Tracing the impact of El Nino on agriculture and life in Mirpur Khas

Drought, flood and decrease in average rainfall are severely impacting Mirpur Khas in Sindh province. This has resulted in several challenges in the agricultural sector. Ghamz E Ali Siyal, Mohsin Ali Kazmi and Benazir Khumbhar trace the impacts of El Nino in the district

Metastases From Nested Variant Urothelial Carcinoma of the Urinary Bladder in Pancreatic Allograft Mimicking Graft Rejection

While not an uncommon tumor, urothelial carcinoma of the urinary bladder is rare in bladders draining pancreatic allografts. A case of urothelial carcinoma directly involving a pancreatic allograft with metastasis that occurred in a 49-year-old pancreas and kidney transplant recipient is described. Her initial clinical presentation and findings of CT scan of the abdomen suggested pancreatitis with features worrisome for rejection. A biopsy of her pancreatic allograft contained poorly differentiated carcinoma and cystoscopic biopsy disclosed an invasive high grade urothelial carcinoma arising in the background of extensive urothelial carcinoma in situ. Exploratory laparotomy revealed that the tumor invaded the right ovary and fallopian tube, cecum, and allograft with extensive retroperitoneal involvement. She underwent en bloc resection of distal ileum and cecum, resection of transplant pancreas, partial cystectomy, ileocolostomy anastomosis, and right salpingo-oophorectomy. Postoperatively, the patient was treated with four cycles of carboplatin and gemcitabine. She ultimately succumbed to her disease approximately 1 year after diagnosis. This case should alert physicians and radiologists to be aware of atypical presentation of urothelial carcinoma in bladder-drained pancreas grafts, the aggressiveness of such lesions, and the need for early biopsy to avoid diagnostic confusion with rejection

A 10-year experience of infection following carotid endarterectomy with patch angioplasty

ObjectiveAlthough infection following carotid endarterectomy is rare, consequences of this seldom seen complication can be devastating. Polyester, polytetrafluoroethylene (PTFE), and vein patches have all been used by many institutions for patch angioplasty, each with reported cases of infection following surgery. Our institution has preferentially used PTFE for the majority of cases, and here, we report our experience with postoperative infection following endarterectomy over the last decade.MethodsFrom January 2000 through July 2009, we treated infections following carotid endarterectomy in 25 patients.ResultsOf the 25 patients undergoing treatment for postoperative infection, 21 had PTFE patches placed during the initial surgery. The remaining four consisted of two polyester patches and two bovine pericardial patches. Twenty-three of the 25 initial endarterectomies were performed at our institution, and the other two were referrals. The majority of cases (56%) were due to gram-positive organisms, with only two cases being polymicrobial. The interval from the original surgery to clinical presentation ranged from 7 days to 85 months, with 20 patients (80%) presenting within 60 days of the first operation. Thirteen patients underwent incision and drainage with antibiotics, and 12 patients underwent definitive surgical treatment. Four received patch excision with vein patch angioplasty, four received patch excision with vein interposition, and four received sternocleidomastoid flaps. The 30-day stroke rate was 8%, and the freedom from recurrent infection was 100% at a mean follow-up of 32 months.ConclusionInfection following carotid endarterectomy occurs <1% of the time; however, the potential for morbidity is significant. Our results show that most infections following PTFE patch angioplasty occur in the early postoperative period (<60 days) and that simple drainage with antibiotics may be an adequate form of treatment in select cases

Interactive Digital Serious Games for the Assessment, Rehabilitation, and Prediction of Dementia

YesDementia is a serious, progressive, and often debilitating illness with no known cure, having a severe adverse effect on memory, behaviour, reasoning, and communication. A comprehensive review of current refereed research material in the use of games in this area is scarce and suffers from being orientated towards commercially available games or derivatives such as “Dr. Kawashima’s brain training.” There is much lesser concern for bespoke research grade alternatives. This review will attempt to assess the current state of the art in research orientated games for dementia, importantly identifying systems capable of prediction before the onset of the disease. It can be ascertained from the literature reviewed that there are clearly a large number of interactive computer game based mechanisms used for dementia. However, these are each highly intrusive in terms of affecting normal living and the patient is aware of being tested; furthermore their long-term or real benefits are unknown as is their effect over conventional tests. It is important to predict cognitive impairment at a stage early enough to maximise benefit from treatment and therapeutic intervention. Considering the availability, use, and increasing power of modern mobile smartphones, it is logically plausible to explore this platform for dementia healthcare

Household and personal air pollution exposure measurements from 120 communities in eight countries: Results from the PURE-AIR study

