Background: The purpose of this study is to develop and test the validity and reliability of a questionnaire to evaluate dietary supplement use based on the Theory of Planned Behaviour (TPB). Methods: The questionnaire has sections on demographics, physical activity, dietary supplements, and cognitive constructs based on the TPB. Three stages are followed. In Stage 1, elicitation interviews are conducted on five varsity athletes, five physically active non-athletes, and five physically inactive University of Guelph (UofG) students. In Stage 2, comments and ratings of the TPB-based statements are gathered from 10 subject matter experts to check for content validity. In Stage 3, Cronbach’s α is calculated to determine the internal consistency of the cognitive constructs by a pilot test on 84 Applied Human Nutrition UofG students. Results: Interviews assisted in the formulation of the cognitive constructs’ statements, including intentions, attitudes, injunctive norms, descriptive norms, and perceived behavioural control. Content validity ensured that these constructs did not overlap. Few statements from the cognitive constructs were omitted based on findings from the reliability test, achieving acceptable Cronbach’s α values across all constructs (≥0.70). Conclusions: This supplement use questionnaire will be used in a future study to investigate the use and determinants of dietary supplements among Canadian athlete and non-athlete UofG students. The use of dietary supplements is increasingly reported worldwide, particularly among athletes, who use it to enhance athletic performance and improve exercise recovery ,2,3. In Dietary supplementation is also becoming more prevalent in the general population. The use of dietary supplements has been commonly reported among physically active non-athletes in a number of studies ,13,14,15This increased use of dietary supplements should not be ignored, considering its potential for toxicity, its potential for nutritional imbalances, and its association with the risk of doping. Cross-contamination with prohibited substances or undeclared ingredients on the label of dietary supplements has also been reported ,17,18, rA unique aspect of the present study is not only the investigation of dietary supplement use and the underlying reasons and sources of information among athletes and non-athletes in a university setting in Ontario, but also the incorporation of the Theory of Planned Behaviour (TPB) to explore the determinants of this use. The TPB was designed to predict health behaviour change under volitional control . In thisThe TPB appears to offer a useful framework for understanding or predicting behaviours based on psychological constructs generally theorized to influence individuals’ behaviour. Athletes’ psychosocial environments were found to have a significant impact on their decision to use performance-enhancing substances in a study by Goulet et al. (2010) . UnderstIn the current article, we describe the development, validity, and reliability testing of a newly adapted comprehensive supplement use questionnaire that will be used in a larger scale study to assess the use of, beliefs about, and experiences with dietary supplements among athlete and non-athlete students in a university setting in Ontario.The questionnaire included four sections: physical activity patterns, dietary supplements, cognitive constructs based on the TPB, and demographics. The format of the questionnaire consisted of multiple-response questions, 1 to 5 Likert-type rating scales, and open-ended questions. https://sites.google.com/site/theipaq/). The six questions assess the frequency (days per week) and duration (minutes per day) of three types of physical activity during the last seven days: vigorous physical activity, moderate physical activity, and walking. According to the IPAQ scoring protocol, metabolic equivalent (MET) values of 8.0, 4.0, and 3.3 were assigned to each activity, respectively. Total MET minutes per week were calculated. Based on the MET values, individuals were also classified as less physically active (<1000 MET minutes per week) or more physically active (≥1000 MET minutes per week). A cut-off value of 1000 MET minutes per week, equivalent to double the minimal physical activity recommendations for health, was reported to be associated with significant health benefits [In the first section, physical activity level was assessed using six questions from the short-form of the widely used international physical activity questionnaire  . In the The third section was based on statements related to the different cognitive constructs of the TPB, including intentions, attitudes, subjective norms (injunctive and descriptive norms), and perceived behavioural control, with respect to the use of dietary supplements. The statements were based on a consensus process initiated by Fishbein and Ajzen (1975)  on the TA draft of the supplement use questionnaire was prepared, with the addition of questions addressing different TPB constructs. Three sequential steps were taken to further develop the questionnaire, particularly the five TPB sub-scales. In Stage 1, an elicitation study was conducted to elicit beliefs, attitudes, and norms regarding dietary supplement use. In Stage 2, ratings and comments were obtained from subject matter experts on the draft questionnaire’s content. In Stage 3, the revised questionnaire was administered to undergraduate and graduate Applied Human Nutrition students at the UofG to assess its reliability. For all three steps, the questionnaire and the study protocol were approved by the Research Ethics Committee of UofG. The first step, an elicitation study following a recommended protocol ,26, aimeContent validity was examined by receiving feedback from a panel of subject matter experts, who are individuals with deep understanding, knowledge, and expertise in a particular area or topic. They evaluated the questionnaire for 12 factors, including brevity, length, number of items, clarity, repetition, order, precision of language, response options, scale, bias, double-barreled questions, and appropriateness of questions. These factors were suggested to be reasonable to assess when conducting content validation of a questionnaire . In addiThe reliability of the revised questionnaire was tested on 84 out of the 100 targeted undergraduate and graduate students enrolled in the Applied Human Nutrition program at UofG. This sample of 84 participants was considered adequate because of the strong Cronbach’s alphas of almost all cognitive constructs that were achieved, even before deletion of some of the cognitive constructs’ statements. Students completed an online version of the questionnaire through the Qualtrics software. Cronbach’s alpha was calculated for each set of statements within each of the five components of the “cognitive construct” section to examine internal consistency. George and Mallery (2003) provided the following rules of thumb for the classification of Cronbach’s alpha values: “>0.9 – excellent, >0.8 – good, >0.7 – acceptable, >0.6 – questionable, >0.5 – poor, and <0.5 – unacceptable”  (p. 231)2. In addition, BMI was classified as underweight (<18.5 kg/m2), normal weight (18.5–24.9 kg/m2), and overweight/obese (≥25.0 kg/m2) [2 and the p value of the different models were computed, reflecting how close the data were to the fitted regression model. A p value < 0.05 was considered statistically significant.In Stage 3, statistical analyses were conducted using SPSS software . Descriptive statistics (mean and standard deviation) were used to describe continuous variables, and frequency statistics (number and percentage) were used to describe categorical variables. Self-reported body mass index (BMI) was calculated as weight (kg)/height (m)0 kg/m2) . In the A total of 15 undergraduate students participated in Stage 1 of the study. All participants were female. The average ages of the participants were 21 for physically active athletes, 21 for physically active non-athletes, and 20 for physically inactive individuals.Eleven subject matter experts were contacted. Ten of them, including M.Sc. student/student investigators (n = 2), applied social psychology researcher (n = 1), applied human nutrition researchers (n = 3), human health and nutritional sciences researchers (n = 2), exercise physiologist (n = 1), and registered dietitian (n = 1), agreed to participate in Stage 2 of the study. Of the 84 students, most participants were female (96.4%) and in the 21–23-years category (59.8%), with an average age of 22 years old. Most of the participants were physically active non-athletes (80.2%) versus physically active athletes (6.2%) and physically inactive individuals (13.6%). In this stage, statements within each of the TPB cognitive constructs were formulated based on the scripts of the interviews. Examples of these statements are “In the next 6 months, I intend to take or keep taking a dietary supplement to improve my performance or general health.” (intention); “I believe that using dietary supplements may improve my physical appearance.” (attitude); “Among your friends, how often have you heard about someone engaging in supplement use?” (descriptive norm); “My teammates or training partners would support my use of dietary supplements to improve my performance or general health.” (injunctive norm); and “The price of dietary supplements would influence my use.” . In this stage, comments on the questionnaire developed in Stage 1 and ratings for the cognitive construct statements were gathered from subject matter experts and then used to further revise the questionnaire. Ratings were gathered on whether each statement in the cognitive construct section of the questionnaire was relevant to the construct being tested . Overall, median of the ratings of the different constructs were 3  . Significant changes to the questionnaire were made. Some of the revisions included increasing the clarity of questions, revising the order of questions; requesting training hours per week from the participating varsity athletes, placing the demographics section at the end of the questionnaire, and including “prefer not to disclose” for sensitive questions. In addition, the supplement use section was revised by asking participants to report how long, how often, and the reason(s) for taking each of the selected supplements rather than supplements overall. The wording “prohibited supplements” was replaced with “non-dietary supplements” because it did not emphasize by whom it was prohibited. The corresponding question was placed at the end of the supplement use section, since the scope of the questionnaire is not the exploration of WADA-prohibited substances.A number of comments were, in particular, made on the intention and perceived behavioural control constructs. Changes were applied accordingly to these constructs. The intention construct had comments on the wording used and the overlapping among statements. For example, in the statement “In the next 6 months, I want to take or keep taking a dietary supplement to improve my performance or general health.” one may think you want to perform a behaviour  but still not intend to do it. This statement was evaluated to be unnecessary and was removed. The perceived behavioural control construct had comments on the wording used and the double-barreled statements. For example, the wording “would” was replaced by “is” to reflect a present term. An example of a double-barreled statement is “I believe that using dietary supplements may be a safe, evidence-based way to improve my performance or energy.”. Beliefs that the use of dietary supplements will improve performance  or “energy”  are two different concepts. This issue was addressed by removing energy so that the statement reads, “I believe that using dietary supplements will improve my performance.”