (CEoP) needs a systemic perspective on the mechanical recycling processes. Nevertheless, the assessment of multiple parameters influencing the mechanical recycling of PW is a complex decision-making problem for the development of triple-bottom-line mechanical recycling. A systemic perspective of various mechanical recycling scenarios was performed by employing a multi-criteria decision-making approach to examine the complexity of interlinked factors in the present investigation. Analytical hierarchy process (AHP) integrated with grey relational analysis (GRA) was used to evaluate the criteria that directly influence quality-oriented mechanical recycling. Data were collected by conducting semi-structured interviews using a framed questionnaire in stakeholder engagement with mechanical recyclers of PW. The first level hierarchy included economy, technical, resource consumption and environmental criteria. These criteria were further categorized into various significant indices such as quality of recyclate, recyclability, water and energy consumption during recycling. The results of the integrated grey relational analysis indicated that the technical parameters including quality of recyclate, resource efficiency, PW processing rate and recyclability have a significant influence on mechanical recycling. Based on AHP-GRA, scenario MR6, i.e. manufacturing of PET strap from recycled PET flakes, was ranked the optimal mechanical process amongst the various scenarios. MR6 was followed by Straps and Films at the second and third rank. The lowest ranking was observed for polymer blend recycling. These processes with higher ranks produced good quality recyclate with better efficiency and recyclability. Moreover, these processes consumed optimal resources during manufacturing. These processes also exhibited less maintenance cost, high production rate, low chemical consumption and waste generation as well as implemented pollution control practices.

Counseling intervention improves treatment adherence among newly diagnosed drug sensitive Tuberculosis patients of Ahmedabad city - A mixed methods approach.

INTRODUCTION: Counselling sessions based on the health behaviour module for patients on TB treatment may help improve the level of understanding of tuberculosis and its treatment, importance of adherence to therapy, possible side effects, dietary habits and to address any misconceptions; leading to better adherence and improved outcome. Hence, study attempted to assess the impact of brief counselling intervention through treatment adherence supportive activist (TASA) in improving adherence to treatment among drug sensitive TB patients. METHODS: An explanatory mixed methods design (QUAN-Qual) was carried out. Out of 23 Tuberculosis units (TUs) in Ahmedabad Municipal Corporation (AMC) two were selected, one interventional group where trained counsellor was recruited while other was the control group. All drug sensitive TB patients diagnosed at both selected TUs during January to March 2020 were included in the study. Among all patients who were non-adherent in both the TUs, 14 were selected to explore factors contributing to non-adherence to treatment. RESULTS: At the end of intensive phase, drug adherence in the study TU was 85.71% while it was 67.5% in the control TU. At the end of one month of treatment, the proportion of patients having better level adherence was more among counselled patients as compared to non-counselled patients. Marital status, religion, gender did not affect the level of adherence. Reasons for non-adherence as well as perceived barriers to adherence to TB treatment were treatment related, patient related and social barriers. CONCLUSION: Dedicated NTEP counsellor (TASA) can help improve the treatment adherence and impact of physical counselling.

DNA mechanocapsules for programmable piconewton responsive drug delivery.

The mechanical dysregulation of cells is associated with a number of disease states, that spans from fibrosis to tumorigenesis. Hence, it is highly desirable to develop strategies to deliver drugs based on the "mechanical phenotype" of a cell. To achieve this goal, we report the development of DNA mechanocapsules (DMC) comprised of DNA tetrahedrons that are force responsive. Modeling shows the trajectory of force-induced DMC rupture and predicts how applied force spatial position and orientation tunes the force-response threshold. DMCs functionalized with adhesion ligands mechanically denature in vitro as a result of cell receptor forces. DMCs are designed to encapsulate macromolecular cargos such as dextran and oligonucleotide drugs with minimal cargo leakage and high nuclease resistance. Force-induced release and uptake of DMC cargo is validated using flow cytometry. Finally, we demonstrate force-induced mRNA knockdown of HIF-1α in a manner that is dependent on the magnitude of cellular traction forces. These results show that DMCs can be effectively used to target biophysical phenotypes which may find useful applications in immunology and cancer biology.

Human health risk assessment and uncertainty analysis of silver nanoparticles in water.

