From the Editors

We are proud to publish the 14th issue of the Jefferson Medicine Forum. The editorial staff would like to acknowledge the support of Dr. Diemer in producing this year’s forum. We appreciate your guidance and support in bringing this issue to print. Over the years, the Medicine Forum has provided a unique opportunity for our housestaff and medical students to not only share scholarly activities, but also to pursue their interests outside of the medical field. This year, we are proud to announce the addition of medical application reviews as well as an opinion piece on the use of opiates in primary care – a controversial topic that often leads to heated debates. We have also been fortunate enough to include interesting travel experiences, unique case reports, and exciting review articles, along with some breathtaking photography and original cartoon

A Case Series of Lyme Carditis with Complete Heart Block

Case 1 A 25-year-old Caucasian male with a history of a benign functional heart murmur presented to the emergency department for evaluation of 10 days of dyspnea with minimal exertion, such as walking a few blocks or climbing a flight of steps. Dyspnea was accompanied by moderate, dull, left-sided chest pain, which had been progressively worsening over the previous 3-5 days. The symptoms initially occurred only with exertion, but progressed to last 30-45 minutes after discontinuation of activity. He also noticed palpitations during these episodes, but did not try any remedies for his symptoms. Of note, two weeks prior to presentation, the patient had been camping in Shenandoah National Park, Virginia for four days. During that trip, he sustained over 30 mosquito bites, but never noticed any tick bites or rashes. He also traveled to Brazil five months ago, during which time he took malaria prophylaxis

Effect of Demographic Factors, Occupational Stress and Job Satisfaction on Dysfunctional Audit Behaviour among Auditors

This study aims to examine the factors of dysfunctional behaviour among auditors in Malaysia.  Factor analysis was employed to analyse three factors (1) demographic factors (a type of firm and period of audit experience), (2) Occupational stress (time budget pressure and complexity of audit task) and (3) Job Satisfaction that affects dysfunctional audit behaviour which is reduced audit quality and underreporting time. A questionnaire was distributed among 223 respondents employed by the Big 4 and non-Big 4 audit firms located in Kuala Lumpur and Selangor. The findings revealed that all the tested variables have a significant influence towards reduced audit quality, whereas underreporting time show a non-significant relationship with demographic factors. The findings are anticipated to provide beneficial insights not only to audit practitioners but to many other regulators, professional bodies, policy makers, practitioners and academics that are relevant to their future decisions. This study is also subject to limitations that serve as consideration for future research. Keywords: Dysfunctional Audit Behaviour; Audit Behaviour Factors; Fraud Detection; Audit Quality eISSN: 2398-4287© 2021. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open-access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under the responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians/Africans/Arabians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. DOI: https://doi.org/10.21834/ebpj.v7iSI7.388

Different glucose analyzers report different glucose concentration values in term newborns

Background: The American Academy of Pediatrics and Pediatric Endocrine Society neonatal hypoglycemia guidelines based their glucose concentration treatment thresholds on studies that predominantly used Beckman and Yellow Springs Glucose Oxidase Analyzers. Currently, a majority (76%) of U.S. hospital laboratories utilizing glucose oxidase methodology use Vitros® Glucose Analyzers. However, a bias of ~+5% between glucose concentrations from Beckman vs. Vitros Glucose Analyzers has been reported; this could have a clinically significant effect when using published guideline treatment thresholds. Methods: To determine if there is similar instrument bias between Beckman and Vitros Analyzers in reported glucose concentrations from term newborns, we compared plasma glucose concentrations measured within the first 3 h after birth by Beckman vs. Vitros Analyzers in a total of 1,987 newborns (Beckman n = 904, Vitros n = 1,083). Data were fit using nonlinear cubic spline models between collection time and glucose concentration. Results: The non-linear patterns of initial glucose concentrations (during the first 3 h after birth) as measured by Beckman and Vitros Analyzers paralleled each other with no overlap of the fit spline curve 95% confidence intervals, with an approximate +5 mg/dL constant bias. Additionally, in method comparison studies performed in the Chemistry Laboratory on adult samples, there was a +4.2-7.4 mg/dL measured glucose bias for the Beckman vs. Vitros Analyzer. Conclusion: Glucose concentrations from term, appropriate size for gestational age newborns were about 5 mg/dL higher when measured by Beckman vs. Vitros Analyzers. Perhaps, concentrations of 45 mg/dL reported from Beckman Analyzers may be equivalent to 40 mg/dL from Vitros Analyzers. When managing neonatal hypoglycemia, it is important to know which analyzer was used and whether adjusting for potential instrument bias is necessary when following published guidelines. Keywords: glucose; glucose analyzer; guideline; neonatal hypoglycemia; newborn

