With prevalence rates of postnatal depression (PND) as high as at least 7%, there was a need for early detection and intervention of postpartum mental illness amongst Singaporean mothers. This is a report on the first year results of our country's first PND Intervention Programme. The programme consists of two phases: (1) postpartum women were screened with the Edinburgh Postnatal Depression Scale and provided appropriate care plans; (2) individualized clinical intervention using a case management multidisciplinary team model. Screening for PND was generally acceptable, as 64% eligible women participated voluntarily. Nine percent (126) were identified as probable cases from 1369 women. Forty-one women accepted intervention and achieved 78% reduction in the EPDS symptom scores to below the cutoff of 13, 76% had improvement in GAF functioning scores, and 68% had improved health quality scores. Preliminary results are promising, and this intervention model can be replicated. The prevalence of perinatal depression in Singapore is about 12% for antepartum depression and about 7% for postpartum depression , impaireBeyondblue, the Australian National Depression Initiative also includes a programme targeting the postpartum depression [In the USA, a number of comprehensive and integrated services have been established to cater maternal mental health , 7. Beyopression . WithoutThe programme, funded by the health ministry, ran at the Kendang Kerbau Women's and Children's Hospital (KKH), which handles some 12,000 deliveries annually, representing about a third of the national births. The psychiatric service was established in 2006 to provide liaison consultative and outpatient psychiatric services, and referral had largely relied on the interests and the limited resources of the frontline obstetric professionals who were understandably more focused on obstetric issues. An integrated service was needed to provide accessible screening and early intervention for postpartum depression. Whilst intervening antenatally is ideal as antepartum depression is an important risk factor for postpartum depression , 10, witscreening and early detection of postpartum depression and severe postpartum mental illness,managing postpartum depression early using a case management multidisciplinary model to improve the outcomes.We report here the results of the first year of the programme.This is a prospective cohort study of postpartum women, conducted at KKH between 1 April 2008 to 31 March 2009, approved by the KKH Institutional Review Board, and funded by the Ministry of Health and the KKH Research Small Grant.Participants were recruited from two obstetric outpatient clinics handling about 2000 postpartum women annually, at 2 weeks to 6 months postdelivery. Excluded were (i) adolescent mothers (<18 yrs), as they were already cared for on an established medical social work programme, which included emotional support, (ii) women with stillbirth or early neonatal loss, (iii) those already receiving psychiatric treatment and close monitoring since the antepartum.Participants were interviewed by the perinatal mental health case managers, using the Edinburgh Postnatal Depression Scale (EPDS)  as a guiThe high scorers (EPDS > 12), or those who answered yes to any of the three additional questions, were offered a psychiatric consultation, thus entering the intervention phase. Those scoring borderline (EPDS 10–12) were mostly found to have minor problems or difficulties related to adjustment to motherhood, not amounting to clinical depression, and they were provided counselling and offered follow-up phone review and/or counselling by the assigned case manager. The case manager would then advise if there was a need to see the psychiatrist, if the difficulties worsened or continued, or be directed to community resources as was appropriate. For high scorers that declined to the intervention, the assigned case managers would conduct phone followup to check on their progress. The process flow of the programme is detailed in Early intervention for the high scorers included full psychiatric assessments, with supportive counseling, psychoeducation, and problem-solving focused counseling incorporating the principles of interpersonal and cognitive behavioural therapy . AntidepMeasures were taken at (a) baseline, when women first engaged into clinical intervention with the psychiatrist and then (b) repeated at 6 months or at discharge, whichever was earlier. These included the EPDS (described earlier), the Global Assessment of Functioning Scale (GAF) , and theThe GAF is a 100-point scale that measures overall level of psychological, social, and occupational functioning on a hypothetical continuum and is particularly useful for managed care-driven diagnostic evaluations to determine the eligibility for treatment and disability benefits and to delineate the level of care required for patients. The EuroQol health index, EQ5D, is a generic measure of health-related quality of life that consists of a self-classifier and a visual analogue scale and can be used in the clinical and economic evaluation of health care and in population health surveys. The self-classifier consists of 5 items assessing health in 5 dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression on a 3-point Likert scale. The visual analog scale is a vertical, graduated thermometer from 0  to 100 . We also administered a patient satisfaction survey at discharge: a 5-point Likert scale we developed to ask participants three questions, whether they were satisfied with medical care, counselling support, and psychoeducation provided about postpartum depression. Satisfaction was determined by a response ranging from “very dissatisfied” to “very satisfied”.t-test  or Mann-Whitney U test  was used to compare mean scores. For variables that involved categorical data, Pearson's chi-square was used. We used the Kruskal-Wallis test when comparing the EPDS scores category of the four race categories. Analyses were conducted with SPSS version 14.0.Data in numbers, percentages, means, and standard deviations were presented as descriptives. For the scale/interval ratio variables, independent 2148 postpartum women presented at the selected clinics, and 64% (1367) participated in screening and received educational information about postnatal depression.Two-thirds (71%) of the women who participated in the screening programme were aged 25 to 34 years, with mean age 30.52 years (SD = 5.00), range from 18 to 44 years old. Half of the participating women were Chinese (52.1%), with Malays (19.2%) and Indians (14.2%) forming one-third of the sample, whilst 14.5% were of other races. 56.5% were Singapore-born, whilst 43.5% were foreign-born. The majority of women (94%) lived in public housing, whilst 6% lived in private housing.Of the 1367 women screened, the majority (85%) scored below 10 on the EPDS, with 6% (80) having borderline scores of 10–12 see . Nine peP < .05).Pearson's chi-square tests compared the EPDS scores category between Singaporean and foreign-born migrant women , and theχ2  = 15.502, P = 0.001).Looking at the comparison across races , the resThere was no difference in terms of EPDS scores when comparing between those who lived in private housing with those who lived in public housing.Only 32.5% (41) of the 126 women with high EPDS scores accepted clinical intervention. The others declined referral due to various reasons, such as no time, cost concerns, stigma of receiving psychiatric disorder, no insight, and other reasons. 2 foreign-born women left Singapore.The characteristics of the 41 women who entered intervention are summarized in Sixty percent (24) were Chinese, 95% (39) married, with 83% (34) having at least secondary-level or high-school-equivalent education, and 66% (23) were working. Interestingly, two-thirds (22) had not planned their pregnancy, and this was the first pregnancy for almost two-thirds of the women (25). One-third (14) had other children below the age of 5. Thirty-nine percent (16) had no available help whilst the others had help from live-in domestic help, relatives, or nursery.Of the 41 women who engaged in clinical intervention, diagnosis was made based on DSM-IV criteria . 44%  experiencing a reduction of scores to below the cut-off score of 13. 2 patients had increased scores, and 1 had no change . 76% 31. Three pTogether with the 67% 84) of high scorers who rejected intervention, 80 women with borderline EPDS scores (10–12) were provided supportive counselling by the case managers. Repeating EPDS showed that 74% (62) of high scorers and 56% (45) of borderline scorers benefited from this, with reduction in the EPDS scores .Those who accepted clinical intervention presented significantly later in the postpartum period, compared to those who declined (8 weeks versus 4.3 weeks) (P < .05). Those who declined clinical care had lower mean baseline EPDS score compared to the high scorers who accepted intervention (15.8 versus 19.1), with this difference being statistically significant (P < .05).In terms of improvement in the EPDS symptom scores, the mean difference between those who entered intervention was 12.9, compared with 10.7 for those who declined clinical care, and this was statistically significant  of the depressed mothers who accepted treatment responded well to the intervention. Social risk factors, particularly marital conflicts and lack of social support, were seen in the women who experienced no improvement or worsening outcomes. Indeed, depressed patients with greater dyadic  discord have been found to have a lower likelihood of remission of their depression during medication treatment . Both the screening and intervention programme were well accepted, with more than 95% and 71% patient satisfaction, respectively. With no previous existing screening programme in Singapore, we believe that many women have struggled or presented late when the impact of the illness would have set in. With this programme, we now have the means to address the maternal mental health needs of our women. Indeed, with a foreign-born population representing almost half of our cohort, with nationalities or races from many countries, this model can be applicable to a wider global community.Postpartum depression is a significant public health problem, but with a right-tier approach integrated on-site into obstetric setting, outcomes can be improved, and this model of care can be replicated.The authors declare that there is no conflict of interests.


