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Background: Children in low-resource countries like Georgia often have limited access to assessment measures for mental health care services. This study adapts and validates the mental health screening tool the Strength and Difficulties Questionnaire for use in Georgian children. Methods: A total of 16 654 children were assessed by a parent and/or teacher using Georgian-adapted Strength and Difficulties Questionnaire. Receiver operating characteristic analyses were performed to assess the discriminative validity of the Strength and Difficulties Questionnaires and to establish an optimal cutoff score. Results: Data from 15 738 parents- and 13 560 teachers-administered Strength and Difficulties Questionnaire were analyzed. The internal consistency analysis showed Cronbach's alpha to be 0.625 and 0.621 for parent- and teacher-administered Strength and Difficulties Questionnaire, respectively. The area under the curve (95% CI) shows that the Strength and Difficulties Questionnaire can differentiate risk group children from typically developing peers: parent-administered questionnaires-0.629 (0.556-0.702) and teacher-administered questionnaires-0.680 (0.611-0.789). Parent-administered Strength and Difficulties Questionnaire has a cutoff value of 16 or more with 92.5% of sensitivity and teacher-administered Strength and Difficulties Questionnaire-14 or more with a sensitivity of 85.6%. Conclusion: The study finds that the Strength and Difficulties Questionnaire is a valid screening instrument and does not depend on the informant-parent or teacher. It suggests that with appropriate cultural adaptation, the SDQ can be used in the Republic of Georgia to identify children at risk for mental disorders and help guide resource allocation.
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Infants are highly vulnerable, requiring the protection of caregivers for their survival. Unfortunately, infant abandonment continues to be committed regularly, posing a serious challenge to the dignity of human life. To identify the motivation and background information of this crime, we analyzed 20 cases of infant abandonment to determine their critical characteristics. We aimed to gather data to assist in crime prevention and ultimately to address the need for new policies to prevent this crime. The results of our analysis are as follows: The mothers who abandoned their infants were in their teens and twenties in 15 cases (75%). The relationship between the biological parents was that of longterm partners in 12 cases (60%). The place of childbirth was the perpetrator’s home in 16 cases (80%). The place of abandonment wasoutdoors in 9 cases (5 cases alive, 4 cases dead) and indoors in 10 cases (5 cases alive, 5 cases dead). Basic life support for the infant was provided in 4 cases. The most common excuse for abandonment was to conceal childbirth in 12 cases, followed by economic hardship in 8 cases. Executions were suspended in 19 cases, and the reasons for the sentences often seemed inadequate, even in light of the provisions of the criminal code. These results indicate that our society has the need to develop the appropriate acts or policies to stop the crime of infant abandonment.
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Syringocystadenoma papilliferum (SCAP) and apocrine hidrocystoma (AH) are benign apocrine neoplasms that usually occur separately. SCAP arises predominantly in head and neck, while AH typically develop in periorbital area. We report a case of a 68-year-old male with an asymptomatic erythematous papulonodule that occurred on his back 3 years ago. Histologic examination showed cystic invagination extending from the epidermis into the dermis with some papillary projections. The invaginated portion was lined by epithelial bilayer composed of cuboidal and columnar cells, and decapitation secretion was observed in the inner epithelial layer. In the deep dermis, multiple cystic spaces with variable sizes were observed, and these cysts also presented double layers of the epithelium and decapitation secretion.According to such histologic features, the coexistence of SCAP and AH within a single lesion was demonstrated. The patient was recommended to completely remove the remaining lesion after punch biopsy, but he refused further surgical management. Herein, we report an unusual case of complex apocrine tumor with a rare composition in an atypical site.
