Risk factors for miscarriage in Syrian refugee women living in non-camp settings in Jordan: results from the Women ASPIRE cross-sectional study

Background Syrian refugee women face health care disparities and experience worse pregnancy outcomes, including miscarriage. We investigated risk factors for miscarriage in Syrian refugee women living in non-camp settings in Jordan to identify targets for interventions. Methods We analyzed data from Women ASPIRE, a cross-sectional study of gendered physical and mental health concerns of 507 Syrian refugee women (≥ 18 years old) living in non-camp settings in Jordan. We recruited women using systematic clinic-based sampling from four clinics. We limited our analyses to women who had a history of pregnancy and whose most recent pregnancy was single, took place in Jordan, and ended in term live birth or miscarriage (N = 307). We grouped the women by the primary outcome (term live birth or miscarriage) and compared the sociodemographic and clinical characteristics of the two groups. We used Pearson’s χ2 test or the Mann–Whitney U test to obtain unadjusted estimates and multivariable binomial logistic regression to obtain adjusted estimates. Results The most recent pregnancies of 262 women (85%) ended in term live birth and another 45 (15%) ended in miscarriage. Since crossing into Jordan, 11 women (4%) had not received reproductive health services. Of 35 women who were ≥ 35 years old, not pregnant, and did not want a (or another) child, nine (26%) did not use contraception. Of nine women who were ≥ 35 years old and pregnant, seven (78%) did not plan the pregnancy. The adjusted odds of miscarriage were higher in women who had been diagnosed with thyroid disease (aOR, 5.54; 95% CI, 1.56–19.07), had been of advanced maternal age (aOR, 5.83; 95% CI, 2.02–16.91), and had not received prenatal care (aOR, 36.33; 95% CI, 12.04–129.71). Each additional previous miscarriage predicted an increase in the adjusted odds of miscarriage by a factor of 1.94 (1.22–3.09). Conclusions We identified several risk factors for miscarriage in Syrian refugee women living in non-camp settings in Jordan. The risk factors may be amenable to preconception and prenatal care

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Differential Characteristics and Prognosis of PD-L1–Positive Endometrial Carcinomas: A Retrospective Chart Review

Women with endometrial carcinomas that express PD-L1 may respond better to immunotherapy. Our aim was to investigate the differential characteristics of PD-L1–positive endometrial carcinomas and the prognostic significance of PD-L1. We performed a retrospective chart review of 231 women with endometrial carcinomas who were managed at King Hussein Cancer Center (2007–2016) and performed immunohistochemistry for MLH1, PMS2, MSH2, MSH6, p53, and PD-L1. Overall, 89 cases (38.5%) were MMR-deficient. PD-L1 was expressed in 49 cases (21.2%) and its expression was significantly associated with MLH1/PMS2 deficiency (p = 0.044) but not MSH2/MSH6 deficiency (p = 0.59). p53 was mutant in 106 cases (46.5%), and its mutation was significantly associated with MMR proficiency (p &lt; 0.001) but not PD-L1 expression (p = 0.78). In women with endometrioid adenocarcinomas, PD-L1 expression was significantly associated with the Fédération Internationale de Gynécologie et d′Obstétrique (FIGO) grade (p = 0.008). Overall, PD-L1 expression did not significantly predict overall survival in unadjusted or adjusted analyses (p = 0.92 and 0.54, respectively). In conclusion, tumors with MLH1/PMS2 loss and high-grade endometrioid adenocarcinomas were more likely to express PD-L1 in tumor cells. Further research is required to investigate whether the presence of either characteristic signals a higher likelihood of a favorable response if immunotherapy is administered

