Clinics and Practice

The devastating COVID-19 pandemic has created several gaps in the management of viral infections, leaving biocontainment and supportive measures as the only resorts for control. As such, there has been a dramatic increase in the use of dietary supplementations and herbal medicine for COVID-19. However, serious concerns regarding the efficacy, safety, and recommended doses of these medicines have been raised. In this study, we aimed to assess the population knowledge about alternative medicine administration for COVID-19 and the associated factors. Using a self-administered cross-sectional survey, we analyzed a total of 2042 valid responses. Most of the included participants were females (69.7%), with an overall mean age of 20.8 ± 11.8 years. Most respondents (62.8%) obtained their knowledge from social media while only 16.6% received knowledge from the health care workers. Half of the participants (50.6%) correctly identified all COVID-19 symptoms, where fever (18.5%) and loss of smell and taste (17.1%) were the most frequent answers. On the use of traditional medicines and supplements for COVID-19, 57.8% did not answer, 23.7% admitted regular use, and 18.5% used sometimes. Family members or friends suggested the use of traditional medicines and dietary supplements to 28.0% of the participants while only 14.7% were advised by a nutritionist, physician, pharmacist, nurse, or a health worker. Moreover, seniors and illiterate portions of society had lower knowledge scores and increased utilization of alternative medicine. Marital status, income, and previous COVID-19 were all significant predictors of the awareness and knowledge score. Thus, this study has identified overuse of unregulated medicinal products in the region, which potentially aggravates COVID-19 or other underlying risks of the disease, making clinical management challenging, particularly in geriatrics and women’s health. Regulation of medicinal products and establishment of educational campaigns about the disease have become imperative. Full article

The aim of this study is to show the usefulness of collaborative work in the evaluation of prostate cancer from T2-weighted MRI using a dedicated software tool. The variability of annotations on images of the prostate gland (central and peripheral zones as well as tumour) by two independent experts was firstly evaluated, and secondly compared with a consensus between these two experts. Using a prostate MRI database, experts drew regions of interest (ROIs) corresponding to healthy prostate (peripheral and central zones) and cancer. One of the experts then drew the ROI with knowledge of the other expert’s ROI. The surface area of each ROI was used to measure the Hausdorff distance and the Dice coefficient was measured from the respective contours. They were evaluated between the different experiments, taking the annotations of the second expert as the reference. The results showed that the significant differences between the two experts disappeared with collaborative work. To conclude, this study shows that collaborative work with a dedicated tool allows consensus between expertise in the evaluation of prostate cancer from T2-weighted MRI. Full article

In this convergent mixed-methods study, the aim was to explore how objective and subjective quality ratings of school nurses’ motivational interviewing (MI) correlate whilst also considering the perceptions of delivering and participating in the same MI sessions. Quantitative and qualitative data were derived from seven intervention schools participating in the Healthy School Start Plus parenting support intervention. School nurses were trained in MI and conducted an MI session with parents of 6–7-year-old children to discuss children’s physical health and development. Quantitative data comprised objective ratings of school nurses’ MI competence using the Motivational Interviewing Treatment Integrity 4.2 [MITI-4] protocol, as well as parents’ and school nurses’ subjective ratings of the MI sessions. Qualitative data comprised semi-structured interviews with parents and school nurses about their perceptions of the MI sessions. First, quantitative data were analysed using Spearman’s rank correlation, and qualitative data were analysed using content analysis. Next, quantitative and qualitative findings were merged. Our findings suggest that school nurses’ MI performances were rated and perceived as valuable and family-centred by both school nurses and parents who had left the meeting feeling motivated and empowered to promote their children’s healthy behaviours. Nonetheless, school nurses were critical to their own MI technical performance, and they found that reflections were easier to deliver and to self-rate. Overall, MITI ratings were the lowest and parents’ ratings were the highest. Future studies should focus on relating clients’ subjective ratings of MI with clients’ behavioural outcomes. Full article

Idiopathic scoliosis is a condition characterized by a three-dimensional curvature of the spine. However, in addition to the spinal curvature, it has also been reported that patients with idiopathic scoliosis can display other abnormal physiologic parameters, such as hormone imbalances, genetic variants, and micronutrient deficiencies. The present study evaluates the salivary progesterone levels from a historical cohort of patients seeking treatment at a single integrative medicine clinic. A group of female patients with a history of idiopathic scoliosis is compared to a group of non-scoliosis female patients. Salivary progesterone levels were 49% higher in non-scoliosis patients compared to the scoliosis group (p < 0.05). When compared by the menstrual cycling status, non-scoliosis females had a 60% higher average progesterone level, while the progesterone level among non-cycling, non-scoliosis females was 39% higher than non-cycling scoliosis females. These results suggest a potential relationship between salivary progesterone and idiopathic scoliosis among female patients. Full article