To examine the risk of adverse effects of special interest in persons vaccinated against seasonal influenza compared with unvaccinated persons aged 65 and above.We retrospectively observed 41,986 vaccinated elderly persons and 50,973 unvaccinated elderly persons in Taiwan from October 1, 2008, through September 30, 2009, using the National Health Insurance database. Neurological and autoimmune disorders and one-year hospitalization rates and in-hospital mortality rates were analyzed according to the vaccination status. Propensity score analysis was used to assess the relationship between adverse outcomes, hospitalization rates, and vaccination status.45% of the elderly received influenza vaccination. Multiple logistic regression showed that the probability of being vaccinated was related to more patients visiting for URI symptoms (odds ratio (OR), 1.03; 95% CI, 1.02–1.03), men , increased age , and more comorbidities . There were no statistical differences in neurological and autoimmune diseases between the vaccinated and unvaccinated individuals using propensity score analysis, but vaccinated persons had a reduced hospitalization rate of 19%  for the first six-months and 13% for one-year of follow-up .Based on data from the one-year follow-ups among 93,049 elderly persons in Taiwan, reassuring results for selected neurological and autoimmune diseases were found among the vaccinated individuals after adjusting other factors. Influenza vaccination decreased the risk for hospitalization. Public health strategies must continue to improve the influenza vaccination rate among the elderly with information based upon tangible evidence. Influenza, which typically occurs during the late fall through early spring in the United States, is associated with high rates of morbidity and mortality, especially for the elderly Although the protective effect of influenza vaccinations have been proven, concern about influenza vaccination safety is often cited by the mass media or persons who decline to undergo vaccination. Several neurological disorders have been reported to be associated with influenza vaccinations. Bell's palsy, Guillain-Barre syndrome (GBS), pericarditis, and nephritic syndrome have been noted in individuals with influenza vaccination in case reports Given the suggestive but limited data on influenza vaccinations and the risk of autoimmune diseases and neurological disorders, we conducted a retrospective cohort study using the National Health Insurance (NHI) Research Database in Taiwan, a unique nationwide, population-based claims data system with information on the medical history of all citizens.This study was initiated after approval by the Institutional Review Board of Buddhist Dalin Tzu Chi General Hospital, Taiwan. Since all identifying personal information was stripped from the secondary files before analysis, the review board waived the requirement for written informed consent from the patients involved.www.nhri.org.tw) The National Health Insurance program, which provides compulsory universal health insurance, was implemented in Taiwan in 1995. It enrolls up to 99% of the Taiwanese population and contracts with 97% of all medical providers. The database contains comprehensive information on insured subjects, including dates of clinical visits, diagnostic codes, details of prescriptions, and expenditure amounts. This study used the Longitudinal Health Insurance Dataset for 2008–2009 released by the Taiwan National Health Research Institute. The patients studied did not significantly differ statistically from the larger cohort in age, gender, or health care costs, as reported by the Taiwan National Health Research Institute  , Vaxigrip (Pasteur Merieux Connaught) and Fluarix (Glaxo SmithKline). Fluvirin, Vaxigrip and Fluarix are inactivated, split, not-adjuvanted, trivalent, and seasonal influenza vaccines. A 0.5 mL dose contains 15 mcg each of antigens similar to those of A/Brisbane/59/2007 (H1N1), A/Brisbane/10/2007 (H3N2), and B/Florida/4/2006. The type and amount of viral antigens contained in Fluvirin, Vaxigrip or Fluarix conform to the United States Public Health Services (USPHS) requirements and World Health Organization (WHO) recommendations for the season. The free vaccination program ran from October 1 through December 31, 2008.The neurological and autoimmune diagnoses for follow-up were in line with the previous study and the European Medicines Agency strategy for monitoring the safety of the pandemic vaccines, which was defined according to the ICD-9 codes for hospitalization and ambulatory visits Hospitalization for all causes between the two cohorts during the study period were recorded Patients were characterized by age, gender, number of outpatient visits for URI during the six months before the vaccination date (for the vaccinated group) or the first day when the free vaccination was offered (for the unvaccinated group), comorbidities, geographic region and urbanization of residence, and individual socioeconomic status (SES). The comorbidities of each patient included existing heart disease, lung disease, diabetes, stroke, renal disease, and catastrophic illnesses (cancer and rare diseases) This study used income-related insurance payment amount as a proxy measure of individual SES at the time of diagnosis. The individuals were classified into three groups: (1) low SES: lower than US$571 per month (New Taiwan Dollar (NT$) 20,000); (2) moderate SES: between US$571-1,141 per month ; and (3) high SES: US$1,142 per month  or more The SAS statistical package, version 9.2 , and SPSS version 15  were used for data analysis. Pearson's chi-square test was used for categorical variables, demographic characteristics , comorbidities, and individual socioeconomic status in vaccinated and unvaccinated individuals. Continuous variables, such as age, and URI OPD# were analyzed with two-sample t-tests in this series. Multiple logistic regression was used to estimate the predictors for receiving a flu vaccination based on each individual's observed variables, which included URI OPD# in the prior six months, gender, age, comorbidity, geographic region and urbanization of residence, and individual SES.2 test.The cumulative risk of neurological outcomes/autoimmune diseases was estimated as a function of time from initial treatment. To adjust for the potential bias caused by self-selection, propensity score was used p<0.05 was considered statistically significant in the regression models.In order to clarify the benefit of vaccination, the odds ratio of hospitalization for all cases of vaccinated and unvaccinated individuals was performed using propensity score analysis. A By December 31, 2008, virtually all vaccination activity had been completed, with a cumulative 41,986 people vaccinated (45.1% of the study population). The risks of neurological and autoimmune diseases were further analyzed according the first six-months and one-year of follow-up after the vaccination campaign. During the first six-months of follow up, there was no statistical difference in GBS (p = 0.144), Bell's palsy (p = 0.083), multiple sclerosis (p = 0.218), an/hypoesthesia, or paraesthesia (p = 0.848), sudden hearing loss (p = 0.744), rheumatoid arthritis (p = 0.461), and type I diabetes (p = 0.342) between the two groups. There was also no statistical difference in GBS (p = 0.144), Bell's palsy (p = 0.083), multiple sclerosis (p = 0.218), an/hypoesthesia, or paraesthesia (p = 0.848), sudden hearing loss (p = 0.744), rheumatoid arthritis (p = 0.461), and type I diabetes (p = 0.342) between the two groups after one-year of follow up in univariate analysis. During the first six-months of follow-up, the hospitalization rate was 10.2% for vaccinated individuals and 11.3% for unvaccinated individuals (p<0.001). After one-year of follow-up, the vaccinated group had a lower hospitalization rate .Due to the unequal distribution of baseline characteristics between the vaccinated and unvaccinated groups, propensity score analysis was performed. After adjusting other factors, influenza vaccinations decreased the hospitalization rate to 19% for the first six-months of follow-up  and 13% for one year of follow-up .Influenza epidemics occur yearly and have a significant impact on the health of the elderly and medical expenditures. Although public health vaccination is freely available in Taiwan, up to 55% of the elderly did not receive an influenza vaccination. Concerns about the adverse effects of influenza vaccination may be one of the barriers. More clinics visiting for URI symptoms, men, increased age, and number of comorbidies were independent predictors for those receiving an influenza vaccination. In this series, the increased risks were not evident for selected neurological and autoimmune diseases for the first-six months and one-year of follow up among the vaccinated individuals. Furthermore, influenza vaccination reduced the rate of all causes for hospitalization.The strengths of our study are that it is based upon a large population , the population experienced almost complete follow-up of neurological and autoimmune outcomes (99%) and had routine monitoring of diagnosis accuracy by the National Health Insurance Bureau of Taiwan. We found the elderly in Taiwan to have an influenza vaccination rate of 45%. There were also significant differences patient characteristics between the vaccinated and unvaccinated groups. Multiple logistic regression showed that more visiting clinics for URI symptoms in the prior 6 months, men, increased age, number of comorbidies, and residence in central/southern Taiwan were positive predictors for influenza vaccination. However, residence in urban/suburban areas and high SES were negative predictors for vaccination. These predictors, which are in agreement with previous series in Taiwan, could be used to find the target population in order to increase the future influenza vaccination coverage rate by the National Health Research Institution Several studies reported adverse events following influenza vaccination. After vaccination with the 1976 H1N1 influenza vaccine, 8.8 excess GBS cases per million vaccine doses were noted Previous literature questioned the association of the influenza vaccination and autoimmune diseases Up to 88% of elderly persons have one or more chronic conditions Barriers and predictors for influenza vaccination have been explored. Among the elderly, individuals with threat-responsiveness or perceived risk , men, persons aged 70 to 74 years, and those with chronic disease were more likely to have an influenza vaccination in Taiwan Consideration must also be given to the potential limitations of the present study that may have influenced the observed conclusions. First, the diagnoses of neurological and autoimmune disease, and any other comorbid conditions, are completely dependent on ICD codes among the administrative data. However, the National Health Insurance Bureau of Taiwan randomly reviewed the charts and interviewed patients in order to verify the diagnosis. Hospitals with outlier chargers or practice could undergo an audit, with subsequent heavy penalties for malpractice or discrepancies. The diagnosis of GBS were further verified by the neurology specialists and the validity of coding for GBS in administrative data is confirmed [44]. The diagnosis of multiple sclerosis, rheumatoid arthritis and type I diabetes were confirmed by catastrophic disease dataset released from the NHIRD. Second, the database does not contain information on tobacco use, dietary habits, and body mass index, which may also be risk factors for neurological events and may contribute to hospitalization for cardiovascular diseases. We hope to further link the NHIRD with primary survey data in the future. Third, we used in-hospital mortality as a proxy of estimation of mortality rate. There may have been a few individuals with severe disease who chose not to seek medical help. However, the barriers to medical access is almost negligible because the National Health Insurance system in Taiwan allows patients to visit any clinic or hospital freely without referral by a general practitioner and cover up to 90% of the hospitalization costs.In conclusion, 45% of the elderly aged 65 years or older received influenza vaccinations in 2008. Based on data from one year of follow-up, we did not find statistically increased risks for neurological and autoimmune diseases among the vaccinated individuals after adjusting for other factors. Influenza vaccinations decreased the risk for hospitalization by 13% in elderly patients during the one-year of follow-up. Based on these reports, we could try to provide more information based upon tangible evidence on influenza vaccination, particularly its effect on preventing epidemic outbreaks and the protective effects of hospitalization to those who do not think the vaccine is necessary and for those who are concerned about the adverse effects.


