Fwd: Air Quality, Atmosphere ,Health

Air Quality, Atmosphere ,Health
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Development of air quality forecasting system in Macedonia, based on WRF-Chem model Abstract Urban air quality is composed of a complex interaction of factors associated with anthropogenic emissions, atmospheric circulation, and geographic factors; also, most of the urban pollution presents aerosols and trace gases toxic to human health and responsible for damaged flora, fauna, and materials. The air quality system based on the state-of-the-art Weather Research and Forecasting model coupled with chemistry (WRF-Chem) has been configured and designed for Macedonia. An extensive set of experiments have been performed with different model settings to forecast simultaneously the weather and air pollution over Macedonia. For the present work, a numerical simulation of extreme pollution episode over the urban area in Skopje has been simulated using 1-km WRF-Chem model and a newly developed set of urban mobile emissions. The modeled results implied that the model is very sensitive to the initial meteorological conditions, grid spacing, and mobile emissions. The results are validated against available observations for meteorological fields and pollutant concentrations. While the model forecasts with coarser horizontal grid resolution well fit with the hourly values of some air quality monitoring stations, these experiments tend to underpredict the peak level of about 1250 μg/m3 evidenced at the air quality station "Karpos." A WRF-Chem 5-km simulation shows increased PM10 concentrations with a peak value of about 1325 μg/m3 a few hours before the evidenced extreme concentration while 2.5-km grid run indicates the initial accumulation of air pollution with relatively high concentration with peak PM10 on 5 February 2017 at 0100 UTC. The 1-km model configuration well captures the PM10distribution over Skopje valley and the location and timing of the maximum measured air pollution. The verification analysis indicates that the best performance in the sense of the correlation coefficient is achieved with the 5-km WRF-Chem v.3.91 forecast. Numerical simulations with coarser grid resolution show less confidence and lower CC. The results suggest that model initialization and initial data using a mobile source emission provide a better quantitative assessment of extreme air pollution in urban areas. Overall, the present case study shows that the WRF-Chem model has an acceptable performance for meteorological variables as well as PM10concentration over Skopje. This study provides a general overview of WRF-Chem simulations and can serve as a reference for future air quality modeling studies.

Complex analysis focused on influence of biodiesel and its mixture on regulated and unregulated emissions of motor vehicles with the aim to protect air quality and environment Abstract The main task of this study is to perform a complex analysis dealing with influence of biodiesel and its mixture on regulated and unregulated gaseous emissions of diesel engine, which is installed in a motorcar as a driving unit determined for standard road traffic. As a real technical platform intended for realisation of the required experiments, a motor vehicle equipped with the TDI engine was chosen because just this kind of engine was directly affected by the affair "dieselgate". This type of piston combustion engine is widely used in the traffic, together with negative impacts on the air quality. Various diesel fuel mixtures, which represented the applied experimental fuels, were created by mixing of the ultra-low sulphur diesel fuel (ULSDF) with the biodiesel, using different mixture ratios. The individual experiments were performed during a 13-mode test cycle especially developed for the diesel engine in such a way, so that it was possible to identify influence of the engine loading and engine speed on the regulated and unregulated gaseous emissions of the given TDI diesel engine. It is possible to say according to the obtained results that a higher portion of the biodiesel in the fuel mixture reduces the amount of the hydrocarbons (HC), carbon monoxide (CO) and particulate matters (PM) in the gaseous emissions, but it increases volume of the nitrogen oxides (NOX). A higher portion of the biodiesel causes a growth of the formaldehyde emissions and acetaldehyde emissions in the case of unregulated diesel engine emissions. The same trend is also typical for the 1,3-butadiene, propene and ethene. The biodiesel additive increases emissions of benzene; however, it reduces emissions of the toluene and xylene within the aromatic substance emissions. The obtained results confirm a fact that all the gaseous emissions are influenced by the engine operational regimes, especially by the engine loading status.

Uncertainty associated with ambient ozone metrics in epidemiologic studies and risk assessments Abstract Epidemiologic studies relating ambient ozone concentrations to adverse health outcomes have typically relied on spatial averages of concentrations from nearby monitoring stations, referred to as "composite monitors." This practice reflects the assumption that ambient ozone concentrations within an urban area are spatially homogenous. We tested the validity of this assumption by comparing ozone data measured at individual monitoring sites within selected US urban areas to their respective composite monitor time series. We first characterized the temporal correlation between the composite monitor and individual monitors in each area. Next, we analyzed the heteroskedasticity of each relationship. Finally, we compared the distribution of concentrations measured at individual monitors to the composite monitor distribution. Individual monitors showed high correlation with the composite monitor over much of the range of ambient ozone concentrations, though correlations were lower at higher concentrations. The variance between individual monitors and the composite monitor increased as a function of concentration in nearly all the urban areas. Finally, we observed statistical bias in the composite monitor concentrations at the high end of the distribution. The degree to which these results introduce uncertainty into studies that utilize composite monitors depends on the contributions of peak ozone concentrations to reported health effect associations.

International prevalence of chemical sensitivity, co-prevalences with asthma and autism, and effects from fragranced consumer products Abstract Chemical sensitivity is a medical condition characterized by adverse health effects from exposure to common chemical pollutants and products. This study investigated the prevalence of chemical sensitivity in four countries—the United States (US), Australia (AU), Sweden (SE), and the United Kingdom (UK). In addition, it investigated the co-prevalence of chemical sensitivity with medically diagnosed multiple chemical sensitivities (MCS), fragrance sensitivity (health problems from fragranced products), asthma/asthma-like conditions, and autism/autism spectrum disorders (ASDs). Using nationally representative population samples in each country, data were collected in June 2016 and June 2017 through on-line cross-sectional surveys of adults (n = 4435). Results found that, across the four countries, 19.9% of the population report chemical sensitivity, 7.4% report medically diagnosed MCS, 21.2% report either or both, and 32.2% report fragrance sensitivity. In addition, 26.0% of the population report asthma/asthma-like conditions, of which 42.6% report chemical sensitivity and 57.8% fragrance sensitivity. Also, 4.5% of the population report autism/ASDs, of which 60.6% report chemical sensitivity and 75.8% fragrance sensitivity. Among individuals with chemical sensitivity, 55.4% also report asthma/asthma-like conditions, 13.5% autism/ASDs, and 82.0% fragrance sensitivity. Although the prevalence of chemical sensitivity across the countries is statistically different, its co-prevalences with other conditions are statistically similar. Results also found that, for 44.1% of individuals with chemical sensitivity, the severity of health effects from fragranced products can be potentially disabling. Further, 28.6% of those with chemical sensitivity have lost workdays or a job, in the past year, due to exposure to fragranced products in the workplace. Results indicate that chemical sensitivity is widespread across the four countries, affecting over 61 million people, that vulnerable individuals such as those with asthma and autism are especially affected, and that fragranced consumer products can contribute to the adverse health, economic, and societal effects.

Evaluation of particulate matter deposition in the human respiratory tract during winter in Nanjing using size and chemically resolved ambient measurements Abstract Size-segregated ambient aerosols were collected by a five-stage impactor at a suburban Nanjing site during the winter of 2016–2017 to estimate the chemical composition and size distribution of particles deposited in different parts of the human respiratory tract. Chemical compositions of carbonaceous aerosols, water-soluble ions, and trace heavy metals were measured. Particulate matter (PM) mass deposited in nasopharyngeal (NOPL), tracheobronchial (TB), and pulmonary (P) was obtained by integrating the size-dependent deposition fractions. During the sampling period, the average PM10 and PM2.5 concentrations were 108.8 ± 30.8 and 77.2 ± 24.2 μg/m3, respectively. Organic matter and water-soluble ions were major components in fine particles. The fine particles had a significant contribution to the particulate pollution in winter Nanjing. The mass concentration of particles increases significantly from the clean days to the pollution days, especially for particles in 1–2.5 μm. The proportion of NO3− and undetected components in particulate matter increases on pollution days, while the proportion of elemental carbon (EC), SO42−, and NH4+ decreases. During the study period, the total particulate matter deposit per minute in the NOPL, TB, and P was 1.06 ± 0.35, 0.10 ± 0.03, and 0.42 ± 0.14 μg, respectively, assuming normal respiration of tidal volumes of 1450 cm3 per breath and 15 breaths per minute. Particles in 2.5–10 μm had the highest deposition mass in NOPL of 0.57 ± 0.16 μg, while particles in < 0.5 μm had the highest deposition mass in TB (0.03 ± 0.01 μg), and particles in 1–2.5 μm had the highest deposition mass in P (0.14 ± 0.06 μg). The total particulate matter deposited in the NOPL, TB, and P increased from 0.79 ± 0.25, 0.08 ± 0.02, and 0.30 ± 0.09 μg on the clean days to 1.23 ± 0.29 μg, 0.12 ± 0.03 μg, and 0.49 ± 0.11 μg on the pollution days. More secondary inorganic aerosol (SNA) and metals (especially Zn, Cr, and Cu) were in the PM deposited in TB and P than in the ambient PM, while more undetected components in the PM deposited in NOPL. The chemical composition fractions deposited in a specific region were different from those measured in the ambient atmosphere, indicating that health effect studies of PM should consider the deposition rates of PM in the human respiratory tract, in addition to the ambient size and chemical characteristics of ambient PM.