Significant anti-spike protein receptor-binding domain (S-RBD) antibody responses have been demonstrated in patients with chronic disorder of consciousness (DOC) completing a COVID-19 vaccine regime with BNT162b2 (Pfizer–BioNTech). We now provide further prospective data on the immunogenicity of these patients followed by heterologous booster injection with mRNA-1273 (Moderna). These patients were compared with two different demographically comparable healthcare workers (HCW) groups who underwent homologous booster injection with BNT162b2 vaccine or heterologous booster injection with mRNA-1273. Antibody responses were evaluated at 21 days after the administration of the booster dose of vaccination. Results: No severe adverse reactions were reported after each type of vaccination. Heterologous boosting with mRNA-1273 elicited a higher increase of S-RBD IgG levels than homologous boosting with BNT162b2 both in DOC patients and HCW who had previously received two doses of BNT162b2. No significant difference was detected between DOC and HCW patients who received heterologous boosting. Conclusions: Despite the small sample size, our preliminary results suggest that heterologous boosting with mRNA-1273, following initial vaccination with BNT162b2, is safe and tends to be more immunogenic than homologous boosting, either in fragile people or in healthy controls. Full article

Background: Treatment of high blood pressure is a combination of lifestyle changes and medications, and appropriateexercise therapy is recommended as one of the lifestyle-related changes. Recently, stretching, a low-intensity exercise, was reported to be antihypertensive and effective for improving arteriosclerosis, in addition to aerobic exercise. The present study investigated the short-term effects of continuous stretching and rest-induced rebound on vascular endothelial function in hypertensive patients. Methods: This study was conducted as a single-arm prospective interventional study including patients between 30 and 70 years of age undergoing treatment for hypertension from October 2019 until May 2021. The intervention consisted of six months of daily stretching, one month of rest, and another three months of stretching. We measured arteriosclerosis indices such as cardio ankle vascular index (CAVI), ankle brachial pressure index (ABI) and reactive hyperemia index (RHI), and flexibility at the baseline and one, three, six, seven, and ten months from the baseline. Results: We included a total of ten patients (three males and seven females) with an average age of 60.10 ± 6.05 years. The exercise rate for the entire period was 90% or more, and the anteflexion measurement value improved significantly before and after the intervention (p < 0.001). Blood pressure and CAVI/ABI were well controlled throughout the study period. RHI did not show any significant improvement during the initial six months, and only slightly improved by the third month (p = 0.063). Even after the rest phase and resumption of stretching, RHI remained stable. Conclusions: The compliance of the stretching program we used, evaluated by the exercise implementation rate for the entire period, was 90% or more; therefore, easy to perform and continue by hypertensive patients. However, we did not observe a significant positive effect on arteriosclerosis index or blood pressure in this study. Full article

Recently, the genetic background of pheochromocytomas/paragangliomas (PPGLs) has been rapidly revealed. These tumors have been referred to as the “ten percent tumor”; however, the frequency of genetic variants of PPGLs has turned out to be more common than expected. PPGLs are potentially hereditary tumors and appear clinically sporadic. Here, we report a case of bilateral pheochromocytoma (PCC) with a variant in the MYC-associated factor X (MAX) gene (c.295 + 1G > A). A male patient was diagnosed with adrenal pheochromocytoma (PCC) and underwent a left adrenalectomy at the age of 40. A new tumor in the right adrenal gland was detected at the age of 43. Urinary metanephrine and normetanephrine concentrations gradually increased. The size of the right adrenal PCC continued to increase one year after detection. Genetic testing of the peripheral blood revealed the presence of a pathogenic variant in MAX. The natural history of adrenal PCCs with the MAX variant has not yet been clarified, because the number of reported cases is not sufficient. Thus, clinicians should consider a MAX variant when they find bilateral or multiple PCCs. Full article