.The revised draft from Stage 2 was additionally revised based on the reliability test completed in a pilot test on 84 Applied Human Nutrition UofG students. In order to achieve the most acceptable Cronbach’s α values across all constructs, a total of four statements were removed from the cognitive construct section, including 1 intention statement, 2 attitude statements, and 1 perceived behavioural control statement . After tOf the 84 participants, 88.1% (n = 74) reported the use of one or more dietary supplements in the past 6 months. All males  and most females  consumed one or more dietary supplements. Most 18–20-year-olds  and 21–23-year-olds  and all of 24–26-year-olds  and > 27-year-olds  consumed one or more dietary supplements. Based on physical activity categories, all physically active athletes , most physically active non-athletes , and most physically inactive individuals  consumed one or more dietary supplements. Finally, based on sport type (if a varsity athlete), all endurance athletes  and power/strength athletes  and no intermittent athletes  consumed one or more dietary supplements. The most commonly used dietary supplements were vitamins/minerals, protein, fatty acids, prebiotics/probiotics, and carbohydrates. One hundred percent of participants who used dietary supplements in the past 6 months had used vitamins/minerals .The most commonly used sources of information on dietary supplements were health care professionals  (81.1%), my own judgment (73.0%), the internet (67.6%), friends/family (48.6%), and other(s) (28.4%). In univariate linear regression, five predictors were significant. Specifically, age , body weight , gender , university major , and medical condition  were significant predictors . RegardiTo our knowledge, our focus on the TPB as a model to explore the use of dietary supplements among both athlete and non-athlete university students is relatively unique in Canada. In this study, a supplement use questionnaire was developed, assessed for face validity, and tested for inter-item reliability in the target population of university athlete and non-athlete students. Studies on the use of dietary supplements have generally implemented previously designed questionnaires without retesting their validity and reliability. Erdman et al. ,5, in thBased on findings related to the elicitation study, content validity, and Cronbach’s alpha values, our supplement use questionnaire appeared to be a valid and reliable tool to implement on university students irrespective of their physical activity habits. Reliability was evaluated by assessing the internal consistency of the questionnaire, particularly the cognitive construct section, reflected by the Cronbach’s alpha values. This reliability testing method was different from ones used in other studies in Canada exploring dietary supplement use; test and retest as well as Kappa coefficient tests were used to assess the reliability of their questionnaires ,3. HowevWith respect to feasibility and respondent burden, the online format allows respondents to skip some sections, while prompting them to consider all types of supplements compared to open-ended questions. With 121 individual items and four distinct subsections, it took participants approximately 25 minutes to complete the questionnaire. Further work is needed to see if the length of the questionnaire can be reduced.In the present study, 100% of athletes reported the use of one or more dietary supplements in the past 6 months. Therefore, our findings confirm that young athletes, in Ontario as in other provinces, rely on dietary supplements to support different sports-related performances. An earlier study that examined dietary supplementation of elite level athletes in Canada found that most (88.4%) had used one of more dietary supplements in the last 6 months . In addiVitamins/minerals, protein, fatty acids, prebiotics/probiotics, and carbohydrates by both athletes and non-athletes were the most commonly used dietary supplements. One hundred percent of participants who used dietary supplements have used vitamins/minerals. Similarly, other studies have shown that young Canadian athletes most frequently consume multivitamins, multi-minerals, vitamin C, vitamin D, sports bars, and protein powders . FurtherIn the current study, health care professionals were the most commonly used sources of information on dietary supplements, followed by my own judgment, the internet, friends/family, and other(s). Therefore, there is still some dependence on unreliable sources but lower than reported in other studies ,3,5. HowThe present study has several strengths. A key advantage is that, to our knowledge, this is the first questionnaire developed, validated, and tested for reliability to assess dietary supplement use among Ontario university students of different physical activity patterns, including athletes, physically active non-athletes, and physically inactive individuals. As well, to our knowledge, this is the first questionnaire developed to explore the psychosocial determinants of supplement use in addition to use, reasons for use, and sources of information. The main limitation of this study is the potential for response bias when receiving self-reported data via personal recall in Stage 3. Participants, especially athletes, might decide not to report on their dietary supplement use for a number of reasons. Athletes might not report the use of prohibited or non-prohibited supplements if they perceive the consequences of a positive doping test as unacceptably high. In addition, there are cultural and religious norms, moral values, and social pressure from close relatives and friends against the use of supplements . PossiblThis study encompassed the development of a questionnaire tailored to determine dietary supplement use based on the TPB among young university athletes and non-athletes in Ontario. Findings from this study as well as other future studies using this questionnaire may contribute to a better understanding of the status and determinants of supplement use in the younger population of Ontario, irrespective of their physical activity patterns, and may inform health care professionals to design effective educational materials on dietary supplements, their benefits, and their risks. Further research that examines the additional validity of the questionnaire and test-retest reliability is warranted.


Hypertension is a major health problem that remains a significant threat to the health and general wellbeing of many people all over the world. In some patients, the etiology and prognosis of hypertension have been linked to psychological factors including personality traits. One primary goal of management is to improve the health-related quality of life (HRQoL) of patients with hypertension. This study aimed to examine the association between personality traits, clinical characteristics, and HRQoL in hypertension. A hospital-based cross-sectional quantitative study was conducted in a sample of 331 individuals with hypertension. Data on sociodemographic characteristics, clinical information, personality traits, and HRQoL were obtained from participants using an interviewer administered questionnaire. The number of participants with a 1–10 years' duration of diagnosis for hypertension was highest (56.8%), with 52.9% having comorbidities such as diabetes (40.2%) and dyslipidaemia (20.9%). The average number of medications taken per patient was 2.14 (SD±0.79) and about 47.1% of the participants reported adequate medication adherence. Significant associations for age, education, monthly income, number of years with hypertension, and HRQoL were observed. While conscientiousness was significantly associated with all HRQoL domains, extraversion and agreeableness were significantly related to only the environmental domain. This study has demonstrated that clinical characteristics and patients' perception of their personality are relevant to their health-related quality of life outcomes. The findings suggest that when intervention efforts to improve the quality of life of patients with hypertension are being considered, a biopsychosocial approach should be employed. The implication is that treatment of hypertension in Ghana should be broadened to include the expertise of mental health professionals. Hypertension is a major health problem that remains a significant threat to the health and general wellbeing of many people all over the world. Even though there is a significant advancement in the detection, evaluation, and treatment of hypertension, the prevalence rates are high worldwide and in Ghana –4. WhileQuality of life is an important indicator when evaluating hypertensive treatment outcomes and health-related quality of life (HRQoL) is directly influenced by health-related issues which reflect the patient's burden associated with the disease –10. ExamIn some patients, hypertension has been reported to be a psychosomatic or behavioral disorder, where its etiology and prognosis have been linked to some psychological factors including personality traits –25. PersWhile HRQoL may be compromised in patients with hypertension, there is limited body of research examining the determinants of HRQoL among persons with hypertension particularly in Ghana. This study aims to contribute to filling this gap by examining the association between personality, clinical characteristics, and HRQoL.A hospital-based cross-sectional study of patients with hypertension was carried out from December 2015 to January 2016.The study was conducted at the Ledzokuku Krowor Municipal Assembly (LEKMA) Hospital in Teshie, an urban poor community in Accra, Ghana, which serves as a primary hospital for the people in the surrounding communities. The hospital runs specialized clinics on Tuesdays and Thursdays for patients with hypertension during which data were collected from the patients.The minimum sample size was estimated at 312 using a projected prevalence of hypertension in an urban poor community in Ghana at 28.3% . To compParticipants were eligible for inclusion if they were 18 years and older, were diagnosed with hypertension with/without comorbidities, and were on medications for at least 6 months prior to data collection.The sociodemographic characteristics, clinical information, personality characteristics, medication adherence, and HRQoL information were obtained from participants using an interviewer administered questionnaire. A summary of the assessment areas and tools has been provided in The sociodemographic characteristics included age, sex, marital status, education, employment status, and an estimated monthly income. Some medical information including period since diagnosed, presence of comorbidities, and number of medications taken were also obtained from the patient records.The Ten Item Personality Inventory (TIPI) is a very brief measure of the Big Five personality domains and was used for the assessment of personality traits, comprising two items for each of the traits of agreeableness, conscientiousness, extraversion, neuroticism, and openness . Each itThe Medication Adherence Questionnaire (MAQ) was used to assess medication adherence and the questions covered medication intake behavior of patients. The total score ranged from zero to four representing low (3-4), moderate (1-2), and high (0) adherence, respectively .The HRQoL was measured using the shorter version of the WHO Quality of Life Scale (WHOQOL-BREF) which is a 26-item cross-cultural scale that covers the four domains of quality of life: psychological, physical, social relationships, and environmental domains . The meaTo ensure the reliability and appropriateness of the questionnaire, a pilot study was conducted involving 30 participants. The TIPI was reliable with Cronbach alpha of 9.1, 9.2, 7.8, 7.8, and 8.8 for agreeableness, conscientiousness, extraversion, neuroticism, and openness, respectively. Similarly, the psychological (0.92), physical (0.88), social relations (0.90), and environmental (0.87) domains of HRQoL scale as well as the MAQ (0.75) were reliable.The data were entered into SPSS version 20 for analysis. Descriptive analysis was carried out to determine frequencies, means, and standard deviations. Linear regression analysis and a three-step hierarchical regression model were performed to evaluate the effect of clinical characteristics on HRQOL dimensions . During The number of participants with a 1–10 years' duration of diagnosis for