Clinical characteristics and treatment outcomes of germ cell tumor in Jordan: A tertiary center experience.

Objective: In the Middle East, there is a paucity of data regarding germ cell tumor characteristics and treatment outcomes. Herein, we aim to present the largest series in Jordan reporting our cancer center experience managing GCT. Methods: Between 2010 and 2020, a total of 241 patients with a pathological diagnosis of GCT were treated at our cancer center. Demographic, epidemiologic, and pathological data were retrospectively collected. In addition, survival and relapse outcomes based on tumor stage and adjuvant treatment were collected. Results: A total of 241 patients were diagnosed with GCT, of whom 108 (44.8%) had seminoma and 133 (55.2%) had non-seminoma tumors (NSGCT). Median age (interquartile range) at diagnosis was 31 years (25-36). Patients with seminoma (68.5%) had pT1 disease post orchiectomy, while only 37.5% of patients with NSGCT had pT1 on final pathology. Elevated tumor markers such as beta-human chorionic gonadotropin were present in 10% of seminomas. Following radical orchiectomy and staging, 88 (36.5%) went for active surveillance while 153 patients (63.5%) received adjuvant treatment. With regard to pathology slides read outside, rereading by our genitourinary pathologist yielded a discrepancy on GCT type in 41 (19.3%) out of 212 patients. The median follow-up was 36 (24-48) months. Twenty-two patients relapsed after an average follow-up time of 39 months. The 5-year overall survival for stage I, II, and III was 98%, 94%, and 87%, respectively, and 3-year recurrence-free survival for stage I, II, and III was 94.8%, 78%, and 67%, respectively. Conclusion: Our data on testicular GCT including demographic, histological, and treatment outcomes were comparable to that of developed countries. In light of the pathology discrepancy rate revealed in our study, authors recommend a second review by expert genitourinary pathologists to ensure proper classification and management of GCT.

Quality of life and other patient-reported outcomes in adult Lebanese patients with type 2 diabetes during COVID-19 pandemic.

INTRODUCTION: Several studies have shown that COVID-19 pandemic has a negative impact on type 2 diabetic mellitus (T2DM) patients' quality of life (QoL). However, very few studies were performed in Middle Eastern countries. AIM: The aim of the current study was to assess, the QoL and diabetes-specific QoL, treatment satisfaction and psychological distress of Lebanese patients with T2DMs using: the Audit of Diabetes-Dependent Quality of Life (ADDQoL), Diabetes Treatment Satisfaction Questionnaire status version (DTSQs) and Kessler 10 (K10) questionnaires and to compare results to those obtained during the pre-COVID-19 period. RESULTS: 461 patients with T2DM participated in the study; 52.6% men, 47.4% women; median age 59 years old. The respective median ADDQoL and DTSQs scores were - 2.2 (interval interquartile range (IQR) - 3.9, - 0.8) (range from - 9 maximum negative impact to + 3 maximum positive impact) and 30(IQR22-36) (range from 0 maximum dissatisfaction to 36 maximum satisfaction). K10 median score was 26(IQR18-35) (range from minimum score of 10 indicating no distress to maximum score of 50 indicating severe distress). Rural dwelling, lack of exercise, current smoking, diabetic complications, injectable diabetes treatment, and previous COVID-19 infection were all associated with significantly worse ADDQoL, DTSQs, and K10 score indicating greater distress. A significant worsening of ADDQoL scores followed onset of the pandemic with no significant change in DTSQs scores. CONCLUSION: During the COVID-19 pandemic, T2DM Lebanese patients experienced more negative impact of diabetes on QoL and mental health. Those infected with COVID-19 also reported worse QoL, treatment satisfaction and mental health. This highlights the need for community and individual support.

Orbital symmetries of charge density wave order in YBa2Cu3O6+x.