Measuring the value of airborne particulate matter reduction in Seoul Abstract Airborne suspended particles, also generally referred to as fine dust, are one of Korea's most serious environmental and economic concerns. This paper estimates the perceived cost of damage from fine dust in the housing market in Seoul. To do this, we collected data on approximately 120,000 apartment transactions in 2016 and created variables explaining the apartment price, including the concentration of fine dust at the district level. Our results indicate that price premiums exist for apartments in areas with fine dust concentration decrease. This finding reflects the willingness to pay for reductions in fine dust levels, which can be viewed as the monetary value of the benefit with respect to a cost-benefit analysis for fine dust reduction policies. This finding might also provide valuable information when making decisions on the degree of effort that our society must make, and the resources needed, to mitigate this problem.

Temperature, temperature extremes, and cause-specific respiratory mortality in China: a multi-city time series analysis Abstract Chronic respiratory diseases cause huge death burden worldwide, especially in developing countries. The influence of ambient temperature on respiratory mortality has attracted growing concerns in the background of climate change. Daily cause-specific respiratory deaths and meteorological variables were collected from 16 Chinese cities during 2007–2013. We first applied the distributed lag non-linear model for each city to calculate the percentage change in respiratory mortality risk with a 1 °C change in moderate and extreme temperature range. Then, random-effect meta-analytical approach was used to produce the pooled effects. Individual-level and city-level effect modifications were separately assessed by the stratified analysis and mixed effects meta-regression model. Both cold and heat effects were associated with respiratory mortality. The pooled excess risk was 4.40% (95%CI: 2.75–6.08%), 2.23% (1.19–3.28%), 2.64% (1.81–3.47%), and 4.21% (3.10–5.33%) for 1 °C change among extreme cold, moderate cold, moderate heat, and extreme heat, respectively. Positive heat and cold effects were found for COPD, asthma, and pneumonia, among which asthma was most vulnerable to extreme cold temperatures, with the effect estimate of 6.52% (2.73–10.46%). The heat effects were much higher in females than males. Slightly higher risks were also observed in the elderly during the heat, and those with lower education level during the heat and extreme cold. City-level modifiers included green coverage rates and diurnal temperature range. Ambient heat and cold temperatures are positively associated with respiratory mortality in China. Individual and city-specific effect modifiers should be taken into consideration in policy-making.

The effect of short-term exposure to O 3 , NO 2 , and their combined oxidative potential on mortality in Rome Abstract There is large epidemiological evidence on the short-term health effects of O3 and NO2. These gaseous pollutants induce oxidative stress through their oxidative potential. Therefore, the evaluation of their combined oxidative capacity (Ox) has been proposed rather than studying the effect of either gas individually. To study the short-term effects of daily concentrations of O3, NO2, and Ox on mortality in Rome, in 2002–2015, daily deaths from the city mortality registry were analyzed along with O3 and NO2 levels observed in Rome and with estimated Ox and Owt (Ox, weighted by the redox potential of O3 and NO2). A Poisson regression model was used considering trends, and meteorological and population changes. The effects on mortality were estimated at lag 0–1 and 0–5 for 10 μg/m3. O3 and NO2 were associated with mortality, with the highest effects at lag 0–5, 0.81% (0.45–1.17) and 2.72% (2.07–3.37), respectively. Ox had an intermediate effect between the two gases. After adjusting for PM10, Owt had a stronger effect (1.72%; 1.14–2.30) than either gas, 0.86% (0.50–1.22) for O3 and 1.61% (1.15–2.06) for NO2. Both Ox and Owt were associated with cerebrovascular, respiratory and, to a lesser extent, cardiac mortality more than either gas. These results suggest that the use of Ox (or Owt) can provide a better assessment of the combined role of O3 and NO2 on mortality and can avoid the uncertainty of the threshold level for ozone. The brain and lungs seem to be the main targets of O3 and NO2.

Artificial turf: chemical flux and development of silicone wristband partitioning coefficients Abstract This work uses passive samplers to identify PAHs and OPAHs not previously associated with artificial turf, and to provide the first quantitative measure of in situ flux of semi-volatile contaminants on artificial turf fields. Both air (1.5-m height) and turf air (immediately above turf surface) were sampled using two sampling materials: low-density polyethylene and silicone. Utilizing a broad targeted screen, we assess both artificial turf and samples of crumb rubber for over 1530 chemicals including pesticides, phthalates, and personal care products. We report the presence of 25 chemicals that have not yet been reported in artificial turf literature, including some with known human effects. The samplers were also quantitatively analyzed for polycyclic aromatic hydrocarbons yielding gas-phase concentrations at breathing height and surface level—the first such report on an artificial turf outdoor field. Turf pore-air and air chemicals were highly correlated at all sites, and particularly at the recently installed indoor site. Flux of chemicals between air and turf surface appear to follow field age although more research is needed to confirm this trend. The thermal extraction process and silicone passive samplers used are suitable for larger-scale environmental sampling campaigns that aim for less solvent and sample processing. By co-deploying silicone passive samplers and conventional low-density polyethylene, partitioning coefficients are derived that can be used for future silicone passive air sampling environmental assessment. This study provides an initial demonstration that passive samplers can be used to quantify volatile and semi-volatile organic chemicals from artificial turf.

Long-range transported biomass-burning aerosols from large-scale wildfires in Russia and surrounding regions with respect to radioactive tracers Abstract Biomass burning caused by anthropogenic activity such as agriculture-burning periods (common practice during harvesting, post-harvesting, or preplanting) or naturally occurring forest fires, and domestic biofuel combustion is a frequent phenomenon causing global concern. Agricultural burning, although restricted in some countries, significantly contributes to regional air-quality deterioration and national emissions. This work focuses on atmospheric measurements at the suburbs of Athens, on August 2010, during extensive forest fires in the European Russian central plains. The effect of these fires on the measured concentrations of specific radioactive isotopes and biomass-burning tracers was studied, for long-range transport of aerosols from Russian plains. Mean total beta radioactivity was found more than 2.5 times higher during the incident compared to background values. High values were also reported for the isotope 40K, and its fluctuations were following the course of the event. 7Be showed no significant difference between the two periods, which is expected due to its origin. During the event 234Th (238U), activity concentrations were also detected. Their fluctuations showed no significant correlation with the course of the event. The average values during the period before and right after the incident is for organic carbon 2.74 μg/m3, elemental carbon 1.53 μg/m3, and for carbonate carbon 0.16 μg/m3. During the incident, the highest values were observed on August 18, with concentrations for organic carbon 5.49 μg/m3, elemental carbon 0.64 μg/m3, and carbonate carbon 0.32 μg/m3. This fact may be considered as an indicator of biomass-burning incident during the period 12–19 August 2010.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Fwd: Health Sciences Education

Health Sciences Education
To:

Two heads are better than one?

Three visions of doctoring: a Gadamerian dialogue Abstract Medicine in the twenty-first century faces an 'identity crisis,' as it grapples with the emergence of various 'ways of knowing,' from evidence-based and translational medicine, to narrative-based and personalized medicine. While each of these approaches has uniquely contributed to the advancement of patient care, this pluralism is not without tension. Evidence-based medicine is not necessary individualized; personalized medicine may be individualized but is not necessarily person-centered. As novel technologies and big data continue to proliferate today, the focus of medical practice is shifting away from the dialogic encounter between doctor and patient, threatening the loss of humanism that many view as integral to medicine's identity. As medical trainees, we struggle to synthesize medicine's diverse and evolving 'ways of knowing' and to create a vision of doctoring that integrates new forms of medical knowledge into the provision of person-centered care. In search of answers, we turned to twentieth-century philosopher Hans-Georg Gadamer, whose unique outlook on "health" and "healing," we believe, offers a way forward in navigating medicine's 'messy pluralism.' Drawing inspiration from Gadamer's emphasis on dialogue and 'practical wisdom' (phronesis), we initiated a dialogue with the dean of our medical school to address the question of how medical trainees and practicing clinicians alike can work to create a more harmonious pluralism in medicine today. We propose that implementing a pluralistic approach ultimately entails 'bridging' the current divide between scientific theory and the practical art of healing, and involves an iterative and dialogic process of asking questions and seeking answers.