The etiology of malignant lymphoma is still largely unknown. This study determines the relationship between exposure to pesticides and the occurrence of lymphoid neoplasms in Shiraz, Southern Iran.Between 2007 and 2008, in a case control study conducted in Nemazee Hospital in Shiraz, Southern Iran, 200 subjects diagnosed with lymphoma according to the World Health Organization (WHO) classification were enrolled. Controls (n=200) were frequency matched to the cases by sex, age, and center. Subjects who were a farmer were compared with all other occupations.Out of the 200 cases that were diagnosed as lymphoid neoplasms, 100 were non-Hodgkin's lymphoma, 54 Hodgkin's lymphoma and 46 multiple myeloma. Seventy two percent of the NHL's were of the B-cell type, 15% of the T-cell type and the rest were not classified. Furthermore, subjects exposed to pesticides were at an increased risk of non-Hodgkin lymphoma and MM, but not Hodgkin lymphoma.Risk of non-Hodgkin lymphoma and MM was highest for exposure to pesticides, among them, insecticide's risk was confirmed. In the past decades, the incidence of non-Hodgkin’s lymphoma has doubled in almost all western countries. The causThe objective of this study was to describe the risk of lymphoid neoplasms among farmers and other subjects exposed to pesticides, with respect to type of exposures, duration of exposures and evaluate other risk factors such as smoking, family history of cancers, HBV, HCV and HIV infections in a case control study in Nemazee Hospital, Shiraz, Sothern Iran.Cases were all subjects over 18 years old diagnosed with lymphoma (Hodgkin and non-Hodgkin's lymphoma) and multiple myeloma admitted in Nemazee Hospital between January 2007 and April 2008. The diagnosis was verified by histology and was supplemented by immunohistochemistry tests. Cases were categorized according to the World Health Organization (WHO) classification for Neoplastic Diseases of the Lymphoid Tissues and included B cell, T cell, multiple myeloma, and Hodgkin’s lymphoma. Ineligibility criteria included a history of organ transplantation, severe systemic diseases or a diagnosis of chronic lymphocytic leukemia, or B or T-cell lymphoblastic leukemia.Of the initial sample, 14 cases were excluded, due to wrong or uncertain diagnosis. Finally, 200 cases were included. Of 200 participating lymphoma patients (participation rate=93.45%), 54 suffered from Hodgkin’s lymphoma, 72 from B-non-Hodgkin’s lymphoma, 15 from T-non-Hodgkin’s lymphoma, 13 from unknown type of Non-Hodgkin’s lymphoma and 46 from multiple myeloma.Controls were hospital patients randomly chosen among subjects admitted in Nemazee Hospital Emergency Room. Controls were frequency matched by age, sex, state of residence, and vital status at the time of interview. A variety of diagnoses were included. Patients with hematopoietic cancer, systemic infection, previous history of organ transplantation, or patients with severe systemic diseases were excluded. Interviews were obtained from 200 controls. No upper age limit was set for cases and controls, but all subjects had to be able to answer a questionnaire.Interviews were conducted directly with the subjects or with their next-of-kin if the subjects were in-capacitated (22% of case objects and 20.3%of control objects). Patients were asked to participate in research about the effects of the infections, occupations and environment on the development of lymphoma, and verbal consent was obtained.Cases and controls were interviewed and answered a questionnaire which contained detailed information on sociodemographic characteristics , familial history (including types of cancer), medical history about presenting disease , past medical history and complete occupational history.Questions regarding occupational history were asked for each job ever held for at least one year. The interviewer listed a series of exposures of interest  for each job. For each of these exposures, the subject specified if the exposure occurred during work, determined the kind of exposure, explained the reason for the exposure, and specified the years of exposure. After finishing the job history, the subject was asked about any extra jobs in crop farming.In this study, the term pesticide referred primarily to herbicides, insecticides, and fungicides.Subjects were asked whether they had used or personally handled specific pesticides; for which kind of crops they used pesticide; the year of first use and last use; and the year of use for specific pesticides, the application method used most often; use of protective equipment were recorded. However, duration and intensity measures were obtained for insecticides, herbicides and fungicides, but not for individual pesticides. Non-occupational use of pesticides  was included. There were few individuals who were completely free of being exposed to pesticides. The duration of insecticide and herbicide use was categorized into 2 groups (< median and median years of exposure) based on the distribution among subjects who used insecticides and herbicides, respectively. The specific chemicals used were reported in an open-ended question at the end of each section. For assistance with exposure assessment, information on what kinds of pesticides were known to be used for different types of crop and pest type  in Fars's cities, Jahad Agricultural Support Services in Shiraz assisted with statistics about the distribution of pesticides in Fars in the last 5 years.At first, we analyzed the relation between occupational exposure and lymphomas as a whole (n=200). Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression analysis, adjusted for different variants effected on lymphoma, including age, family history, viral hepatitis, and blood group. Secondly, we calculated odds ratios for the more frequent lymphoma subentities (with n>30 cases). To increase the statistical power, patients with these lymphoma subentities were compared separately with the entire control group (n=200) using logistic regression analysis.Our analyses for the associations of family history of cancer used only data on the first-degree relatives, because of the low reliability of data on second-degree relatives. The presence of hematopoietic cancer in at least one first-degree relative was considered a positive family history of hematopoietic cancer. A family history of cancer was defined as having cancers other than hematopoietic cancer among first-degree relatives.A 5-mL blood sample was collected from each consenting participant and sent to Shiraz Blood Transfusion Organization. Both, cases and controls underwent; a) ABO blood typing and b) Enzyme-linked immunosorbent assay (ELISA) to test serum samples for hepatitis B surface antigen (HBsAg), hepatitis C antibody (anti-HCV), and HIV antibody.According to the WHO classification, lymphoid neoplasms were grouped in B cell lymphoma , T cell lymphoma , and Hodgkin’s lymphoma. Multiple myeloma was reported separately in this study, but belonged in the classification of B cell lymphoma according to the WHO classification. The group of B cell lymphoma was thus analyzed with excluding multiple myeloma in this study.p values were considered statistically significant at the 0.05 level.Analyses were conducted for ever farming and for farming as longest occupation. Multinomial logistic regression was used to estimate the odds ratios and the 95% confidence intervals to measure association between working in farming and lymphoma risk. Farmers were compared to people who had never held a farming job, and pesticide exposed farmers were compared to non-exposed people. Standard statistical procedures were carried out using SPSS software . T-test and Chi-Square test for differences between groups were used to compare cases and controls with respect to age, sex, educational