ABSTRACT Background: Epistaxis is a mostly self-limiting condition common among children and is rarely severe. In this study, it was aimed to evaluate the incidence, demographic characteristics, causes of bleeding and treatment methods of patients who applied to the Pediatric Emergency Department (PED) with epistaxis, and to determine in which cases a laboratory test should be used. Method: Admitted to Gazi University Faculty of Medicine, PED which provides trauma care and is a tertiary hospital, between January 1, 2019 and December 31, 2019, 452 patients aged 0-18 years who presented with epistaxis to any reason or secondary to systemic disease were analyzed retrospectively. Results: The annual incidence was found 1.23%. The median age was 63 months, 258 of the cases (57.1%) were male. It was found that the cases most frequently applied to the hospital in the autumn months (37.6%). Sixty of the patients (13.3%) had a chronic disease and 54 (11.9%) had a history of drug use. Bleeding time was less than 5 minutes in 75.2% and 84.4% of the bleeding was unilateral. Nasal bleeding is local in 73.4%; 4.7% of them developed due to systemic reasons. The most common cause of epistaxis; while they were trauma at the first 10 years of age, they were idiopathic causes after the age of 10 years. In 434 (96%) of the patients, epistaxis spontaneously stopped and there was no need for additional treatment. Conclusion: As a result of this study, it was concluded that laboratory tests should be performed in cases with chronic disease history, bilateral bleeding, active bleeding and nontraumatic epistaxis. The situation that causes epistaxis in the childhood age group should be determined with a good history and physical examination, laboratory tests should not be used in every patient. Key Words: pediatric emergency, epistaxis, laboratory examinations, complete blood count

Objective: To describe the burden of influenza among pregnant women and their young infants. Design: Prospective cohort study. Setting: Rural western Kenya. Population: Pregnant women below 31 weeks of gestation and their infants aged 6 months and below Methods: We conducted weekly follow-up until 6 months postpartum to identify acute respiratory illnesses (ARI). We collected nasal/nasopharyngeal and oropharyngeal swabs from mothers/infants with ARI and tested for influenza A and B using polymerase chain reaction. We calculated incidence of laboratory-confirmed influenza per 1,000 person-months. Main outcome measure: Incidence of medically attended influenza illness among pregnant women and its impact on birth outcomes. Results: During June 2015–May 2020, we enrolled 3,026 pregnant women at a median gestational age of 16 weeks (interquartile range [IQR], 13, 18) and followed 2,550 infants. Incidence of laboratory-confirmed influenza during pregnancy (10.3 episodes per 1,000 person-months [95% CI 8.6–11.8]) was 2-fold higher than in the postpartum period (4.0 [95% CI 2.6–5.5]; p<0.01), and significantly higher among HIV-infected pregnant women (15.6 [95% CI 11.0–20.6] vs. 9.1 [95% CI 7.5–10.8]; p<0.01). Incidence among young infants was 4.4 (95% CI 3.0–5.9) and similar among HIV-exposed and HIV-unexposed infants. Conclusion: Our findings suggest a substantial burden of influenza illnesses during pregnancy, with a higher burden among HIV-infected mothers. Kenyan authorities should consider the value of vaccinating pregnant women, especially if HIV-infected. Funding: This work was supported by funding [Grant number GH002133] from the U.S. CDC, through the Influenza Division. Keywords: Burden, influenza, pregnant women, infants

Background: We aimed to determine the relationship of ischemia-modified albumin (IMA) with diabetic foot ulcers and its predictive value in the Wagner classification. Methods: Our cross-sectional study was conducted in 120 diabetic foot patients and 60 healthy individuals with similar body mass index and age. Patients with a diabetic foot were classified according to the Wagner classification. Biochemical parameters, C-reactive protein (CRP) and IMA levels were measured in all patients and healthy volunteers. Screening performance characteristics of CRP and IMA were calculated according to Wagner classes and the presence of osteomyelitis. Results: CRP and IMA levels in the patient group were significantly higher than the control group. The highest IMA levels were detected in Wagner grade 5. CRP had higher sensitivity and specificity than IMA in the discrimination of other grades, except for grade 4-5 separation. For Wagner grade 4-5 distinction, IMA had 84.6% sensitivity and 94.7% specificity. Conclusion: IMA may play a role in the pathogenesis of diabetic foot ulcers and had a higher predictive value in discrimination of the Wagner grade 4 and 5. In the management of diabetic foot patients, it may be recommended that IMA is evaluated by clinicians.