Learning climate positively influences residents' work-related well-being Abstract An optimal learning climate is crucial for the quality of residency training and may also improve residents' well-being and empathy. We investigated the associations of learning climate with residents' work-related well-being. A multicenter questionnaire study was performed among 271 surgery and gynaecology residents in 21 training programs from September 2012 to February 2013. Residents were asked to complete work-related well-being measurements: work engagement (Utrecht Work Engagement Scale), job and specialty satisfaction (measures from Physician Worklife Study), and physician empathy (Jefferson Scale of Physician Empathy). The Dutch Residency Educational Climate Test was used to evaluate learning climate. Multivariate adjusted linear regression analyses were used to estimate associations of learning climate with work-related well-being measures. Well-being measures were completed by 144 residents (53.1%). Learning climate was evaluated by 193 residents, yielding 9.2 evaluations per training program on average. Overall learning climate score was positively associated with work engagement [regression coefficient b = 0.58; 95% confidence interval (CI) 0.18–0.98; p = 0.004] and job satisfaction (b = 0.80; 95% CI 0.48–1.13; p < 0.001). No associations were found between learning climate and empathy and specialty satisfaction. Residents' work engagement and job satisfaction are positively related to the learning climate and may be further enhanced by improved learning climates of training programs.

Early identification of first-year students at risk of dropping out of high-school entry medical school: the usefulness of teachers' ratings of class participation Abstract Dropping out from undergraduate medical education is costly for students, medical schools, and society in general. Therefore, the early identification of potential dropout students is important. The contribution of personal features to dropout rates has merited exploration. However, there is a paucity of research on aspects of student experience that may lead to dropping out. In this study, underpinned by theoretical models of student commitment, involvement, and engagement, we explored the hypothesis of using inferior participation as an indicator of a higher probability of dropping out in year 1. Class participation was calculated as an aggregate score based on teachers' daily observations in class. The study used a longitudinal dataset of six cohorts of high-school entry students (N = 709, 67% females) in one medical school with an annual intake of 120 students. The findings confirmed the initial hypothesis and showed that lower scores of class participation in year 1 added predictive ability to pre-entry characteristics (Pseudo-R2 raised from 0.22 to 0.28). Even though the inclusion of course failure in year 1 resulted in higher explanatory power than participation in class (Pseudo-R2 raised from 0.28 to 0.63), ratings of class participation may be advantageous to anticipate dropout identification, as those can be collected prior to course failure. The implications for practice are that teachers' ratings of class participation can play a role in indicating medical students who may eventually drop out. We conclude that the scores of class participation can contribute to flagging systems for the early detection of student dropouts.

Challenging encounters as experienced by registered nurses new to the emergency medical service: explored by using the theory of communities of practice Abstract The aim of this study was to explore challenging encounters experienced by registered nurses (RN) during their first year in the emergency medical service by using the social learning theory of communities of practice. During the first year in a new professional practice, a new RN experiences a transition during which the new professional identity is being formed. This is a challenging and demanding period of time. According to the learning theory of communities of practice by Lave and Wenger, individuals' learning and development in a new professional practice occurs through participation in social activity and is influenced by context. This study is based on the qualitative data from semi-structured interviews. Thirty-two RNs working in the Swedish emergency medical service were interviewed via telephone during the spring of 2017. A qualitative content analysis with deductive reasoning of the interviews was used. The analysis process generated the main category; New RNs participation is challenged by unpredictability and uncertainty in practice. The main category was based on three generic categories; Loneliness in an unpredictable context, Uncertainty about the team, and Uncertainty in action. The challenges new RNs encounter during the first year relate to all three dimensions of a community of practice; mutual engagement, joint enterprise and shared repertoire. The encountered challenges also relate to the EMS context. Taking into account all these aspects when designing support models for RN's professional development may be advantageous for creating positive development for RNs new to the EMS and/or similar practices.

Associations between motivational factors for studying medicine, learning approaches and empathy among medical school candidates Abstract Previous research highlighted associations between students' motivation for medical studies and their learning approaches on the one hand and empathy on the other. Internal motivational factors for studying medicine (e.g., care for patients, save lives) coupled with a deep approach to learning have been positively related to empathy in contrast to external motivational factors (e.g., future earning potential, prestige) and surface learning. However, assessments of these assumptions among medical school candidates are scarce. This study examined the relationship between different motivational factors and empathy among students enrolled in a selection year in medicine by testing the mediating role of learning approaches. A sample of 572 candidates for medical studies answered a self-reported questionnaire half way through their selection year. Measures included internal and external motivational factors for studying medicine, deep and surface learning approaches and empathy. Path-analysis tested the mediation effects of deep and surface approaches to learning on the relationship of internal and external motivational factors with empathy. The deep learning approach partially mediated the significant positive association between internal motivational factors and empathy, while the surface learning approach fully mediated the significant negative association between external motivational factors and empathy. These results suggest that learning approaches could be a pathway by which internal and external motives for studying medicine are related to empathy among medical school candidates. Pedagogical strategies and educational environments accounting for individual differences in motivation and learning may contribute to training students to become professional and caring doctors in the future.

Fostering medical students' clinical reasoning by learning from errors in clinical case vignettes: effects and conditions of additional prompting procedures to foster self-explanations Abstract The present study aims at fostering undergraduate medical students' clinical reasoning by learning from errors. By fostering the acquisition of "negative knowledge" about typical cognitive errors in the medical reasoning process, we support learners in avoiding future erroneous decisions and actions in similar situations. Since learning from errors is based on self-explanation activities, we provided additional prompting procedures to foster the effectiveness of the error-based instructional approach. The extent of instructional support in a web-based learning environment with erroneous clinical case examples was varied in a one-factorial design with three groups by either presenting the cases as (a) unsupported worked examples or by providing the participants with (b) closed prompts in the form of multiple-choice tasks or (c) with open reflection prompts during the learning process. Despite significant learning progress in all conditions, neither prompting procedure improved the learning outcomes beyond the level of the unsupported worked example condition. In contrast to our hypotheses, the unsupported worked example condition was the most effective with respect to fostering clinical reasoning performance. The effects of the learning conditions on clinical reasoning performance was mediated by cognitive load, and moderated by the students' self-efficacy. Both prompting procedures increased extraneous cognitive load. For learners with low self-efficacy, the prompting procedures interfered with effective learning from errors. Although our error-based instructional approach substantially improved clinical reasoning, additional instructional measures intended to support error-based learning processes may overtax learners in an early phase of clinical expertise development and should therefore only be used in moderation.

Supporting self-regulation in simulation-based education: a randomized experiment of practice schedules and goals Abstract Self-regulated learning is optimized when instructional supports are provided. We evaluated three supports for self-regulated simulation-based training: practice schedules, normative comparisons, and learning goals. Participants practiced 5 endoscopy tasks on a physical simulator, then completed 4 repetitions on a virtual reality simulator. Study A compared two practice schedules: sequential (master each task in assigned order) versus unstructured (trainee-defined). Study B compared normative comparisons framed as success (10% of trainees were successful) versus failure (90% of trainees were unsuccessful). Study C compared a time-only goal (go 1 min faster) versus time + quality goal (go 1 min faster with better visualization and scope manipulation). Participants (18 surgery interns, 17 research fellows, 5 medical/college students) were randomly assigned to groups. In Study A, the sequential group had higher task completion (10/19 vs. 1/21; P < .001), longer persistence attempting an ultimately incomplete task (20.0 vs. 15.9 min; P = .03), and higher efficiency (43% vs. 27%; P = .02), but task time was similar between groups (20.0 vs. 22.6 min; P = .23). In Study B, the success orientation group had higher task completion (10/16 vs. 1/24; P < .001) and longer persistence (21.2 vs. 14.6 min; P = .001), but efficiency was similar (33% vs. 35%; P = .84). In Study C, the time-only group had greater efficiency than time + quality (56% vs. 41%; P = .03), but task time did not differ significantly (172 vs. 208 s; P = .07). In this complex motor task, a sequential (vs. unstructured) schedule, success (vs. failure) orientation, and time-only (vs. time + quality) goal improved some (but not all) performance outcomes.