status, smoking and family history of cancer. Two-sided A strictly confidential specimen evaluation was conducted. Ethical approval for the study was obtained from the local ethics committee. All subjects gave their written informed consent for HBV, HCV and HIV screening tests.Of all eligible subjects, 200 controls and 200 cases were included in the study. The corresponding fre-quencies for next of kin were 8% for cases and 12% for controls. Of all subjects, 212 (53%) were male. The mean (standard deviation) age among cases and controls were 42.31 (17.37) and 43.48 (16.9) years, respectively. No statistically significant differences were observed between cases and controls with respect to age, sex, or smoking, but there was a statistically significant difference (p=0.001) for educational status. Each subtype was compared separately with controls by Chi-Square for educational status. There was no difference between B-non-Hodgkin’s lymphoma (p=0.075), T-non-Hodgkin’s lymphomas (0.459) and Hodgkin lymphoma (0.241) with controls. However, multiple myeloma's had lower education. In Among 200 lymphoma patients, 54 suffered from Hodgkin lymphoma, 72 from B-non-Hodgkin’s lymphoma, 15 from T-non-Hodgkin’s lymphoma, and 46 from multiple myeloma. Thirteen cases of non-Hodgkin's lymphoma were not classified. The distribution of malignant lymphomas is shown in Our analyses for the associations of family history of cancer used only data on the parents, brothers, sisters, and children (first-degree relatives). Because of the low reliability of data on second-degree relatives, risk of non-Hodgkin's lymphoma in positive family history cases of malignancy increased 4.4 times that was statistically significant (95% CI=1.46-13.3); however no association was seen in Hodgkin's lymphoma and multiple myeloma.Cases and controls occupations code were recorded similar to International Standard Classification of Occupations code (ISCO-68) in Only 42.5% (85/200) of the malignant lymphoma patients were available for testing by serology for HBS Ag, HCV Ab and HIV Ab during the study period and 2 (2.35%) tested positive including 1 non-Hodgkin’s lymphomas , and 1 Hodgkin's lymphoma (Mixed cellularity) while all screened multiple myelomas were seronegative. In controls, 6 subjects were positive including 2 HBS Ag, 3 HCV Ab and 1 HIV Ab. Due to difficulties in control group for viral assay, information from 400 donors referred to Shiraz Blood Bank were considered because of low positive cases, t test was used to compare all positive cases and controls dispensing with subtypes (p=0.547) that was not statistically significant. Blood group O was the most common blood group in controls (42%); however, blood group AB was a rare blood group in both cases and controls. Although most cases of non-Hodgkin’s lymphomas had group B and O and in multiple myeloma, group A with 34.7% had first rank but they were not statistically significant . 75.5% and 87% of cases and controls were RH positive (p=0.349).Pesticide exposure, duration of exposure and kind of pesticides were shown in Of all malignant lymphoma patients, 58 were farmers . Mean age of farmers was 48.2 and 46.4 years in cases and controls, respectively. Among all farmers, 97% of them reported the use of any pesticide. Furthermore, only 19.14% of the all cases who used pesticides could recall the product names; thus, evaluation of the chemical class of pesticides was not feasible. When lymphoma risk was evaluated for the different exposure categories that were stratified by group of farming, insecticide was the only exposure category that was significantly associated with lymphoma risk among farmers other than general population. The mean (SD) duration of exposure to pesticides was 12.3 (13.0) years. An increased risk was observed for all farmers exposed to pesticides for >17 years. The mean (SD) frequency of exposures was 7 (17) days/year. When types of crops handled by the study subjects were considered, the OR appeared to be higher for vegetables, grain, and other crops than for fruits and flowers, although none of them was statistically significant. Farmers also were asked about safety methods during their spraying. About 50% of farmers did not use any protective methods and less than 5% used more than 2 devices.Non-Hodgkin’s T-type lymphomas were 7.5% in the present study and 9.3% in western countries. Thus; thIn this study, some etiologic factors of lymphoid malignancies were evaluated including family history of cancer, smoking, HBV, HCV and HIV viruses and occupational exposures. Our results confirmed previously reported associations of non-Hodgkin’s lymphomas and a history of cancer among first-degree relatives. Risk of Although we did not find a statistically significant association with serologically confirmed HCV, HBV and HIV infection in non-Hodgkin’s lymphomas, Hodgkin’s lymphomas and multiple myeloma cases, our point estimate was consistent with those from other countries with low prevalence of these viruses.Recent population-based data from large incident case series in the United States and a syIn the data presented, people who had ever been a farmer had an increased risk of lymphoma compared to all other occupations. The hypothesis that farming, agricultural practices14]15][[15][14][[[15][14]Two etiological hypotheses have been advanced to account for the frequently observed association between lymphatic and hematopoietic cancers and agricultural occupations. Farmers may be more frequently exposed to agricultural chemicals, including phenoxy herbicides, chlorophenols and pesticides.19]20][[20][19][[[20][19]We found that persons with exposure to any pesticide had increased the risk of lymphoid neoplasms . Exposure to pesticides increased risk of non-Hodgkin lymphoma , and multiple myeloma . Although risk of Hodgkin lymphoma increased with pesticide exposure, it was not statistically significant . Further analysis of pesticides showed that patients who had been exposed for long periods had an increased risk of lymphoma. This is consistent with findings from another study restricted to women who lived and worked on a farm where pesticides were used for more than 10 years.Less than 20% of the all cases who used pesticides could recall the product names; thus, evaluation by chemical class of pesticides was not feasible. So, risk of lymphoid malignancies was evaluated in 4 pesticide categories: Insecticide, herbicide, fungicide and home pesticides. It was seen that risk of lymphoma increased in insecticide exposures. Most of farmers in this study were in middle age and 45% of farmers were illiterate compared to all other subjects.Pesticides are mostly used by farmers, but other people (for example housekeepers exposed to home pesticides) can also be exposed, which makes comparison between farming studies and exposure studies difficult. In this study, we consider both groups. Moreover, farmers experience multiple exposures. Another problem in comparing the current study to others is that the investigated disease differs between studies and/or that a different classification system may be used. Classification systems differ according to the types of lymphomas included. We analyzed all lymphoma together as well as B cell, T cell, and Hodgkin’s lymphoma separately. Most studies that investigate the cancer risk among farmers only evaluate the risk of non-Hodgkin lymphoma and not for subtype.19] Kato Kato19] Farmers exposed to pesticides were found to be at an increased risk of lymphoma. The risk was clearly observed for herbicides, insecticides and fungicides. This risk was greatest when exposure to pesticides was more than17 years. Furthermore, subjects exposed to pesticides were at an increased risk of non-Hodgkin lymphoma and multiple lymphoma, but not Hodgkin lymphoma.