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Purpose@#Prognostic Index for Natural Killer Lymphoma (PINK) is the most widely accepted prognostic model for patients withextranodal natural killer/T-cell lymphoma (ENKTL) treated with non-anthracycline–based therapy. We aimed to evaluate the prognostic implications of serum β-2 microglobulin (β2M) in the context of PINK and proposed a new prognostic model. @*Materials and Methods@#A total of 138 patients who were newly diagnosed with ENKTL and treated with non-anthracycline-based chemotherapy were identified. The cut-off value of high serum β2M was calculated by maximal-chi square methods (4.1 mg/L). A new prognostic model incorporating serum β2M into PINK was proposed and validated in an independent validation cohort (n=88). @*Results@#The patients’ median age was 53.5 years (range, 19 to 80 years). Patients with high serum β2M levels had significantly worse overall survival (OS) and progression-free survival (PFS). In multivariate analysis, high serum β2M was an independent adverse prognostic factor for OS. A new PINK-B (Prognostic Index for Natural Killer Lymphoma-serum β-2 microglobulin) model stratifiedpatients into three groups with distinct OS and PFS in the training cohort (3-year OS, 84.1% [95% confidence interval, 75.1 to 94.2], 46.8% [36.1 to 60.8] and 17.6% [6.3 to 49.2] for the low-, intermediate, and high-risk groups, respectively; 3-year PFS, 70.6% [59.4 to 83.8], 35.9% [25.9 to 49.8], and 7.35% [1.1 to 46.7] for the low-, intermediate-, and high-risk groups, respectively). The PINK-B model was further validated in an independent cohort. @*Conclusion@#Serum β2M is an independent prognostic factor for ENKTL patients. The new serum β2M-based prognostic model may be useful for identifying ultra-high-risk patients, and it can easily be adopted into daily clinical practice.
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Background@#Guselkumab is a monoclonal antibody that selectively blocks the p19 subunit of interleukin-23. It has shown good efficacy and safety profile in several clinical trials of plaque psoriasis. However, studies on the efficacy of guselkumab in patients treated with other biologics are lacking. @*Objective@#We aimed to investigate the efficacy and safety profile of guselkumab in patients with moderate-to-severe plaque psoriasis. We also compared the efficacy of guselkumab between biologic-naïve (Bio-Naïve) and biologicexperienced (Bio-Ex) patients. @*Methods@#This multicenter, retrospective study included 72 patients treated with guselkumab. The patients’ clinical characteristics and psoriasis area and severity index (PASI) scores were recorded at each visit. The PASI90 and PASI100 responses and mean PASI scores were compared between the Bio-Naïve and Bio-Ex groups. @*Results@#Fifty-five Bio-Naïve patients and 17 Bio-Ex patients were included in the study. At week 20, there were no significant differences in the PASI90 (64.2% vs. 53.8%) and PASI100 (28.3% vs. 15.4%) responses between the groups. However, at weeks 36 and 44, the PASI90 response (week 36: 89.2% vs. 36.4% and week 44: 97.8% vs. 63.6%) and the PASI100 response (week 36: 64.9% vs. 18.2% and week 44: 68.9% vs. 27.3%) were significantly higher in the Bio-Naïve group (p＜0.05). There were no differences in PASI90 and PASI100 responses between the groups in terms of other clinical characteristics and comorbidities at week 20. @*Conclusion@#The efficacy of guselkumab remained consistent among patients in whom other biologics had failed. However, the efficacy was slightly lower in the Bio-Ex group than in the Bio-Naïve group.
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The areola is a rare location for squamous cell carcinoma (SCC) because sunlight exposure, the main risk factor for SCC, is unusual on it. Acantholytic SCC (ASCC) is a rare histologic variant of SCC, characterized by pseudoglandular appearance with acantholytic tumor cells. A 59-year-old male presented a painful erythematous papule on his right areola. He had a history of psoralen ultraviolet A phototherapy for psoriasis in his 20s. Biopsy revealed an epithelial tumor and pseudoglandular structures with acantholytic tumor cells. In immunohistochemistry, cytokeratin 5/6, epithelial membrane antigen, and p63 were positive, while cytokeratin 7, carcinoembryonic antigen, S-100, and estrogen and progesterone receptors were negative. Periodic acid-Schiff stain was negative. Ki-67 labeling index was 79.7%. The final diagnosis was ASCC of the areola. After wide local excision, recurrence have not been reported. Here, we report a case of ASCC on the areola, focusing on its rare histologic variant and uncommon location.