Aims: The COVID-19 pandemic led to hospitals in the United Kingdom substituting face-to-face (FtF) clinics with virtual clinic (VC) appointments. We evaluated the impact of virtual two-week wait (2-ww) lower gastrointestinal (LGI) consultations on stakeholders at a district general hospital in England. Methods: Patients undergoing index outpatient 2-ww LGI clinic assessment between 01/06/2019-31/10/2019 (FtF group) and 01/06/2020-31/10/2020 (VC group) were identified. Relevant data were obtained using electronic patient records. Compliance with national cancer waiting time targets (WTT) was assessed. Environmental and financial impact analyses were performed. Results: In total, 1531 patients were analysed (median age=70, male=852, 55.6%). Of these, 757 (49.4%) were assessed virtually via telephone; the remainder were seen FtF (n=774, 50.6%). Ninety two (6%, VC=44, FtF=48) patients had malignant pathology and 64 (4.2%) had colorectal cancer (CRC); of these, 46 (71.9%, VC=26, FtF=20) underwent treatment with curative intent. The median waiting times to index appointment, investigation and diagnosis were significantly lower following VC assessment (p<0.001). The cancer detection rates (p=0.749), treatments received (p=0.785) and median time to index treatment for CRC patients (p=0.156) were similar. A significantly higher proportion of patients were seen within two weeks of referral in the VC group (p<0.001). VC appointments saved patients a total of 9288 miles, 0.7 metric tonnes of CO2 emissions and £7482.97. Taxpayers saved £80,242.00 from VCs. No adverse events or complaints were reported in the VC group. Conclusion: Virtual 2-ww LGI clinics were effective, safe and were associated with tangible environmental and financial benefits for stakeholders.

Objective: To evaluate the effect of age on the success and complications of percutaneous nephrolithotomy (PCNL) in staghorn renal stones. Materials and Methods: The files of 182 patients who underwent single-access PCNL for staghorn renal stones between 2012 and 2017 were retrospectively analyzed. The patients were divided into two groups according to their age: those aged<65 years were defined as Group-1 and those aged≥65 years as Group-2. The demographic characteristics and perioperative and postoperative results were compared between the two groups. Results: Of the patients with staghorn renal stones,139 were in Group-1 and 43 were in Group-2. The mean age of the patients was 43.9±10.6 years for Group-1 and 67.8±2.1 years for Group-2(p=0.001). The amount of hemoglobin drop was statistically significantly higher in Group-1 (p=0.001). However, blood transfusion rate was higher in Group-2 than in Group-1 (18.6% and 7.2%, respectively). The stone-free rate was 54.7% in Group-1 and 67.4% in Group-2(p=0.139). According to the evaluation of the overall complication rates,34.5% of the patients in Group-1 and 46.5% of those in Group-2 developed complications(p=0.206). According to the Clavien scoring system, the rate of minor complications was found to be 22.3% in Group-1 and 41.9% in Group-2,and the difference was statistically significant (p=0.012). The major complication rates were determined as 4.7% and 12.2% for Group-1 and Group-2, respectively (p=0.155). The number of patients with Clavien grade-2 complications was statistically higher in the elderly patient group (p=0.019). Conclusions: PCNL can be used as an effective and safe treatment method in the treatment of complex stones in elderly patients.