Pleomorphic carcinoma is a rare aggressive type of lung cancer that uncommonly metastasizes to the bowel, leading to bleeding, perforation, obstruction, and rarely intussusception. Serving as a lead point, metastatic lesions in the bowel may precipitate intussusception and require immediate surgical intervention. We present a rare case of colonic metastases from a primary lung malignancy, causing ileocecal intussusception in a 57-year old male. Pleomorphic carcinoma of the lung is rare and accounts for less than 1% of all lung malignancies. Metastasis to the bowel from a primary lung malignancy is a rather uncommon finding and often remains clinically silent. Rarely reported, bowel metastasis may lead to intestinal intussusception, which requires prompt surgical intervention. We describe a case of ileocecal intussusception secondary to metastatic pleomorphic carcinoma of the lung.A 57-year-old African American male presented to the medical emergency room with complaints of progressively worsening dyspnea for 1 month, productive cough for 2 weeks, and hemoptysis for the past 3 days. Review of symptoms was significant for night sweats and an unintentional weight loss of 30 pounds in the last three months. Past medical history included hypertension, dyslipidemia, and 35 pack-years of cigarette smoking. 2, and decreased breath sounds over the left lung base on chest auscultation.Physical examination was significant for marked pallor, a body mass index (BMI) of 17 kg/m3, and a platelet count of 214,000/mm3. Fecal occult blood testing was positive, and there was evidence of iron deficiency anemia.Laboratory studies revealed a hemoglobin of 4.2 g/dL, hematocrit of 13.2%, white blood cell count of 9,100/mmChest radiography showed an infiltrate in the left middle and lower lung fields. Subsequent computed tomography (CT) of the chest showed the presence of a 1.9 × 1.6 cm spiculated mass in the right upper lobe suspicious for a neoplasm , with coThe patient underwent bronchoscopy that did not reveal any endobronchial lesions, and bronchoalveolar lavage and bronchial brushings were negative for any malignant cells.Subsequent CT-guided biopsy of the lung mass was positive for non-small cell lung carcinoma (NSCLC).During the hospital stay, the patient complained of severe abdominal pain, abdominal distension, and nausea. A CT scan of the abdomen revealed cecal colitis with ileocecal intussusception . In viewFurther hospital course was complicated by sepsis, massive hemoptysis, and multiple organ failure which led to the patient's death on day 89 of admission. Pleomorphic carcinoma (PC) is categorized by the World Health Organization (WHO) histologic classification of lung tumors as a subtype of heterogeneous group of non-small cell lung carcinomas (NSCLC) that contain a sarcoma or sarcoma-like component under the designation “carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements” (CPSS) –3.Histopathologically, CPSS is a poorly differentiated tumor, with a dual component of sarcomatoid (spindle and/or giant cells), and carcinoma  elements. Tumors with at least 10 percent of spindle and/or giant cells are considered to be pleomorphic carcinomas. It is a rare lung malignancy that constitutes 0.3 to 1 percent of all malignant lung tumors. This cancer usually occurs in male smokers, with the median age of presentation being 59 years. The tumor usually presents as a peripheral mass predominantly seen in upper lobe of the lung. The prognosis of pleomorphic carcinoma is poor, with a 6-month survival of only 27 percent .Given the lower incidence of pleomorphic carcinoma compared to other tumors of the lung, these may present a diagnostic challenge for pathologists. Nearly half of the cases of pleomorphic carcinoma are diagnosed at an advanced stage, with one-fifth of them already having local chest wall invasion .The metastasis from pleomorphic carcinoma of the lung to other organs including lymph nodes, brain, bone, liver, adrenals, and contralateral lung have been reported, but metastasis to the gastrointestinal tract remains uncommon . Small bOccurring in approximately 1 in 30,000 hospital admissions, the incidence of intussusception is nearly 20-fold more frequent in the pediatric population than in adults . In chilPleomorphic carcinoma is a rare type of lung cancer that infrequently metastasizes to the bowel. Serving as a lead point for possible intussusception, metastatic lesions to the bowel may warrant prompt diagnosis and surgical intervention. Although infrequently reported, one should be aware of the possibility of bowel intussusception from metastatic disease, and suspicion should heighten in patients with lung cancer complaining of abdominal pain.


Recent studies have emphasized an important role for long non-coding RNAs (lncRNA) in epigenetic regulation, development, and disease. Despite growing interest in lncRNAs, the mechanisms by which lncRNAs control cellular processes are still elusive. Improved understanding of these mechanisms is critical, because the majority of the mammalian genome is transcribed, in most cases resulting in non-coding RNA products. Recent studies have suggested the involvement of lncRNA in neurobehavioral and neurodevelopmental disorders, highlighting the functional importance of this subclass of brain-enriched RNAs. Impaired expression of lnRNAs has been implicated in several forms of intellectual disability disorders. However, the role of this family of RNAs in cognitive function is largely unknown. Here we provide an overview of recently identified mechanisms of neuronal development involving lncRNAs, and the consequences of lncRNA deregulation for neurodevelopmental disorders. Therapeutic strategies for the amelioration of neurobehavioral dysfunction in neurodevelopmental disorders such as intellectual disabilities (ID), or autism spectrum disorders (ASD) are often insufficient for a large patient population. These disorders have complex behavioral and cognitive phenotypes that are thought to develop through disturbances in neural circuitry and synaptic function. Moreover, genetic epidemiology and population genetic studies suggested that a spectrum of allelic risk underlies complex traits like ID . HoweverHox-genes expression , a protein family highly abundant in the brain . Due to s SINEs; . Alu RNAXist that binds to one of the X-chromosomes , which is a subunit of the PRC2. The recruitment of the PRC2 complex by Xist, via the RepA sequence, allows trimethylation on lysine-27 of H3 histones (H3K27), effectively repressing gene expression, and inactivating the X-chromosome  complex  and the omosomes . RepA way itself . The Repromosome . Very Re domains .Camkk1, which is involved in male-specific memory formation . A number of ncRNAs were found to be specifically expressed within the hippocampus , a regioormation .Dlx-family, known to be involved in brain development in mammals and Drosophila. Two of the differentially expressed lncRNAs, Evx1as and Hox5b/6as were shown to be associated with trimethylated H3K4 histones and histone methyltransferases (Evf2) is transcribed from the Dlx5/Dlx6 locus, antisense to the Dlx6 gene  is a highly conserved lncRNA that overlaps the Sox2 gene  is an lncRNA that is enriched in nuclear speckles . Metastspeckles . There, speckles .Table 1). The role of lncRNAs is possibly best understood in genomic imprinting disorders such as PWS , Angelman syndrome (AS), ID, and ASD . Necdin deficient mice show a subset of the multiple clinical manifestations of PWS  and partially overlaps the UBE3A gene. Importantly, the downstream introns of SNRPN contain C/D box-containing SNORD116 (HBII-85) snoRNA clusters whose expression is under control of the SNRPN promoter  is located in the proximal chromosome 15q, merely 150 kb distal to SNRPN and is not expressed in patients with 15q11-q13 deletions  is caused by a disruption of the maternal allele of chromosome 15q11-q13, covering the same genomic location as PWS. However, the symptoms are different and include intellectual disability, movement or balance disorder, typical abnormal behaviors, and severe limitations in speech and language. The genetic underpinning of the disorder is thought to be a disruption in the E3A gene . The UBEUBE3A-AS . However complex .Despite the highly variable genetic etiology in ID, only a limited number of molecular and cellular pathways appear to be affected by the magnitude of different gene mutations. ID genes have been shown to cluster in pathways underlying neurogenesis, neural migration, neuronal outgrowth, and synaptic function . NumerouFMR1 gene leading to silencing of the gene by methylation of repeat and promoter  is inherited via an X-linked dominant pattern and characterized by moderate to severe mental retardation, macro-orchidism, and distinct facial features. The disorder is caused by an unstable expansion of a CGG repeat in the promoter , resultipromoter . Accumulcarriers . Followirom FMR1 . Togethe discovered two new transcripts in the FMR1 gene locus: FMR5 and FMR6. FMR5 was similarly expressed in brain regions from unaffected and permutation individuals and full mutation patients, whereas FMR6 was silenced in full mutation and permutation carriers. According to the authors, this might suggest an abnormal transcription or chromatin remodeling prior to transition to the full mutation. In addition to the finding that both FMR5 and FMR6 are expressed in blood leukocytes, these lncRNAs are potentially useful as biomarkers in FXS.Recently, Pastori et al. (2013)FMR1, acts as a translational repressor of specific mRNAs at the synapse and associates with the dendritic RNA BC1  is characterized by arrested development between 6 and 18 months of age in females, regression of acquired skills, loss of speech, stereotypical movements, seizures, and ID. Mutations in the disorder . While ae brains , it was NRON may be involved in DS, since NRON modulates cytoplasmic-to-nuclear transport of NFAT .Down syndrome (DS) or Trisomy 21 (MIM 190685) is characterized by ID, distinct facial characteristics and congenital heart defects. The lncRNA  of NFAT . DecreasON in DS . Recentl editing . This apBCL11A, PAPOLG and REL and one lncRNA gene FLJ16341, although the function of this lncRNA is still elusive.In the last decade, several new rare microdeletion syndromes were identified. One of these is the 2p15-p16.1 microdeletion syndrome , charactde novo mutations, as evidenced by whole-exome and genome sequencing studies in ASD patients , both on the sense and antisense strands that potentially regulate RAY1/ST7. Several rare variants were detected in autism patients on either the RAY1/ST7 or the ST7OT1-3 genes that were not observed in a control population.Autism spectrum disorders is an umbrella term for various developmental disorders, including autism, pervasive developmental disorder not otherwise specified (PDD-NOS) and the Asperger syndrome. Common symptoms of the various ASD disorders include problems of reciprocal social interactions, verbal and non-verbal communication, and rigid and stereotyped behaviors. ASD is a clinically and etiologically heterogeneous disorder with a complex genetic architecture. Not only multiple common genetic variants appear to be involved, each with small effect size, but also rare variants with strong effect size . The latpatients , or copypatients . Microarngements . In the PTCHD1 gene have been reported to involve X-linked ID and ASD  were detected, which may serve as regulators for PTCHD1, since the 5′ exons are adjacent on opposite strands.Mutations in the X-chromosome  and ASD . Althoug and ASD . On the Malat1  under grant agreement no. 278948, and the Marie Curie International Reintegration Grant.