hypertension was highest (56.8%), followed by 11–20 years (20.2%), and least for >40 years (1.8%). The presence of comorbidities was high (52.9%) with the following comorbidities recorded: diabetes (40.2%), dyslipidaemia (20.9%), stroke (10.7%), peptic ulcer (7.4%), osteoarthritis (4.1%), ischaemic heart disease (3.7%), asthma (3.3%), urinary tract infection (2.9%), anaemia (2.1%), gastritis (2.1%), gout (0.8%), lumbago (0.4%), benign prostatic hyperplasia (0.4%), and goitre (0.4%).The number of medications taken per patient was noted (mean = 2.14 ± 0.79). The average number of antihypertensive medications taken per patient was mean = 2.89 ± 1.09 with the following frequencies: Amlodipine (n = 219), Lisinopril (n = 212), Nifedipine (n = 201), Bendrofluazide (n = 184), Atenolol (n = 42), Losartan (n = 14), propranolol (n = 12), Frusemide (n = 8), carvedilol (n = 8), Candesartan (n = 6), Methyldopa (n = 5), and Hydrochlorothiazide (n = 4). Patients who adequately adhered to their medications were 47.1%.The result of the Pearson product-moment correlation analysis showed that conscientiousness was significantly associated with all the dimensions of HRQoL. Extraversion and agreeableness were also significantly associated with the environmental dimension of HRQoL .Only the conscientiousness personality trait correlated statistically significantly with adherence to medication .The present study examined the association between clinical characteristics, personality traits, and health-related quality of life outcomes. While 47.1% of patients adequately adhered to their medications, the findings revealed that age, education, monthly income, and presence of comorbid health conditions were associated with HRQoL. In relation to the Big Five personality characteristics, agreeableness, conscientiousness, and extraversion were also associated with HRQoL while only conscientiousness was related significantly to medication adherence.Some important observations on the demographics showed that most women reporting to the hospital were above the age of 50 years and had the lowest level of income. A plausible reason for this observation could be the likelihood of health seeking behavior among women although they may be in the lower socioeconomic level , 35.An inverse relationship between age and HRQoL was found in this study and this is consistent with findings from previous studies , 36. ThiThe association between educational level and quality of life has been reported , 42, wheOur results indicated that monthly income was negatively associated with the physical domain of HRQoL. Income and low socioeconomic status have been associated with poor quality of life, and undesirable health outcomes such as poor general health, decline in mobility, social isolation, poor emotional coping, and long-term disability , 45.Coexisting diseases may have considerable effects on patients' well-being. Individuals with chronic conditions usually have comorbidities . The finPersonality has been proposed to be relatively stable emotional, cognitive, and behavioral characteristics of an individual which is consistent across adulthood . Since pThe association between conscientiousness and quality of life has been demonstrated for all and some domains of quality of life , 48 withAgreeableness, which refers to the degree of selflessness or hostility towards others, and extraversion, which is characterized by attributes such as sociability, also showed significant associations with the environmental domain of HRQoL. The observed positive association implied that high scores on agreeableness and extraversion were related to better environmental quality of life. Considering the fact that agreeableness could be useful for harmony in many environments , it suggThis study acknowledges the limitation that it employed a quantitative approach and though an adequate sample was used, some in-depth interviews could have been conducted to really understand the personality traits in illness representations, clinical parameters, and the dimensions of quality of life. Thus, future studies could use a mixed method approach to understand the relationship between clinical characteristics, personality traits, and quality of life.This study has demonstrated that clinical characteristics and patients' perception of their personality are relevant to their health-related quality of life outcomes. The findings suggest that when intervention efforts to improve the quality of life of patients with hypertension are being considered, a biopsychosocial approach should be employed. The implication is that treatment of hypertension in Ghana should be broadened to include the expertise of mental health professionals such as clinical and health psychologists.


N-methylmesoporphyrin IX for fluorescence detection. The biosensor displayed significantly higher signal intensity at 2 mM melamine , which was sufficient to detect melamine at high concentrations, in raw milk.Melamine, a nitrogen-rich compound, has been used as a food and milk additive to falsely increase the protein content. However, melamine is toxic, and high melamine levels in food or in milk can cause kidney and urinary problems, or even death. Hence, the detection of melamine in food and milk is desirable, for which numerous detection methods have been developed. Several methods have successfully detected melamine in raw milk; however, they require a sample preparation before the analyses. This study aimed to develop an aptamer-DNAzyme conjugated biosensor for label-free detection of melamine, in raw milk, without any sample preparation. An aptamer-DNAzyme conjugated biosensor was developed via screening using microarray analysis to identify the candidate aptamers followed by an optimization, to reduce the background noise and improve the aptamer properties, thereby, enhancing the signal-to-noise (S/N) ratio of the screened biosensor. The developed biosensor was evaluated via colorimetric detection and tested with raw milk without any sample preparation, using  Melamine is a nitrogen-rich compound widely used as a manufacturing material. Unfortunately, melamine contamination in food has been a persistent issue owing to its toxicity; the most severe of which is the large-scale adulteration of milk and pet food, with melamine, to falsely increase the protein content. Melamine at high concentrations can cause kidney and urinary problems or even death ,2,3. HenAccurate and highly sensitive methods involving liquid chromatography/mass spectrometry (LC/MS) , gas chrN-methylmesoporphyrin IX (NMM)  Triton X-100, pH 7.4) and incubated for 10 min, at 75 °C. The chip was then gradually cooled to the room temperature (25 °C), for more than 1 h, to allow the probes to fold into their correct conformations. The buffer was replaced with hemin solution  without the melamine and incubated for 30 min, at room temperature, with a gentle agitation in the dark. The hemin solution was replaced with the substrate solution (2 mM H2O2 and 0.1 mg/mL FMA in hemin solution) without the melamine and mixed gently via repeated pipetting before the microarrays were scanned. The chip was immediately washed, thrice, with DNAzyme buffer, to eliminate the substrate solution after the scanning of the microarray chip. Signal intensity (redox activity of hemin and substrate) was measured using an ElectraSense Reader  [The designed oligonucleotides were directly synthesized on the microarray . The microarray chip was immersed in 200 μL of DNAzyme buffer  was denatured for 5 min, at 95 °C. The solution was then gradually cooled to the room temperature to allow for an attainment of the appropriate conformation. Hemin in DMSO and KCl  were added, and the volume was adjusted to 20 μL, with a DNAzyme buffer. A sample of 25 μL of the solution, with or without melamine, was added and incubated for 15 min at the room temperature. The substrate solution, which includes 2.5 μL of L-012, as a luminol derivative , and 2.5 μL of H2O2 , was injected into the DNAzyme solution. The chemiluminescence intensity was measured immediately, using a TECAN Infinite 200 reader . A hemin solution (200 nM hemin in DNAzyme buffer with no DNAzyme oligonucleotide) was used as a negative control.A DNA solution  was denatured for 5 min, at 95 °C. The solution was then cooled gradually to the room temperature, to allow for the attainment of the appropriate conformation of the sensor. Hemin in DMSO and KCl  were added. Sample solutions were spiked with each diluted concentration of melamine and incubated for 15 min, at the room temperature. Thereafter, ABTS  and H2O2 were added to the DNA solution. The total volume was 100 μL. The absorbance of each sample was measured at 415 nm, by a TECAN Infinite 200 reader.A DNA solution  was denatured for 5 min, at 95 °C. The solution was then gradually cooled to the room temperature, to allow for the attainment of the appropriate conformation of the sensor. NMM and KCl  were added. Thereafter, 25-μL samples of raw milk were spiked with each dilution of melamine, and incubated for 10 min, at room temperature. The fluorescence intensity was measured using a TECAN Infinite M1000 Pro , with an extraction wavelength of 399 nm and an emission wavelength of 605 nm.A DNA solution , and its S/N ratio was 2.1 (= 5510/2564). This screened biosensor had no block sequence for the aptamer region, had three bases for the DNAzyme block sequence (bold ccc) and one base for the internal loop sequences (underlined t). As the subsequent (ccctC), which included the aptamer stem region, could stack directly with a part of the DNAzyme (GGGAG), the aptamer region did not require a block sequence, in this case. Most of the sequences containing no aptamer block sequence showed better S/N ratios  was modified four times to produce Sensor 2 to Sensor 5, sequentially. The sequences of each biosensor are shown in Sensor 1 was identified via a microarray screening. Sensors 2 and 3 were designed to reduce background noise by extending the DNAzyme block sequence. Sensor 4 was designed to improve the stability of the aptamer region by extending its stem region. Sensor 5 included the poly-T sequence, which was extended to form a 60-mer, in total. The changes from Sensor 1 are shown in boldface. The signal-to-noise ratio for each step is also shown.The optimized biosensor was subjected to colorimetric detection, and Inhibition of redox activity in raw milk was assessed via chemiluminescence detection. Redox activity displayed a weaker signal at 0.01% than at 0% milk. Redox activity in 1% and 10% milk was quite low . TherefoFluorescence detection was performed instead of analysis of redox activity, to evaluate the biosensor for use in raw milk, without any sample preparation. The aptamer-DNAzyme conjugated biosensor for melamine detection was developed using a combination of screening and optimization procedures. Screening with microarray technology proved useful in identifying the approximate length of the block and the internal loop sequences, from among numerous sequence designs. Optimization helped reduce the background noise and improve aptamer properties, and the resulting S/N ratio was greatly improved by the screened biosensor. The developed biosensor was evaluated via colorimetric detection, and the color gradients were related to the concentration of melamine, in the buffer. To address its practical application, the biosensor was also assessed with raw milk without any sample preparation, by using NMM for fluorescence detection. The biosensor showed significantly higher signal intensity at 2 mM melamine, which was sufficient to detect melamine at high concentrations, in milk.Such convenient fluorescence detectors are currently in use. Therefore, biosensors with a portable detector using the same wavelength as that described in our study, have the potential, among those available globally, to provide real on-site detection of melamine. This approach is cost-effective compared to the use of AuNP-based biosensors. In general, oligonucleotides and NMM are not toxic; hence, the biosensor can be assessed safely. Owing to these advantages, biosensors could have potential practical applications.