Despite frequent detection in environmental waters, literature which quantifies the health risk of silver nanoparticles (Ag NPs) through oral ingestion is scarce. This study compiled literature data to find the removal of Ag NPs from different treatment schemes (i.e., natural, engineered, or hybrid). Ag NP concentrations were found either in surface water or in groundwater based on where the effluent of treatment schemes was discharged, i.e., either in surface water or in groundwater. Monte-Carlo simulation was carried out for probabilistic assessment of health risks for children for two hypothetical exposure scenarios: (a) ingesting river water while swimming and (b) drinking groundwater. Bio-accessible fraction, dietary metal adsorption factor, and concentrations of silver ions were incorporated to simulate realistic situations. Different treatment schemes were ranked for their nanoparticles' removal efficiency with respect to (i) exceedance probability from guideline value and (ii) health risk to children. Hybrid treatment combinations, i.e., conventional primary and secondary treatment units followed by nature-based units (constructed wetlands and soil aquifer treatment), were ranked the best. The health risk value was found to be less than 1, with the 99th percentile value less than 10-3 in all cases. The maximum allowable concentration of Ag NPs was found to be as low as 1.43 mg/L for groundwater, suggesting probable potential for risk. Uncertainty analysis revealed that the uncertainty of the influent NPs concentration in raw wastewater contributes > 99% to the variance of the hazard index. The results of this work indicate that the use of natural treatment technologies with existing engineered treatments provides higher nanoparticle removal from wastewater without the requirement of any tertiary treatment unit.

Segmental infralesional pathological spontaneous activity in subacute traumatic spinal cord injury.

INTRODUCTION/AIMS: There is a dearth of knowledge regarding the status of infralesional lower motor neurons (LMNs) in individuals with traumatic cervical spinal cord injury (SCI), yet there is a growing need to understand how the spinal lesion impacts LMNs caudal to the lesion epicenter, especially in the context of nerve transfer surgery to restore several key upper limb functions. Our objective was to determine the frequency of pathological spontaneous activity (PSA) at, and below, the level of spinal injury, to gain an understanding of LMN health below the spinal lesion. METHODS: Ninety-one limbs in 57 individuals (53 males, mean age = 44.4 ± 16.9 years, mean duration from injury = 3.4 ± 1.4 months, 32 with motor complete injuries), were analyzed. Analysis was stratified by injury level as (1) C4 and above, (2) C5, and (3) C6-7. Needle electromyography was performed on representative muscles innervated by the C5-6, C6-7, C7-8, and C8-T1 nerve roots. PSA was dichotomized as present or absent. Data were pooled for the most caudal infralesional segment (C8-T1). RESULTS: A high frequency of PSA was seen in all infralesional segments. The pooled frequency of PSA for all injury levels at C8-T1 was 68.7% of the limbs tested. There was also evidence of PSA at the rostral border of the neurological level of injury, with 58.3% of C5-6 muscles in those with C5-level injuries. DISCUSSION: These data support a high prevalence of infralesional LMN abnormalities following SCI, which has implications to nerve transfer candidacy, timing of the intervention, and donor nerve options.

Nanodiscoidal Nucleic Acids for Gene Regulation.

Therapeutic nucleic acids represent a powerful class of drug molecules to control gene expression and protein synthesis. A major challenge in this field is that soluble oligonucleotides have limited serum stability, and the majority of nucleic acids that enter the cells are trapped within endosomes. Delivery efficiency can be improved using lipid scaffolds. One such example is the nanodisc (ND), a self-assembled nanostructure composed of phospholipids and peptides and modeled after high density lipoproteins (HDLs). Herein, we describe the development of the nanodiscoidal nucleic acid (NNA) which is a ND covalently modified with nucleic acids on the top and bottom lipid faces as well as the lateral peptide belt. The 13 nm ND was doped with thiolated phospholipids and thiol-containing peptides and coupled in a one-pot reaction with oligonucleotides to achieve ∼30 DNA/NNA nucleic acid density. NNAs showed superior nuclease resistance and enhanced cellular uptake that was mediated through the scavenger receptor B1. Time-dependent Förster resonance energy transfer (FRET) analysis of internalized NNA confirmed that NNAs display increased stability. NNAs modified with clinically validated antisense oligonucleotides (ASOs) that target hypoxia inducible factor 1-α (HIF-1-α) mRNA showed enhanced activity compared with that of the soluble DNA across multiple cell lines as well as a 3D cancer spheroid model. Lastly, in vivo experiments show that ASO-modified NNAs are primarily localized into livers and kidneys, and NNAs were potent in downregulating HIF-1-α using 5-fold lower doses than previously reported. Collectively, our results highlight the therapeutic potential for NNAs.