We report a 4-year-old girl of Mexican origins with a clinical diagnosis of Dubowitz syndrome who carries a de novo terminal deletion at the 14q32.33 locus identified by array comparative genomic hybridization (aCGH). Dubowitz syndrome is a rare condition characterized by a constellation of features including growth retardation, short stature, microcephaly, micrognathia, eczema, telecanthus, blepharophimosis, ptosis, epicanthal folds, broad nasal bridge, round-tipped nose, mild to moderate developmental delay, and high-pitched hoarse voice. This syndrome is thought to be autosomal recessive; however, the etiology has not been determined. This is the first report of this deletion in association with this phenotype; it is possible that this deletion may be causal for a Dubowitz phenocopy. Dubowitz syndrome was originally described in 1965 by Dubowitz –4. DubowApproximately, 10 cases of 14q32.3 terminal deletion have been reported, and although quite rare, a phenotype of the “14q32.3 deletion syndrome” has been established –7. ThereDubowitz syndrome is a multiple congenital anomalies syndrome with intellectual deficits and growth failure. Rarely do patients fit all of the clinical features of this syndrome. To date, Dubowitz syndrome has been described as a rare, autosomal recessive disease characterized by microcephaly, growth retardation, facial asymmetry, blepharophimosis, sparse hair and eyebrows, low-set ears, and mental retardation. In addition, other characteristics include a soft high-pitched voice, dental and craniofacial abnormalities, palate deformations, eczema, language difficulties, and an aversion to crowds. Significant phenotypic variability has been described. Because of a lack of array comparative genomic hybridization (aCGH) testing in other cases of Dubowitz, it is not possible to say whether our patient's deletion overlaps the cases previously described as the 14q32.3 terminal deletion syndrome. We believe that our patient with an array-detected 14q32.3 deletion has many features of Dubowitz syndrome.The proband is a female born to a 27-year-old gravida 3 para 2 mother by vaginal delivery which was induced at 33 weeks gestation because of intrauterine growth restriction (IUGR) and oligohydramnios. Her mother denies alcohol or drug use during pregnancy. The pregnancy was significant for IUGR since 20 weeks of gestation with a 3-4-week growth lag.At birth, the proband was blue and floppy with no respiratory effort and required positive pressure ventilator assistance. Her APGAR scores were 5 at 1 minute and 7 at 5 minutes. Birth parameters were small for gestational age at 1477 g (10–25%), length 42 cm (25–50%), and head circumference 30 cm (25–50%). A wide fontanelle that was open from midforehead to occiput with continuity of posterior and anterior fontanelles, bilateral microphthalmia, small mouth with micrognathia, and a left low-set ear were noted. 7-dehydrocholesterol analysis was performed and was within normal limits. She remained in the NICU for 18 days and was then discharged to her parents. A review of the reported family medical history is non-contributory. There is no history of birth defects, developmental delays, mental retardation, or multiple miscarriages. The parents report no consanguinity. There are two older siblings without developmental concerns, birth defects, or dysmorphic features. At 25 months of age, clinical features suggested a possible diagnosis of Dubowitz syndrome. The patient was noted to have an open-mouth habitus, ptosis of the left eye, downward slanting palpebral fissures, telecanthus, epicanthal folds, microcephaly (less than the 2nd centile), developmental delays and growth delays. By 48 months of age, the patient continued to have speech delay and reportedly knew many simple words and was just beginning to form 2-3-word phrases. The patient was attending a special education preschool to help with developmental skills. The patient continued to have significant difficulty gaining weight (approximately the 3rd percentile for her age group) despite high calorie nutritional supplementation , performed in duplicate with 3141 BAC probes targeting multiple loci across all chromosomes revealed a genomic imbalance. The array exhibited a terminal deletion at 14q32.33 to 14qter between the BAC probes labeled CTD-2194E2 and RP11-47P23. This corresponds to genomic coordinates 103,572,825 to 106,339,477 according to hg18 annotation . Parental aCGH studies were subsequently performed which were normal, thus this deletion in the patient is presumably de novo. No other family members were tested.The differential diagnoses for Dubowitz often includes fetal alcohol syndrome and fetal alcohol spectrum disorders, Bloom syndrome, DiGeorge syndrome, Jacobsen syndrome, and Michels syndrome . All of these syndromes were excluded for the patient. Bloom syndrome presents with pre- and postnatal growth deficiency, sun sensitivity, and telangiectatic hypo- and hyperpigmented skin. DiGeorge syndrome includes the presence of congenital heart defects, immunodeficiency, orofacial clefting, micrognathia, abnormal pinna, hypertelorism, and blunted nose. Jacobsen syndrome is identified by growth delays, developmental delays, trigonocephaly, strabismus, telecanthus, broad nasal bridge, and retrognathia. Michels syndrome is noted by blepharophimosis, blepharoptosis, and epicanthus inversus plus a developmental defect of the anterior segment of the eye as well as skeletal defects in the form of spina bifida occulta, craniosynostosis, cranial asymmetry, cleft lip and palate, hearing loss, and mild mental retardation. No specific skin findings or sun sensitivity in relationship with Bloom syndrome were noted for our patient. Additionally, the absence of congenital heart defects, orofacial clefting, skeletal anomalies, as well as trigonocephaly, or other forms of craniosynostosis makes a diagnosis of DiGeorge, Jacobsen, and Michels syndrome unlikely. CKBE, a gene associated with brain type creatine kinase, is a necessary component of energy metabolism in the central nervous system. HFM and MCOP1 are genes associated with hemifacial microsomia and isolated type 1 microphthalmia, respectively. Both of which are associated with craniofacial morphogenesis which could be linked to the Dubowitz phenotype. SMALED, autosomal dominant lower extremity spinal muscular atrophy, is also a part of the deleted region. We feel that this is a gene of interest due to hypotonia being a common feature in Dubowitz and chromosome 14q32 deletion syndromes.There are forty-eight known genes in the region of interest; sixteen of which have been associated with specific clinical features . AdditioJAG2 is present and is known to create a ligand for the receptor protein Notch1. JAG1, associated with the autosomal dominant Alagille syndrome, and JAG2 are similar in structure to all of the currently identified Notch ligands [JAG1 and JAG2 association with facial dysmorphism lend support that JAG2 is a critical gene disrupted and may result in the proband's phenotype.Within the region of the deletion, the gene  ligands , 10 and  ligands . The assDubowitz syndrome is a rare condition which is previously believed to be autosomal recessively inherited with no known diagnostic testing available. We believe that our patient provides an example of a chromosome abnormality with clinical features of Dubowitz syndrome. We suggest that the 2.77 Mb deletion at 14q32.33 to 14qter may shed light on the pathogenesis of Dubowitz syndrome in the future and bring a clearer understanding of the genes and loci involved in these phenotypes. Historically, chromosome deletions and rearrangements via chromosome analysis have aided the medical community in identifying candidate regions for disease identification. Deletions, like that seen in our patient, can identify candidate genes in autosomal recessive conditions by causing a knockout effect. At this time, we cannot determine whether the cases of Dubowitz-like syndrome are related to a chromosome deletion as a single causative factor or if the deletion would knock out one copy of the gene and there is another pathogenic mutation in the same gene on the homologous chromosome. Future studies may be warranted.JAG2 gene disruptions via gene deletions or point mutations may be resulted in Dubowitz syndrome or the phenotype previously described as the 14q32.3 deletion syndrome. This could also cause a contiguous gene syndrome effect resulting in the described phenotype. In addition, aCGH testing of those with 14q32 terminal deletion syndrome could help determine whether there is overlap between our patient's deletion and the previously reported deletions.Testing other patients with Dubowitz using aCGH technology could reveal whether this is an isolated occurrence or common to patients with Dubowitz.