Impact of funding allocation on physical therapist research productivity and DPT student graduates: an analysis using panel data Abstract Financial support for institutional research is relatively stagnant, and thus institutions are likely to seek tuition revenue to offset the costs of research and teaching. It is likely that this has led to increases in tuition driven activities, and thus has limited research activities of academic physical therapy (PT) programs in particular. However, the relationships between sources of program revenue, the number of graduates from PT programs, and the scholarly production of PT faculty have not been studied. The purpose of this paper is to study the effects of types of funding—including research grants and tuition—on the number of physical therapy graduates from each program and the research productivity of physical therapy faculty. Data from 2008 to 2016 were utilized to perform a fixed-effects panel analysis. Panel models created predictions for the number of graduates and the number of peer-reviewed publications for programs from grant funding, annual tuition, and number of funded faculty members. In any given program, a 1% increase in annual tuition is associated with 24% more graduates per year, but a single percentage point increase in the mix of NIH grant funding over other funding types is associated with 8% fewer graduates, all else equal. For every 1% increase in annual tuition, a program can expect to have 41% fewer publications per year. Those institutions with higher numbers of graduates tended to have higher numbers of publications. Higher annual program tuition appears to be associated with both higher numbers of physical therapy graduates and lower levels of publications. Different funding sources have variable effects on degree production and scholarly productivity. Data are self-reported by programs on the Annual Accreditation Report, and cause and effect cannot be established through observational design.

Student participation in governance of medical and veterinary education: experiences and perspectives of student representatives and program directors Abstract Student participation in governance of education is of growing interest. However, it remains unclear what factors render this participation in institutional governance a success or a failure. Another question is: what are the perceived benefits for schools and students? We empirically explored experiences and perspectives of student representatives and program directors of all (8) medical and (1) veterinary schools in the Netherlands on factors that influence student participation in institutional governance and its values and challenges for schools and student representatives. A constructivist grounded theory study was performed. A theoretical sample of student representatives was invited to fill out an explorative, qualitative questionnaire. Next, focus groups with student representatives and interviews with all program directors were conducted. Data was analyzed using open, axial and selective coding by all authors. Experiences and perspectives of students and program directors were remarkably similar in both perceived influences and values. Four main categories of influences could be distinguished in student participation: (1) individual student characteristics, (2) individual staff characteristics, (3) the organization of student representatives and (4) the school's organization, including its culture and policy regarding student participation. A cohesive, well-organized and independent student organization has crucial impact on student participation in educational governance processes. For representatives, major benefits of participation are personal and career development. Challenges are low effectiveness and efficiency of their actions. A clear school policy on student participation and better introduction, feedback and coaching of representatives should be provided to improve student participation in governance processes.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Pediatrics

Planetary Pediatrics: The Next Generation Publication date: Available online 27 April 2019 Source: Academic Pediatrics Author(s): Susan Bennett

Planetary Pediatrics Publication date: Available online 26 April 2019 Source: Academic Pediatrics Author(s): Jeffrey Goldhagen

The challenge of child management during dental care: use of non-pharmacological approaches Publication date: Available online 26 April 2019 Source: Academic Pediatrics Author(s): Marília Leão Goettems, Francine dos Santos Costa, Vanessa Polina Pereira da Costa

Food Insecurity Associated with Underestimation of Weight Status in Children with a Healthy Weight Status Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Jaclyn M. Dovico, Rebecca J. Palmer, Eliana M. Perrin, Callie L. Brown ABSTRACT Objective Accurate parental weight perception of one's child is an important step in addressing healthy behaviors, but its associations with socioeconomic status (SES) and household food insecurity (HFI) are unclear. We aimed to assess the association of parental weight perception with HFI. Methods This was a secondary data analysis of a cross-sectional study of 284 children ages 2-8 whose parents completed surveys about weight perception, SES, and HFI. Height/weight were measured for child BMI and self-reported in parents. We performed chi-square tests to compare HFI and accuracy of parental weight perception and used logistic regression to assess accuracy, adjusting for significant covariates and stratifying by child weight category. Results Approximately two-thirds of children had healthy weight, 18% had overweight, and 15% had obesity. About one-third of parents inaccurately identified their child's weight category, almost always underestimating weight status. Twenty-eight percent of families were food insecure. HFI was not associated with parental weight perception in bivariate analysis. When stratified by weight status, food insecure families with a child at healthy weight had 0.16 times the odds of accurately perceiving their child's weight status. There was no association between HFI and accuracy of weight perception in children with overweight or obesity. Conclusion Food insecurity was associated with a decrease in accuracy of parental weight perceptions in children with healthy weight. Pediatricians should clearly communicate about weight status, as families with HFI may adopt unhealthy eating behaviors under the incorrect assumption that their child is underweight.

Teaching Students How to Improve Safety and Quality in Two Children's Hospitals: Building a Pediatric Clerkship Patient Safety and Quality Experience Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Frank J. Genuardi, Maria N. Kelly, Eric I. Rosenberg, Erik W. Black, Kara Dawson

Let them speak for themselves: Improving adolescent self-report rate on pre-visit screening Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Randall W. Grout, Erika R. Cheng, Matthew C. Aalsma, Stephen M. Downs Abstract Background Adolescent pre-visit screening on patient-generated health data is a common and efficient practice to guide clinical decision making. However, proxy informants (e.g., parents or caregivers) often complete these forms, which may lead to incorrect information or lack of confidentiality. Our objective was to improve the adolescent self-report rate on pre-visit screening. Methods We conducted an interventional study using an interrupted time-series design to compare adolescent self-report rates (percent of adolescents ages 12-18 years completing their own pre-visit screening) over 16 months in general pediatric ambulatory clinics. We collected data using a computerized clinical decision support system with waiting room electronic tablet screening. Pre-intervention rates were low, and we created and implemented two electronic workflow alerts, one each to the patient/caregiver and clinical staff, reminding them that the adolescent should answer the questions independently. We included the first encounter from each adolescent and evaluated changes in adolescent self-reporting between pre- and post-intervention periods using interrupted time series analysis. Results Patients or caregivers completed 2,670 qualifying pre-visit screenings across 19 pre-intervention, 7 intervention, and 44 post-intervention weeks. Self-reporting by younger adolescents nearly doubled with a significant increase of 19.3 percentage points (CI 9.1-29.5) from the baseline 20.5%. Among older adolescents, the stable baseline rate of 53.6% increased by 9.2 absolute percentage points (CI -7.0-25.3). There were no significant pre- or post-intervention secular trends. Conclusions Two automated alerts directing clinic personnel and families to have adolescents self-report significantly and sustainably improved younger adolescent self-reporting on electronic patient-generated health data instruments.

Family-Centered Care Across the Border: A Postmortem Reflection Publication date: Available online 25 April 2019 Source: Academic Pediatrics Author(s): Zachary Foughty, Allison Silverstein

A Learning Loop Model of Collaborative Decision Making in Chronic Illness Publication date: Available online 19 April 2019 Source: Academic Pediatrics Author(s): Sarah D. Ronis, Lawrence C. Kleinman, Kurt C. Stange Abstract Shared decision-making is a core attribute of quality healthcare that has proved challenging to implement and assess in pediatric practice. Current models of shared decision-making are limited, including their capacity: to incorporate multiple stakeholders; to integrate downstream effects of subacute or minor decisions; and to account for the context(s) in which such decisions are being made and enacted. Based on a review of literature from organizational psychology, cognitive sciences, business, and medicine, we propose an iterative decision-making model of care planning, and identify targets at several levels of influence warranting measurement in future studies. Our Learning Loop Model posits the relationship between pediatric patients, their parents, and their clinicians as central to the collaborative decision making process in the setting of chronic illness. The model incorporates the evolution of both context and developmental capacity over time. It suggests that "meta-learning" from the experience of and outcomes from iterative decision-is a key factor that may influence relationships and thus continued engagement in collaboration by patients, their parents, and their clinicians. We consider the model in light of the needs of children with special healthcare needs, for whom understanding the ongoing iterative effects of decision making and clinician-parent-child dynamics are likely to be particularly important in influencing outcomes.