Attitudes of Physicians in Jordan Toward Non-Disclosure of Health Information

Objectives: Our aim was to investigate the attitudes of physicians in Jordan toward non-disclosure and the differential attitudes of physicians who are “always truthful” and those who are not. Methods: Our report is based on the second subset of data from a cross-sectional study of the truth disclosure practices and attitudes of physicians in Jordan, which was conducted between January and August 2016. We selected 240 physicians from four major hospitals by stratified random sampling, and we invited them to complete a self-administered questionnaire regarding truth disclosure attitudes. We compared the attitudes of physicians who were “always” truthful and those who were not. Results: In total, 164 physicians (68%) completed the questionnaire, of whom 17 (10%) were “always truthful”, while the remaining 144 (90%) were not. Physicians who were “always truthful” were more likely to indicate that non-disclosure is “unethical” (77% v. 39%; p=0.009). Moreover, physicians who were “always truthful” were more likely to disagree that non-disclosure is beneficial for the physical and psychological health of patients (82% v. 55%; p=0.03). The majority of physicians agreed that all patients have the right to know their diagnosis, most patients prefer to know their diagnosis, and the introduction of legislation to enforce disclosure would positively affect medical practice in Jordan. Conclusion: The differential attitudes of physicians who were “always truthful” and those who were “not always truthful” suggest a rationale behind independent non-disclosure, namely that non-disclosure is ethically justifiable and beneficial for the physical and psychological health of patients.Keywords: Truth Disclosure • Physicians • Attitude • Jordan • Middle East • Cross-Sectional Studie

Normative Values of Peripapillary Retinal Nerve Fiber Layer Thickness in a Middle Eastern Population

Purpose. Peripapillary retinal nerve fiber layer (pRNFL) thickness is subject to high variability. Normative values of pRNFL thickness remain undocumented in the Middle East. The aim of our study is to assess the normative values of pRNFL thickness in a Middle Eastern population. Methods. A retrospective chart review of 74 patients was conducted. Outpatients who had presented to the ophthalmology clinic at the Jordan University Hospital between January 2016 and July 2018 were consecutively sampled. Measurements had been recorded using Fourier-domain optical coherence tomography. Multivariable regression models were developed to generate predicted normative values with adjustments to candidate confounders. Results. The mean global pRNFL thickness was 99 ± 11 μm. The mean quadrantic pRNFL thickness increased from the nasal quadrant (75 ± 16 μm) to the temporal (82 ± 20 μm), superior (114 ± 20 μm), and inferior (125 ± 20 μm) quadrants. Gender and eye sidedness did not contribute to the variability in pRNFL thickness. The relationship between aging and pRNFL thinning is independent of diabetes mellitus type 2 and systemic hypertension. Both systemic conditions significantly predicted pRNFL changes despite negative fundoscopic findings. Conclusions. Our set of predicted normative data may be used to interpret measurements of pRNFL thickness in Middle Eastern patients. Our findings suggest that systemic conditions with potential ocular manifestations may require consideration in predictive models of pRNFL thickness, even in the absence of gross fundoscopic findings. Normative data from additional Middle Eastern populations are required to appraise our models, which adjust for common clinical confounders

An intronic single-nucleotide polymorphism (rs13217795) in FOXO3 is associated with asthma and allergic rhinitis: a case–case–control study

Abstract Background Asthma and allergic rhinitis are respiratory diseases with a significant global burden. Forkhead box O3 (FOXO3) is a gene involved in the etiology of a number of respiratory diseases. The objective of this study is to assess the association of rs13217795, an intronic FOXO3 single-nucleotide polymorphism, with asthma and allergic rhinitis. Methods In this case–case–control genetic association study, genotyping was conducted using the PCR–RFLP method. Genotype-based associations were investigated under the general, recessive, and dominant models of disease penetrance using binomial logistic regression; and, allele-based associations were tested using Pearson’s chi-squared test. Results The final study population consisted of 94 controls, 124 asthmatics, and 110 allergic rhinitis patients. The general and recessive models of disease penetrance were statistically significant for both case–control comparisons. Under the general model, the odds of the asthma phenotype were 1.46 (0.64 to 3.34) and 3.42 (1.37 to 8.57) times higher in heterozygotes and derived allele homozygotes, respectively, compared to ancestral allele homozygotes. The corresponding odds ratios for the allergic rhinitis phenotype were 1.05 (0.46 to 2.40) and 2.35 (0.96 to 5.73), respectively. The dominant model of disease penetrance was not statistically significant. The minor allele in all study groups was the ancestral allele, with a frequency of 0.49 in controls. There was no deviation from Hardy–Weinberg equilibrium in controls. Both case–control allele-based associations were statistically significant. Conclusions Herein we present the first report of the association between rs13217795 and allergic rhinitis, and the first independent verification of the association between rs13217795 and asthma. Marker selection in future genetic association studies of asthma and allergic rhinitis should include functional polymorphisms in linkage disequilibrium with rs13217795