Racial and ethnic disparities exist in diabetes prevalence, access to diabetes care, diabetes-related complications and mortality rates, and the quality of diabetes care among Americans. We explored racial and ethnic disparities in primary care quality among Americans with type 2 diabetes.We analyzed data on adults with type 2 diabetes derived from the household component of the 2012 Medical Expenditure Panel Survey. Multiple regression and multivariate logistic regressions were used to examine the association between race/ethnicity and primary care attributes related to first contact, longitudinality, comprehensiveness, and coordination, and clusters of confounding factors were added sequentially.Preliminary findings indicated differences in primary care quality between racial/ethnic minorities and whites across measures of first contact, longitudinality, comprehensiveness, and coordination. After controlling for confounding factors, these differences were no longer apparent; all racial/ethnic categories showed similar rates of primary care quality according to the 4 primary care domains of interest in the study.Results indicate equitable primary care quality for type 2 diabetes patients across 4 key domains of primary care after controlling for socioeconomic characteristics. Additional research is necessary to support these findings, particularly when considering smaller racial/ethnic groups and investigating outcomes related to diabetes. Approximately 29.1 million Americans have diabetes, and type 2 diabetes accounts for 90% to 95% of all diagnosed cases in adults , which was the latest publicly accessible data set at the time of our study. MEPS is a nationally representative survey of the US noninstitutionalized civilian population, comprising survey data of families and individuals and their medical providers and employers. MEPS is supported by the Agency for Healthcare Research and Quality . The 201The household component of MEPS collects detailed data on demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to primary care, satisfaction with care, health insurance coverage, annual income, and employment. In this study, measures of primary care attributes (dependent variables), race/ethnicity (independent variable), and individual characteristics (covariates) were used.According to previous work conducted on primary care –19, we cAndersen and Aday’s access-to-care framework, among the most well-known and widely used models for demonstrating the factors that lead to the use of health care services, was used in the selection of individual covariates that may be related to the experience of primary care . Accordi2 tests to determine whether there were differences among racial/ethnic groups in primary care quality. We also constructed 4 scored summary variables representing each of the primary care domains. We first assigned scores to each of the questions and then created an integrated variable by summing the total scores of questions within each domain. Therefore, the score ranges for the 4 domains — first contact, longitudinality, comprehensiveness, and coordination — were 0 to 8, 0 to 1, 0 to 1, and 0 to 2, respectively. However, we recoded the coordination domain as dichotomous because of the distribution of total scores within the domain. We recoded the coordination domain score as 0 if the original score was 0 or 1, and we recoded the domain score as 1 if the original score was 2. ANOVA was performed to determine whether there was significant difference among racial/ethnic groups in first contact quality. We used χ2 tests to determine whether there were differences among racial/ethnic groups in longitudinality, comprehensiveness, and coordination domains. Multiple regression and multivariate logistic regressions were used to examine the association between race/ethnicity and primary care attributes related to first contact, longitudinality, comprehensiveness, and coordination, by sequentially adding the clusters of confounding factors in the following order: predisposing factors, enabling factors, and need factors. In our regression models, we used the 4 integrated variables of 4 primary care domains rather than individual items and applied hierarchical modeling approach to investigate in greater depth, so we could understand the contributors to disparities in primary care quality. Model 1 was unadjusted regressions. Model 2 was adjusted for predisposing factors. Model 3 was adjusted for predisposing and enabling factors. Model 4 was fully adjusted, accounting for predisposing, enabling, and need factors. We used standard errors, P values, β coefficients, odds ratios (ORs), and 95% confidence intervals (CIs) to interpret significance and effect size.Data analysis was performed using Stata/SE version 14.0 , accounting for the multistage, stratified cluster sampling associated with MEPS. All analysis accounted for sampling weights. Bivariate comparisons were performed between an individual’s race/ethnicity and primary care attributes. We used χIn 2012, 21,813,781 American adults had type 2 diabetes. Most of those with the condition were aged 46 to 64 years (43.8%); 42.8% were aged 65 or older. Adults with a high school diploma, the unemployed, and those with annual income below $20,000 accounted for more than half of those with diabetes. The southern census region represented 41% of diabetes cases; urban areas accounted for 82% .P < .01) (P < .001); hospitals accounted for 25% of USC locations among non-Hispanic blacks, 43% among Hispanics, 25% among non-Hispanic others, and only 17% and 18% among non-Hispanic whites and Asians, respectively (P < .001). No significant differences were found in mean scores for first contact domain among the 5 racial/ethnic groups. Non-Hispanic others reported going to a USC for preventive health care at a lower rate (96%) than did Hispanics and non-Hispanic white, black, and Asian adults, who all reported approximately 99% on this comprehensiveness item (P < .05). A similar pattern emerged when looking at whether individuals sought care at a USC for referrals, where non-Hispanic others reported 91%, compared with 98% to 99% for the other racial/ethnic groups (P < .01). The results for the recoded measure of evaluating the coordination domain were also significantly different among the 5 racial/ethnic groups; 82% of non-Hispanic blacks, 83% of Hispanics, 74% of non-Hispanic Asians, and 69% of non-Hispanic others reported as having primary care coordination, compared with 83% of non-Hispanic whites (P < .05)  . Non-HisP < .05) .P < .01) — no other significant associations were found among racial/ethnic groups and differences in the first contact scores. For longitudinality indicators, non-Hispanic blacks  and Hispanics  were less likely to report that their USC providers listened to them compared with non-Hispanic whites. With respect to comprehensiveness indicators, non-Hispanic others  were less likely than whites to report that they went to their USC for preventive health care.P < 0.01) after accounting for individuals’ predisposing factors. For the first contact domain, adults aged 46 to 64 years were associated with significantly lower scores , adults with an annual income of $20,000 to $39,999 were associated with significantly higher scores , and married adults  were associated with significantly higher scores. Similar results were also found in Models 3 and 4. Moreover, enabling factors such as MSA and census region were also significantly associated with differences in first contact scores; whereas need factors were not.Models 2 through 4 show the results of multiple regressions or multivariate logistic regressions . The β cP < .05), was still significantly associated with lower odds in reporting that USC provider listened in Model 2, and no negative associations were found in Models 3 and 4. The predisposing factors of being older than 64 years and female were associated with higher odds of reporting that providers listened to them. No enabling and need factors were associated with the longitudinality indicator. For the longitudinality domain, the significant differences that were found in Model 1 were no longer apparent in Model 2 after adjusting for predisposing factors, in Model 3 after adjusting for predisposing and enabling factors, and in the fully adjusted Model 4 after accounting for all predisposing, enabling, and need factors. Only one racial/ethnic minority group, Hispanics  is a stronger determinant of diabetes status and outcomes than is race/ethnicity ,22.Healthy People 2000, efforts to eliminate racial/ethnic disparities have been on the US national health policy agenda (Beginning with y agenda ,24. A gry agenda . Previouy agenda . Our resWhen looking at differences by race/ethnicity, patterns for non-Hispanic others often mirrored those of Hispanics and non-Hispanic blacks, with primary care quality being lower for these adults than for non-Hispanic white and Asian adults. Additional research should be conducted on the composition of the “other” racial/ethnic category to draw more precise conclusions about the primary care needs of this diverse population.Our study has limitations. First, MEPS data on primary care are self-reported and are subject to recall bias. Second, the secondary nature of the data set precluded causal inferences. Third, the study investigated the primary care experience reported by the patients rather than their health outcomes. More studies are needed to examine the associations between the process and outcome of primary care among minority patients with diabetes. Finally, our measures of primary care attributes were operationalized from MEPS rather than being researcher-initiated measures, which limited the ability to include all the major measures of primary care, especially for measures of longitudinality and comprehensiveness . Other mDespite these limitations, this study presents relevant findings to the field and could improve the care provided to patients with diabetes. Our findings indicate that primary care quality is equitable for diabetes patients across 4 key domains of primary care. In addition to racial/ethnic disparities in health and health care, other socioeconomic stratification factors, such as minorities disproportionately having low income and vulnerable populations having higher risk of being chronically ill and disabled, may be the cause of these disparities in population health . Federal