Introduction: Vancomycin is a glycopeptide antibiotic that is considered as the drug of choice against many Gram-positive bacterial infections, especially Methicillin-resistant Staphylococcus aureus (MRSA). Also, it is a hydrophilic drug with predominantly renal elimination. Given the vancomycin narrow therapeutic index, therapeutic drug monitoring (TDM) is essential to achieve an optimum clinical response and avoid vancomycin-induced adverse drug reactions including nephrotoxicity and ototoxicity. Although different studies are available on vancomycin pharmacokinetic assessment and vancomycin TDM, still there are controversies regarding the selection among different pharmacokinetic parameters including trough concentration (Cmin), the daily area under the curve to minimum inhibitory concentration (AUC24h/MIC) ratio, AUC of intervals (AUCτ), elimination constant (k), vancomycin clearance (ClV) and methods of their calculations for TDM purposes. Methods: In this review, different pharmacokinetic parameters for vancomycin TDM have been discussed in detail along with corresponding advantages and disadvantages, based on the literature review. Determination of vancomycin concentration at steady state (Css) during 24h continuous injection are mentioned. Also, vancomycin pharmacokinetic assessments are discussed in detail in patients with altered pharmacokinetic parameters including those with renal and/or hepatic failure, critically ill patients, patients with burn injuries, intravenous (IV) drug users, obese and morbidly obese patients, those with cancer, patients undergoing organ transplantation, and vancomycin administration during pregnancy and lactation. Results and Discussion: An individualized dosing regimen is required to guarantee the optimum therapeutic results and minimize severe adverse reactions such as acute kidney injury (AKI) in these special groups of patients with altered pharmacokinetic parameters. Also, according to the pharmacoeconomic data on vancomycin TDM, pharmacokinetic assessments would be cost-effective in the mentioned groups of patients with altered pharmacokinetics and associated with shorter hospitalization period, faster clinical stability status, and shorter courses of inpatient vancomycin administration.

Primary cardiac tumors are extremely rare.Most primary tumors are benign,and malignant tumors comprise about 15%1.Angiosarcoma is the most common type of primary cardiac malignant tumors.Compared with the left atrium or ventricle,the tumor prefer to occur in the right atrium or ventricle,especially the right atrium.In this case report,we present the case of a 32-year-old female with cardiac angiosarcoma primary to the right atrial appendage(RAA).

Keywords: Pediatric, Renovascular, Hypertension, Evolution, MedicineAbbreviations: renal artery stenosis (RAS), fibromuscular dysplasia (FMD), Takayasu arteritis (TA), ACE insertion/deletion (ACE I/D), renovascular hypertension (RVH), angiotensin I (ang I), angiotensin II (ang II), angiotensin converting enzyme (ACE), midaortic syndrome (MAS), angiotensinogen (AGT)Correspondence: 1130 14th Street, Huntington, WV, 25701, Apartment 133Email: chhabra@marshall.edu 

Background: Individuals with cystic fibrosis (CF) and fungal airway infection may present with fungal bronchitis, allergic bronchopulmonary aspergillosis (ABPA) or may appear unaffected despite fungal detection. We sought to characterize people with CF with frequent detection of fungi from airway samples and determine clinical outcomes. Methods: This retrospective study included individuals with CF with ≥ 4 lower airway cultures over a 2-year baseline period and ≥ 2 years of follow-up. We defined two groups: ≤ 1 positive fungus culture (rare) or ≥ 2 positive cultures during baseline (frequent). Clinical characteristics and outcomes were determined. Results: Between 2004-2016, 294 individuals met inclusion with 62% classified as rare and 38% as frequent fungi during baseline. Median follow-up was 6 years (range 2-9 years). Aspergillus fumigatus was the most common fungal species detected. Individuals with frequent fungi were older (13.7 vs. 11.7 yrs, p = 0.02) and more likely to have Stenotrophomonas maltophilia (35% vs 17%, p < 0.001) at baseline, but did not differ in lung function or ABPA diagnosis. During follow-up, those with frequent fungi were more likely to have chronic P. aeruginosa and S. maltophilia. Individuals with ABPA and frequent fungi had the highest rates of co-infection and co-morbidities, and a trend towards more rapid lung function decline. Discussion: Fungal infection in CF was associated with frequent P. aeruginosa and S. maltophilia co-infection even in those without ABPA. Individuals with frequent fungi and ABPA had worse outcomes, highlighting the potential contribution of fungi to CF pulmonary disease.