Background:Rheumatic diseases are referred to as conditions affecting joints, muscles, ligaments, tendons, and bones. According to a report by World Health Organization, rheumatic and musculoskeletal diseases were labeled as the second most reported cause of disability around the globe. The purpose of this study was to estimate the prevalence of rheumatic diseases in a tertiary care hospital of Karachi; additionally, associations with age groups, gender and comorbidities were obtained as well.Methods:A cross-sectional study was conducted at the Orthopedic Out Patient Department (OPD) of Dr. Ruth KM Pfau Civil Hospital, Karachi over a span of three months in 2018 (February till May). All 346 patients were follow-up diagnosed cases in the age range of 11-90 years, divided into groups of adolescents, young adults, adults, and older adults. The subjects were questioned about their symptoms, duration of illness, presence of comorbidities, genetic background and the therapy they are undergoing along with compliance. Simple statistical analysis of frequency was done, whereas chi-square test was applied to study associations with gender, age groups, and comorbidities.Results:During the study period, a total of 2000 patients visited the orthopedic OPD, 346 of which were diagnosed cases of rheumatic diseases, yielding a prevalence of 17.3%. The mean age of rheumatic patients who partook in the study was 46.15 ± 15.49 (Range: 12 – 84). Osteoarthritis was recorded as the most prevalent condition, followed by non-specific low back pain and rheumatoid arthritis. Osteoarthritis was statistically significant in young adults, adults, and older adults, while non-specific low back pain had significant associations with gender, young adults, and adults. Diabetes was significantly associated with osteoarthritis, non-specific low back pain, shoulder pain syndrome and psoriatic arthritis, while hypertension significantly co-existed with systemic lupus erthematosus.Conclusion:Rheumatic diseases constitute a major disease burden in almost all of the age groups, especially in young patients (18-40 years) within our setup. The term ‘rheumatic diseases’ refers to roughly 200 conditions that affect joints, muscles, ligaments, tendons, and bones; with arthritis representing rheumatic conditions solely confined to joints. The most commonly known rheumatic diseases are osteoarthritis, rheumatoid arthritis and gouty arthritis. One third of the world population suffers from rheumatic diseases inflicting enormous financial price globally, with Europe bearing almost 200 billion euros per annum . Being tIn reference to researches carried out in the recent years on disabled people, the World Health Organization has reported rheumatic and musculoskeletal diseases as the second most known cause of disability around the globe . AlthougThis work, primarily, aimed to assess the prevalence of rheumatic diseases in the orthopedic outpatient department (OPD) of a tertiary care hospital in Karachi which largely caters to the under-privileged population from rural areas all over Pakistan. The secondary goal of this study was to learn about the frequency of various rheumatic diseases within different age groups and their association with gender and comorbidities.Over a span of three months (February till May) in the year 2018, a cross-sectional study was conducted by a group of medical students after approval from the institutional review board of Dow University of Health Sciences. It aimed to assess the prevalence of different rheumatic diseases in a tertiary care hospital i.e. Dr. Ruth KM Pfau Civil Hospital, Karachi. A self-administered questionnaire was used to acquire study related information from the diagnosed patients visiting the Orthopedic OPD of the hospital for follow up. Patients’ permission to participate in the study was ensured by a consent form. It was translated and explained to the participants in their native language and signed by them. Consent was obtained by the parents and/or guardians for children below the age of 18.Our inclusion criteria comprised of individuals with rheumatic diseases including the following types: Degenerative , inflammatory (rheumatoid arthritis and dermatomyositis), soft tissue rheumatism , crystal-induced (gout), autoimmune (systemic lupus erythematosus and scleroderma), metabolic (osteoporosis) and spondyloarthropathy (ankylosing spondylitis and psoriatic arthritis). Discrimination on the basis of gender, socioeconomic status, religion, and ethnicity was forgone. However, age ranges from 11 years to 90 years were approached for the interviews. The age groups were subdivided into four categories: adolescents from 11 years of age to 17 years of age, young adults from 18 years of age to 40 years of age, adults from 41 years of age to 65 years of age and older adults from 66 years of age to 90 years of age. Exclusion of traumatic injuries and bone tumors was implied.The questionnaire was based on a total of 20 questions directed towards the diagnosed cases of rheumatic diseases, mainly focusing on their symptoms, duration of illness, presence of comorbidities, genetic background and the therapy they are undergoing along with compliance. The interviews were conducted by research participants, who were guided to wear identical lab coats and explained the questions to each interviewee in English and Urdu.The sample size was calculated through Open Epi version 3.01 considering prevalence of rheumatic diseases to be 15.1%; a confidence level of 99% was taken with a confidence limit of 5% . The comDuring the study period, a total of 2000 patients visited the orthopedic OPD, 346 of which were diagnosed cases of rheumatic diseases, yielding a prevalence of 17.3%. The mean age of rheumatic patients who partook in the study was 46.15 ± 15.49 (Range: 12 – 84). Females were notably predominant in all diseases with the exception of ankylosing spondylitis, which had an equal male to female ratio. Osteoarthritis was the most common rheumatic disease, followed by non-specific low back pain and rheumatoid arthritis. Commonly encountered patients were adults, followed by a near equal frequency of young adults while few cases of older adults and even fewer cases of adolescents were seen. Diabetes and hypertension were observed as singleton comorbidities in 23 (6.6%) and 101 (29.2%) patients respectively, conjointly in 41 (11.9%) participants while being non-existent in 181 (52.3%) subjects. The prevalence, frequency, percentages, and distribution of rheumatic diseases amongst males and females are listed in Table Males with diagnosed rheumatic diseases were 38 (11%) in number, their blights contributing to one-sixth cases of osteoarthritis, one-fourth of cases of cervical or lumbar spondylosis, one-third of cases of shoulder pain syndrome and systemic lupus erthematosus each, and a single case of osteoporosis and gouty arthritis each. In contrast to females, close to none cases of males were seen in non-specific low back pain and rheumatoid arthritis. Tendinitis, carpal tunnel syndrome, vasculitis, dermatomyositis, fibromyalgia, psoriatic arthritis, and scleroderma were not chanced upon in males, considering that each of these had very low prevalence. Non-specific low back pain, systemic lupus erthematosus, and shoulder pain syndrome were the only diseases to have a significant association with gender, their p-values being 0.02, 0.03 and 0.03 respectively.Osteoarthritis was significantly seen in young adults, adults and older adults (p<0.05); thirty-five 23.8%) of the osteoarthritis afflicted patients significantly suffered from diabetes  while 66 44.9%) were hypertensive . Non-specific low back pain was significantly seen in young adults and adults (p<0.05), however, only a few cases were identified in adolescents. As per data, eight (10.1%) were diabetic, bearing a significant association  while 31 (39.2%) had hypertension . Rheumatoid arthritis was seen mainly in young adults and adults having a frequency of 26 (51%) and 20 (39.2%) respectively, while three (5.9%) cases were seen in adolescents. Six (11.8%) patients suffered from diabetes  while 20 (39.2%) were hypertensive . Tables .8% of th4.9% wereThe adolescent population was afflicted with only a handful of conditions, namely non-specific low back pain, rheumatoid arthritis and systemic lupus erthematosus, of which only the lattermost was statistically significant . Cervical or lumbar spondylosis, gouty arthritis, osteoporosis, tendinitis, and vasculitis were mostly seen in adults. Shoulder pain syndrome was mostly found in young adults  and was significantly affiliated with diabetes  while systemic lupus erthematosus was the only disease to have a significant association with hypertension . Psoriatic arthritis stumbled upon in a single female, co-existed with diabetes significantly  and hypertension . Overall, diabetes and hypertension whether individually or in conjunction, were found in 12 patients of osteoporosis, seven patients of cervical or lumbar spondylosis, six patients of shoulder pain syndrome, two patients each of gouty arthritis and tendinitis, one patient each of systemic lupus erthematosus, carpal tunnel syndrome, ankylosing spondylitis, fibromyalgia, and psoriatic arthritis. Diseases which were devoid of both the comorbidities were dermatomyositis, scleroderma, and vasculitis.Rheumatic diseases have been deemed as inherently disabling entities. In the year 2015, they were responsible for 16.4%–20.9% of the global years lived with disability (YLDs) . As a coUnexpectedly, osteoarthritis was found to be statistically significant with the young adult population. Obesity, genetic factors, congenital anomalies of joints, vocational, and leisure activities such as contact sports as well as recurrent joint trauma and endocrine disorders like diabetes are thought to be the predisposing agents . In contMajority of the plight of non-specific low back pain was borne by females . This gender bias was in corroboration with the studies conducted previously -23. MensThe data in this study may help in contributing to the development of such healthcare facilities that will effectively screen the incoming patients and allocate them as those plagued by a rheumatic disease or not. This can be accomplished by creating awareness amongst the general population regarding rheumatic diseases and its risk factors, educating the primary health care physicians and paramedical professionals, and conducting more epidemiologic and etiologic researches featuring rheumatic diseases in the country.The inflow of patients was more than our team could cover and in spite of exerting our best efforts, this emerged as the predominant limitation. Secondly, our study was confined to a singular department in a tertiary care setup and thus cannot exhibit the accurate prevalence of rheumatic diseases in our population, which in all likelihood is expected to be much higher than the one procured in our study. Our research technique was non-probability convenience sampling and as it is highly prone to selection bias, this too surfaced as a major limitation. Discrepancies in translating English to Urdu led to a communication barrier. A few patients who could have been diagnosed with rheumatic diseases did not follow up with the lab and/or radiological investigations ordered, thus, were missed.To conclude, this study exhibited the prevalence of different rheumatic diseases and demonstrated its burden within different age groups and genders, hinting at various risk factors that should be explored further for the said ailment. This data could aid tertiary care hospitals for the provision of sound healthcare and arrangement of community based programs to spread awareness amongst the mass population of developing countries.