Obstructive Sleep Apnea (OSA) is a partial or total upper airway collapse resulting in sleep-breathing disturbances. There are many medical comorbidities associated with OSA; hence, this study is important as the prevalence of patients with medical comorbidities associated with OSA is increasing. The study aimed to correlate medical comorbidities and OSA symptoms of the patients along with their upper airway dimensions using Cone Beam Computed Tomography (CBCT) scans to identify patients at risk of developing OSA. This cross-sectional study included patients who had CBCT imaging taken between 2014 and 2020. A questionnaire was used to gather information on patients’ medical history and OSA symptoms. The upper airway dimensions of the CBCT scans were evaluated before logistic regression and Fisher’s exact test were carried out to determine the relationships between the variables. p ≤ 0.05 was considered statistically significant. Logistic regression revealed an association of longer length (p = 0.016), smaller total volume (p = 0.017) and width (p = 0.010) of upper airways with hypertension. Furthermore, loud snoring was seen in patients with hypertension, heart disease and obesity whereas difficulty concentrating during the day was present in subjects with deviated nasal septum, tonsillitis and depression. For upper airway dimensions, a smaller average volume was associated with loud snoring (p = 0.037), difficulty concentrating during the day (p = 0.002) and mood changes (p = 0.036). A larger anterior-posterior dimension was also associated with excessive daytime sleepiness (p = 0.042), difficulty concentrating during the day (p < 0.001) and mood changes (p = 0.009). Longer airway length was additionally found to be associated with loud snoring (p = 0.021). CBCT taken for dental investigations could be correlated with patients’ medical history and OSA symptoms to screen patients at risk of OSA. Full article

(1) Background: Tacrolimus is an immunosuppressive agent commonly used in the management of solid organ allogeneic transplants in the prevention of rejection. Serious ophthalmic adverse effects with Tacrolimus have been reported in the literature, which includes cortical blindness and optic neuropathy. (2) Methods: We describe a rare case of maculopathy as a possible complication of Tacrolimus therapy. A 56-year-old man receiving Tacrolimus for immunosuppression after liver transplantation developed unilateral visual disturbance with a central scotoma. (3) Results: Ophthalmologic examination revealed unilateral maculopathy; a Tacrolimus macular toxicity was suspected. After drug discontinuation, a complete visual recovery was observed; however, the ultrastructural macular damage was irreversible. (4) Conclusions: Reports regarding maculopathy associated with Tacrolimus are limited. This case report adds to the current literature regarding the possible macular toxicity of this immunosuppressive agent, especially if it exceeds therapeutic serum levels. Further data are needed to confirm this possible association. A careful ophthalmologic examination should be promptly performed in patients manifesting visual disturbance while taking Tacrolimus to prevent irreversible, permanent vision loss due to possible drug toxicity. Full article

Contraception is one of the common methods of family planning. The oral contraceptive pill (OCP) is among the most effective methods of contraception. This study aimed to assess the knowledge, attitude, and practice of oral contraception use and its side effects among women in the Jazan region, Saudi Arabia. A cross-sectional study was carried out among adult women 18 years and older in the Jazan region. A pre-tested questionnaire was used to assess their demographic characteristics, knowledge, attitudes, previous experience, and pattern of OCP usage. Descriptive analysis and a logistic regression model were used to analyse data. About 570 questionnaires were distributed and achieved a 98.3% response rate. The majority of women participants were between 18 and 25 years old, and 51.4% of the respondents reported that they had previously used or were using OCP. We found that women had good knowledge and a positive attitude towards OCP, with more than half of the users preferring them over other contraceptive methods. This study indicates that attitude, knowledge, and prior experience of OCP have no significant effect on the usage pattern of OCP among women with relatively high socioeconomic status in the Jazan region, Saudi Arabia. Full article

Coronavirus disease 2019 (COVID-19) can directly or indirectly affect the central and peripheral nervous systems, resulting in cognitive impairment, memory problems, and a wide range of neuromuscular involvement, including neuropathies. However, the long-term neurological complications of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection are not clear. The aim this study was to analyze a case report the presence of neurological sequelae due to post-Coronavirus disease 19 in a patient without apparent previous neurological symptoms. Clinical case: A 46-year-old patient, with no relevant history for the described condition, who, after severe COVID-19 infection, started a mixed neuropathy and mental fog syndrome as the main sequel. Multiple laboratory and imaging studies were performed during and after his hospital stay, and it was corroborated by an electromyography that it occurred from a neuropathy triggered by COVID-19 infection. Conclusions: This case provides additional evidence that mixed neuropathy and brain fog syndrome are potential complications of post-coronavirus disease 2019 syndrome. The neurological sequelae that manifest after a COVID-19 episode can be rapidly enhanced as a consequence of another alteration in some systems of the organism. However, future studies are necessary to elucidate the incidence of these neurological complications, their pathophysiological mechanisms and their therapeutic options. Full article