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Background@#The nuclear factor erythroid 2-related factor 2/Kelch-like ECH-associated protein 1 (Nrf2/Keap1) signaling pathway is involved in the regulation of cellular responses to oxidative stress. Nrf2 acts as a cell protector from inflammation, cellular damage, and tumorigenesis, whereas Keap1 is a negative regulator of Nrf2. Dysregulation of the Nrf2/ Keap1 pathway results in tumorigenesis and the active metabolism of tumor cells, leading to high resistance to radiotherapy. This study aimed to evaluate the predictive role of Nrf2 and Keap1 in the radiosensitivity and prognosis of locally advanced rectal cancer (LARC). @*Methods@#In total, 90 patients with LARC underwent surgery after preoperative chemoradiotherapy (CRT). Endoscopic biopsies from the tumors were obtained before radiation, and the Nrf2 and Keap1 expressions were assessed by immunohistochemistry. The response to therapy was evaluated after surgery following CRT according to the pathologic tumor regression grade. The disease-free survival (DFS) and overall survival rates were also documented. The association between the Nrf2 and Keap1 immunoreactivity and the clinicopathological parameters was analyzed. @*Results@#The overexpression of the nuclear Nrf2 before CRT showed a significant correlation with better DFS. The cytoplasmic Nrf2 expression was associated with more residual tumors after radiotherapy and a more unfavorable DFS, indicating lower radiosensitivity. @*Conclusion@#CRT is an important issue in LARC and is a major aspect of treatment. Thus, the Nrf2/Keap1 expression may be a potential predictor of preoperative therapeutic resistance.The Nrf2-Keap1 modulators that interact with each other may also be effectively applicable to CRT effect in LARC.
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Introduction: Tube thoracostomy is a relatively infrequent, high-risk procedure that is a required competency for emergency medicine residents. Simulation-based mastery learning is the gold standard for procedure training and has been used to successfully train residents in high-risk procedures. Methods: We developed a simulation-based mastery learning course for tube thoracostomy for PGY 2 emergency medicine residents. The course included (1) precourse work, (2) baseline assessment using a modified version of the TUBE-iCOMPT checklist, (3) anatomy/radiology review, (4) deliberate practice to master individual aspects of the procedure, and (5) final assessment. If a minimum passing score was not achieved, additional coaching and deliberate practice occurred until the learner was able to achieve a minimum passing score. Results: After piloting the course with a cohort of seven PGY 2 emergency medicine residents, we successfully trained 24 additional PGY 2 residents in the subsequent two classes. Combining all three cohorts (N = 31), there was a statistically significant increase in learners' modified TUBE-iCOMPT scores (pretest M = 61.2, SD = 10.0; posttest M = 75.5, SD = 2.9; p < .001). Learners' confidence in their ability to correctly place a chest tube increased, rated on a 10-point Likert scale (1 = not very confident, 10 = very confident; precourse M = 5.6, SD = 1.8; postcourse M = 8.3, SD = 1.1; p < .001). Discussion: This simulation-based course was well received by learners. Our assessment demonstrated that learners improved directly observed procedural skills in simulation and confidence in tube thoracostomy placement.
