ObjectiveWe assessed the impact of political conflict (Boko Haram) on tuberculosis (TB) case notifications in Adamawa State in North-east Nigeria.DesignA retrospective analysis of TB case notifications from TB registers (2010–2016) to describe changes in TB notification, sex and age ratios by the degree of conflict by local government area.SettingAdamawa State.Participants21 076 TB cases notified.Results21 076 cases (62% male) were notified between 2010 and 2016, of which 19 604 (93%) were new TB cases. Areas affected by conflict in 2014 and 2015 had decreased case notification while neighbouring areas reported increased case notifications. The male to female ratio of TB cases changed in areas in conflict with more female cases being notified. The young and elderly (1–14 and >65 years old) had low notifications in all areas, with a small increase in case notifications during the years of conflict.ConclusionTB case notifications decreased in conflict areas and increased in areas without conflict. More males were notified during peace times and more female cases were reported from areas in conflict. Young and elderly populations had decreased case notifications but experienced a slight increase during the conflict years. These changes are likely to reflect population displacement and a dissimilar effect of conflict on the accessibility of services. TB services in conflict areas deserve further study to identify resilient approaches that could reach affected populations.

Background Intraoperative bleeding during functional endoscopic sinus surgery (FESS) poses a challenge to both surgeon and anesthetist. The primary aim of this study was to evaluate the effectiveness of local, intravenous and combined use of tranexamic acid (TA) in improving the surgical field quality during FESS. Methods We conducted a randomized controlled double‐blinded prospective trial on 120 patients scheduled for elective FESS. After induction of general anesthesia, patients were randomly and evenly assigned to one of four groups; IV TA, local TA, both IV and local TA, and placebo. Surgical field was assessed using five‐point Boezaart scale. Total fentanyl and esmolol consumption, operative time, recovery time, and postoperative complications were recorded. Results Surgical field quality score was the best in IV and local TA group compared to others (p < 0.001). Mean operative time was found significantly shorter in IV and local TA group than placebo one. Total fentanyl consumption was significantly lower in IV and local TA group comparing to others (p = 0.025). Mean recovery time was significantly shorter for IV and local TA group compared to others. Total fentanyl consumption was significantly lower in IV and local TA group comparing to others. No significant differences were found of mean arterial pressure and heart rate decline in four groups. None of the patients in four groups required esmolol administration. No statistically significant differences were found in change of hemoglobin, hematocrit, prothrombin time, and partial thromboplastin time over time in all groups. Conclusion The combined use of topical and intravenous TA provided the best surgical field in FESS, less fentanyl consumption, and less recovery time without causing significant side effects.

SummaryBackgroundDegranulation of mast cells (MCs) releases several mediators such as vascular endothelial growth factor (VEGF), chymase, tryptase, histamine, and cytokines, which all have important roles in the severity of dengue infection. We aimed to investigate the role of MCs in severity of dengue.MethodsWe searched for relevant studies in 10 databases on 15 August 2016. Meta‐analysis (MA) was conducted by R version 3.5.0.ResultsWe included 24 studies. in vivo and in vitro studies showed higher MC products released from infected mice/cells with dengue virus. In addition, when administering MC stabilizers or antihistaminic drugs, there was a decrease in vascular/capillary permeability. In human and at early stages, studies revealed an insignificant difference in VEGF levels in dengue fever (DF) versus dengue hemorrhagic fever (DHF) (standardized mean difference [SMD] 0.145; 95% confidence interval [CI], −0.348‐0.638). Meanwhile, at acute stages and compared with healthy controls, high heterogeneity with an inconclusive difference in VEGF levels were noted in DF and DHF. However, pooled serum and plasma levels of VEGF were increased significantly in dengue shock syndrome (DSS) versus healthy controls (SMD 0.65; 95% CI, 0.3‐0.95). There were also significantly higher chymase levels in DHF patients compared with DF during the acute phase (MD −6.531; 95% CI, −12.2 to −0.9).ConclusionVEGF and chymase levels are mediators in dengue pathogenesis. However, limited data were available to support their role in severe dengue cases. Further studies are needed to evaluate the function of other mediators in dengue severity.

The Patient Protection and Affordable Care Act (PPACA) addresses consumer protection, employer-provided insurance coverage, as well as the government’s role in providing health care access to the most vulnerable populations. Within the practice of neurology, the PPACA has the challenging goal of reconciling the needs of the growing elderly population with the financial barriers to costly yet available health care services. To bridge that gap, all health care professionals working in the field of neurology must reflect on the effect previous Medicare reimbursement policies have had on the current practice of neurology, and utilize lessons learned in recent years. The test of time will tell whether the PPACA will achieve the goal of decreasing in health care spending while ensuring quality universal healthcare services.