Characteristics of High Performing Primary Care Pediatric Practices: A Qualitative Study Publication date: Available online 18 April 2019 Source: Academic Pediatrics Author(s): Sarah L. Goff, Kathleen M. Mazor, Aruna Priya, Penelope S. Pekow, Peter K. Lindenauer Abstract Objective Performance on pediatric quality measures varies across primary care practices. Healthcare quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures. Methods Using a positive deviance approach, semi-structured interviews were conducted with pediatricians and staff (n=35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (e.g., care processes) and contextual factors (e.g., teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods. Results We identified four major themes (MT): MT1) Practice Culture; MT2) Practice Structures and Quality Improvement Tools; MT3) Attitudes and Beliefs Related to Measuring Care Quality; and MT4) Perceived Barriers to Achieving High Performance on Quality Measures. MT1 sub-themes included contextual factors such as teamwork, leadership, and feeling respected as an employee; MT2 subthemes included fixed characteristics such as practice size and strategies such as use of an electronic medical record; MT3 and MT4 subthemes linked these constructs to factors external to the practices. Conclusions This study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver.

The relationship between housing instability and poor diet quality among urban families Publication date: Available online 13 April 2019 Source: Academic Pediatrics Author(s): Clement J. Bottino, Eric W. Fleegler, Joanne E. Cox, Erinn T. Rhodes ABSTRACT OBJECTIVE To examine associations between housing instability and poor diet quality in a sample of urban parents and children. METHODS Cross-sectional study of 340 parent/guardian-child dyads visiting a pediatric primary care center in Boston, Massachusetts. The parent/guardian (hereafter, parent) completed two Harvard Service Food Frequency Questionnaires, one regarding their own dietary intake and one regarding their child's intake, and an assessment of health-related social needs. Diet quality was measured using the Healthy Eating Index-2010 (HEI-2010; score range 0–100). Housing instability was defined as: (1) homeless or in sheltered housing, (2) doubled up with another family, (3) utilities threatened or shut off, or (4) concerned about eviction. Multivariable logistic regression was used to measure associations between unstable housing and lowest-quartile HEI-2010 scores, adjusting for parent age, race/ethnicity, education, income, and child age. RESULTS Median (interquartile range) parent and child HEI-2010 scores were 63.8 (56.3–70.8) and 59.0 (54.2–64.7), respectively. Housing instability was found in 136 dyads (40%). In multivariable analysis, it was associated with increased odds of lowest-quartile total parent HEI-2010 scores (aOR 1.9 [95% CI 1.1–3.5]) but not child scores (aOR 1.4 [95% CI 0.8–2.5]). It was also associated with increased odds of lowest-quartile parent HEI-2010 dietary component scores for Total vegetables and Greens and beans (aOR 2.0 [95% CI 1.1–3.7] and aOR 2.5 [95% CI 1.3–4.8], respectively). CONCLUSIONS In this urban primary care population, housing instability is associated with lower diet quality scores for parents but not children. Lower vegetable consumption appears to drive this association.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Anesthesia

Anesthesia practice for endovascular therapy of acute ischemic stroke in Europe Purpose of review Anesthetic assistance is often required during endovascular therapy (EVT) of large vessel occlusion in patients with acute ischemic stroke. It is currently debated whether EVT should be performed under general anesthesia or conscious sedation. This review will summarize the recent literature with emphasis on the influence of anesthesia method on neurological outcome. Recent findings Recent randomized trials have reported no difference in outcome after EVT performed under either conscious sedation or general anesthesia. This is in contrast to a substantial number of retrospective studies, which found that EVT performed under general anesthesia was associated with a worse neurologic outcome compared with conscious sedation. Anesthetic drugs affect vessel tone and the level of blood pressure may influence outcome. The most favorable choice of anesthetic agents and ventilatory strategy is still debated. Summary The optimal anesthetic practice for EVT remains to be identified. Currently, conscious sedation is often an easy first-line strategy, but general anesthesia can be considered an equal and safe alternative to conscious sedation when there is a carefully administered anesthetic that maintains strict hemodynamic control. Attention to ventilation is advocated. The presence of a specialized neuroanesthesiologist or otherwise dedicated anesthesia personnel is highly recommended. Correspondence to Mads Rasmussen, Section of Neuroanesthesia, Department of Anesthesia, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark. Tel: +45 30566977; e-mail: mads.rasmussen@vest.rm.dk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Nonoperating room anesthesia education: preparing our residents for the future Purpose of review Nonoperating room anesthesia (NORA) is the fastest growing segment of anesthetic practice. This review provides an overview of knowledge and trends that will need to be introduced to residents as part of their education. Recent findings Topics for the future include, but are not limited to, new medications, artificial intelligence and big data, monitoring depth of hypnosis, translational innovation and collaboration, demographic changes, financial driving forces, destination hubs, medical tourism, and new approaches to education training and self-management. Summary Implementing new medical technologies for anesthesia outside the operating room will help to successfully master this ever evolving subspecialty. Anesthesiologists require specific preparation for the diverse settings that they will encounter during their training. In this rapidly changing field, cognitive fitness must be factored into teaching and evaluation of residents. We describe the most important topics to consider when educating anesthesiology residents, and highlight research that addresses upcoming challenges. Correspondence to Steven D. Boggs, MD, MBA, Department of Anesthesiology, The University of Tennessee School of Health Sciences Memphis, Chandler Building, Suite 600, 877 Jefferson Avenue, Memphis, TN 38103, USA. Tel: +1 901 448 5988; e-mail: sboggs6@uthsc.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia-administered sedation for endoscopic retrograde cholangiopancreatography: monitored anesthesia care or general endotracheal anesthesia? Purpose of review The decision to undertake monitored anesthesia care (MAC) or general endotracheal anesthesia (GEA) for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is influenced by many factors. These include locoregional practice preferences, procedure complexity, patient position, and comorbidities. We aim to review the data regarding anesthesia-administered sedation for ERCP and identify the impact of airway management on procedure success, adverse event rates and endoscopy unit efficiency. Recent findings Several studies have consistently identified patients at high risk for sedation-related adverse events during ERCP. This group includes those with higher American Society of Anesthesiologists class and (BMI). ERCP is commonly performed in the prone position, which can make the placement of an emergent advanced airway challenging. Although this may be alleviated by performing ERCP in the supine position, this technique is more technically cumbersome for the endoscopist. Data regarding the impact of routine GEA on endoscopy unit efficiency remain controversial. Summary Pursuing MAC or GEA for patients undergoing ERCP is best-approached on an individual basis. Patients at high risk for sedation-related adverse events likely benefit from GEA. Larger, multicenter randomized controlled trials will aid significantly in better delineating which sedation approach is best for an individual patient. Correspondence to Zachary L. Smith, DO, University Hospitals Digestive Health Institute, 11100 Euclid Ave, Wearn 2nd Floor, Cleveland, OH 44106, USA. Tel: +1 216 844 6172; fax: +1 216 844 7480; e-mail: zachary.smith2@uhhospitals.org Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia for peroral endoscopic myotomy in Japan Purpose of review Peroral endoscopic myotomy (POEM) was developed in Japan as a less invasive treatment for esophageal achalasia requiring general anesthesia under positive pressure ventilation. In 2018, the Japan Gastroenterological Endoscopy Society published the first guidelines describing the standard care for POEM. Based on these guidelines, we discuss the typical approach to anesthesia during POEM for the management of esophageal achalasia in Japan. Recent findings Prior cleansing of the esophagus is essential to prevent both aspiration during induction of anesthesia and contamination of the mediastinum and thoracic/abdominal cavity by esophageal remnants after endoscopic resection of the esophageal mucosa. Although rare, adverse events related to intraoperative carbon dioxide insufflation occur. These are treated through percutaneous needle decompression and insertion of a chest drainage tube for pneumoperitoneum and pneumothorax, respectively. Caution should be exercised regarding the development of subcutaneous emphysema and its involvement in airway obstruction. Summary Prevention of aspiration pneumonia and adverse events related to the insufflation of carbon dioxide is essential in the management of esophageal achalasia through POEM. Close cooperation between gastrointestinal endoscopic surgeons and anesthesiologists is indispensable in POEM. Correspondence to Hiroaki Murata, Department of Anesthesiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan. Tel: +81-95-819-7370; fax: +81-95-819-7373; e-mail: h-murata@nagasaki-u.ac.jp Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Cancer

"Financial audit of wastage of anticancer drugs: Pilot study from a tertiary care center of India": A commentary Fatih Safa Erenay, Susan Horton Indian Journal of Cancer 2019 56(2):99-100