Anthropogenic debris is an environmental problem that affects beaches and coastlines worldwide. The abundance of beach debris is often documented with the use of public volunteers. To date, such community participations have been largely confined to the marine environment, but the presence and impact of anthropogenic debris on freshwater shorelines has been increasingly recognized. Our study presents the first such information from the African Great Lakes, specifically Lake Malawi. A total of 490,064 items of anthropogenic litter were collected by over 2000 volunteers in a clean-up campaign that took place annually between 2015 and 2018. Approximately 80% of the anthropogenic debris was comprised of plastic litter, with plastic carrier bags being the most common item. The dominance of plastic litter, and in particular the presence of plastic bags, which have subjected to bans in some African countries, is discussed. The broader implications of citizen science in the African Great Lakes area is also discussed. Anthropogenic debris is an environmental problem that affects beaches and coastlines worldwide ,2. TypicThe documenting of beach debris has taken place globally on marine shorelines. Examples include clean-ups and surveys on beaches along the Pacific coast of Chile , in Gree2, mean depth: 264 m, maximum depth: 700 m, 19). Together with Lakes Victoria and Tanganyika, Lake Malawi holds approximately 25% of the world’s total surface freshwater supply [To date, such community participations have been largely confined to the marine environment, but the presence and impact of anthropogenic debris on freshwater shorelines has been increasingly recognized, with a handful of surveys and clean-ups conducted along the shoreline of the North American Great Lakes . Howeverr supply ,21,22,23r supply . In thisLates niloticus) and Nile tilapia (Oreochromis niloticus), contained MPs within their digestive tracts [In general, there is a scarcity of information regarding the presence and abundance of plastics (and microplastics) in Africa and specifically within the African Great Lakes , but twoe tracts . In totae tracts . Togethee tracts .In the present, relatively small-scale, study, anthropogenic debris was surveyed and collected from three sites over a four-year period (2015–2018 inclusive) located in Central and Northern regions of Malawi. The clean-up sites represent the busiest beaches along Lake Malawi. In total, over 2000 volunteers took part in the clean-up activities, which were directed by Malawi beach and underwater clean-up, an environmental NGO. The protocol to instruct the volunteers was that of the ocean conservancy clean-up, which has been widely used in coastal locations. The data presented here adds to the little information on anthropogenic and plastic debris collected from freshwater shorelines and specifically is the first of its kind from the African Great Lakes. The present study was conducted along the Malawian shorelines of Lake Malawi. Tourism, transportation, trade, agriculture, and fisheries related activities are found within a growing number of towns along the shoreline. Several district townships have hydrological linkage with the lake shoreline through rivers, stream, and storm waters. The most notable townships in Malawi within proximity of Lake Malawi (estimated population from 2018 census) are: Lilongwe , Mangochi , Salima , Karonga , and Nkhata bay . Three beaches were selected for clean-ups based on their proximity to urbanization, tourism, fishing, commerce, and transportation. Kambiri beach  and Mpatsa beach  are located towards the southern end of Lake Malawi, whereas Nkhata jetty  is more northernly . Whilst Beach clean-ups were conducted each September from 2015 to 2018 during the dry season. Clean-ups were organized by the ‘beach and underwater clean-up’, an NGO based in Lumbadzi, Malawi. The timing coincided with that of the ocean conservancy’s international coastal clean-up day, an annual global event which takes place in September and October. Each year only one beach was selected, as follows: Kambiri beach in 2015 and 2016, Mpatsa beach in 2017, and Nkhata jetty in 2018 . Upon arrival, each volunteer was registered and provided with clean-up equipment such as gloves, collection bags, and gumboots. At each site, the name, location, time, distance, and number of volunteers were recorded in a pre-designed data collection form according to Lewis (2002) . During The methodology for clean-up events was adopted from the international coastal cleanup protocol ,13. The Litter larger than 2 cm was collected by hand, enumerated, and then classified into categories: glass, metal, paper, construction material, and plastic . For easLitter items in each major category  were compiled and totaled, as described in the ocean conservancy protocols. Plastic litter was further divided as carrier bags, personal hygiene products, beverage bottles, fishing gear, cups, packaging materials, bottle caps, lids, food wrappers, cutlery, cigarette butts, tires, and straws/stirrers.2) > Kambiri beach  > Mpatsa beach (0.96 items/m2) > Kambiri beach . These densities are marginally lower than those reported elsewhere, 2 to 10 items/m2 along the coast of Chile [2 reported along Brazilian coast [2 [2 was recorded from Japanese beaches [A total of 490,064 items of anthropogenic litter were collected by over 2000 volunteers at the three locations over the four-year period. With reference to the number of items collected, Nkhata jetty  was the most impacted site, followed by Kambiri beach  and 2015  and the Mpatsa beach  . Typicalof Chile  and 2.3  beaches , though 2 value of 0.995 . Thus, it is difficult to make conclusive comments regarding the relative abundance and density of anthropogenic debris at the different sites on the Lake Malawi shoreline when citizen participation appears to be such an influential factor, but certainly the greater the number of volunteers, the more litter is likely to be collected. Furthermore, in this case where volunteer numbers greatly influenced the number of items collected, we refrain from further discussing densities, instead using the percentages of items in each category for comparative purposes.The apparent greater levels of litter at Nkhata jetty beach may be attributed to its function as a busy port which links Malawi to Tanzania. Ports and associated activities have been reported to cause high level of debris in their surrounding environment . ConversThe composition of debris across all beaches was plastic 80.2 ± 5.0%, metal 9.5 ± 2.5%, glass 4.9 ± 3.8%, paper 4.6 ± 4.0%, and construction material 0.9 ± 1.5%. Moreover, the percentages of each category remained relatively consistent across all sites, with plastic litter being by far the most abundant type of anthropogenic debris . Again, As with anthropogenic debris, in general the composition of plastic debris was also relatively consistent across sites: plastic carrier bags (22.5–49.4%), personal hygiene products (7.15–18.6%), beverage bottles (1.9–18.8%), fishing gears (0.21–20.25%), cups (1.9–13.3%), packaging materials (1.3–13.8%), bottle caps (4.4–11.6%), lids (1.0–8.8%), and food wrappers (4.4–11.5%) . RemainiSimilar findings of plastic litter have also been reported elsewhere. The shoreline of the remote freshwater lake, Lake Hovsgol in northwest Mongolia, was dominated by plastics bags, beverage bottles, and discarded fishing gear . MoreoveThe issue of plastic bags is particularly prescient for Africa, as several countries have proceeded to reduce or ban plastic bag use. Such measures have been made on the grounds of environmental and public health, as discarded plastic bags have been shown to block gutters and drains which create storm water problems and collect water, which provides a breeding ground for mosquitos that spread malaria, and the use of bags as toilets has been linked to the spread of disease ,33. The The present study was the first to document the results of beach clean-up activities in the freshwater African Great Lakes. Though limited in size and scope, a pattern emerged that confirms previous coastal findings that plastic litter is the dominant type of anthropogenic debris. This study highlights the role that volunteers can play in both the remediation of the environment and the collection of scientific data. Citizen science has become a widely used initiative in combating plastic pollution. Organizations such as the national oceanic and atmospheric administration (NOAA) in the United States have developed a mobile phone application called “Marine Debris Tracker app” together with Southeast Atlantic marine debris initiative (SEA-MDI), which allows the public to report findings of litter from beaches and waterways . SimilarAn interesting finding of this study is the strong positive correlation between volunteer numbers and total debris collected. This may suggest that not all litter was collected at each site, which may be due to the fixed time restrictions placed on the clean-up (4 h). Under these conditions, greater public involvement would lead to better results, but it should be noted that the number of sites is too low to make any conclusive statements on this relationship. One grouping that has been shown to be particularly valuable are students. Students can play an active role in collecting and monitoring data using mobile applications, such as the one made by NOAA. In just one example from the Roskilde Fjord region in Denmark, students collaborated with scientists to produce data on the occurrence of marine litter at 12 beaches around the fjord . The stuEven though the described cases are from Europe and the United States, there is equal potential in other places, such as within Africa. It is not correct to say that African nations and people are unaware of the issues surrounding plastic pollution. Currently, Africa has the highest percentage of countries (∼46%) with plastic bans  and nume