Introduction Cystic fibrosis (CF) related liver disease (CFLD) manifests as a wide spectrum of hepatobiliary disease and can progress to need liver transplantation. Elexacaftor/tezacaftor/ivacaftor (elx/tez/iva) is a cystic fibrosis transmembrane conductance regulator (CFTR) modulator which has superior efficacy compared to previously approved modulators. Use of elx/tez/iva, should be approached with caution in individuals with CFLD or following liver transplantation due to possible increases in LFTs and drug-drug interactions with several immunosuppressant medications. Objective The purpose of this case series was to explore if the use of elx/tez/iva is safe and tolerable in patients with CF post-liver transplantation. Methods A retrospective case series including patients prescribed elx/tez/iva following liver transplantation and an immunosuppressive regimen consisting of drug therapy metabolized by P-glycoprotein was completed. Results Ten patients at six CF centers with a median age of 22.1 years (range 14-43.4 years) and median time from transplant of 6.9 years (range 0.6-22 years) were included. Most patients (8, 80%) received a reduced or full dose of elx/tez/iva for a mean duration of 10.4 months (range 7-12 months). Fluctuations in LFTs occurred in all patients (10, 100%) and led to therapy discontinuation in two patients (20%). Elx/tez/iva initiation resulted in elevations in tacrolimus trough concentration in 7 patients (70%). Most patients who tolerated elx/tez/iva had symptomatic and quality of life improvement, increased body-mass-index, and maintained or improved lung function. Conclusion Initiation of elx/tez/iva in patients with CF who received a liver transplantation may be safe with clinical benefits.

Castleman disease is a rare, heterogeneous disorder that driven by proinflammatory responses. Human herpes virus-8 has a major role in pathogenesis of multicentric Castleman disease. There is also a subgroup of cases, human herpes virus-8 negative, idiopathic multicentric Castleman disease. The role of primary immunodeficiencies in idiopathic Castleman disease are poorly described. DOCK8 deficiency is a combined primary immunodeficiency. It has a broad clinic spectrum including atopy, autoimmunity and cancer. We present a 10-year-old, DOCK8 deficient patient. He had giant lobular capillary hemangiomas on his neck, iliac and gluteal regions and multiple lymphadenopathies. Abdominal lymph node pathology revealed hyaline vascular type Castleman disease and human herpes virus-8 staining was negative. His lesions were shown to be infected with orf virus. Our case is the first case to relate idiopathic multicentric Castleman disease and DOCK8 deficiency; also, very unusual presentation of orf virus infection in humans.

Needle-free Epicutaneous For t 2 DNA Vaccine is Effective for Preventing and Treating Biting Midge (Forcipomyia taiwana) allergy in a murine modelTo the Editor,Allergen-specific immunotherapy (ASIT) remains the only treatment capable of inducing immune tolerance to the corresponding allergen and potentially treating the root cause of the allergic disease.1 As the treatment course of protein-based vaccines for ASIT is time-consuming, an easily administered epicutaneous anti-allergic DNA-based vaccine is an attractive method, especially in light of the COVID-19 pandemic.2 We established a mouse model of biting midge allergy to test the concept of the epicutaneous DNA vaccine.The biting midge, Forcipomyia taiwana , is the most prevalent cause of biting insect allergy in Taiwan. It is a tiny hematophagous midge that attacks en masse. As many as 60% of exposed individuals develop allergic reactions to the bites.3 The midge is widely distributed throughout Taiwan and southern China. Among the identified allergens, For t 2 is the most predominant, with 75% of midge-allergic patients showing specific IgE to For t 2.4E.coli -expressed For t 2 recombinant protein (rFor t 2) was used as an allergen to sensitize and challenge the mice.5For t 2-encoding fragment (GenBank accession EU678971) was amplified by PCR. The PCR products were subcloned into pVAX1 (Life Technologies, Carlsbad, CA) . The experiments were designed using two approaches: therapeutic and prophylactic (Fig 1). Twenty-five μg For t 2 DNA was determined as the optimal dose after several dose-finding experiments (Fig S1, data not shown). For each treatment, the hair of the abdominal area of the mice was removed using a depilatory, tape-stripped, then patched with 25 μg For t 2 DNA vaccine for one hour and removed. A total of three treatments were given spaced one week apart (Fig 1 and Fig S2). For t 2 proteins were detected in the patched skin and the immune organ spleen at 24 hours and had significantly increased at 48 hours (Fig S3). Scratch bouts after rFor t 2 challenge were used as a clinical surrogate of itch. We measured total IgE and For t 2-specific IgG2a in the sera as well as mRNA and proteins of IL-13, interferon-gamma, IL-10, and FOXP3 in the culture supernatants of splenocytes after stimulation with various doses of rFor t 2 at 37℃ for 3-5 days by ELISA and real-time quantitative PCR. Histopathology of the challenged skins was examined.We found that after epicutaneous DNA vaccination, the allergen-induced itch of the mice significantly improved, and For t 2-specific IgG2a increased (Fig 2). Both mRNA and protein of IL-13, and eosinophils infiltration in the targeted skin, significantly decreased. Expression of FOXP3 mRNA increased (Fig S4-S6).This is the first study to demonstrate an epicutaneous anti-allergic DNA vaccine that is effective at both treating an established allergic condition and preventing the development of an allergic disease using biting midge allergy as a model. After epicutaneous DNA vaccination, in addition to the significant improvement in allergen-induced itch, the changes of biomarkers for allergic inflammation, including IgE, allergen-specific IgG2a, allergen-challenge-induced eosinophil infiltration in the skin, Th2 cytokines from the splenocytes, and regulatory T cell-related transcription factors, suggest that immune tolerance was induced after three patches of the epicutaneous DNA vaccine.Our data show that though the molecular weight of the For t 2 DNA vaccine is as high as 4000 base pairs, it is able to penetrate the dermal barrier and translates the corresponding protein in the targeted skin as well as the spleen of the vaccinated mice. It is possible that the DNA vaccine passes the epidermis via the hair follicles as the skin is tape-stripped before epicutaneous vaccination.6The mode of this anti-allergic epicutaneous DNA vaccine may have potential for use in other specific immunotherapies for other allergens.Mey Fann Lee1Chi Sheng Wu2 Shyh Jye Lin3Yi Hsing Chen2,4*1Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan2Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan3School of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung, Taiwan4School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan