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As diagnostic and therapeutic modalities for Hodgkin's Lymphoma (HL) continue to improve, patient‐related factors affecting survival become more difficult to identify. Very little is known about the relationship between the primary site of lymph node (LN) involvement and survival of HL patients. We retrospectively analyzed the United States Surveillance, Epidemiology and End Results (SEER) database for 12,658 HL patients reported between 1973 and 2010 using survival analysis and time‐interval multiple logistic regression (MLR) to disclose that relationship. The effect of all primary LN sites on the survival of HL patients was supported. The intra‐abdominal (IAB) primary LN site was significantly associated with the worst survival. The pelvic (P) LN sites were significantly and independently associated with nearly 2 times and 2.5 times the probability of having 1‐year overall mortality (OM) and 1‐year cancer‐specific mortality (CSM), respectively. Head, face and neck (HFN) primary LN sites were significant and independent predictors of better overall and HL‐specific survival. A worse survival with the intra‐abdominal primary LN site was probably related to their association with higher age, or advanced stages of HL. The biological basis behind the aggressiveness of intra‐abdominal and pelvic LN sites is yet to be investigated.

Background and Objectives Iron overload in thalassaemia is a crucial prognostic factor and a major cause of death due to heart failure or arrhythmia. Therefore, previous research has recommended amlodipine as an auxiliary treatment to current chelating agents for reducing iron overload in thalassaemia patients. Materials and Methods A systematic review and meta‐analysis of the results of three randomized clinical trials evaluating the use of amlodipine in thalassaemia patients through 12 databases were carried out. Results Our final cohort included 130 patients. Insignificant difference in decreasing liver iron concentrations was found between amlodipine and control groups {weighted mean difference = −0·2, [95% confidence interval = (−0·55–0·15), P = 0·26]}. As regards serum ferritin, our analysis also showed no significant difference in serum ferritin between amlodipine and control groups {weighted mean difference [95% confidence interval = −0·16 (−0·51–0·19), P = 0·36]}. Similarly, there was insignificant difference in cardiac T2* between amlodipine and control groups {weighted mean difference [95% confidence interval = 0·34 (−0·01–0·69), P = 0·06]}. Conclusions Despite the growing evidence supporting the role of amlodipine in reducing iron overload in thalassaemia patients, our meta‐analysis did not find that evidence collectively significant. The results of our simulation suggest that when more data are available, a meta‐analysis with more randomized clinical trials could provide more conclusive insights.

e19069 Background: The prognostic factors influencing survival and optimal management of primary pulmonary lymphomas (PPLs) have not been clearly defined due to rarity of the disease. This study sought to characterize the significant prognostic factors of PPL and develop a prognostic nomogram for individualized prediction of survival outcomes in patients with PPL. Methods: Patients diagnosed with PPL between 1983 and 2010 were identified using the Surveillance, Epidemiology, and End Results (SEER) Program database. Kaplan-Meier survival analysis and Cox proportional hazards regression model were performed to identify significant independent prognostic factors for overall survival (OS) in patients with PPL. A nomogram was constructed for the prediction of 5-year OS probability based on these variables. Results: The study cohort of 2325 PPL patients has a 5-year OS rate of 52% and a median OS of 67 months. Older age at diagnosis (HR 1.031; 95% CI, 1.026-1.036; p<0.001], males (HR 1.434; 95% CI, 1.267-1.622; p<0.001), Hispanic race (HR 1.370; 95% CI, 1.113-1.687; p=0.003), non-marginal zone B-cell lymphoma of mucosa associated lymphoid tissue (MALT) histology (p<0.001), primary site at main bronchus (HR 1.326; 95% CI, 1.014-1.735; p=0.039), Ann Arbor stage IV (HR 1.542; 95% CI, 1.324-1.795; p<0.001) were significantly associated with worse OS. All treatment modalities, including chemotherapy (HR 0.615; 95% CI, 0.536-0.706; p<0.001), surgery (HR 0.666;95% CI, 0.577-0.769; p<0.001) and radiotherapy (HR 0.829; 95% CI, 0.693-0.992; p=0.041) were independent predictors of survival. The nomogram constructed using these variables has a higher concordance index of 0.716 (95% CI, 0.699-0.734) compared to that of Ann Arbor staging system [0.571 (95% CI,0.552-0.591); p<0.001]. Conclusions: Older age, male sex, Hispanic race, non-MALT histology, primary site at main bronchus, advanced Ann Arbor stage, not receiving treatment were independent prognostic factors that are associated with worse OS in patients with PPL. The nomogram demonstrated good agreement between the predicted probabilities and actual observations on calibration plots.