Kawasaki disease (KD) is an acute, febrile, vasculitis of mainly large to medium-sized vessels. KD is a self-limited illness of infancy and childhood and 80% of the patients are younger than four years of age with an incidence of 5.6/100,000 in the United States. We present an unusual case of an 18-year-old man with several unique features of KD. He was admitted to the hospital with fever, rash, and arthralgia for one week. KD was among the differentials for fever, rash, and arthralgia. Later all the laboratory diagnosis for bacterial and viral infections including blood and urine culture came out negative and he was further evaluated for KD with electrocardiography (EKG), echocardiography, and angiography which showed myocarditis. Based on typical features of fever, rash, arthralgia, bilateral conjunctival injection, cervical lymphadenopathy, and prominent tongue papillae he was diagnosed with KD. Kawasaki disease (KD) is an acute vasculitis of large to medium-sized vessels. KD is a self-limited illness of infancy and childhood and 80% of the patients are younger than four years of age with an incidence of 5.6/100,000 in the United States -4. In geKD typically manifests with erythema of the palms and soles, conjunctival and oral erythema, edema of the hands and feet, a desquamative rash, and cervical lymph node enlargement. Approximately 20% of untreated patients develop cardiovascular sequelae, ranging from asymptomatic coronary arteritis to coronary artery ectasia and large coronary artery aneurysm which eventually rupture or get thrombosed leading to infarction, and sudden death. The diagnostic criteria for KD as defined by the Centers for Disease Control and Prevention (CDC) include an unexplained fever lasting five days or more and at least four out of the five following criteria. 1) polymorphous exanthema; 2) changes in the peripheral extremities, erythema or indurative edema of the palms and soles (acute phase) or desquamation around the fingertips ; 3)bilateral nonexudative conjunctival injection; 4) changes in the oropharynx, that is, injected or fissured lips, strawberry tongue, and injected pharynx; and 5) acute nonsuppurative cervical lymphadenopathy. Patients having less than four of these clinical signs can be diagnosed as having atypical KD [KD has two phases: an acute phase lasting for one to two weeks, followed by a chronic or “convalescent” phase. Common laboratory findings include leukocytosis with a predominance of immature and mature granulocytes, normochromic normocytic anemia, elevated acute-phase proteins, and slightly elevated serum transaminase is a characteristic of the acute phase of KD. Thrombocytopenia may occur in clot formation consumption which is evident by a markedly elevated D-dimer level. Urinalysis may show sterile pyuria in up to 80% of patients. Antinuclear antibody and rheumatoid factor are usually absent. Hypoalbuminemia is associated with more severe acute disease -7.An 18-year-old man presented to the emergency department with a one-week history of fever, rash, and arthralgia. He was previously healthy, without any significant medical, surgical and family history. The patient denied any recent chest pain, shortness of breath, orthopnea, dyspnea, bacterial and viral infection. He had no history of intravenous drug use, new sexual partners, tattoos or any animal exposure including contact with domestic dogs, cats, cattle, and deer. On examination, he was febrile 102 F), his blood pressure was 120/80 mm Hg and his pulse was 110/bpm. Head and neck examination revealed injected conjunctiva, dry oral mucositis, fissured lips, and prominent tongue papillae  count of 14.0×109/l and hypoalbuminemia (2.5 g/dl). He had elevated erythrocyte sedimentation rate of 80 mm/h, C-reactive protein of 98.3 mg/l and alanine aminotransferase of 56 IU/l. Urinalysis showed sterile leukocyturia (30 cells/µl). However, anti-nuclear antibody (ANA), rheumatoid factor, and serum angiotensin-converting enzyme (ACE) levels were normal. His blood and urine cultures and pharyngeal swab culture for Streptococcus pyogenes were negative. Furthermore, serological assays for human immunodeficiency virus, hepatotropic viruses, Epstein-Barr virus, and cytomegalovirus were negative. Chest radiograph was normal but echocardiography showed left ventricular ejection fraction (LVEF) of 37% and angiography was suggestive of myocarditis without aneurysm and stenosis. Electrocardiography (EKG) revealed sinus tachycardia (140-150 bpm). KD was diagnosed based on clinical examination, absence of infection, failure to improve with antibiotic therapy, and the presence of all the signs and symptoms for diagnostic criteria of childhood KD. The patient improved gradually with the use of high dose immunoglobulin (IVIG) infusion according to total body weight (2 g/kg) and oral aspirin (100 mg/kg) divided into four doses, and the dose of aspirin was reduced subsequently. On the seventh day of hospitalization, congestion of the conjunctiva, desquamation of hands, and erythema had resolved. Follow up after two months showed significant clinical improvement in signs and symptoms of the patient. KD should always be considered in the differential diagnosis when an adult patient presents with unexplained fever and a rash.The complex genetics behind KD has been evaluated and up to 65% of the genetic risk for KD susceptibility may be due to polymorphisms in calcium signaling pathways, the TGFβ pathway, and human leukocyte antigens as reported by some literature. One of the theories postulated for the cause of KD in genetically susceptible patient is infection with a virus leading to activation of both the innate and adaptive immune systems where neutrophils are among the first responder to invade the arterial wall followed by CD8+ T cells, dendritic cells, monocytes/macrophages and eventual activation of the interleukin (IL)-1 and TNF-alpha pathway leading to vessel wall inflammation with subsequent weakening and destruction of elastic lamina and intima leading to formation of aneurysm .The arterial lesion develops early in the acute phase of the disease and develops rarely more than four weeks after the disease onset. Coronary artery sequelae are usually the formation of aneurysms in 20% to 25%, seen in 90% of fatal cases. An aneurysm occurs predominantly in the proximal segments and bifurcations of coronary arteries. Coronary artery lesions are dynamic in the late acute and early convalescent phases. The longer the aneurysms or stenotic lesions persist, the less likely they are to resolve. Lesions in the right and left coronary arteries appear to progress differently. Massive thrombosis of the aneurysm is seen predominantly in the right coronary artery, usually within one year after the disease onset. Progressive localized stenosis at the aneurysm inlet or outlet is seen in the left coronary artery, usually within one year after the initial insult. Coronary artery aneurysms are classified as localized or giant measuring >8 mm in diameter and are diagnosed by echocardiography, most of the cases resolve spontaneously and in 50% of cases. Complete resolution is seen on angiography within one year of onset -8,10. PaA study conducted by Inoue O showed that 1,215 patients with coronary artery aneurysms and KD developed giant coronary artery aneurysms in 5% (n=64) patients. Among these 64 patients, only 5% (n=3) regressed without complications. Furthermore, 23% patients (n=15) had myocardial infarction, and 47% patients (n=30) had stenosis .Myocarditis occurs to some degree during the acute phase of KD which resolved completely overtime and seldom affects the left ventricular systolic function in the absence of any coronary lesion. When it occurs clinical findings include an S3 or S4 gallop on physical examination, nonspecific ST-T changes, and cardiomegaly on a chest radiograph. The aortic and mitral valves are rarely involved ,14. AlveNo specific diagnostic tests are available for KD, and the diagnosis is based solely on the presence of characteristic clinical findings and recognition of symptoms based on clinical criteria meticulous history-taking and thorough physical examination. The low diagnostic accuracy and masquerading of adult-onset KD, in contrast to that in pediatric patients, can be attributed to the several differential diagnoses that are possible in adult cases. In most of the patients, a disease usually resolves spontaneously after several weeks. Until recently, the standard treatment for acute-phase KD was a four-day regimen of intravenous (IV) gamma globulin (400 mg/kg daily), supplemented with aspirin (100 mg/kg daily divided in four doses). Now, the standard treatment is a single infusion of IV gamma globulin (2 g/kg) followed by low-dose aspirin therapy. The newer regimen is more effective because it safely accelerates the resolution of systemic inflammation. With intravenous immunoglobulin therapy and aspirin, the rate of symptomatic coronary artery disease is reduced to about 4% .KD should always be considered in the differential diagnosis when an adult patient presents with unexplained fever and a rash as this disease comes with fatal coronary and heart complications leading to poor prognosis and eventually death. Hence, comprehensive cardiac monitoring with echocardiography and angiography should be carried out. Prompt recognition of clinical features of KD by physicians diligently and early institution of IVIG and aspirin can prevent life-threatening cardiac complications.