Bone tumors are a group of histologically diverse diseases which occur across all ages. Two of the commonest, osteosarcoma (OS) and Ewing sarcoma (ES), are regarded as characteristic AYA cancers with an incidence peak in AYAs. They are curable for some but associated with unacceptably high rates of treatment failure and morbidity. The introduction of effective new therapeutics for bone sarcomas is slow, and to date, complex biology has been insufficiently characterized to allow more rapid therapeutic exploitation. This review focuses on current standards of care, recent advances that have or may soon change that standard of care and challenges to the expert clinical research community that we suggest must be met.

Microbial volatiles are important factors in symbiotic interactions with plants. Mortierella hyalina is a beneficial root-colonizing fungus with a garlic-like smell, and promotes growth of Arabidopsis seedlings. GC-MS analysis of the M. hyalina headspace and NMR analysis of the extracted essential oil identified the sulfur-containing volatile tris(methylthio)methane (TMTM) as the major compound. Its incorporation in seedlings was shown by 34S labeling experiment. Under sulfur deficiency, TMTM downregulated sulfur deficiency-responsive genes, prevented glucosinolate (GSL) and glutathione (GSH) diminishment, and sustained plant growth. However, excess TMTM led to accumulation of GSH and GSL and reduced plant growth. Since TMTM is not directly incorporated into cysteine, we propose that the volatile from M. hyalina influences the plant sulfur metabolism by interfering with the GSH metabolism, and alleviates sulfur imbalances under sulfur stress.

Objectives The aim of our study was to identify, in mechanically ventilated neonates <30 weeks GA with clinical evidence of bronchopulmonary dysplasia (BPD), factors likely to be predictive of a first course of systemic dexamethasone leading to extubation within 14 days and remaining extubated for at least 7 days. Methods We studied a retrospective cohort of neonates (23+0-29+6 weeks GA), with evidence of BPD, prescribed their first course of systemic dexamethasone to aid in extubation from mechanical ventilation. The data collected only pertained to the first course of dexamethasone for any given neonate, with the primary outcome of interest of successful extubation within 14 days (i.e., extubated within 14 days of starting dexamethasone and remaining extubated for at least seven days). Binary logistic regression was employed. Results A total of 287 neonates were included. Each additional week of GA at birth led to a 1.53 increase in the odds of successful extubation (95% CI 1.122-2.096, p<0.01). Higher average fraction of inspired oxygen (FiO2) requirements in the preceding 24 hours resulted in a 0.94 decrease in the odds of successful extubation (p<0.05) and higher mean airway pressure (MAP) resulted in 0.76 decrease in odds of successful extubation (p<0.01). Conclusions Mechanically ventilated neonates born at <30 week GA, with evidence of BPD requiring dexamethasone to facilitate extubation, had a lower likelihood of successful extubation by day 14 if at the time of commencing steroids they were less mature at birth, had higher MAPs and higher oxygen requirements.