Primary fallopian tube carcinoma is very rare. Diagnosis is challenging. The description of our case concerns an asymptomatic 71-year-old patient who came for a routine gynecological examination. Imaging of the pelvis revealed the presence of a two-chambered cystic formation in the anatomical position of the right ovary. It was decided to investigate the disease by laparotomy. Examination of the frozen section from the site of the cystic lesion was negative for malignancy. An abdominal total hysterectomy was performed with bilateral salpingo-oophorectomy. Serous carcinoma of the fallopian tube was diagnosed postoperatively by histological examination of the surgical preparation. Immediately after surgery, the patient’s health was good.The patient was referred to an oncology center and was monitored. Chemotherapy based on platinum and taxane was recommended. Six months after the operation the patient is in good health. The possibility of a second surgery to treat fallopian tube cancer with pelvic lymph node dissectionis under discussion and is expected to be decided by oncologists and gynecologists-oncologists. In this article, after describing the case report, a brief review of this rare entity disease’s diagnostic and therapeutic approach is attempted. Full article

This study evaluated a pharmacist-led telephonic Medication Therapy Management (MTM) program for rural patients in Arizona with poor access to healthcare services. A pharmacist provided telephonic MTM services to eligible adult patients living in rural Arizona communities with a diagnosis of diabetes and/or hypertension. Data were collected and summarized descriptively for demographic and health conditions, clinical values, and medication-related problems (MRPs) at the initial consultation, and follow-up data collected at 1 and 3 months. A total of 33 patients had baseline and one-month follow-up data, while 15 patients also had three-month follow-up data. At the initial consultation, the following MRPs were identified: medication adherence issues, dose-related concerns, adverse drug events (ADE), high-risk medications, and therapeutic duplications. Recommendations were made for patients to have the influenza, herpes zoster, and pneumonia vaccines; and to initiate a statin, angiotensin converting enzyme inhibitor, angiotensin receptor blocker, beta-blocker, and/or rescue inhaler. In conclusion, this study demonstrated that while pharmacists can identify and make clinical recommendations to patients, the value of these interventions is not fully realized due to recommendations not being implemented and difficulties with patient follow-up, which may have been due to the COVID-19 pandemic. Additional efforts to address these shortcomings are therefore required. Full article

Spontaneous events have been reported after COVID-19 vaccination. In this case, we report a thrombotic event in an unusual site (ulnar artery) after COVID-19 vaccination. The patient (69 year-old-male) had no changes after a laboratory investigation regarding thrombophilic pattern, but nevertheless had atherothrombotic predisposing conditions. Arterial thrombotic events have more frequently been reported after mRNA vaccines than after adenovirus vaccines. This is the first case reported of thrombosis of the ulnar artery occurring in the same side of the body where the vaccination took place. However, it must be noted that COVID-19 vaccines cumulatively offer a net positive effect, despite rare adverse effects. Full article

The resection of tumors within the primary motor cortex is a constant challenge. Although tractography may help in preoperative planning, it has limited application. While it can give valuable information on subcortical fibers, it is less accurate in the cortical layer of the brain. A 38-year-old patient presented with paresis of the right hand and focal epileptic seizures due to a tumor in the left precentral gyrus. Transcranial magnetic stimulation was not applicable due to seizures, so microsurgical resection was performed with preoperative tractography and intraoperative direct electrical stimulation. A histopathological assessment revealed a diagnosis of glioblastoma. Postoperative magnetic resonance imaging (MRI) showed complete resection. The paresis dissolved completely during follow-up. Surgery within the precentral gyrus is of high risk and requires multimodal functional planning. If interpreted with vigilance and consciousness of the underlying physical premises, tractography can provide helpful information within its limitations, which is especially subcortically. However, it may also help in the identification of functional cortex columns of the brain in the presence of a tumor. Full article

This study aims to identify the relationship between knee functional status and Health-Related QoL (HRQoL) in mild to moderate knee osteoarthritis (OA) patients and to ascertain which subdomain of knee functional status best predicts good HRQoL. A cross-sectional study was conducted in an orthopaedic clinic of a tertiary hospital in Malaysia. Patients aged 40–75 years old with mild–moderate primary knee OA were recruited. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and SF-36 questionnaires were used to measure knee functional status and HRQoL, respectively. Subdomains of KOOS include “function in daily living”, “function in recreational activities”, “pain”, “symptom”, and “knee-specific quality of life”. Subdomains for SF-36 are Physical Component Summary (PCS) and Mental Component Summary (MCS). Overall, 290 patients fulfilled the inclusion criteria of the study, with a mean age of 66.8 years old (±7.06). Majority were female (57.6%) and Malay (79.7%). The relationships between all KOOS and HRQoL subdomains were significant. “Pain” contributed most towards better physical HRQoL ((PCS) Adj. B (95% CI); 0.063 (0.044, 0.169)), while “function in daily living” contributed most towards better mental HRQoL ((MCS) Adj. B (95% CI); 0.624 (0.478, 0.769)). Thus, better HRQoL was related to better pain control and improved “function in daily living” in these patients. Full article