Actinic keratosis (AK) is a common skin lesion in adults which usually occurs on chronically photoexposed areas and considered as a precancerous lesion or a superficial squamous-cell carcinoma. Many classifications have been proposed and its diagnosis is generally clinical but, sometimes, its wide variety of presentations can make diagnosis difficult, even among expert observers. The malignant potential of AKs imposes an early diagnosis and treatment in order to reduce morbidity and mortality, and, for the characterization of photodamaged skin, noninvasive diagnostic techniques, such as dermoscopy, have proved to be useful, while multiple therapeutic strategies, lesion-directed versus field-directed therapies, are available for the treatment of AKs. In this study, we evaluated the efficacy of ingenol mebutate for the treatment of AKs, with a particular focus on patients' compliance, correlating it to clinical and dermoscopic grading, pre- and posttreatment, of these lesions. Fifty-two enrolled patients with AKs received treatment with ingenol mebutate gel  and multiple dermatological evaluations. End points of the study were complete and partial clearance of clinically visible AKs on day 90. All acquired data were recorded and statistical analyses were performed. Univariate and multivariate analyses were used to identify possible predictive factors. We retrospectively analyzed patient-related and lesion-related factors to identify which variables, among age, gender, lesion site, pain, LSR score, and pretreatment clinical and dermoscopic grading, could independently predict the response to ingenol mebutate treatment. Our findings showed that pretreatment dermoscopic grade II represents an independent predictive factor of the efficacy of ingenol mebutate therapy  and that response rates differ on the basis of the treated anatomical sites . Data from this study provide evidence that ingenol mebutate gel is an effective treatment for AK, with relative ease of use, short exposure, and rapid resolution of local reactions, benefits contributing to high adherence of this therapy. Moreover, dermoscopic analysis of skin lesions offers more information than clinical evaluation alone and can be helpful in identifying different groups of AKs, thus selecting the adequate therapeutic choice. Actinic keratosis (AK) is a common skin lesion which usually occurs on photoexposed skin as a consequence of the cumulative exposure to ultraviolet (UV) radiation and it can be considered a precancerous lesion or, as more recently stated, a superficial squamous-cell carcinoma (SCC) . In geneOver time, numerous classification schemes have been proposed , 10, botAK is characterized by a chronic and unpredictable nature and its natural history has three possibilities: regression, stable staying, or progression to invasive disease , 18. The Euphorbia peplus plant, for the treatment of actinic keratoses, with particular attention to patients' compliance, and the relationship between treatment efficacy and pretreatment clinical and dermoscopic grading, in order to better guide physicians in the choice of this therapy, in relation to the type of actinic keratosis presented by the patient.Based on these observations, in this study, we evaluated the efficacy of ingenol mebutate, diterpene ester derived from theConsecutive patients suffering from actinic keratosis were retrospectively enrolled among those who presented at dermatology clinic of the Plastic and Reconstructive Surgery Unit of Campus Bio-Medico University in Rome, between December 2016 and February 2017, to receive treatment with ingenol mebutate gel .Eligibility criteria included an age greater than or equal to 18 years and the presence of at least one clinically visible actinic keratosis. As opposed, patients were excluded from this study if they had received previous treatment with laser therapy or cryotherapy in the same area, if they had a history of ingenol mebutate allergy, or if the target treatment area contained hyperkeratotic lesions, cutaneous horns, or wounds. Additional exclusion criteria were recent use of medications or other treatments that could interfere with evaluation of the treatment area .Before starting treatment with ingenol mebutate, patients were adequately made aware of the characteristics of the active ingredient, the mode of administration, and possible adverse effects, referred to as local skin reactions (LSR). All patients provided written informed consent to their participation in the study and allowed clinical and dermoscopic pictures of the selected treatment area to be taken and used. Approval for this study was granted by the ethics committee of Campus Bio-Medico University of Rome.2 contiguous area once daily for 3 consecutive days, for AKs on the face or scalp, and of ingenol mebutate gel 0.05% (500 mcg/g) once daily for 2 consecutive days, for AKs on the trunk or extremities.Therapy involved the self-application of ingenol mebutate gel 0.015% (150 mcg/g) to a 25-cmThe simultaneous application of other topical medications during the treatment period was strictly forbidden.All enrolled patients underwent dermatological examination at baseline  and on days 5, 14, 28, 45, 60, and 90. To date, these patients are still on follow-up, with dermatological examination every three months, in order to evaluate the possible relapse of disease or the onset of new lesions to be treated.For the management of lesion sites, the entire body surface was divided into three sections: face, scalp, and trunk and extremities.The primary end point of the study was complete clearance of all clinically visible actinic keratoses in the treated area on day 90. As secondary end point of the study, partial clearance, defined as a reduction of 75% or more in the number of clinically visible AKs in the target treatment area, was evaluated on day 90.All lesions were evaluated both clinically and dermoscopically, giving each of them a clinical and dermoscopic grading. In fact, as described in the literature, AK can be subdivided into three different clinical grades, which correspond to specific dermatoscopic, reflectance confocal microscopic, and histopathologic substrates. In particular, Zalaudek et al. , 19, stuFor each patient, a record containing clinical and dermoscopic pictures of the treated sites was drafted, in order to optimize the monitoring of the therapy. All these lesions were analyzed using a Heine Delta® 20 dermatoscope (magnification ×15)  connected to a Nikon Coolpix 4500® camera equipped with an optical zoom (×4) .x,y,z,…), ranging from 0 to 4 for each response, thus leading to define, for each patient, a composite local-skin-response score (LSRTOT), the sum of the six individual scores .During examination on days 5 and 14, expected local skin reactions, erythema, flaking or scaling, crusting, swelling, vesiculation or pustulation, and erosion or ulceration, were analyzed and recorded by using a grading scale .χ2 test and ANOVA test as appropriate. After univariate analysis, significant variables (P<0.10) were included in a multivariate logistic regression model in order to identify potential independent predictors of the efficacy of ingenol mebutate; adjusted odds ratios (OR) and 95% confidence interval (CI) were calculated and a p value of less than 0.05 (P<0.05) was considered statistically significant.The acquired demographic, clinical, and dermoscopic data were entered into a database and correlated with the response to therapy  using All statistical analyses were performed with the use of MedCalc® Statistical Software version 15.2 .A total of 52 patients were included in the study, 40 (76.9%) males and 12 (23.1%) females, with a mean age of 76.4 ± 6.7 years. All the patients completed the applications of ingenol mebutate gel, as scheduled; the majority, 27 (51.9%), were treated on the face and 21 (40.4%) on the scalp, while 4 (7.7%) patients were treated on trunk and extremities.Regarding efficacy, evaluation of the response to treatment showed that therapy with ingenol mebutate produced a clinical benefit in 84.62% (44/52) of the patients. In particular, at day 90, complete clearance occurred in 25 (48.08%) patients , Panel 1Furthermore, in order to evaluate which group of actinic keratoses was more responsive to treatment with ingenol mebutate, we compared the mean response-to-therapy values. Specifically, the lesion improvement was quantified by subtracting the value of posttreatment dermoscopic grading to the value of pretreatment dermoscopic grading, for each lesion. In particular, AKs with pretreatment dermoscopic grade II showed a higher mean improvement of the lesion after topical treatment with ingenol mebutate , as compared to AKs with pretreatment dermoscopic grades I and III, which reported mean improvement values of 0.58 ± 0.51  and 1.72 ± 0.99 , respectively (P=0.0001).There were no significant differences between the proposed groups  in basic characteristics such as age and gender or considering VAS and LSR scores. The detailed results of univariate analysis are shown in A different rate of effectiveness of topical treatment with ingenol mebutate gel was observed in relation to the site of application. Specifically, at day 90, considering the three macroareas mentioned above, a complete clinical response to the treatment occurred in 66.7% (18/27) of the lesions on the face and in 75% (3/4) of the ones on trunk and extremities, while, regarding the lesions on the scalp, a complete clearance was observed only in 19% (4/21) . Data juA relationship between the clinical response-to-therapy rate, complete or partial, and the value attributed to the subjective component of pain during treatment, measured by means of VAS scale at day 5, was observed . SpecifiTOT) for patients treated with ingenol mebutate was 6.2 ± 4 (range 2-21), deriving from the overall analysis of various degrees of severity, from patients with mild reactions (LSRTOT = 2/24) up to a patient who showed more severe reactions (LSRTOT = 21/24) [All patients presented at least one of the six local skin reactions evaluated. In detail, ordered by decreasing frequency, the following LSRs were observed: erythema, 88% (46/52); flaking or scaling, 67% (35/52); crusting, 58% (30/52); swelling, 52% (27/52); erosion or ulceration, 38% (20/52); and vesiculation or pustulation, 19% (10/52). The mean composite local-skin-response score (LSR= 21/24) . Onset oMultivariate logistic regression analysis revealed that AKs with a pretreatment dermoscopic grade of II were almost 15 times more likely to achieve a complete clearance . Conversely, AKs on the scalp were associated with a decreased odd of complete response , compared to lesions located on the face or trunk and extremities . Other pThis study aimed to test the efficacy of ingenol mebutate for the therapy of actinic keratoses, correlating it to clinical and dermoscopic grading, pre- and posttreatment, of these lesions. The analysis of our patient cohort showed that ingenol mebutate is effective in the treatment of AKs: at 90 days from the start of treatment, 84.62% (44/52) of patients demonstrated a response, partial or complete, to this therapy. In addition, all patients enrolled, to date still in follow-up, showed no recurrence of disease in the area treated with ingenol mebutate gel. In particular, it should be noted that data presented above were completely compatible with the results of the Phase III study related to this drug .Dermoscopic analysis of skin lesions offers more information than clinical evaluation alone , 13, whiThe finding that the intensity of subjective pain during treatment with ingenol mebutate was almost double in patients with partial/complete response compared to those with poor response (VAS: 2.8 ± 2.4 versus 4.3 ± 2.3) is of particular interest. In fact, in the first phase of its mechanism of action, the molecule under investigation induces cell death with caustic mechanism and the subsequent locoregional release of proinflammatory cytokines, with consequent recall of cells of innate immunity, generates an inflammatory reaction that, the more intense it is, the more it should cause pain in the patient. Therefore, it could be hypothesized that the intensity of the inflammatory reaction generated by treatment with ingenol mebutate directly correlates with the efficacy of the therapy; further investigations and studies conducted on AKs and SCCs will be necessary to validate this last hypothesis.Results from this study point out that ingenol mebutate gel, having shown a complete response rate of 48.08%, is an effective treatment for AK. In AKs with pretreatment dermoscopic grade II, the complete clearance rate rises to 63.64%. Moreover, the relative ease of use, short application time and rapidity of resolution of any adverse events, determine a greater adherence to this treatment by patients .Our study has some limitations: first of all, the study was conducted in a single clinical setting and the number of patients was small, which may have limited our ability to discover potentially significant associations. Other limitations were the low number of patients treated on trunk and extremities, the absence of histopathological assessment and correction for multiple testing, the limited number of factors analyzed. Lastly, a major restriction was the retrospective design of the present study. Further larger and controlled studies are needed to confirm our results and to investigate other relevant predictors of the efficacy of ingenol mebutate.In conclusion, our findings showed that pretreatment dermoscopic grade II represent an independent predictive factor of the efficacy of ingenol mebutate therapy and that response rates differ on the basis of the treated anatomical sites. These results might help clinicians to better select patients affected by AKs to be submitted to treatment with ingenol mebutate.