Aim: To determine the safety of Coenzyme Q10 (CoQ10) in breast cancer patients receiving doxorubicin treatment. Methods: Phase I randomized, placebo-controlled, cross-over, dose-finding pharmacokinetic study among women with stage I-III breast cancer receiving 4 cycles of doxorubicin plus cyclophosphamide. The study was designed to test the maximum tolerated dose of CoQ10 using up to 1200 mg/day. Eligible patients were randomized to Arm A (CoQ10 after Cycle 3, followed by placebo after Cycle 4) or Arm B (placebo after cycle 3, followed by CoQ10 after cycle 4). CoQ10 concentrations and total antioxidant capacity (TAC) were measured before and after chemotherapy cycles. Non-compartmental pharmacokinetic parameters of doxorubicin and its active metabolites were measured with and without CoQ10. Paired t-tests assessed intra-patient differences in pharmacokinetic parameters, serum CoQ10 concentrations, TAC and adverse events. Results: Six patients received 300 mg/day of CoQ10 [Arm A (n=3), Arm B (n=3)]. One patient received 600 mg/day of CoQ10 but was discontinued due to non-adherence. Serum CoQ10 concentrations were increased in patients receiving 300 mg/day (mean±SD change: CoQ10, 1.6±0.9 ug/mL; placebo, -0.01±0.3 ug/mL; P=0.01). There were no clinically significant pharmacokinetic interactions between 300 mg/day CoQ10 and doxorubicin and no differences in TAC or adverse events during treatment and nontreatment periods. The trial was closed early due to slow accrual. Conclusions: 300 mg/day of CoQ10 with doxorubicin did not change doxorubicin pharmacokinetics and was not associated with treatment-related adverse events. Future studies should evaluate the long-term effects of CoQ10 at 300 mg/day and safety studies should examine higher doses.

Quantifying and understanding catchment sediment yields is crucial both from a scientific and environmental management perspective. To deepen the understanding of land use impacts and climate change on sediment load, we explore mechanisms of the suspended sediment yield formation in the Northern Caucasus during the Anthropocene. We examine how sediment flux of various river basins with different land-use/landcover and glacier cover changes during the 1925-2018 period. Our analysis is based on observed mean annual suspended sediment discharges (SSD, kg·s−1) and annual fluxes (SSL, t·yr−1) from 33 Roshydromet gauging stations (Russia). SSL series have been analyzed to detect statistically significant changes during the 1925-2018 period. The occurrence of abrupt change points in SSD was investigated using cumulative sum (CUSUM) charts. We found that SSL has decreased by −1.81% per year on average at most gauges. However, the decline was not linear. Several transition years are expected in the region: increasing trends from the 1950s and decreasing trends from 1988-1994. Correlation analyses showed that variation in SSL trend values is mainly explained by gauging station altitude, differences in land use (i.e., the fraction of cropland), and catchment area. Nonetheless, more accurate quantifications of SSL trend values and more refined characterizations of the catchments regarding (historical) land use, soil types/lithology, weather conditions, and topography may reveal other tendencies.