Objectives: Plunging ranula intruding into the cervical region is rare and a standard therapy has not yet been consolidated. This paper investigates the outcomes and side effects of OK-432 treatment in patients with a ranula extending into the cervical region. Methods: The study design and setting consisted of a planned data collection at Tohoku Medical and Pharmaceutical University and Fukase Clinic. Eight patients with ranula extending into the cervical region received OK-432 treatment between January 2016 and February 2019. OK-432 treatment was performed for patients with ranula extending into the cervical region. Results: In all patients, a total shrinkage and marked reduction in lesions were observed without local scars or deformations after OK-432 treatment. Complications were local swelling and mild fever (37.5–38.5 °C), which lasted a few days in half of the patients. Conclusions: OK-432 treatment is straightforward, secure, and efficacious and can be substituted for surgery in the treatment of ranula extending into the cervical region. Full article

Pulmonary embolism (PE) is the third most common vascular disease in the US, a frequently underdiagnosed and potentially fatal condition where embolic material blocks one or more pulmonary arteries impairing blood flow. In this study, we aim to describe the prevalence, outcomes, and predictors of mortality of PE patients treated with mechanical (MT) and surgical thrombectomy (ST). This is a retrospective study using the Agency for Healthcare Research and Quality’s HCUP NIS data from 2010–2018. We used the ninth and tenth revisions of the International Classification of Diseases clinical modification codes (ICD-9-CM and ICD-10-CM) to identify patients admitted with a primary diagnosis of PE (ICD-10-CM codes I26.02, I26.09, I26.92, I26.93, I26.94, and I26.99; ICD-9-CM codes 415.11, 415.13, and 415.19). We extracted demographics, hospital-level, and patient-level characteristics, and defined the severity of comorbid conditions using Deyo modification of the Elixhauser Comorbidity Index. The primary outcomes of interest were the utilization trends of PE (treated with MT and ST); the secondary outcomes were mortality, discharge to facility, peri-procedural complications, and length of hospital (LOS) stay; the tertiary outcome was to identify the predictors of in-hospital mortality. From 2010–2018, there were 1,627,718 hospitalizations for PE, of which 6531 (0.39%) underwent MT and 3465 (0.21%) underwent ST. The utilization trend of MT increased from 336 (0.20%) in 2010 to 1655 (0.87%) in 2018; the utilization trend of ST was 260 (0.15%) in 2010 and 430 (0.23%) in 2018. The unadjusted in-hospital mortality for MT was 9.1% with the mean LOS being 7(±0.3) days; for ST, mortality was 13.9% with a mean LOS of 13(±0.4) days. The occurrences of periprocedural complications for MT and ST were as follows: invasive mechanical ventilation was 13.8% and 32%; cardiopulmonary bypass was 3.3% and 68.3%; pulmonary embolectomy surgery was 1.7%; and bleeding complications were 1.4% and 3.4%. Predictors associated with in-hospital mortality for MT were: increasing age (OR 1.2, 95% CI 1.0–1.3, p < 0.026), female sex (OR 1.9, 95% CI 1.2–2.8, p < 0.004), large hospitals (OR 2.2, 95% 1.4–3.5, p < 0.001), and teaching hospitals (OR 1.8, 95% CI 1.1–3.1, p < 0.023). The predictor of in-hospital mortality for ST was increasing age (OR 1.2, 95% CI 1.0–1.4, p < 0.046). The number of MT procedures performed has rapidly increased over the past decade. Further studies are warranted to determine their rise and therapeutic use. Full article

Background: Little is known about exercise prescription practices in cardiac rehabilitation (CR). Therefore, the purpose of this study was to understand how initial exercise is prescribed and how exercise intensity is progressed among cardiac patients enrolled in United States CR programs. Methods: A 22-question survey was sent out to US CR clinics. Results: Ninety-three clinics responded to the survey. RPE was the most commonly reported exercise intensity indicator used for prescribing exercise, followed by resting HR + 20–30 bpm. Exercise progression practices were also based on patient sustained RPE values. Conclusions. Exercise prescription practice has become reliant on subjective indicators of exercise intensity. This may limit patient outcomes, such as improvement in functional measures. Full article