Charge density wave (CDW) order has been shown to compete and coexist with superconductivity in underdoped cuprates. Theoretical proposals for the CDW order include an unconventional d-symmetry form factor CDW, evidence for which has emerged from measurements, including resonant soft x-ray scattering (RSXS) in YBa2Cu3O6+x (YBCO). Here, we revisit RSXS measurements of the CDW symmetry in YBCO, using a variation in the measurement geometry to provide enhanced sensitivity to orbital symmetry. We show that the (0 0.31 L) CDW peak measured at the Cu L edge is dominated by an s form factor rather than a d form factor as was reported previously. In addition, by measuring both (0.31 0 L) and (0 0.31 L) peaks, we identify a pronounced difference in the orbital symmetry of the CDW order along the a and b axes, with the CDW along the a axis exhibiting orbital order in addition to charge order.

Nematicity in stripe-ordered cuprates probed via resonant x-ray scattering.

In underdoped cuprate superconductors, a rich competition occurs between superconductivity and charge density wave (CDW) order. Whether rotational symmetry-breaking (nematicity) occurs intrinsically and generically or as a consequence of other orders is under debate. Here, we employ resonant x-ray scattering in stripe-ordered superconductors (La,M)2CuO4 to probe the relationship between electronic nematicity of the Cu 3d orbitals, structure of the (La,M)2O2 layers, and CDW order. We find distinct temperature dependences for the structure of the (La,M)2O2 layers and the electronic nematicity of the CuO2 planes, with only the latter being enhanced by the onset of CDW order. These results identify electronic nematicity as an order parameter that is distinct from a purely structural order parameter in underdoped striped cuprates.

Orbital symmetry of charge-density-wave order in La1.875Ba0.125CuO4 and YBa2Cu3O6.67.

Recent theories of charge-density-wave (CDW) order in high-temperature superconductors have predicted a primarily d CDW orbital symmetry. Here, we report on the orbital symmetry of CDW order in the canonical cuprate superconductors La1.875Ba0.125CuO4 (LBCO) and YBa2Cu3O6.67 (YBCO), using resonant soft X-ray scattering and a model mapped to the CDW orbital symmetry. From measurements sensitive to the O sublattice, we conclude that LBCO has predominantly s' CDW orbital symmetry, in contrast to the d orbital symmetry recently reported in other cuprates. Furthermore, we show for YBCO that the CDW orbital symmetry differs along the a and b crystal axes and that these both differ from LBCO. This work highlights CDW orbital symmetry as an additional key property that distinguishes the different cuprate families. We discuss how the CDW symmetry may be related to the '1/8-anomaly' and to static spin ordering.

Symmetry of charge order in cuprates.

Charge-ordered ground states permeate the phenomenology of 3d-based transition metal oxides, and more generally represent a distinctive hallmark of strongly correlated states of matter. The recent discovery of charge order in various cuprate families has fuelled new interest into the role played by this incipient broken symmetry within the complex phase diagram of high-T(c) superconductors. Here, we use resonant X-ray scattering to resolve the main characteristics of the charge-modulated state in two cuprate families: Bi2Sr(2-x)La(x)CuO(6+δ) (Bi2201) and YBa2Cu3O(6+y) (YBCO). We detect no signatures of spatial modulations along the nodal direction in Bi2201, thus clarifying the inter-unit-cell momentum structure of charge order. We also resolve the intra-unit-cell symmetry of the charge-ordered state, which is revealed to be best represented by a bond order with modulated charges on the O-2p orbitals and a prominent d-wave character. These results provide insights into the origin and microscopic description of charge order in cuprates, and its interplay with superconductivity.

Impact of quenched oxygen disorder on charge density wave order in YBa2Cu3O6+x.