Primary esophageal diffuse large B-cell lymphoma (DLBCL) is an extremely rare clinicopathologic entity. We report one case from our clinical experience and undertake a review of the previously published cases. A systematic literature search of the medical databases PubMed and Google Scholar was conducted. A total of 15 cases fulfilled the inclusion criteria. The data on patients’ characteristics, epidemiology, clinical features, HIV status, gross appearance of the lesion, esophageal location, treatment, and outcome were collected and analyzed. Primary esophageal DLBCL was more common among males, primarily in the fifth and sixth decades of life. Dysphagia was the most common initial clinical presentation. Tissue biopsy with immunohistochemistry was an indispensable diagnostic modality. The mainstay of treatment was chemotherapy with cyclophosphamide, vincristine, doxorubicin, and prednisone regimen, in addition to anti-CD20 antibody rituximab, with or without radiotherapy. This review serves to outline our current understanding of the epidemiology of and risk factors for primary esophageal DLBCL, the pathophysiology of this disorder, and currently available approaches to diagnosis and management. It predominantly involves immunocompromised patients with HIV infection as a potential risk factor.4 Although the exact pathogenesis of primary esophageal DLBCL is unknown, the proposed mechanism implicates genetic aberrations in mature B cells. These cells normally differentiate in the bone marrow and migrate to the secondary lymphoid organs where antigen-dependent differentiation occurs. Several genetic alterations, occurring at any point in the pathway of differentiation, can contribute to their neoplastic transformation. These include downregulation of tumor suppressor genes like p53, MYC, and BCL-2 or overactivation of proto-oncogenes like BCL-6.5Primary esophageal non-Hodgkin’s lymphoma is an uncommon gastrointestinal pathology that was first reported by Berman and colleagues in 1979.6 Initial detection of the lesion is carried out by radiological and endoscopic evaluations. Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) cytology helps to visualize the histopathologic architecture of the tumor. Moreover, immunohistochemistry (IHC) plays a key role in the differentiation from other benign and malignant lesions of the esophagus.7 With regard to the management, no specific guidelines exist. The chemotherapeutic regimen consisting of cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab (R-CHOP) has been used as the mainstay of treatment, which is occasionally followed by radiotherapy. The number of chemotherapeutic cycles depends on the severity and extent of the lesions. The patients with a limited disease usually receive 3 cycles, but those with an aggressive lymphoma undergo 6 to 8 cycles along with radiotherapy.8 In the present study, we chronicle a case of primary esophageal DLBCL where the diagnosis was established on the basis of pathognomonic histopathologic and IHC findings. Furthermore, we present a comparative review of this rare entity encompassing patient demographics, presenting signs and symptoms, investigative findings, treatment of individual cases, and clinical outcomes.Primary esophageal DLBCL commonly presents with dysphagia and/or odynophagia.A 54-year-old female presented to our medical center with a 2-month history of progressive dysphagia and odynophagia. The patient experienced a sensation of solid foods “getting hung up” in her neck. However, she did not report choking or gagging. Before her current presentation, she underwent neck ultrasonography at the office of her primary care physician, which revealed a 6.1-cm complicated cyst. Considering it an infectious etiology, she was empirically treated with antibiotics, but her symptoms persisted. Her past medical history was significant for hypertension. She had no other complaints and there was no history of immunosuppressive disorders like HIV/AIDS, celiac disease, or inflammatory bowel disease. She denied nausea, vomiting, fever, chills, gastroesophageal reflux symptoms, or weight loss. Family history was negative for cancer. Physical examination was significant for a large, tender, and palpable neck mass.Laboratory studies for hematology, serum biochemistry, and urine analysis were within normal limits. Computed tomography (CT) scan of the head and neck showed a 7.3 × 3.1 × 6.6-cm mass in the neck, which was inseparable from the cervical esophagus . It was The patient was initiated on chemotherapy with R-CHOP regimen. She received a total of 4 chemotherapeutic cycles followed by radiotherapy.She tolerated the treatment well without serious adverse events. The clinical response was good with resolution of dysphagia achieving complete remission in 3 months. During the 3-year follow-up period, the patient did not experience a recurrence of the lesion. She continues to do well to date.4 We systematically searched the published medical literature in order to retrieve the available data. The articles were collected as of November 2018 using the medical databases PubMed  and Google Scholar. Different MeSH  terminologies, including “primary,” “diffuse large B-cell lymphoma,” and “esophagus,” were combined using the Boolean operators “AND” and “OR” with the terms “DLBCL,” “primary esophageal lymphoma,” and “treatment.” Furthermore, a few articles were retrieved through a manual search using the reference list of all accessible publications. The study inclusion criteria for the final comparative analysis comprised of the characteristics, 1) articles describing primary esophageal DLBCL, 2) availability of content in the full-text form, and 3) documentation of study findings in the English language.Primary esophageal DLBCL is a variant of non-Hodgkin’s lymphoma with only a handful of cases reported thus far.n = 11; females, n = 4). Clinical presentation was dominated by progressive dysphagia and unintentional weight loss. A few patients also reported constitutional symptoms. Although HIV infection has been deemed as a risk factor for gastrointestinal DLBCL, it was negative in 10 out of 15 cases included in this study. Therefore, it should also be suspected among HIV-negative individuals who present with symptoms and signs suggestive of esophageal malignancy. Among these patients, the distal esophageal involvement (n = 8) was more common compared with mid (n = 4) or upper segments (n = 3) of the esophagus.A total of 57 articles consisting of but not limited to original articles, case series, and case reports were initially obtained using the above-mentioned search strategy. The titles and abstracts of all these articles were carefully reviewed for their relevance to our study. A total of 17 articles were first enlisted for re-review, while 40 studies were excluded as they were not related to primary esophageal DLBCL, were in a language other than English, and/or full-text versions were not available. After removing duplicate and redundant papers, 11 articles were included in the present study for the final review and analysis. A thorough reading of these articles yielded a total of 15 cases. The data of individual cases of primary esophageal DLBCL regarding epidemiology, clinical presentation, endoscopic findings, management, and outcome are summarized in 16 In these patients, EUS-guided FNA is a safe procedure and should be considered for initial detection of lymphoma as well as its differentiation from other esophageal disorders presenting with dysphagia.1719 However, standard endoscopic biopsy, as in the present case, may have a low diagnostic yield. Interventional radiology may then be used to solve this diagnostic predicament.20 In selected patients, neck exploration or open biopsy may also be performed, if all other methods fail to make the correct diagnosis. In the current review, biopsy with IHC was used for the etiology establishment in all the patients. Pathologic examination showed lymphoid infiltration of the muscularis mucosa and adventitia, without infiltration of fat or sclerosis. IHC was mainly positive for tumor markers like CD10, CD20, CD45, CD 79a, PAX5, MUM1, and BCL6, and negative for BCL2, ALK, CD30, and cyclin D1. In most cases, the proliferation index (Ki-67 index) was more than 40% to 50%, which conferred a poor prognosis. 18F-FDG PET/CT was also performed in a few patients demonstrating an increased glucose uptake in the involved segment of the esophagus.Primary esophageal DLBCL may pose a diagnostic dilemma due to the marked heterogeneity and nonspecificity observed in diagnostic investigations. In this review, barium swallow was frequently employed as an initial detection modality. CT neck and chest showed significant thickening of the esophageal wall causing luminal narrowing. Endoscopic evaluation showed a friable esophageal mass in most cases. Radiologically and endoscopically, these lesions may appear as ulcers, multiple submucosal nodules, strictures, enlarged folds, varicoid-like lesions, and rarely as aneurysmal dilatation.21 In the present review, most patients received 6 cycles that were occasionally followed by field irradiation for consolidation. Surgery in the form of subtotal esophagectomy was also performed in a few cases. Surgical intervention like open or minimally invasive esophagectomy can be undertaken in patients with early disease. However, in cases with late diagnosis, chemotherapy or irradiation is employed to shrink the size of the tumor before treating it with surgery. Similarly, surgery can also be performed in patients who develop complications or as a palliative treatment. Although radiotherapy is predominantly reserved for patients who are unable to tolerate chemotherapy, it may or may not be coupled with chemotherapy in cases with moderate-to-severe disease. Therefore, a case-by-case approach is applied in this regard. In terms of outcome analysis of the cases included in our review, 6 patients showed complete remission of the disease, whereas 2 showed significant improvement, 1 patient refused treatment, and exact outcome was not reported in 1 patient. Unfortunately, 5 patients died.Due to rarity of the primary esophageal DLBCL, a standard treatment approach remains to be determined. The frequently used chemotherapy regimen, as in other subtypes of non-Hodgkin’s lymphoma, is R-CHOP.22 In the present study, survival duration was not reported in a majority of cases (n = 9). In those patients where survival was documented (n = 5), it ranged from 1 week to 3 months and only 1 patient survived for over 3 years.The exact trends of mortality and overall prognosis of primary esophageal DLBCL have not been deciphered. However, major prognostic factors include age at the time of diagnosis, functional status of the patient, presence of comorbidities (HIV infection), the presence of B symptoms, the nodal and extranodal extensions of the disease, serum lactate dehydrogenase levels, stage of the disease, and bone marrow involvement. Although the data are limited, the survival rates are observed to be ranging from 26% to 73%.Primary esophageal DLBCL is a rare clinical entity with only a few cases described in the published medical literature.Endoscopic biopsy with histopathology and IHC is usually performed to identify these lesions. A deep tissue biopsy may also be required in cases where initial biopsies fail to yield a diagnosis.R-CHOP regimen is the mainstay of treatment in patients with primary esophageal DLBCL.The response to prompt chemotherapy with or without radiotherapy is considerably good, achieving complete remission in a majority of cases.Physicians should be vigilant for this tumor in not only immunocompromised but also in immunocompetent individuals presenting with consistent clinical features.