Desmoplastic small round cell tumor (DSRCT) is a rare and aggressive malignancy with a poor outcome that occurs in adolescents and young adults; <200 cases of DSRCT have been reported. Renin-producing tumors are also rare and cases of extrarenal renin-producing tumors are even rarer. The present study describes the case of a 20-year-old male that was diagnosed with DSRCT and presented with severe hypertension and hypokalemia, as well as metabolic alkalosis. The plasma renin activity (PRA) level was identified to be markedly elevated  and the plasma aldosterone level was also increased . The symptoms of the patient were consistent with the renin-secreting tumor triad, which comprises hypertension, hypokalemia and elevated PRA. Paraneoplastic syndromes must always be considered in cancer patients exhibiting unusual clinical findings, despite their rarity. The current patient was diagnosed with paraneoplastic secondary hypertension due to the presence of disseminated renin-secreting DSRCT. The patient was treated with the VAC/IE regimen  for six cycles. Following this treatment, the serum renin and aldosterone levels fell to within the normal range and the patient’s blood pressure was normalized without antihypertensive medication. Although an immunohistochemical evaluation of renin was not conducted as the sample size was inadequate, the present study demonstrated that the tumor had produced renin. The biosynthesis of renin was identified by the presence of mRNA that coded for the renin precursor, which was observed in the ascites of the patient. The current study describes, to the best of our knowledge, the first reported case of paraneoplastic secondary hypertension in a patient presenting with a renin-producing DSRCT. Howeveret al  did not l  with a complaint of abdominal distension and a palpable mass in the abdomen. The symptoms had begun two months previously and the palpable mass had gradually grown over the two weeks prior to presentation. The patient’s personal and family medical histories were non-specific with the exception of high blood pressure .The patient’s vital signs were as follows: Body temperature, 36.6°C ; BP, 180/110 mmHg; pulse, 108 beats per min ; and respiratory rate, 18 breaths per min .Physical examination revealed a 1-cm non-tender, hard and fixed nodule surrounding the umbilicus with abdominal distension and without fluid shifting.3 ; hemoglobin, 14.3 g/dl ; platelet count, 282×103/mm3 ; total protein, 7.83 g/dl ; albumin, 4.49 g/dl ; aspartate aminotransferase, 19 IU/l ; alkaline aminotransferase, 14 IU/l ; alkaline phosphatase, 115 IU/l ; serum lactate dehydrogenase level, 530 IU/l , blood urea nitrogen, 12.3 mg/dl ; creatinine, 1.12 mg/dl ; serum sodium, 138 mEq/l ; serum potassium, 3.0 mEq/l ; and chloride level, 97 mEq/l . In addition, metabolic alkalosis was observed in the arterial blood gas analysis test .The laboratory results were as follows: White blood cell count, 5,740/mmComputed tomography CT;  revealedHypermetabolism was observed by positron emission tomography-CT in the left supraclavicular LN, right internal mammary artery, retrosternal area and conglomerated LNs of the mesentery, aortocaval, paraaortic and pericaval areas . Physicain situ hybridization analysis, the EWSR1 gene (22q12) rearrangement was detected in 93% of the cells.First, a percutaneous needle biopsy of a palpable peritoneal nodule was performed. The biopsy specimen revealed the presence of a poorly differentiated tumor of variable size and shape composed of nests of small round cells surrounded by a prominent desmoplastic stroma . ImmunohThus, malignant cells of the small round cell type, which were expressing CD99, desmin, cytokeratin and the EWSR1 gene (22q12) rearrangement were identified, as well as a malignant mass that was predominantly in the abdominal area of the young, male patient.2 on day 1 every three weeks, adriamycin 37.5 mg/m2 on day 1 and 75 mg/m2 on day 2 every three weeks. Subsewuently, etoposide 100 mg/m2 was administered on days 1–5 every three weeks and ifosfamide 1,800 mg/m2 was administered on days 1–5 every three weeks. However, the patient complained of a sudden visual disturbance during hospitalization, and therefore, underwent an ophthalmic examination and brain magnetic resonance imaging (MRI). During the ophthalmic examination, macular edema and macular detachment were observed, which were considered to be secondary hypertensive changes . Vincristine 2 mg on day 1 for every three weeks, cyclophosphamide 900 mg/m changes . The bra changes .Additional hormone tests were performed during the secondary hypertension evaluation due to the severe hypertension , hypokalemia, metabolic alkalosis, and hypertensive ophthalmic and cerebral vascular changes that were observed in this young patient that did not have a family history of hypertension.Serum renin activity was 31.9 ng/ml/h in the supine position , while the aldosterone level was greatly increased to 64 ng/dl . The patient’s urinary vanillylmandelic acid level was 5.8 mg/day , metanephrine was 0.7 mg/day  and cortisol was 75.2 μg/day ; these levels were all within the normal range. Doppler sonography of the kidney revealed normal blood flow without renal artery stenosis and a CT examination revealed no masses or vessel abnormalities in the kidney. However, mild hydronephrosis was observed in the left kidney. The 24-h BP monitoring revealed an average BP of 167/123 mmHg.These findings were strongly indicative of a renin-secreting DSRCT. The patient was prescribed an aldosterone antagonist , an angiotensin II antagonist  and a calcium channel blocker . Upon treatment, the patient’s systolic BP decreased to 100–120 mmHg.Following a second cycle of the VAC/IE regimen, a partial response was achieved . The renThe patient was treated with a total of six cycles of the VAC/IE regimen and achieved a partial response . However2, 10 pmol of each primer and 4 μl Fast Starter Mix buffer . The primers and conditions used for RT-qPCR are shown in Following a four-month break from chemotherapy, the patient was readmitted to the Chosun University Hospital complaining of abdominal discomfort. It was identified that the tumor size had increased  and the DSRCT is a rare and aggressive malignant neoplasm that occurs in adolescents and young adults. The mean age at diagnosis is ~22 years, and ranges between six and 49 years; the male to female ratio is 4:1 . ClinicaDespite their rarity, paraneoplastic syndromes must always be considered in cancer patients with unusual clinical findings. The current patient exhibited hypokalemia at presentation, therefore, an endocrine cause for the hypertension was sought out. Serum renin and aldosterone were found to be markedly elevated, which explained the abnormal clinical findings. The juxtaglomerular apparatus predominantly secretes renin into the interstitium of the kidney, and not the lumen of the vessel. In addition to the kidney, renin has also been identified in a number of organs, including the brain, genital tract, salivary gland, vessels, skeletal muscle and heart. Therefore, tumors arising from these organs are capable of secreting renin. Renin-secreting tumors are classified into the following three groups: i) Tumors arising from the juxtaglomerular apparatus of the kidney; ii) renin-secreting renal tumors, including Wilms’ tumor, clear cell-type renal cell carcinoma, oncocytoma and mesoblastic nephroma; and iii) extrarenal tumors, including granulosa cell tumors, lung cancer and pancreatic cancer –11. In tHowever, immunostaining and electron microscopic identification are not readily available in clinical practice and the use of these methods in the context of this case report is experimental and not universal.In conclusion, although immunostaining for renin or electron microscopic examination were not performed in the present study, the diagnosis of a renin-producing tumor was determined due to the elevated serum renin and aldosterone levels, which normalized during tumor regression and were re-elevated during tumor progression. In addition, the biosynthesis of renin was confirmed by the demonstration of mRNA in the patient’s ascites that codes for the renin precursor. To the best of our knowledge, the current report is the first to demonstrate an extremely rare case of renin secretion from a rare type of cancer termed DSRCT. The results of the current study indicated that DSRCT may be considered as one of the differential diagnoses for extrarenal renin producing tumors.