Background: Approximately 2·8 billion people are exposed to household air pollution from cooking with polluting fuels. Few monitoring studies have systematically measured health-damaging air pollutant (ie, fine particulate matter [PM2·5] and black carbon) concentrations from a wide range of cooking fuels across diverse populations. This multinational study aimed to assess the magnitude of kitchen concentrations and personal exposures to PM2·5 and black carbon in rural communities with a wide range of cooking environments.Methods: As part of the Prospective Urban and Rural Epidemiological (PURE) cohort, the PURE-AIR study was done in 120 rural communities in eight countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Data were collected from 2541 households and from 998 individuals (442 men and 556 women). Gravimetric (or filter-based) 48 h kitchen and personal PM2·5 measurements were collected. Light absorbance (10-5m-1) of the PM2·5 filters, a proxy for black carbon concentrations, was calculated via an image-based reflectance method. Surveys of household characteristics and cooking patterns were collected before and after the 48 h monitoring period.Findings: Monitoring of household air pollution for the PURE-AIR study was done from June, 2017, to September, 2019. A mean PM2·5 kitchen concentration gradient emerged across primary cooking fuels: gas (45 μg/m3 [95% CI 43-48]), electricity (53 μg/m3 [47-60]), coal (68 μg/m3 [61-77]), charcoal (92 μg/m3 [58-146]), agricultural or crop waste (106 μg/m3 [91-125]), wood (109 μg/m3 [102-118]), animal dung (224 μg/m3 [197-254]), and shrubs or grass (276 μg/m3 [223-342]). Among households cooking primarily with wood, average PM2·5 concentrations varied ten-fold (range: 40-380 μg/m3). Fuel stacking was prevalent (981 [39%] of 2541 households); using wood as a primary cooking fuel with clean secondary cooking fuels (eg, gas) was associated with 50% lower PM2·5 and black carbon concentrations than using only wood as a primary cooking fuel. Similar average PM2·5 personal exposures between women (67 μg/m3 [95% CI 62-72]) and men (62 [58-67]) were observed. Nearly equivalent average personal exposure to kitchen exposure ratios were observed for PM2·5 (0·79 [95% 0·71-0·88] for men and 0·82 [0·74-0·91] for women) and black carbon (0·64 [0·45-0·92] for men and 0·68 [0·46-1·02] for women).Interpretation: Using clean primary fuels substantially lowers kitchen PM2·5 concentrations. Importantly, average kitchen and personal PM2·5 measurements for all primary fuel types exceeded WHO\u27s Interim Target-1 (35 μg/m3 annual average), highlighting the need for comprehensive pollution mitigation strategies.Funding: Canadian Institutes for Health Research, National Institutes of Health

Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries

Objectives: We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study.Methods: We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age \u3e55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1-all three drug types were available and affordable, group 2-all three drugs were available but not affordable and group 3-all three drugs were not available. We used multivariable Cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors.Results: Of 163 466 participants, there were 93 200 with high CVD risk from 21 countries (mean age 54.7, 49% female). Of these, 44.9% were from group 1, 29.4% from group 2 and 25.7% from group 3. Compared with participants from group 1, the risk of MACEs was higher among participants in group 2 (HR 1.19, 95% CI 1.07 to 1.31), and among participants from group 3 (HR 1.25, 95% CI 1.08 to 1.50).Conclusion: Lower availability and affordability of essential CVD medicines were associated with higher risk of MACEs and mortality. Improving access to CVD medicines should be a key part of the strategy to lower CVD globally

Autologous Hematopoietic Stem Cell Transplantation in Active Multiple Sclerosis: A Real-world Case Series

Objective To examine outcomes in people with multiple sclerosis (PwMS) treated with autologous hematopoietic stem cell transplantation (AHSCT) in a real-world setting. Methods This was a retrospective cohort study of PwMS treated with AHSCT at 2 centers in London, UK, consecutively between 2012 and 2019 who had ≥6 months of follow-up or died at any time. Primary outcomes were survival free of multiple sclerosis (MS) relapses, MRI new lesions, and worsening of Expanded Disability Status Scale (EDSS) score. Adverse events rates were also examined. Results The cohort includes 120 PwMS; 52% had progressive MS (primary or secondary) and 48% had relapsing-remitting MS. At baseline, the median EDSS score was 6.0; 90% of the evaluable cases showed MRI activity in the 12 months preceding AHSCT. Median follow-up after AHSCT was 21 months (range 6–85 months). MS relapse-free survival was 93% at 2 years and 87% at 4 years after AHSCT. No new MRI lesions were detected in 90% of participants at 2 years and in 85% at 4 years. EDSS score progression–free survival (PFS) was 75% at 2 years and 65% at 4 years. Epstein-Barr virus reactivation and monoclonal paraproteinemia were associated with worse PFS. There were 3 transplantation-related deaths within 100 days (2.5%), all after fluid overload and cardiac or respiratory failure. Conclusions Efficacy outcomes of AHSCT in this real-world cohort are similar to those reported in more stringently selected clinical trial populations, although the risks may be higher. Classification of Evidence This study is rated Class IV because of the uncontrolled, open-label design

3,5-Diamino-4H-1,2,4-triazol-1-ium (6-carb­oxy­pyridine-2-carboxyl­ato)(pyridine-2,6-dicarboxyl­ato)cuprate(II) trihydrate

In the complex anion of the title compound, (C2H6N5)[Cu(C7H4NO4)(C7H3NO4)]·3H2O, the CuII atom is coordinated by tridentate 6-carb­oxy­pyridine-2-carboxyl­ate and pyridine-2,6-dicarboxyl­ate ligands and is surrounded by four O atoms in the equatorial plane and two N atoms in axial positions in a distorted octa­hedral geometry. In the crystal, the components are linked into a three dimensional network by O—H⋯O, N—H⋯O, N—H⋯N and C—H⋯O hydrogen bonds and a π–π inter­action with a centroid–centroid distance of 3.6080 (8) Å