The Clinical Potential of Circulating Immune Cell Counts in Primary Gastric Lymphoma

Background: High neutrophil-lymphocyte ratio (NLR) is linked to poor overall survival (OS) in gastrointestinal tract cancers. This study explores the clinical value of NLR, in addition to absolute lymphocyte count (ALC) and other hematologic parameters in association with distant metastases and OS in primary gastric lymphoma (PGL) patients. Methods: Clinical data of 139 PGL patients who received treatment at King Hussein Cancer Center (KHCC), Amman-Jordan were retrospectively evaluated. Using data from complete blood count (CBC) tests, the following hematologic parameters: absolute neutrophil count (ANC), ALC, absolute eosinophil count (AEC), absolute monocyte count (AMC), NLR, platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) were assessed in association with the following clinical outcomes: presence or absence of baseline distant metastases and OS. We conducted univariate and multivariate analyses assessing the various hematologic parameters in association with distant metastases. Results: Univariate and multivariate analyses indicated that patients with an elevated NLR (\u3e3.14) displayed more baseline distant metastases compared to patients with a low NLR (≤3.14), (P value: 0.02 and 0.018, respectively). High baseline ALC (\u3e1,819/µL) was associated with lower baseline distant metastases (P value: 0.04). In the OS analysis, high baseline ANC (\u3e5,100/µL), NLR (\u3e2.75), and PLR (\u3e0.16) were associated with poor OS, (P value: 0.027, 0.016, and 0.011 respectively). Conclusions: High NLR and ALC were associated with baseline distant metastases. High baseline ANC, NLR, and PLR were associated with poor OS. Hematologic parameters might be potentially helpful in assessing and correlating NLR with the response success to treatment in PGL

Life-Threatening Complications of Influenza vs Coronavirus Disease 2019 (COVID-19) in US Children

BACKGROUND: Clinical differences between critical illness from influenza infection vs coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients. METHODS: We compared demographics, clinical characteristics, and outcomes of US children (aged 8 months to 17 years) admitted to the intensive care or high-acuity unit with influenza or COVID-19. Using mixed-effects models, we assessed the odds of death or requiring life support for influenza vs COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity. RESULTS: Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median, 5.2 years vs 13.8 years), less likely to be non-Hispanic Black (14.5% vs 27.6%) or Hispanic (24.0% vs 36.2%), and less likely to have ≥1 underlying condition (66.4% vs 78.5%) or be obese (21.4% vs 42.2%), and a shorter hospital stay (median, 5 days vs 7 days). They were similarly likely to require invasive mechanical ventilation (both 30.2%), vasopressor support (19.6% and 19.9%), or extracorporeal membrane oxygenation (2.2% and 2.9%). Four children with influenza (2.2%) and 11 children with COVID-19 (2.9%) died. The odds of death or requiring life support in children with influenza vs COVID-19 were similar (adjusted odds ratio, 1.30; 95% confidence interval, .78-2.15; P = .32). CONCLUSIONS: Despite differences in demographics and clinical characteristics of children with influenza or COVID-19, the frequency of life-threatening complications was similar. Our findings highlight the importance of implementing prevention measures to reduce transmission and disease severity of influenza and COVID-19