Spatial and temporal bottom sediment characteristics of Pahang river estuary, Pahang, Malaysia

Bottom sediment samples from Pahang river- estuary were analyzed for the sediment characteristics in order to understand better sedimentation processes in the estuary. The mean, sorting,skewness and kurtosis values of each sample were determined by the Moment’s method. This study showed that the sediment characteristics were not significantly differ (p > 0.05) with the seasonal changes, except for sorting (p < 0.05). The sediment mean size becomes finer towards the estuarine area with the range of very coarse sand to fine silt. This indicates that the characteristics of deposited sediments at each station are much dependant upon the combination of physical forces such as freshwater run-off, tidal currents and waves

Site-Specific Analysis of the Incidence Rate of Enterotoxigenic \u3ci\u3eEscherichia coli\u3c/i\u3e Infection Elucidates an Association with Childhood Stunting, Wasting, and Being Underweight: A Secondary Analysis of the MAL-ED Birth Cohort

Asymptomatic infection by fecal enteropathogens is a major contributor to childhood malnutrition. Here, we investigated the incidence rate of asymptomatic infection by enterotoxigenic Escherichia coli (ETEC) and assessed its association with childhood stunting, wasting, and being underweight among children under 2 years of age. The Malnutrition and Enteric Disease birth cohort study included 1,715 children who were followed from birth to 24 months of age from eight distinct geographic locations including Bangladesh, Brazil, India, Peru, Tanzania, Pakistan, Nepal, and South Africa. The TaqMan array card assay was used to determine the presence of ETEC in the nondiarrheal stool samples collected from these children. Poisson regression was used to estimate the incidence rate, andmultiple generalized estimating equations with binomial family, logit link function, and exchangeable correlation were used to analyze the association between asymptomatic ETEC infection and anthropometric indicators such as stunting, wasting, and being underweight. The site-specific incidence rates of asymptomatic ETEC infections per 100 child-months were also higher at the study locations in Tanzania (54.81 [95% CI: 52.64, 57.07]) and Bangladesh (46.75 [95% CI: 44.75, 48.83]). In the Bangladesh, India, and Tanzania sites, the composite indicator of anthropometric failure was significantly associated with asymptomatic ETEC infection. Furthermore, a significant association between asymptomatic heat-stable toxin ETEC infections and childhood stunting, wasting, and being underweight was found in only the Bangladesh and Tanzania sites

Analysis of the effects and relationship of perceived handwritten signature's size, graphical complexity, and legibility with dynamic parameters for forged and genuine samples

This article presents an analysis of handwritten signature dynamics belonging to two authentication groups, namely genuine and forged signature samples. Genuine signatures are initially classified based on their relative size, graphical complexity, and legibility as perceived by human examiners. A pool of dynamic features is then extracted for each signature sample in the two groups. A two-way analysis of variance (ANOVA) is carried out to investigate the effects and the relationship between the perceived classifications and the authentication groups. Homogeneity of variance was ensured through Bartlett's test prior to ANOVA testing. The results demonstrated that among all the investigated dynamic features, pen pressure is the most distinctive which is significantly different for the two authentication groups as well as for the different perceived classifications. In addition, all the relationships investigated, namely authenticity group versus size, graphical complexity, and legibility, were found to be positive for pen pressure

The effect of early nutritional supplementation with a mixture of probiotic, prebiotic, fiber and micronutrients in infants with acute diarrhea in Indonesia