"We are everyone's ASHAs but who's there for us?" a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India.

OBJECTIVE: More than a million female village-level lay providers called 'Accredited Social Health Activists (ASHAs)', who deliver primary care, face high levels of stress due to work demands and low compensation, within the context of poverty and gender inequality. Evidence on ASHAs has focused on workplace challenges from a system perspective, without sufficient probing into individual-level stress. This study aims to gain perspectives into the experiences of work stress, the related health symptoms, and the responses to stress among ASHAs in India. METHODS: Focus group discussions (FGDs) conducted with ASHAs in Sehore district, Madhya Pradesh, were audio-recorded and transcribed. Grounded theory was used to generate themes under the various domains of ASHAs' work and domestic life. We identified pathways between the conditions that trigger stressful events, experiences of these events, resulting perceptions, effects on health and wellbeing, and approaches used by ASHAs to respond to stress. RESULTS: Six FGDs with 59 ASHAs generated the following themes: (a) Facility: Workload, undue pressures, unstructured work; ASHAs' relationships with seniors (e.g., feelings of being disrespected, blamed, or targeted), and low access to physical and administrative resources; (b) Home: Feelings of guilt for putting less time for family/child care; disrespect by the elderly for a poorly incentivised job; (c) Community: Low acceptance by the villagers; caste- and gender-bias; difficult community-level relationships (emotional labour, fear/stigma towards her services); (d) Somatic and psychological symptoms: headache, exhaustion, depressive symptoms (to cite a few); and (e) Responses to stress: Motivation (support from peers, family, a sense of identity/pride, incentives), Individual strengths (e.g., social responsibility), and spiritual recourse mechanisms. CONCLUSIONS: This study will inform the development of a strengths-based coaching intervention to address work stress among ASHAs. The findings are relevant to building the evidence on alleviation of work stress among female frontline cadres in low-resource settings globally.

School Health Services in India: Status, Challenges and the Way Forward.

Schools provide a crucial platform for health and well-being interventions targeting children and adolescents. Early promotive and preventive initiatives are vital for enabling children and adolescents to reach their optimal potential, thereby adding to the country's social return-on-investment, creating a favourable demographic dividend. This review analyses the evolution of school health initiatives in India, including the current curriculum proposed under the Ayushman Bharat program. The manuscript highlights the challenges, and gaps in implementation of the current school health programs and proposes potential pathways for bridging these gaps for promotion of adolescent well-being. The review also discusses the concept of Health Promoting Schools and suggests adaptations and key recommendations to Indian context regarding 'how' to translate it into on-field reality based on the appraisal of successful case studies from other countries. Though India started school health services more than 100 y ago, the school health programmes in most Indian states are weak and fragmented, with piecemeal health screening with minimal focus on health promotion and well-being. The recently launched School Health and Wellness initiative under the Ayushman Bharat program has lots of promise. However, it needs to be translated into effective implementation to prevent it from meeting the fate of its forerunner programs. The school health program needs to move beyond the screening centric approach and be aspirational and holistic in nature focusing upon the overall well-being of the adolescents. Concerted efforts through intersectoral convergence are needed to optimally utilise the platforms of schools for promotion of adolescent well-being.

SLC20a1/PiT-1 is required for chorioallantoic placental morphogenesis.