The competition between superconductivity and charge density wave (CDW) order in underdoped cuprates has now been widely reported, but the role of disorder in this competition has yet to be fully resolved. A central question is whether disorder sets the length scale of the CDW order, for instance by pinning charge density fluctuations or disrupting an otherwise long-range order. Using resonant soft x-ray scattering, we investigate the sensitivity of CDW order in YBa2Cu3O6+x (YBCO) to varying levels of oxygen disorder. We find that quench cooling YBCO6.67 (YBCO6.75) crystals to destroy their o-V and o-VIII (o-III) chains decreases the intensity of the CDW superlattice peak by a factor of 1.9 (1.3), but has little effect on the CDW correlation length, incommensurability, and temperature dependence. This reveals that while quenched oxygen disorder influences the CDW order parameter, the spatial extent of the CDW order is insensitive to the level of quenched oxygen disorder and may instead be a consequence of competition with superconductivity.

Resonant X-ray scattering measurements of a spatial modulation of the Cu 3d and O 2p energies in stripe-ordered cuprate superconductors.

A prevailing description of the stripe phase in underdoped cuprate superconductors is that the charge carriers (holes) phase segregate on a microscopic scale into hole-rich and hole-poor regions. We report resonant elastic x-ray scattering measurements of stripe-ordered La(1.475)Nd(0.4)Sr(0.125)CuO(4) at the Cu L and O K absorption edges that identify an additional feature of stripe order. Analysis of the energy dependence of the scattering intensity reveals that the dominant signature of the stripe order is a spatial modulation in the energies of Cu 3d and O 2p states rather than the large modulation of the charge density (valence) envisioned in the common stripe paradigm. These energy shifts are interpreted as a spatial modulation of the electronic structure and may point to a valence-bond-solid interpretation of the stripe phase.

Distinct charge orders in the planes and chains of ortho-III-ordered YBa2Cu3O(6+δ) superconductors identified by resonant elastic x-ray scattering.

Recently, charge density wave (CDW) order in the CuO(2) planes of underdoped YBa(2)Cu(3)O(6+δ) was detected using resonant soft x-ray scattering. An important question remains: is the chain layer responsible for this charge ordering? Here, we explore the energy and polarization dependence of the resonant scattering intensity in a detwinned sample of YBa(2)Cu(3)O(6.75) with ortho-III oxygen ordering in the chain layer. We show that the ortho-III CDW order in the chains is distinct from the CDW order in the planes. The ortho-III structure gives rise to a commensurate superlattice reflection at Q=[0.33 0 L] whose energy and polarization dependence agrees with expectations for oxygen ordering and a spatial modulation of the Cu valence in the chains. Incommensurate peaks at [0.30 0 L] and [0 0.30 L] from the CDW order in the planes are shown to be distinct in Q as well as their temperature, energy, and polarization dependence, and are thus unrelated to the structure of the chain layer. Moreover, the energy dependence of the CDW order in the planes is shown to result from a spatial modulation of energies of the Cu 2p to 3d(x(2)-y(2)) transition, similar to stripe-ordered 214 cuprates.

An in-vacuum diffractometer for resonant elastic soft x-ray scattering.

We describe the design, construction, and performance of a 4-circle in-vacuum diffractometer for resonant elastic soft x-ray scattering. The diffractometer, installed on the resonant elastic and inelastic x-ray scattering beamline at the Canadian Light Source, includes 9 in-vacuum motions driven by in-vacuum stepper motors and operates in ultra-high vacuum at base pressure of 2 × 10(-10) Torr. Cooling to a base temperature of 18 K is provided with a closed-cycle cryostat. The diffractometer includes a choice of 3 photon detectors: a photodiode, a channeltron, and a 2D sensitive channelplate detector. Along with variable slit and filter options, these detectors are suitable for studying a wide range of phenomena having both weak and strong diffraction signals. Example measurements of diffraction and reflectivity in Nd-doped (La,Sr)(2)CuO(4) and thin film (Ga,Mn)As are shown.

Determination of total x-ray absorption coefficient using non-resonant x-ray emission.