Subject(s)
Emergency Medicine , Internship and Residency , Chest Tubes , Clinical Competence , Emergency Medicine/education , Humans , ThoracostomyABSTRACT
ImportanceHeterogeneous mental health outcomes during the COVID-19 pandemic are recognized in the general population, but it has not been systematically assessed in youth with neurodevelopmental disorders (NDD), including autism spectrum (ASD). ObjectiveIdentify subgroups of youth with ASD/NDD based on the pandemic impact on symptoms and service changes, as well as predictors of outcomes. Design, Setting, and ParticipantsThis is a naturalistic observational study conducted across 14 North American and European clinical and/or research sites. Parent responses on the Coronavirus Health and Impact Survey Initiative (CRISIS) adapted for Autism and Related Neurodevelopmental Conditions (AFAR) were cross-sectionally collected from April to October 2020. The sample included 1275, 5-21 year-old youth with ASD and/or NDD who were clinically well-characterized prior to the pandemic. Main Outcomes and MeasuresTo identify impact subgroups, hierarchical clustering analyzed eleven AFAR factors measuring pre- to pandemic changes in clinically relevant symptoms and service access. Random forest classification assessed the relative contribution in predicting subgroup membership of 20 features including socio-demographics, pre-pandemic service, and clinical severity along with indices of COVID-19 related experiences and environments empirically-derived from AFAR parent responses and global open sources. ResultsClustering analyses revealed four ASD/NDD impact subgroups. One subgroup - broad symptom worsening only (20% of the aggregate sample) - included youth with worsening symptoms that were above and beyond that of their ASD/NDD peers and with similar service disruptions as those in the aggregate average. The three other subgroups showed symptom changes similar to the aggregate average but differed in service access: primarily modified services (23%), primarily lost services (6%), and average services/symptom changes (53%). Pre-pandemic factors (e.g., number of services), pandemic environments and experiences (e.g., COVID-19 cases, related restrictions, COVID-19 Worries), and age emerged in unique combinations as distinct protective or risk factors for each subgroup. Together they highlighted the role of universal risk factors, such as risk perception, and the protective role of services before and during the pandemic, in middle childhood. Conclusions and RelevanceConcomitant assessment of changes in both symptoms and services access is critical to understand heterogeneous impact of the pandemic on ASD/NDD youth. It enabled the delineation of pathways to risk and resilience that include universal and ASD/NDD specific contributors.
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BACKGROUND: Drug shortages contribute to avoidable medication error and patient harm; these shortages are exacerbated in the Emergency Department due to the time-sensitive nature of acute care. METHODS: We performed a cross-sectional study to describe the frequency and duration of drug shortages associated with the most frequent medications administered in the ED. We identified the most frequently used ED medications and calculated number of visits associated with these medications using the 2006-2019 National Hospital Ambulatory Medical Care Survey. We obtained the frequency and duration of shortages associated with these medications from the University of Utah Drug Information System. We calculated duration and total ED visits associated with shortages of the most frequently used ED medications. RESULTS: From 2006 through 2019, the most frequently used drugs were ondansetron (255.1 million ED visits), 0.9% normal saline (251.3 million ED visits), and ibuprofen (188.5 million ED visits). All but two of the top thirty most frequently used medications experienced a shortage. The median shortage duration was 425 days, while the longest were for injectable morphine (3,202 days). The number of ED visits associated with drugs experiencing shortages increased from 2,564,425 (2.2% of U.S. ED visits) in 2006 to 67,221,968 (60.4%) in 2019. The most common reasons for shortage include manufacturing delays and increased demand. CONCLUSIONS AND RELEVANCE: Drug shortages were more frequent and persistent from 2006 through 2019. Further studies on the clinical impact of these shortages are needed, in addition to policy interventions to mitigate shortages.
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Emergency Service, Hospital , Medication Errors , Critical Care , Cross-Sectional Studies , Health Care Surveys , Humans , United StatesABSTRACT
Endovascular repair of popliteal artery aneurysms (PAA) using a stent graft is suitable for patients with favorable anatomy. In the domestic situation where Gore Medical withdrew, we report two cases of unusual complications of pseudoaneurysm after endovascular repair of PAA. A 44-year-old male with a history of bypass surgery for a PAA presented with recurrent vein graft pseudoaneurysm. Endovascular treatment using a domestic stent graft was performed. However, pseudoaneurysm developed due to the graft fabric tear 1 month later, requiring surgical removal. In another case, an 84-year-old female presented with acute limb ischemia related to PAA. Endovascular aneurysm repair with the same domestic stent graft was performed. However, stent graft failure occurred 2 years later and the patient underwent open surgical repair. There was a graft fabric disintegration. When proper endovascular device is not available, open surgical treatment is the best option for treating PAA.