The placenta mediates the transport of nutrients, such as inorganic phosphate (Pi), between the maternal and fetal circulatory systems. The placenta itself also requires high levels of nutrient uptake as it develops to provide critical support for fetal development. This study aimed to determine placental Pi transport mechanisms using in vitro and in vivo models. We observed that Pi (P33) uptake in BeWo cells is sodium dependent and that SLC20A1/Slc20a1 is the most highly expressed placental sodium-dependent transporter in mouse (microarray), human cell line (RT-PCR) and term placenta (RNA-seq), supporting that normal growth and maintenance of the mouse and human placenta requires SLC20A1/Slc20a1. Slc20a1 wild-type (Slc20a1+/+) and knockout (Slc20a1-/-) mice were produced through timed intercrosses and displayed yolk sac angiogenesis failure as expected at E10.5. E9.5 tissues were analyzed to test whether placental morphogenesis requires Slc20a1. At E9.5, the developing placenta was reduced in size in Slc20a1-/-. Multiple structural abnormalities were also observed in the Slc20a1-/-chorioallantois. We determined that monocarboxylate transporter 1 protein (MCT1+) cells were reduced in developing Slc20a1-/-placenta, confirming that Slc20a1 loss reduced trophoblast syncytiotrophoblast 1 (SynT-I) coverage. Next, we examined the cell type-specific Slc20a1 expression and SynT molecular pathways in silico and identified Notch/Wnt as a pathway of interest that regulates trophoblast differentiation. We further observed that specific trophoblast lineages express Notch/Wnt genes that associate with endothelial cell tip-and-stalk cell markers. In conclusion, our findings support that Slc20a1 mediates the symport of Pi into SynT cells, providing critical support for their differentiation and angiogenic mimicry function at the developing maternal-fetal interface.

Preparation and Characterization of Clopidogrel Bisulfate-hydroxypropyl-ß-Cyclodextrin Mixed Inclusion Complex for Improved Intestinal Solubility and Anti-Thrombotic Efficacy.

The study aimed to increase the intestinal solubility and absorption of orally bioavailable clopidogrel-bisulfate (CPB) by complexing with hydroxypropyl-ß-cyclodextrin (HCD) to form a binary inclusion complex that was stabilized by Tween 80 (T80) resulting into mixed inclusion complex. The results of phase solubility studies and molecular docking of CPB with ß-cyclodextrin (ß-CD) and HCD suggested higher solubility and binding energy of the stable CPB: HCD complex in the presence of T80 as compared to the CPB: ß-CD complex. The D-Optimal mixture design was used to optimize the formulation containing the CPB: HCD: T80 mixed inclusion complex. The results suggest the enhanced stability of the CPB: HCD inclusion complex in the presence of T80. The spectral attributes confirmed the inclusion complexation and pointed out the central position of CPB in a hydrophilic cavity of HCD. Further, the prepared soft gelatin capsule successfully confirmed the importance of obliterating the intestinal precipitation associated problem of CPB through an in-vitro release study. The anticoagulant activity in rabbits confirmed that soft gelatin capsules showed 1.2 folds and 1.3 folds increase in clotting time, 1.2 fold and 1.5 folds increase in bleeding time when compared to marketed formulation and pure drug, respectively. Conclusively, soft gelatin capsules exhibit the potential to enhance the oral bioavailability of CPB, leading to reduction of the dose and dose-related side effects.

Ultrastructural and molecular approach as a tool for taxonomic identification of aquatic macroinvertebrates: A review.

Aquatic insects require water at one or other phase for the completion of their life cycle. The insect larvae serve as food for larger invertebrates and vertebrates in aquatic food chain. Their diversity, number, and abundance act as water quality indicators, and thus species are classified accordingly as pollution tolerant or sensitive. So, identifying these aquatic larvae and macroinvertebrates are important for determining the biodiversity, and classification of insect species, followed by assessment of water health, and understanding the influence of climate change and anthropogenetic activities on these. Chances of misidentification have been reported due to loss of expertise, absence of taxonomic keys for larvae or intermediate stages, or damaged structure during collection or preservation. Recent advances in molecular and electron microscopy have revolutionized the identification procedure. Scanning electron microscopy detail the structure and morphology of the insect, while molecular techniques employing PCRs, DNA barcoding, and molecular markers allow the identification of the insects from any tissue (whole/part), and comparing the nucleotide sequences helps in the evaluating the family tree and lineage. The review summarizes the present status of aquatic invertebrates identification and the importance of these two techniques in the taxonomic identification of aquatic insects.

Application of ALFA-Tagging in the Nematode Model Organisms Caenorhabditis elegans and Pristionchus pacificus.