An alternative measure of x-ray absorption spectroscopy (XAS) called inverse partial fluorescence yield (IPFY) has recently been developed that is both bulk sensitive and free of saturation effects. Here we show that the angle dependence of IPFY can provide a measure directly proportional to the total x-ray absorption coefficient, µ(E). In contrast, fluorescence yield (FY) and electron yield (EY) spectra are offset and/or distorted from µ(E) by an unknown and difficult to measure amount. Moreover, our measurement can determine µ(E) in absolute units with no free parameters by scaling to µ(E) at the non-resonant emission energy. We demonstrate this technique with measurements on NiO and NdGaO(3). Determining µ(E) across edge-steps enables the use of XAS as a non-destructive measure of material composition. In NdGaO(3), we also demonstrate the utility of IPFY for insulating samples, where neither EY or FY provide reliable spectra due to sample charging and self-absorption effects, respectively.

[Perioperative use of antithrombotic agents: recommendations of the American College of Chest Physicians (ACCP) and the French Superior Health Authority (HAS)]. / La prise en charge périopératoire des traitements antithrombotiques. Des recommandations de l'American College of Chest Physicians (ACCP) à celles de la Haute Autorité de santé (HAS).

The purpose of this work was to analyse management practices for patients given anticoagulants or antiplatelet agents such as aspirin, clopidogrel and who are to undergo an invasive procedure or surgery. The modalities for the transition from oral agents to low-molecular-weight-heparin (LMWH) or unfractionated heparin (UFH) are studied. The recommendations or suggestions using the ACCP score: grade 1 recommendations are strongly motivated and indicate whether the benefit overbalances or not the risk, the burden, and the cost of the treatment. Grade 2 recommendations are considered to be suggestions. They imply that the individual physician chooses between different therapeutic strategies. For the purpose of this work, the most important recommendations are the following:

[Treatment of deep venous thrombosis by low molecular weight heparins. Comments on the recommendations of the North American Consensus]. / Le traitement de la thrombose veineuse profonde par les héparines de bas poids moléculaire. Commentaires sur les recommendations du Consensus Nord-Américain.

LMW heparins have recently come into use in North America for treatment of venous thrombosis. Their first line recommendation is a major innovation of the last north american consensus conference on antithrombotics published in Chest at the beginning of 2001. This recommendation is grade 1A regarding its advantageous benefit-risk ratio. An earlier oral vitamine K antagonist treatment and a more regular nomogram use allow to reduce the relay duration and to obtain more often the targeted INR. The more predictable anticoagulant response with weight-based doses induces a simplified anti-Xa activity survey limited to renal dysfunction and obese or less than 50 Kg body weight persons but a regular platelet count remains mandatory. Several questions need to be discussed: once or twice daily subcutaneous injection use and treatment duration which seem related to the persistence of triggering factors, the variety of thrombophilia and comorbidity conditions. Due to a greater evidence-based medicine, the antithrombotic strategy becomes more related to a closer evaluation of the individual thrombotic risk level.

Coexistence of acute cellular rejection and lymphoproliferative disorder in a lung transplant patient.

We report the case of a 37-year-old man who underwent bilateral lung transplantation for end-stage cystic fibrosis. Two months after his operation, a computed tomographic scan showed multifocal nodules throughout both lungs. Endobronchial biopsies revealed an Epstein-Barr virus-associated B-cell lymphoproliferation. Transbronchial biopsies revealed perivascular lymphoid infiltrates composed of predominantly small T lymphocytes. These perivascular infiltrates were retrospectively considered to be an acute cellular rejection rather than the periphery of the lymphoproliferative disorder. This opinion was based on several arguments: (a) a decrease in dosage of maintenance immunosuppression led to total regression of the lymphoproliferation but did not affect the perivascular lymphoid infiltrates; (b) the treatment of the acute cellular rejection temporarily induced the disappearance of the perivascular infiltrates; (c) the expression of Epstein-Barr virus was not detected in the perivascular infiltrates; and (d) on autopsy, performed 1 year later, severe obliterative bronchiolitis lesions were discovered, for which acute cellular rejection is the main risk factor. These observations point to the possibility that acute cellular rejection and an Epstein-Barr virus-associated lymphoproliferative disorder may coexist.