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Background/Aims@#The incidence of multiple myeloma (MM) in Korea is rapidly increasing. The diagnostic criteria of MM have been updated and novel therapeutic agents are available. This study explored the features of MM patients registered at Asan Medical Center (AMC) and the outcomes over the past 15 years. @*Methods@#Data were obtained from the AMC MM registry, which has been collecting the data of MM patients prospectively. The 774 MM patients included in our analysis were diagnosed from 2003, when thalidomide became available as a novel therapeutic agent, until April 2019. The 2-year survival rate of these patients was assessed. Patients were divided into two groups based on whether they were older or younger than 65 years, which is the cutoff age for the indication of autologous stem cell transplantation. Patients were also grouped according to the year of diagnosis: up to 2006, when bortezomib became available, and up to 2010, when the cost of lenalidomide was reimbursed. @*Results@#Patients < 65 years of age had better prognostic features, including a better performance, less advanced disease stage, and fewer abnormalities in their fluorescent in-situ hybridization (FISH) analysis results. A comparison of our Korean patients with patients registered in the Myeloma Related Disorder Registry data of Australia and New Zealand, showed ethnic discrepancies. The median overall survival of all patients was 3.7 years, with a 5-year survival rate of 41.8% and a 10-year survival rate of 23.4%. Survival progressively improved in patients diagnosed later. Age, performance status, renal function, C-reactive protein level, lactate dehydrogenase level, and cytogenetic findings were identified as significant prognostic factors. @*Conclusions@#This real-world survey revealed the clinical features and survival rates of patients at a tertiary Korean Hospital who were diagnosed with MM at the beginning of 21st century.
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Crimes committed by the mentally ill may give rise to critical conflicts on whether the criminals should receive punishment or treatment. Therefore, our criminal code has a legal provision for mental handicap and criminal responsibility, which can reduce or exempt the criminal penalty. This process requires a psychiatric evaluation of the defendants as well as normative decisions by judges. The psychiatric evaluation and diagnosis precede the court judgement, and are used by the court to judge the mental handicap of the defendant at the time of the crime. However, judgments on the criminal responsibility of a defendant with mental disorder are very complex and challenging because of time gaps and difficulties faced in the evaluation of human mental ability. We analyzed court rulings in 19 cases where the defendants claimed to be mentally handicapped. The analysis results showed that the mental handicap was recognized in nine cases, rejected in four cases, and not mentioned by the court in six cases. Further, psychiatric evaluation was not performed in three cases. Apart from the result of the evaluation, the judges seem to consider other factors for sentencing, like recidivism risk, premeditation of crimes, and their brutality. These results suggest that the rationale and procedure of court rulings involving mentally handicapped persons may be debatable. We argue that psychiatric evaluations should be made indispensable in judicial procedures for cases involving mentally handicapped persons, and judges should clearly indicate their decision on mental handicap or criminal responsibility in the sentencing.
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Background@#Herpes zoster (HZ) is a neurocutaneous disease caused by reactivation of the varicella zoster virus after primary infection. In Korea, it is recommended that all adults aged ＞60 be vaccinated against HZ. However, breakthrough infection with HZ can occur infrequently in vaccinated individuals. @*Objective@#This study aimed to investigate the effects of the HZ vaccine on the clinical manifestations and courses of HZ in immunocompetent elderly individuals aged 60 years and older. @*Methods@#Among 848 immunocompetent HZ patients, 52 were vaccinated and 796 were unvaccinated. From this cohort, we chose 156 unvaccinated patients through a 1:3 propensity score matching analysis using three parameters;age, sex, and involved dermatome. We subsequently compared the clinical manifestations and courses between the vaccinated (n=52) and unvaccinated (n=156) groups. @*Results@#The vaccinated group had a lower peak numeric rating scale pain score and a lower rate of consultation with the pain control clinic than the opposite. Additionally, mild skin lesions without vesicles were more frequent in the vaccinated group than in the opposite. The vaccinated group had a shorter duration of total follow-up, shorter antiviral treatment period, lower admission rate, and shorter hospital stay than the opposite. Although postherpetic neuralgia occurred more frequently in the unvaccinated group than in the unvaccinated group, the incidences of other HZ-related complications showed no significant difference between the two groups. @*Conclusion@#Despite the possibility of breakthrough infection, the HZ vaccine should be recommended in the elderly as it can weaken the clinical features and course of the disease.