The detection, manipulation and purification of proteins is key in modern life sciences studies. To achieve this goal, a plethora of epitope tags have been employed in model organisms from bacteria to humans. Recently, the introduction of the rationally designed ALFA-tag resulted in a highly versatile tool with a very broad spectrum of potential applications. ALFA-tagged proteins can be detected by nanobodies, the single-domain antibodies of camelids, allowing for super-resolution microscopy and immunoprecipitation in biochemical applications. Here, we introduce ALFA-tagging into the two nematode model organisms Caenorhabditis elegans and Pristionchus pacificus. We show that the introduction of the DNA sequence, corresponding to the 13 amino acid sequence of the ALFA-tag, can easily be accommodated by CRISPR engineering. We provide examples of high-resolution protein expression in both nematodes. Finally, we use the GW182 ortholog Ppa-ain-1 to show successful pulldowns in P. pacificus. Thus, the ALFA-tag represents a novel epitope tag for nematode research with a broad spectrum of applications.

A Stroke of Luck: Central Diabetes Insipidus Unmasked by a Heat Stroke.

Diabetes insipidus is a rarely encountered cause of hypernatremia, often presenting a diagnostic and therapeutic dilemma for the encountering physician. Patients are often asymptomatic for a number of years due to compensation of their polyuria with polydipsia, but may have dramatic presentations in situations where they lose access to hydration. Our case is of a 62-year-old woman who was found unconscious with signs and symptoms of a heat stroke, and later was found to have resistant hypernatremia that persisted despite extensive free water supplementation. She had dilute polyuria throughout her hospital course, eventually warranting testing for diabetes insipidus with a vasopressin challenge test. She responded well to therapy with intranasal desmopressin and currently remains asymptomatic. Because our patient was reported to have polyuria and polydipsia for a number of years presumed to be due to underlying diabetes mellitus, it is possible that she had pre-existing central diabetes insipidus that was exacerbated by the lack of access to free water while she was in her intubated and sedated state. Alternatively, she may have also developed new-onset diabetes insipidus due to severe hyperthermia. This case serves to highlight a dramatic presentation of diabetes insipidus, and the importance of careful consideration of its diagnosis in patients with persistent dilute polyuria despite signs of intravascular volume depletion.

Survey implementation process and interviewer effects on skipping sequence of maternal and child health indicators from National Family Health Survey: An application of cross-classified multilevel model.

Implementing a large-scale survey involves a string of intricate procedures exposed to numerous types of survey errors. Uniform and systematic training protocols, comprehensive survey manuals, and multilayer supervision during survey implementation help reduce survey errors, providing a consistent fieldwork environment that should not result in any variation in the quality of data collected across interviewers and teams. With this background, the present study attempts to delineate the effect of field investigator (FI) teams and survey implementation design on the selected outcomes. Data on four of the bigger Empowered Action Group (EAG) states of India, namely Uttar Pradesh, Madhya Pradesh, Bihar, and Rajasthan, were obtained from the fourth round of the National Family Health Survey (NFHS-4) for analysis. A fixed-effect binary logistic regression model was used to assess the effect of FI teams and survey implementation design on the selected outcomes. To study the variation in the outcome variables at the interviewer level, a cross-classified multilevel model was used. Since one interviewer had worked in more than one primary sampling unit (PSU) & district and did not follow a perfect hierarchical structure, the cross-classified multilevel model was deemed suitable. In addition, since NFHS-4 used a two-stage stratified sampling design, two-level weights were adjusted for the models to compute unbiased estimates. This study demonstrated the presence of interviewer-level variation in the selected outcomes at both inter- and intra-field agencies across the selected states. The interviewer-level intra-class correlation coefficient (ICC) for women who had not availed antenatal care (ANC) was the highest for eastern Madhya Pradesh (0.23) and central Uttar Pradesh (0.20). For 'immunisation card not seen', Rajasthan (0.16) and western Uttar Pradesh (0.13) had higher interviewer-level ICC. Interviewer-level variations were insignificant for women who gave birth at home across all regions of Uttar Pradesh. Eastern Madhya Pradesh, Rajasthan, and Bihar showed higher interviewer-level variation across the selected outcomes, underlining the critical role of agencies and skilled interviewers in different survey implementation designs. The analysis highlights non-uniform adherence to survey protocols, which implies that not all interviewers and agencies performed in a similar manner in the field. This study recommends a refined mechanism for field implementation and supervision, including focused training on the challenges faced by FIs, random vigilance, and morale building. In addition, examining interviewer-level characteristics, field challenges, and field agency effects may also highlight the roots of interviewer-level variation in the data. However, based on the interviewer's performance in the field, the present study offers an intriguing insight into interviewer-level variations in the quality of data.