Incidence, prevalence, and mortality associated with head and neck cancer in India: Protocol for a systematic review Aayush Poddar, Ritchlynn Aranha, Madhav Madurantakam Royam, Kodiveri Muthukaliannan Gothandam, Ramesh Nachimuthu, Rama Jayaraj Indian Journal of Cancer 2019 56(2):101-106 BACKGROUND: Head and neck cancer (HNC) is a heterogeneous tumor at various anatomic sites and one of the most common cancers in India. Published and existing reports and studies highlight an alarming increase in the incidence, prevalence, and mortality of HNC. Despite its high incidence, there is a dearth of more precise estimates of reliable epidemiological data pertaining to HNC in India. AIM: This protocol aims to conduct a full-scale systematic review and meta-analysis on the HNC epidemiology (incidence, prevalence, and mortality) in 29 states and 7 union territories of India. METHODS AND ANALYSIS: We will search for eligible published studies through PubMed, Scopus, Science Direct, MEDLINE, Web of Science, and Cochrane Review. Cancer registries such as (but not limited to) World Health Organization, International Agency for Research on Cancer, and the National Centre for Disease Informatics and Research-National Cancer Registry Program, which is maintained by the Indian Council of Medical Research, will be used for extracting relevant data using a standardized data collection form. The random-effects model of meta-analysis will be employed to aggregate the pooled estimates of relative ratios with 95% confidence intervals. Publication bias will be assessed using a funnel plot, and Egger's regression will be applied to test the symmetry of the funnel plot. DISCUSSION: This review will provide updated evidence of the current burden of HNC in India. This will guide future studies and cancer registry reports to provide holistically representative epidemiological data. SYSTEMATIC REVIEW REGISTRATION: In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews and was assigned the registration number, CRD42017077482.

Role of community health worker in a mobile health program for early detection of oral cancer N Praveen Birur, Keerthi Gurushanth, Sanjana Patrick, Sumsum P Sunny, Shubhasini A Raghavan, Shubha Gurudath, Usha Hegde, Vidya Tiwari, Vipin Jain, Mohammed Imran, Pratima Rao, Moni Abraham Kuriakose Indian Journal of Cancer 2019 56(2):107-113 Background: The global incidence of oral cancer occurs in low-resource settings. Community-based oral screening is a strategic step toward downstaging oral cancer by early diagnosis. The mobile health (mHealth) program is a technology-based platform, steered with the aim to assess the use of mHealth by community health workers (CHWs) in the identification of oral mucosal lesions. MATERIALS AND METHODS: mHealth is a mobile phone-based oral cancer-screening program in a workplace setting. The participants were screened by two CHWs, followed by an assessment by an oral medicine specialist. A mobile phone-based questionnaire that included the risk assessment was distributed among participants. On specialist recommendation an oral surgeon performed biopsy on participants. The diagnosis by onsite specialist that was confirmed by histopathology was considered as gold standard. All individuals received the standard treatment protocol. A remote oral medicine specialist reviewed the uploaded data in Open Medical Record System. Sensitivity, specificity, positive and negative predictive values were calculated. Inter-rater agreement was analyzed with Cohen's kappa coefficient (κ) test, and the diagnostic ability of CHWs, onsite specialist, and remote specialist was illustrated using receiver operating characteristic curve. RESULTS: CHWs identified oral lesions in 405 (11.8%) individuals; the onsite specialist identified oral lesions in 394 (11.4%) individuals; and the remote specialist diagnosed oral lesions in 444 (13%). The inter-rater agreement between the CHW and the onsite specialist showed almost perfect agreement with the κ score of 0.92, and a substantial agreement between CHW and remote specialist showed a score of 0.62. The sensitivity, specificity, positive and negative predictive values of CHWs in the identification of oral lesion were 84.7, 97.6, 84.8, and 97.7%, respectively. CONCLUSION: The trained CHWs can aid in identifying oral potentially malignant disorders and they can be utilized in oral cancer-screening program mHealth effectively.

Optimization of sentinel lymph node identification techniques in the Indian setting: A randomized clinical trial V Seenu, Suhani Suhani, Anurag Srivastava, Rajinder Parshad, Sandeep Mathur, Rakesh Kumar Indian Journal of Cancer 2019 56(2):114-118 INTRODUCTION: The recommended technique of sentinel lymph node biopsy (SLNB) in breast cancer is a combination of blue dye and radiotracer. In the Indian scenario, SLNB is still not routinely practiced due to lack of nuclear medicine facilities and unavailability of isosulfan blue or patent blue violet (PBV). This study was conducted for optimizing SLN identification techniques by comparing the identification rate using PBV and methylene blue (MB) in combination with radiotracer. MATERIALS AND METHODS: Single-blinded two-arm parallel design randomized control trial was conducted at an apex teaching and research medical institute in India. Patients with axillary LN–negative breast cancer were included. Blue dye and radio tracer were injected preoperatively, and SLNB was performed using a combination technique. Frozen section was performed. Demographic, clinical, radiological, operative, and histopathological data were recorded. Descriptive statistics were used to represent patient characteristics. Baseline characteristics for entire cohort and between groups were compared using Student's t-test for quantitative variables and Chi-square test for qualitative variables. RESULTS: A total of 119 patients were randomized for mapping with MB and 118 patients with PBV between 2011 and 2015. SLN was identified in 116 patients with MB and 115 with PBV. SLN identification proportions were 97.4% (MB) and 96.6% (PBV). In patients undergoing axillary lymph node dissection, concordance with SLNB was 98.5% and 96.61% in MB and PBV, respectively. False-negative proportion for MB was 2.56% and 7.69% for PBV, respectively. The cost of MB is about INR 15 per ~10-mL vial. The cost of PBV is approximately ~$91 per ampoule (equivalent to approximately INR 8190). CONCLUSION: SLNB using MB can be recommended as the technique of choice in low-resource settings.

FISH and HER2/neu equivocal immunohistochemistry in breast carcinoma Geeta Vikram Patil Okaly, Dipti Panwar, Kavitha Bidadli Lingappa, Prasanna Kumari, Abhishek Anand, Prashantha Kumar, Manju Hosur Chikkalingaiah, Rekha Vijay Kumar Indian Journal of Cancer 2019 56(2):119-123 AIM: The aim of this study was to validate the role of fluorescence in situ hybridization (FISH) in investigating HER2/neu gene amplification (human epidermal growth factor receptor 2) in patients with HER2/neu equivocal breast cancer diagnosed on immunohistochemistry (IHC). MATERIALS AND METHODS: This was a retrospective study conducted from January 2013 to October 2017. A total of 134 patients diagnosed with invasive breast carcinoma and HER2/neu equivocal status on IHC were analyzed. Also, the cases for the years 2016 and 2017 formed a subgroup that was analyzed further to study the impact of pre-analytical factors on IHC and FISH results. RESULTS: A total of 134 women with HER2/neu IHC equivocal breast cancer were included in the study with a median age of 50 years (range 25–81). HER2/neu amplification by FISH was noted in 72 (54%) cases, whereas it was non-amplified in 52 (39%) cases. Ten cases were reported as equivocal even on FISH (ASCO/CAP 2013 guidelines). Polysomy 17 was noted in 55 cases (41%), of which 26 patients were≤50 years and 29 patients were >50 years of age. Twenty (36%) of these 55 cases showed HER2/neu amplification, whereas 26 (48%) cases were non-amplified and 9 (16%) cases were reported as equivocal on FISH. Also, more than half of the polysomy cases were hormone receptor negative. CONCLUSION: IHC is a good screening tool for negative and positive results. Any patient targeted for trastuzumab therapy should undergo confirmation of HER2/neu equivocal status by FISH analysis. We also suggest that if a non-classical FISH pattern is seen, the test should be repeated with a non-centromeric chromosome 17 reference locus probe for better treatment planning.