Gertjan Geerling1,3, Ellis Penning1, Christine Rogers1, Cindy van de Vries - Safavi Nic1, Valesca Harezlak1, Stanford Wilson2, Gennadii Donchyts11Deltares, Delft, The Netherlands2Rijkswaterstaat-WVL, Lelystad, the Netherlands3Deptartment of Environmental Science, Radboud University, Nijmegen, the NetherlandsCorresponding author: Gertjan Geerling email: gertjan.geerling@deltares.nlAcknowledgementsThis research was funded by the research programme of the Dutch National Water Authority (KPP-Corporate Innovation Programme and the KPP- Innovative Monitoring). We thank the valuable discussions with the Floodplain Management Team of the National Water Authority (RWS-ON) and all other contributing stakeholders.AbstractIn deltas, rivers are often embanked and have a limited discharge capacity. In case these rivers also have a fixed riverbed for navigation, vegetation succession in the floodplains will reach climax stages. This leads to increasing hydraulic roughness that lowers the discharge capacity and prompts the river manager to intervene in the floodplain vegetation. The Dutch river manager depended on a 6-year map cycle of manually digitized aerial photographs for assessment of the state of hydraulic resistance. As the amount of agriculture in floodplains is receding in favor of nature rehabilitation projects, the vegetation dynamics increase. At the same time, the bigger floods were anticipated in the future. Therefore, more up-to-date floodplain vegetation maps with a short processing time were needed for about 500 kms of river in the Netherlands. We present an operational web-based monitoring tool that analyses sentinel-2 data on the fly though Google Earth Engine to provide an overview of the current state of the vegetation in the entire floodplain area of the Dutch river systems Rhine and Meuse. It is the first satellite-based application in an operational setting for the Dutch National River Manager (Rijkswaterstaat). The tool compares a map of allowable vegetation with the remotely sensed current situation for a quick scan of hotspots and can create reports on the cadastral (landowner) level. We describe the results of the image classifications and the role of this tool in the full process of the Dutch flood risk management process.Keywords: river management, vegetation, vegetation succession, remote sensing, open data, google earth engine

Microbially influenced corrosion (MIC) may contribute significantly to overall corrosion risks, especially in the gas and petroleum industries. In this study, we isolated four Prolixibacter strains, which belong to the phylum Bacteroidetes, and examined their nitrate-respiration- and Fe0-corroding activities, together with two previously isolated Prolixibacter strains. Four of the six Prolixibacter strains reduced nitrate under anaerobic conditions, while the other two strains did not. The anaerobic growth of the four nitrate-reducing strains was enhanced by nitrate, which was not observed in the two nitrate-non-reducing strains. When the nitrate-reducing strains were grown anaerobically in the presence of Fe0 or carbon steel, the corrosion of the materials was enhanced by more than 20-fold compared to that in aseptic controls. This enhancement was not observed in cultures of the nitrate-non-reducing strains. The oxidation of Fe0 in the anaerobic cultures of nitrate-reducing strains occurred concomitantly with the reduction of nitrite. Since nitrite chemically oxidized Fe0 under anaerobic and aseptic conditions, the corrosion of Fe0- and carbon-steel by the nitrate-reducing Prolixibacter strains was deduced to be mainly enhanced via the biological reduction of nitrate to nitrite, followed by the chemical oxidation of Fe0 to Fe2+ and Fe3+ coupled to the reduction of nitrite.

Objective To describe the characteristics and outcomes of women with inherited bleeding disorder during pregnancy and birth. Design Retrospective cohort study. Setting Tertiary care hospitals, NSW and Victoria Australia. Population 100 women with inherited bleeding disorders, who birthed 134 live infants from 132 pregnancies. Methods Data was retrospectively obtained from the patient and neonatal medical records. Descriptive analysis was used to report maternal and pregnancy characteristics, birth and neonatal outcomes. Main outcome measures Factor replacement, neuraxial analgesia use and complications, post-partum haemorrhage and neonatal complications. Results PPH occurred in 22% of deliveries with primary PPH occurring in 20% and secondary PPH in 4% of births. 48% of PPHs were classified as major. PPHs occurred across the spectrum of IBD and was evenly distributed between women who had “normalised” their factor levels in pregnancy compared to those requiring factor at the time of birth. An obstetric cause was identified in more than half of PPHs. Conclusions Women with inherited bleeding disorders can deliver safely and receive neuraxial analgesia without complication when best practices are adhered to. PPH appears to occur at higher rates than the general population despite adequate factor levels or planned replacement. Whilst an obstetric cause was demonstrable in the many cases, these findings raise concern over the current definition of “adequate” factor levels at the time of birth.

