Objective: To explore (a) the risk factors associated with a deficiency of vitamin B12, and (b) the baseline (cutoff) serum level of vitamin B12 for a clinically-symptomatic deficiency in the Jordanian adult population. Background: Compared to the data available for developed countries, there is a marked scarcity of information on the levels and symptomology of vitamin B12 deficiency in developing countries, particularly in the Middle Eastern region. Methods: A total of 485 subjects were included in this study. Blood samples were drawn for biochemical analysis and data regarding socio-demographics, general health, anthropometric measures, and past medical, surgical, and medication history were collected. To explore the cut-off point, we compared all parameters included in a standard complete blood count as well as main symptoms reported to be associated with B12 deficiency between groups of different B12 cut-off values, consisting of those above and below 200, 175, 150 and 125 pg/ml. Results: Dietary habits, age, recurrent headaches, heart burn and peptic ulcer disease were found to be significantly associated with lower vitamin B12 levels. Surprisingly, daily smoking was associated with significantly higher B12 levels. The results revealed that none of the included potential indicators of B12 deficiency could be considered an indicative feature of deficiency. There were no significant differences neither in the symptoms nor in the CBC parameters between any of the tested study groups. Conclusion: Low dietary intake, older ages, recurrent headaches, heartburn and peptic ulcer disease, all could be considered as a risk factors of having low vitamin B12 levels within the Jordanians. Also, they tend to have lower levels of vitamin B12 levels, in comparison to countries in the West, without necessarily having deficiency symptoms. Cut-off value to diagnose functional B12 deficiency could be less than 125 pg/ml for the Jordanians. More local studies are needed to establish an accurate vitamin B12 cut-off value for the population in Jordan.

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Background Acute ischemic stroke (Stroke) and transient ischemic attacks (TIA) are known complications in cancer patients and those with atrial fibrillation (AF). The role AF plays in Stroke/TIA in the setting of cancer is unclear. The purpose of this study was to assess the relationship between AF and Stroke/TIA in cancer patients. Methods We conducted a case-control study comparing all patients who developed Stroke/TIA from 2014 to 2019 following a cancer diagnosis at King Hussein Cancer Center (KHCC), matched to Stroke/TIA-free controls based on age, gender, and cancer site. Results Two hundred seventy-two patients were included (136 per group). The mean age was 63.95 ± 13.06 and 57% were females. The Stroke/TIA group had more AF at the time of event (14% vs. 4%, OR: 4.25, 95%-CI: 1.39 - 17.36) and had a larger proportion of death on study conclusion (OR: 9.4, 95%-CI: 3.74 - 23.64). On conditional logistic regression, patients in the Stroke/TIA group had higher odds of: AF (OR: 7.93, 95%-CI: 1.6 – 39.18), ischemic stroke before cancer diagnosis (OR: 9.18, 95%-CI: 2.66 – 31.74), being on active cancer treatment (OR: 3.11, 95%-CI: 1.46 – 6.62), dyslipidemia (OR: 3.78, 95%-CI: 1.32 – 10.82), and renal disease (OR: 4.25, 95%-CI: 1.55 – 11.63). On another conditional logistic regression model built to assess the role of the CHA2DS2-VASc score, a score of >=2 in males and >=3 in females significantly increased the risk of developing Stroke/TIA in cancer patients (OR: 2.45, 95%-CI: 1.08 - 5.58). Conclusion AF, previous ischemic stroke, active cancer treatment, dyslipidemia, and renal disease are independent risk factors for Stroke/TIA and a higher CHA2DS2-VASc score significantly increases the risk in cancer patients regardless of AF.

Continued smoking in cancer patients is commonly observed in Jordan. In a country that exhibits some of the highest smoking rates globally, enhancing patient education regarding the value of smoking cessation for cancer care is vital. The objectives of our study were to describe sociodemographic and clinical factors associated with continued smoking in Jordanian smokers after a cancer diagnosis; to identify reasons for smoking and knowledge regarding smoking’s impact on care; to examine in a multivariable manner the factors associated with continued smoking, and to accordingly generate patient counseling recommendations. An interviewer-administered survey using the Theoretical Domains Framework was employed. Among 350 subjects (mean age 51.0, median 52.7), approximately 38% of patients had quit or were in the process of quitting; 61.7% remained smokers. Substantial knowledge gaps with regard to the impact of continued smoking on cancer care were observed. Remaining a smoker after diagnosis was associated with being employed, not receiving chemotherapy or surgery, having lower confidence in quitting, and having a lower number of identified reasons for smoking. Interventions to promote cessation in Jordanian cancer patients who smoke should focus on enhancing patient awareness about the impact of smoking in cancer care and raising perceived self-efficacy to quit.