Survival and treatment outcomes of metaplastic breast carcinoma: Single tertiary care center experience in Pakistan Zarka Samoon, Madiha Beg, Romana Idress, Adnan A Jabbar Indian Journal of Cancer 2019 56(2):124-129 BACKGROUND: Metaplastic breast carcinoma (MBC) is a rare disease with incidence of less than 1%. MBC present with a larger tumor size, less number of nodes involved, mostly undifferentiated triple negative tumors. We aimed to determine progression-free and overall survival and reported hospital-based incidence of MBC. MATERIAL AND METHODS: A retrospective closed Cohort study elicited data of 42 patients with MBC from January 2008 to December 2013; followed till August 2016. Kaplan-Meier method was applied to compute overall and progression-free survival analysis. Cox Proportional hazard ratios were computed to assess associations between survival and independent variables. RESULTS: Hospital-based incidence of MBC was 1.92% (42/2187), 95% CI [1.41-2.56]. The median age at tumor diagnosis was 54 years (range, 25–81 years). Thirty-nine (92.9%) patients had Grade III tumor. The most common histopathology was squamous (69%). The median tumor size was 4.5 cm (range, 0.8–17 cm). Nineteen (45.2%) patients had nodal involvement at diagnosis. Four patients (9.5%) had metastatic disease at presentation. Hormone receptors were positive in 19 (45.2%) patients. Her-2 neu receptor was positive in 9 (19%) patients. Sixteen (38.1%) patients had triple negative disease. Neoadjuvant and adjuvant chemotherapy was received by 10 (31.25%) and 19 (45.2%) patients respectively. Both median progression-free and overall survival was 38 months. CONCLUSION: Five-year progression-free and overall survival was 79.5% and 76.3%, respectively. We report better survival outcomes when compared to series described earlier despite our patient population presenting mostly with high grade, large tumors, and half of them exhibiting nodal and hormonal involvement.

Association of serum level of vitamin D and VDR polymorphism Fok1 with the risk or survival of pancreatic cancer in Egyptian population Amal Ahmed Mohamed, Ahmed Moustafa Aref, Soha M Talima, Reham A A Elshimy, Shawkat S Gerges, Mohamed Meghed, Fawkia Eissa Zahran, Eman H EL-Adawy, Sherief Abd-Elsalam Indian Journal of Cancer 2019 56(2):130-134 BACKGROUND AND AIMS: Pancreatic cancer (PC) is the fourth most common cause of death from cancer in Egypt. Few studies have been conducted to assess the relationship between vitamin D serum level and vitamin D receptor (VDR) polymorphisms with the survival of PC patients. This is the first study in Egypt to investigate the association of the status of vitamin D serum level and genotypic distribution of single nucleotide polymorphisms (SNP) Fok1 with the risk of developing PC and whether they could detect survival or not. PATIENTS AND METHODS: The study included a total of 47 PC cases that were histopathologically proven to have PC, and 37 controls that were attending at the same time for investigation but proved that they were all PC free. Pre-diagnostic concentrations of vitamin D and VDR polymorphism Fok1 were assessed from all participants in the study. RESULTS: There was a 1.5-fold increase in the serum level of vitamin D in PC patients when compared to non-PC subjects. Regarding VDR Fok1, polymorphism distribution in PC was CC (Wild Type) 26 (55.3%), CT 16 (34%), and TT 5 patients (10.7%). For the control group, CC was found in 24 (64.8%), CT in 12 (32.4%), and TT genotype was found only in one individual 1 (2.8%) with no statistically significant difference between the two studied groups (P 0.72). CONCLUSION: Low serum vitamin D or VDR-SNP is not a risk factor for PC in Egyptian patients. Recommendations to increase vitamin D concentrations in healthy persons for the prevention of cancer and improving overall survival should be carefully considered.

Analysis of clinicopathological and immunohistochemical parameters and correlation of outcomes in gastrointestinal stromal tumors Vaibhav Kumar Varshney, Rakesh Kumar Gupta, Sundeep Singh Saluja, Ila Tyagi, Pramod Kumar Mishra, Vineeta V Batra Indian Journal of Cancer 2019 56(2):135-143 INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. We analyzed the clinicopathological features, resectability, immunohistochemical markers, and various factors predictive of disease recurrence and survival. MATERIALS AND METHODS: Retrospective analysis of prospectively maintained database of GIST patients managed from 2005 to 2016 was done. Size, site, malignant potential, nuclear pleomorphism, histopathological variety, immunohistochemical markers, type of surgery, and adjuvant imatinib therapy were analyzed. RESULTS: Ninety-two patients with GIST were analyzed. Immunohistochemistry showed positivity for c-kit (82.4%), DOG1 (75%), and PDGFR-α (79%). Among 16 patients with c-kit-negative tumors, 10 patients were positive for DOG1, PDGFR-α, or both. The most common primary site was stomach (44, 47.8%) followed by small bowel (17, 18.5%) and duodenum (14, 15.2%). Of 92 patients, 80 (87%) underwent R0 resection with organ sparing resection in 56 (70%) patients. Seventeen (21.3%) patients showed recurrence at a median follow-up of 6 years. Median and 5-year overall survival (OS) was 36 months (12–120) and 75%, respectively, and 5-year RFS was 81.8%. On univariate analysis, size, mitotic activity, malignant potential, and nuclear pleomorphism were predictors of recurrence. However, on multivariate analysis, only nuclear pleomorphism was significant. CONCLUSIONS: GISTs had a wide spectrum of presentation, and immunohistopathological features with organ sparing resection were conceivable in maximum. Nuclear pleomorphism may be considered as an important variable to predict recurrence in addition to malignant potential of tumors.

MCQs for "Analysis of clinicopathological and immunohistochemical parameters and correlation of outcomes in gastrointestinal stromal tumors" HS Darling, S Jayalakshmi, Pradeep Jaiswal Indian Journal of Cancer 2019 56(2):144-145

Financial audit of wastage of anticancer drugs: Pilot study from a tertiary care center in India Veena Reshma D'Souza, Princy Louis Palatty, Thomas George, Mohammed Adnan, Suresh Rao, Manjeshwar Shrinath Baliga Indian Journal of Cancer 2019 56(2):146-150 PURPOSE: Drug wastage is a major concern in oncology where costs of antineoplastic drugs are exorbitant, and the disposal of toxic drugs increases the chances of occupational hazards to healthcare and sanitary workers and environmental pollution at the site of disposal. The principal objective of this study was to ascertain the extent of drug wastage and calculate its financial costs. MATERIALS AND METHODS: This was a prospective pilot study conducted to ascertain the quantity of drug wastage in a tertiary care hospital. This pilot study was conducted in day care and inpatient facilities in February 2016. The prescription of cytotoxic drugs, recommended dose, the quantity used, and remainder (waste) left were recorded from the nurses and pharmacy files of the hospital. Cost evaluation of the actual use and the waste was undertaken and an audit was conducted to understand in which anticancer drug the maximum wastage was generated. RESULTS: The results of this study indicated that 6.1% of the total amount of reconstituted drugs was wasted. The highest drug wastage was observed in trastuzumab (29.55%), followed by etoposide (20.4%), dacarbazine (17.14%), daunorubicin (16.67%), and carboplatin (11.29%). Cost analysis showed that the total cost of the drug issued during the study period was Rs. 1,294,975 and the cost of drug wastage amounted to Rs. 143,820 (11.1%). CONCLUSION: To the best of authors' knowledge, this is the first study from India and the results indicate that the financial impact of anticancer drug wastage was substantial. Attempts should be directed at minimizing the wastage and cost savings without risking patients' treatment regimen and administering effective dose schedule.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Cardiovascular

Checklists, artificial intelligence, and much more! Sandeep Seth, Shyamal K Goswami Journal of the Practice of Cardiovascular Sciences 2019 5(1):1-1

Checklists – The road to a safer healthcare in heart failure patients Bharat Raj Kidambi, Sandeep Seth Journal of the Practice of Cardiovascular Sciences 2019 5(1):2-11 Health care today is complex and mistakes can occur due to multiple reasons from lack of knowledge to simply lack of attention to detail. Checklists are a way to prevent mistakes and implement common standards of care but there are difficulties in implementing checklists. In this article we are showing a series of checklists which we have successfully used in the management of heart failure in a tertiary care hospital in India. The checklists start from the time the patient is admitted (the Intensive care Check list) to the time of discharge. The patient's visit to the out patient department is also covered by multiple education cards and checklists (Heart Failure Checklist, HRIDAY CARD). There are also standard prognostic tools (Seattle heart failure score and many others) which are used to prognosticate patients which do not respond to drug therapy. The I-NEED-HELP tool is explained to choose patients who might benefit from an cardiac assist device or a heart transplant.

Machine learning and medical research data analysis Rajiv Narang, Jaya Deva, Sada Nand Dwivedi Journal of the Practice of Cardiovascular Sciences 2019 5(1):12-13

Cardiology update - The first quarter Satyavir Yadav, Faraz Ahmed Farooqui, Swati Singh Journal of the Practice of Cardiovascular Sciences 2019 5(1):14-17 The first round of this year covers a lot about dual-antiplatelet therapy duration after stent placement, coronary angiography after a cardiac arrest, transcatheter aortic valve replacement indications in low-risk patients, sodium–glucose cotransporter 2 inhibitor results, angiotensin receptor neprilysin inhibitor in acute heart failure, and many other trials.