A randomized double blind clinical trial was conducted to assess the efficacy of a special infant formula containing Lactobacillus rhamnosus LMG P-22799 (probiotic: 5 x 10 8 CFU/100mL), inulin (prebiotic: 0.15 g/100mL), dietary fiber (soy polysaccharides: 0.2 g/100mL) and increased amounts of zinc+iron (+0.4 and +0.6 mg/100mL, respectively) as active ingredients for the early dietary management of 58 Indonesian well-nourished male infants aged 3-12 months suffering from acute diarrhea with moderate dehydration. After adequate oral rehydration, the patients were randomly assigned to receive either a low lactose infant formula supplemented with added precooked rice (1.5 g/100mL) with the above active ingredients (study group) or a low lactose infant formula with added precooked rice without the above active ingredient supplement (control group). No antibiotic, anti-secretory drug or antiemetic was given at all. Both study and control groups showed similar outcomes for weight gain and stool weight. The duration of diarrhea was significantly shorter in the study group than in the control group (1.63 versus 2.45 days; p&lt;0.05; for the study and control group, respectively). No treatment failure or other side effects were observed during the course of the study. The present study supports the evidence for the efficacy of a special anti-diarrhea infant formula containing probiotic, prebiotic, fiber and iron+zinc after oral rehydration by shortening the duration of infantile diarrhea in developing countries. However, from the results of our study we cannot discern the individual contribution of the active ingredients and also not whether they may act independent from each other or in a synergistic way

Interglial Crosstalk in Obesity-Induced Hypothalamic Inflammation

Glial cells have recently gained particular attention for their close involvement in neuroinflammation and metabolic disorders including obesity and diabetes. In the central nervous system (CNS), different types of resident glial cells have been documented to express several signaling molecules and related receptors, and their crosstalks have been implicated in physiology and pathology of the CNS. Emerging evidence illustrates that malfunctioning glia and their products are an important component of hypothalamic inflammation. Recent studies have suggested that glia–glia crosstalk is a pivotal mechanism of overnutrition-induced chronic hypothalamic inflammation, which might be intrinsically associated with obesity/diabetes and their pathological consequences. This review covers the recent advances in the molecular aspects of interglial crosstalk in hypothalamic inflammation, proposing a central role of such a crosstalk in the development of obesity, diabetes, and related complications. Finally, we discuss the possibilities and challenges of targeting glial cells and their crosstalk for a better understanding of hypothalamic inflammation and related metabolic dysfunctions

Maternal Underweight and Its Association with Composite Index of Anthropometric Failure among Children under Two Years of Age with Diarrhea in Bangladesh

Malnutrition in women has been a long-standing public health concern, with serious effects on child survival and development. Maternal body mass index (BMI) is an important maternal nutritional indicator. There are few published studies although child anthropometric failures do not occur in isolation and identifying children with single versus several co-occurring failures can better capture cases of growth failure in combination: stunting, wasting, and underweight. In the context of multiple anthropometric failures, traditional markers used to assess children’s nutritional status tend to underestimate overall undernutrition. Using the composite index of anthropometric failure (CIAF), we aimed to assess the association between maternal undernutrition and child undernutrition among children with diarrhea under the age of two and to investigate the correlates. Using 1431 mother-child dyads from the Antibiotic for Children with Diarrhea (ABCD) trial, we extracted children’s data at enrollment and on day 90 and day 180 follow-ups. ABCD was a randomized, multi-country, multi-site, double-blind, placebo-controlled clinical trial. The Bangladesh site collected data from July 2017 to July 2019. The outcome variable, CIAF, allows combinations of height-for-age, height-for-weight, and weight-for-age to determine the overall prevalence of undernutrition. The generalized estimating equation was used to explore the correlates of CIAF. After adjusting all the potential covariates, maternal undernutrition status was found to be strongly associated with child undernutrition using the CIAF [aOR: 1.4 (95% CI: 1.0, 1.9), p-value = 0.043] among the children with diarrhea under 2 years old. Maternal higher education had a protective effect on CIAF [aOR: 0.7 (95% CI: 0.5, 0.9), p-value = 0.033]. Our study findings highlight the importance of an integrated approach focusing on maternal nutrition and maternal education could affect a reduction in child undernutrition based on CIAF.publishedVersionPeer reviewe