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Background@#Fever and skin eruption are common manifestations in patients; however, assessing them can be challenging because of the wide range of differential diagnosis. @*Objective@#We aimed to obtain tips that could assist in differential diagnoses in patients with fever and skin eruption through the analysis of clinical features. @*Methods@#Medical records of hospitalized patients who had fever and skin eruption were examined from January 2010 to December 2019. @*Results@#The patients of the adverse drug reaction group were older (p=0.024), and they had underlying diseases (p＜0.001), whole body skin eruption (p=0.018), elevated alanine aminotransferase (p=0.027). The autoimmune disease group was associated with longer total fever and skin eruption duration (p=0.049, 0.037), leukocytosis (p=0.015), and neutrophilia (p=0.006). Infectious erythema group was associated with targetoid lesions (p=0.003). @*Conclusion@#Clinicians should examine patients with fever and skin eruption, considering that there may be various causes. This can be assisted by delicate skin exam and laboratory tests.
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no abstract available.
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Background@#Polo-like kinase 4 (PLK4) is a serine/threonine protein kinase located in the centriole of the chromosome during the cell cycle. PLK4 overexpression has been described in a variety of many common human epithelial tumors. Conversely, PLK4 acts as a haploinsufficient tumor suppressor in some situations, highlighting the importance of strict regulation of PLK4 expression, activity, and function. Meanwhile, the importance of chemoradiation resistance in rectal cancer is being emphasized more than ever. We aimed to analyze PLK4 expression and the tumor regression grade (TRG) in patients with rectal cancer, treated with chemoradiotherapy (CRT). @*Methods@#A retrospective study was conducted on 102 patients with rectal cancer who received preoperative CRT. Immunohistochemistry for PLK4 in paraffin-embedded tissue was performed from the biopsy and surgical specimens. @*Results@#We found significant association between high expression of PLK4 and poor response to neoadjuvant CRT (according to both Mandard and The Korean Society of Pathologists TRG systems) in the pre-CRT specimens. Other clinicopathologic parameters did not reveal any correlation with PLK4 expression. @*Conclusions@#This study revealed an association between high expression of PLK4 in the pre-CRT specimens and TRG. Our results indicated that PLK4 could potentially be a new predictor for CRT effect in patients with rectal cancer.
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BACKGROUND: The contact areas in between primary teeth are broader, flatter, and located further cervically when compared with the contact areas of permanent molars. AIM: We investigated the prevalence of interproximal contact area types of primary molars using CBCT images in children aged 3-10 years. Our second objective was to correlate OXIS contact areas when observed with CBCT images and clinical photographs. DESIGN: A retrospective cross-sectional study was performed with 367 CBCT images of children, aged 3-10 years, obtained from Children's Dental Centre, South Korea. The type of contacts in between primary molars was scored at various levels, specifically, occlusal, middle, and cervical thirds, according to OXIS criteria. Following this, the same patient's records were checked for the presence of clinical photographs and scored according to the same criteria. Prevalence was stated as percentages along with numbers. Chi-square test was applied to determine association of contact areas across genders and arches. The correlation between the two methods was done by Cohen's Kappa correlation test. RESULTS: The prevalence of the OXIS contacts obtained from CBCT images was as follows: I (79.7%), followed by X (10.0%), S (6.6%), and, finally, O (3.7%). The overall score of all the 1343 contact areas matched with the score observed at the occlusal third. All included contacts were of O (open) type at cervical third, and 1,231 contacts were of O (open) type at the middle third. Significant results were observed with respect to arches (P < .001). The correlation between the two methods was found to be 0.958. CONCLUSIONS: The contact area observed at the occlusal level determined the overall type of contact based on OXIS criteria. Thus, reports in the literature concluded that contact areas are broad, flat, and extend further gingivally should be revised. The study also concluded almost perfect agreement between CBCT images and clinical photographs.