Acute coronary syndrome in young - A tertiary care centre experience with reference to coronary angiogram Tammiraju Iragavarapu, T Radhakrishna, K Jagadish Babu, R Sanghamitra Journal of the Practice of Cardiovascular Sciences 2019 5(1):18-25 Background: Acute coronary syndrome (ACS) is a potentially life-threatening condition which is more common in elderly people, and young are relatively protected. Currently, the protective effect on young from coronary artery disease (CAD) is taken away by several risk factors. The aim of this study is to determine the conventional risk factors and angiographic correlation of CAD in young age (<40 years) to that of elderly age (>40 years). Materials and Methods: This study was a hospital-based retrospective cross-sectional analytical study involving 1151 patients of ACS admitted in the cardiac ICU from May 2016 to May 2018. Among these patients, coronary risk factors such as smoking, diabetes, hypertension, dyslipidemia, and family history were studied. Patients were divided into two groups, Group A: <40 years and Group B: >40 years. Patients were evaluated angiographically. The significance of each risk factor between the groups was calculated by employing the Chi-square test and P < 0.05 was taken as statistically significant. Results: A total of 1151 cases were included in the study, of which 120 cases were <40 years of age. The prevalence of CAD in young in our study is 10.42% with male preponderance. P value is statistically significant (P < 0.05) among younger individuals for smoking, dyslipidemia, obesity, family history. Of 120 cases with critical CAD, single-vessel disease (SVD), predominantly the left anterior descending artery, was the most prevalent. SVD and recanalized coronaries were statistically significant among younger group whereas triple-vessel disease (TVD) is statistically significant among the elderly. Thrombus burden is more in young when compared to the elderly. Conclusion: Although ACS is a less common entity in young adults aged 40 years or less, recent epidemiological trend is progressing and it constitutes an important challenge both for a patient and for a treating physician. Young patients with CAD are mainly males, and SVD is more common. Emphasis should be given on diagnosis and management of risk factors in this vulnerable group to prevent mortality and morbidity.

Is there an association of intracardiac mass with high urate level? AIM-HUL study Kamal Sharma, Dhammdeep Humane, Jevin Jhamaria, Sharad Jain, Krutika Patel, Sachin Patil, Sanjeev Bhatia, Jasraj Panwar Journal of the Practice of Cardiovascular Sciences 2019 5(1):26-29 Context: Hyperuricemia is associated with idiopathic left atrium/left ventricular clot, and its association with other intracardiac tumors is not clear. Aim: The study aimed to establish if there is an association of intracardiac mass with high urate level. Settings and Design: This prospective study included 440 individuals, of which 330 were consecutive all comers with intracardiac mass detected on echocardiography from June 2016 to December 2017, who were compared with 110 randomly selected healthy controls undergoing echocardiography during the same without intracardiac mass in a ratio of 3:1. Materials and Methods: Imaging modalities such as transesophageal echocardiography, cardiac computerized tomography, and/or cardiac magnetic resonance imaging were done to analyze the intracardiac mass. Both the groups were analyzed for serum uric acid (SUA) levels at the time of detection of intracardiac mass. Statistical Analysis Used: Univariate analysis was done for continuous variables using Student's t-test, whereas the Chi-square test was used for the categorical data. Logistic regression analysis was performed with the presence of a mass with SUA as the dependent variable. Results: Among a total of 440 patients, 330 were cases and 110 were controls with the mean age of 47.52 ± 16.02 years (18–77 years) versus 45.23 ± 14.10 (18–73 years) years with male:female ratio of nearly 3:2 in both the groups. Mean SUA in cases was significantly higher than controls (7.60 ± 0.93 vs. 4.52 ± 1.20 mg%) (P < 0.001 with 7.6 [95% confidence interval (CI): 7.5–7.7] and 4.52 [95% CI: 4.3–4.74]) with linear logistic regression coefficient of 0.64. There was no significant difference in SUA levels among different types of intracardiac mass (P = 0.31). Conclusion: Hyperuricemia is associated with all comers of intracardiac mass with a regression coefficient of 0.64 irrespective of the nature of mass.

Obstructive coronary artery disease in women presenting with ischemic chest pain: Prevalence and risk determinants Kunal Mahajan, Arvind Kandoria, Rajeev Bhardwaj, Meenakshi Kandoria Journal of the Practice of Cardiovascular Sciences 2019 5(1):30-34 Background: Women present more commonly with atypical angina, false-positive exercise test, and normal/nonobstructive coronary angiogram. It thus becomes essential to identify the predictors of obstructive coronary artery disease (CAD) in women to avoid unnecessary invasive angiograms. Methods: We prospectively recorded the data of consecutive 578 women who underwent coronary angiography in our institute for typical/atypical chest pain suspected to be secondary to CAD. Results: Normal coronaries/nonobstructive CAD were seen in 273 (47.2%) patients, whereas 305 (52.8%) patients were found to have obstructive CAD (P < 0.0001). On multivariate logistic regression analysis, the presence of typical angina, age >55 years, smoking, diabetes mellitus, hypertension, low-density lipoprotein cholesterol >150 mg/dl, and high-density lipoprotein cholesterol <40 mg/dl were found to be independent predictors of obstructive CAD. Conclusion: These risk predictors can help in the reliable assessment of pretest likelihood of obstructive CAD in women, thereby avoiding many unnecessary invasive coronary angiograms. Further larger studies are warranted to validate these results and propose accurate prediction models for the diagnosis of obstructive CAD in women.

Tumor necrosis factor-alpha gene polymorphisms and complex disorders: A study among mendelian population with East Asian Ancestry Salam Kabita, Priyanka Rani Garg, Masan Kambo Newmei, Kallur Nava Saraswathy, Huidrom Suraj Singh Journal of the Practice of Cardiovascular Sciences 2019 5(1):35-43 Background and Objectives: Tumor necrosis factor-alpha (TNF-α)-238G/A and -308G/A single-nucleotide polymorphisms (SNPs) in the promoter region of the gene have been implicated in numerous diseases. The present study aims to investigate the frequency of two TNF-α polymorphisms among Mendelian population of India and to assess their association with various cardiovascular risk variables and outcomes (hypertension [HTN], metabolic syndrome [MetS], and type 2 diabetes mellitus). Materials and Methods: A total of 1142 unrelated individuals aged 35–75 years belonging to Meitei community of Manipur were included in the study. Height, weight, waist and hip circumferences, blood pressures (systolic and diastolic), and lipid profile were measured. Polymerase chain reaction was done using standard protocols. Further, HTN, MetS, diabetic, and healthy individuals were identified, and a nested case–control study design was formulated. Results: The mutant allele frequency was found to be similar (4%) for both the polymorphisms among the Meiteis of Manipur. No mutant homozygote of TNF-α-308G/A polymorphism was observed. No significant risk of the two polymorphisms was found with any of the disease groups in nested case–control analysis. However, TNF-α-308G/A polymorphism, but not TNF-α-238G/A polymorphism, was found to be associated with total cholesterol (TC), triglyceride (TG), and very-low-density lipoprotein (VLDL) in overall population only with TG and VLDL among the HTN cases. Conclusion: The association of TNF-α-308A allele with metabolic risk factors such as TC, TG, and VLDL suggests that though it may not increase the development of any of the diseases considered in the present study, it could possibly enhance the risk of human metabolic disorder. The absence of mutant homozygote among cases is suggestive of lethality of TNF-α-308A allele in double dose coupled with other environmental factors or in the presence of haplotype pairing with TNF-α-238A allele.

Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia M Aseem Basha Journal of the Practice of Cardiovascular Sciences 2019 5(1):44-47

Eisenmenger's syndrome: Management and workup for heart–lung transplant Jay Relan, Sakshi Sachdeva, Neeraj Awasthy, Sivasubramanian Ramakrishnan Journal of the Practice of Cardiovascular Sciences 2019 5(1):48-52 Heart–lung transplant remains the final option for patients with congenital heart disease (CHD) and irreversible pulmonary vascular obstructive disease (PVOD) when the patients are symptomatic despite optimal medical management. This panel discussion, held during cardiovascular disease convergence 2018, takes us through the journey of an 18-year-old patient suffering from a complex cyanotic CHD with irreversible PVOD and severe ventricular dysfunction. Pertinent management issues concerning pharmacotherapy and supportive care are discussed. Finally, workup and listing criteria for heart–lung transplant are discussed. The patient still awaits heart–lung transplant.

Alexandros Sfakianakis
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6948891480

alsfakia@gmail.com