Quality of anthropometric data in India's National Family Health Survey: Disentangling interviewer and area effect using a cross-classified multilevel model.

India has adopted a target-based approach to reduce the scourge of child malnourishment. Because the monitoring and evaluation required by this approach relies primarily on large-scale data, a data quality assessment is essential. As field teams are the primary mode of data collection in large-scale surveys, this study attempts to understand their contribution to variations in child anthropometric measures. This research can help disentangle the confounding effects of regions/districts and field teams on the quality of child anthropometric data. The anthropometric z-scores of 2,25,002 children below five years were obtained from the fourth round of India's National Family and Health Survey (NFHS-4), 2015-16. Unadjusted and adjusted standard deviations (SD) of the anthropometric measures were estimated to assess the variations in measurements. In addition, a cross-classified multilevel model (CCMM) approach was adopted to estimate the contribution of geographical regions/districts and teams to variations in anthropometric measures. The unadjusted SDs of the measures of stunting, wasting, and underweight were 1.7, 1.4, and 1.2, respectively. The SD of stunting was above the World Health Organisation threshold (0.8-1.2), as well as the Demographic and Health Survey mark. After adjusting for team-level characteristics, the SDs of all three measures reduced marginally, indicating that team-level workload had a marginal but significant role in explaining the variations in anthropometric z-scores. The CCMM showed that the maximum contribution to variations in anthropometric z-scores came from community-level (Primary Sampling Unit (PSU)) characteristics. Team-level characteristics had a higher contribution to variations in anthropometric z-scores than district-level attributes. Variations in measurement were higher for child height than weight. The present study decomposes the effects of district- and team-level factors and highlights the nuances of introducing teams as a level of analysis in multilevel modelling. Population size, density, and terrain variations between PSUs should be considered when allocating field teams in large-scale surveys.

A Rare Case of Stage IV Mixed Neuroendocrine Small Cell and Adenosquamous Cell Carcinoma of the Gallbladder.

Gallbladder (GB) carcinoma is the fifth most common type of gastrointestinal cancer. Although a majority of these cancers are found to be adenocarcinomas, we present a rare case in which the GB carcinoma was found to have mixed histology with both small cell neuroendocrine carcinoma and adenosquamous cell carcinoma.

Massive Lower Gastrointestinal Hemorrhage as a Complication of Severe Campylobacter Enteritis.

Campylobacter enteritis is typically caused by Campylobacter jejuni or Campylobacter coli and is a major cause of diarrheal illness worldwide. Patients with Campylobacter gastroenteritis can be asymptomatic, but commonly present with a wide range of clinical symptoms including abdominal pain, diarrhea, vomiting, and occasionally self-resolving hematochezia. Although hematochezia can occur, acute massive lower gastrointestinal (GI) bleeding is a rare complication of Campylobacter gastroenteritis and should be considered as a possible differential diagnosis in the presentation of lower GI bleeds. We describe a unique case of a 48-year-old male who presented with massive lower GI bleeding requiring multiple transfusions and admission to the medical intensive unit; the patient was ultimately diagnosed with severe Campylobacter gastroenteritis.

Enhancing Communication and Patient Care: The Reverse Stethoscope Technique.

Patients with hearing loss have increased difficulties while navigating communication, especially complex conversations that take place in healthcare settings. Patients with hearing disabilities may often find themselves in noisy reception areas or busy emergency departments where their confidentiality is compromised for the sake of communication, resulting in suboptimal care. The reverse stethoscope technique is a tool that healthcare professionals can use to enhance communications to optimize patient care and maintain confidentiality. We describe a case of an 83-year-old male with bilateral hearing loss whose hearing disability became a major obstacle in his access to healthcare in the inpatient setting. With the help of the reverse stethoscope technique, the patient was able to understand his hospital course, diagnosis, and treatment options and was able to actively participate in making an informed decision.