INTRODUCTION: Mastocytosis is a rare disease caused by the abnormal proliferation and accumulation of mast cells in 1 or more organs of the body and is divided into cutaneous and systemic disease. Patients have increased susceptibility to urticaria, pruritis and anaphylactic shock. GI manifestations are thought to be related to direct mast cell infiltration and release of mast cell mediators. CASE DESCRIPTION/METHODS: A 39-year-old woman with a history of cutaneous mastocytosis intolerant to cromolyn sodium, Roux-en-Y gastric bypass, gastritis, celiac disease and hemorrhoids presented with melena and hematemesis following a mastocytosis flare and concurrent pneumonia. She had no prior history of GI bleeding, PUD, H. Pylori infection, NSAID or anticoagulation use, liver disease, or family history of GI malignancies. Prior EGDs and colonoscopies were unremarkable. She was on a chronic high-dose of famotidine and prednisolone taken as needed. Physical exam showed mild epigastric and left upper quadrant tenderness, bilateral rhonchi, and hemodynamic stability. Initial laboratory findings were insignificant. She was given IV pantoprazole BID and continued to have melena while remaining stable; with Hb down-trending to 11.6 gm/dL. EGD revealed a large gastric pouch with Roux-en-Y anatomy and 2 non-bleeding cratered ulcers near the congested, erythematous gastrojejunal anastomosis. The larger ulcer (9 mm) had a visible vessel and was clipped. Pathology revealed reactive gastropathy, mild chronic inflammation without H. pylori. Jejunal biopsies showed congestive mucosa and mild acute on chronic inflammation. The patient resumed IV continuous infusion of pantoprazole for 48 hours then transitioned to oral PPI with her usual famotidine. DISCUSSION: Up to 80% of patients with systemic mastocytosis can present with a variety of GI symptoms, with the most common being diarrhea and abdominal pain. Though the etiology of diarrhea is not well understood, abdominal pain is largely attributed to dyspepsia and gastroduodenal ulcers resulting from acid hypersecretion. Symptomatic treatment for GI symptoms largely depends on anti-mediator therapy where H1 and H2 receptors are typically combined. PPIs are added to treat gastric involvement. Cromolyn sodium is a highly effective treatment for GI manifestations (100-200 mg PO up to 4 times/day). Oral corticosteroids may relieve malabsorption and ascites in the rare cases of liver involvement. Lifestyle modifications include avoidance of triggers and stress management if possible.

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Background: Acute ischemic stroke (AIS) and transient ischemic attacks (TIA) are known complications in cancer patients and those with atrial fibrillation (AF). The role AF plays in AIS/TIA in the setting of cancer is unclear.The purpose of this study was to assess the relationship between AF and AIS/TIA in cancer patients.Methods: We conducted a case-control study comparing all patients who developed AIS/TIA from 2014 to 2019 following a cancer diagnosis at King Hussein Cancer Center (KHCC), matched to AIS/TIA-free controls based on age, gender, and cancer site.Results: 272 patients were included (136 per group). The mean age was 63.95 ± 13.06 and 57% were females. The AIS/TIA group had more AF at the time of event (14% vs. 4%, OR: 4.25, 95%-CI: 1.39 - 17.36) and had a larger proportion of death on study conclusion (OR: 9.4, 95%-CI: 3.74 - 23.64). On conditional logistic regression, patients in the AIS/TIA group had higher odds of: AF (OR: 7.93, 95%-CI: 1.6 – 39.18), ischemic stroke before cancer diagnosis (OR: 9.18, 95%-CI: 2.66 – 31.74), being on active cancer treatment (OR: 3.11, 95%-CI: 1.46 – 6.62), dyslipidemia (OR: 3.78, 95%-CI: 1.32 – 10.82), and renal disease (OR: 4.25, 95%-CI: 1.55 – 11.63). On another conditional logistic regression model built to assess the role of the CHA₂DS₂-VASc score, a score of >=2 in males and >=3 in females significantly increased the risk of developing AIS/TIA in cancer patients (OR: 2.45, 95%-CI: 1.08 - 5.58).Conclusion: AF, previous ischemic stroke, active cancer treatment, dyslipidemia, and renal disease are independent risk factors for AIS/TIA and a higher CHA₂DS₂-VASc score significantly increases the risk in cancer patients regardless of AF.