[Economic assessment of the use of tinzaparin in the treatment of acute pulmonary embolism in France]. / Evaluation économique de l'utilisation de la tinzaparine dans le traitement de l'embolie pulmonaire aiguë en France.

OBJECTIVE: This pharmacoeconomic study was conducted to determine the cost of using tinzaparin, a low-molecular-weight heparin (LMWH), administered intravenously, in comparison with non-fractionated heparin (NFH) for the treatment of acute pulmonary embolism (PE) in France. METHODS: A decision algorithm indicating the therapeutic schedules and their consequences was constructed from data collected during a large-scale multicentric study and from data obtained from interviews with French physicians implicated in the treatment of pulmonary embolism. This model was used to estimate costs and to compare per patient expenditures for the two therapeutic schedules. RESULTS: Cost of instituting treatment per patient (excluding costs common to both schedules) was 202 euros for NFH and 77 euros for tinzaparin (delta 125 euros in favor of tinzaparin). Including follow-up costs for the 90 day analysis period, tizaparin reduced costs by 123 euros per patient (211 versus 334 euros for patients treated with NFH). Taking into account the sole cost of management of the two critical events that occurred during NFH or tinzaparin (8 first days) treatment, tinzaparin reduced costs by 137 euros per patient (112 euros versus 249 euros respectively). CONCLUSION: Tinzaparin reduced health care costs for pulmonary embolism due to easier administration, less complex laboratory tests, and personnel time savings. The robustness of the results was confirmed by the sensitivity analysis.

The thrombophilic state in cancer patients.

Thrombosis and disseminated intravascular coagulation are common complications of cancer. Specific conditions associated with cancer such as stasis due to immobilization or blood flow obstruction, surgery, infections, endothelium damage due to chemotherapeutic agents and abnormalities of blood coagulation contribute to the hypercoagulable and thrombophilic state of cancer patients. This procoagulant state in cancer arises mostly from the capacity of tumor cells to express and release procoagulant activities (cancer procoagulant and tissue factor). Decreased levels of inhibitors of coagulation, impaired fibrinolysis, the presence of antiphospholipid antibodies and an acquired activated protein C resistance contribute to the hypercoagulable state. The activation of coagulation is also implicated in tumor proliferation through interactions of coagulation with inflammation and increased tissue factor pathway inhibitor. Laboratory diagnosis of the thrombophilic state include (1) elevation of clotting factors, fibrinogen/fibrin degradation products, hyperfibrinogenemia and thrombocytosis and (2) elevation of specific markers of activation of coagulation: fibrinopeptide A, fragment 1 + 2, thrombin-antithrombin complexes and D-dimers. However, none of the tests has any predictive value for the occurrence of thrombotic events in one individual patient. In patients with venous thromboembolism a noninvasive screening for occult cancer is able to detect a relatively high incidence of hidden cancer and the search for thrombophilia seems important in patients without known cancer.

Contralateral lung transplantation: a left lung implanted in the right thorax.

Since the inception of lung transplantation in 1982, it has been standard practice to implant donor lungs on the ipsilateral side in the recipient. The development of the techniques of lobar and bilateral lobar transplantation has shown that lung morphology may adapt to the shape of the thorax. Thus, variations in implantation have become possible. We describe a case of a 30-year-old man with severe bronchiectasis due to ciliary dyskinesis which required a left lower lobectomy at the age of 11 years and a left completion pneumonectomy 10 years later. His disease progressed and he was listed for a right lung transplantation. At the time of transplantation, the donor right lung was noted to be edematous and unfit for transplantation. This required grafting the donor left lung in the right thorax of the recipient. Follow-up at 7 years shows good exercise capacity and excellent functional tests without evidence of rejection.