Objective Determine the association of Non-alcoholic fatty liver disease(NAFLD) to the occurrence of GDM and miscarriages. Design Population-based prospective cohort study. Setting Anuradhapura district-Sri Lanka. Sample All pregnant women(gestational age<12 weeks) registered in the national pregnancy care programme(>98%coverage) during July to September-2019, recruited in the Rajarata Pregnancy Cohort(RaPCo)(included 80% of registered mothers). Method Clinical, biochemical parameters and ultrasound scan(USS) of liver were performed at the baseline to assess NAFLD. Excluding pregnant women who reported any type of hyperglycemia at the baseline, the cohort was followed up to assess the occurrence of GDM (using latest WHO criteria) during 24-28 weeks of gestation. Miscarriages were documented. Main outcome measures GDM and miscarriages. Results The prevalence of Fatty liver grade(FLG)-II and I was 14.2%(n=90), 37%(n=234), respectively. The incidence of GDM among the normoglycemic pregnant women with FLG-II, I, and 0 were 162.2, 43.9, 11 per 1000, respectively. After adjusting for age, BMI, and other known risk factors, women with FLG-II had a relative risk(RR) of 12.5(95%CI 2.2-66.4) for developing GDM compared to those with FLG-0. Pregnant women with FLG-I-(RR= 5.1,95%CI-1.7-15.1) and II-(RR=8.4,95%CI-2.6-27.1) had a very high risk of early pregnancy miscarriage compared to FLG-0. Conclusion FLG-2 is a significant risk factor for GDM and miscarriages. Incorporating pre-conceptional or early pregnancy identification of NAFLD using simple USS into routine care provision will enable early risk identification and appropriate action. Funding Accelerating Higher Education Expansion and Development(AHEAD) grant(World Bank-funded project through University grant commission-Sri Lanka) funded this study. Keywords–NAFLD, GDM, Pregnancy, Ultrasound-scan, Miscarriages

1. We focused on 175 patients operated on for otosclerosis. There were 89 in group 1 (preoperative 4000 Hz BC threshold better than 2000 Hz) and 86 in group 2 (preoperative 2000 Hz BC threshold better than 4000 Hz). 2. Preoperatively, there was no significant difference in terms of average bone conduction (BC) thresholds, average air conduction (AC) thresholds and air-bone gap (ABG) between the two groups. 3. Three months and 1 year after surgery, group 1 had better audiometric outcomes than group 2 in terms of average AC and BC thresholds and ABG. 4. Postoperative BC gain was better in group 1 than group 2, particularly at 500 Hz, 1000 Hz and 2000 Hz. 5. When the 4000 Hz BC threshold was preoperatively impaired (group 2), it was not worsened after stapes surgery. This was not the case in group 1.

Purpose: An Expert Panel on Breast Cancer and COVID-19 was convened to address the impact of the COVID-19 pandemic for early breast cancer management. Methods: In order to ensure the most clinically relevant information was addressed, essential information was drawn from several of the latest national and international guidelines and another technical document. The Expert Panel met in five virtual closed sessions from November 2020 to May 2021 to consult on the relevant data from evidence-based results. The data gathered were discussed on an online platform (Within3 ®). Results: This paper reports the Expert Panel's highlights of these meetings' discussions. In addition, it provides practical recommendations covering topics regarding diagnosis, treatment, and management of breast cancer patients in clinical settings routinely encountered by HCPs amid the COVID-19 pandemic. Conclusions: It was provided guidance on several topics regarding eBC management amid the COVID-19 pandemics to inform safer care practices.

Introduction: Although decompensated heart failure (DHF) can complicate catheter ablation of atrial fibrillation (AF), its incidence and risk factors have not been defined. We sought to investigate the incidence and risk factors for DHF in these patients. Methods: In total, 1004 consecutive patients who underwent initial ablation for AF (age, 68 ± 10 years old; females, 346 [34%]; and persistent AF, 513 [51%]) were enrolled. Δheart rate, which was defined as heart rate after ablation minus heart rate before ablation, were calculated. DHF was defined as heart failure requiring medical therapy during post-procedure hospitalization, or re-hospitalization due to heart failure < 90 days after the procedure. DHF was classified into early peri-procedual DHF, which occurring within 2 days after the procedure, and late peri-procedual DHF, which occurring ≥ 3 days after the procedure. Results: The incidence of DHF was 32/1004 (3%) patients. Patients with DHF had a higher prevalence of a past history of symptomatic heart failure (17/32 [53%] versus 154/972 [16%], P < 0.01) and lower Δheart rate after the procedure than those without (−16 ± 28 versus 2 ± 21 beats/min, P < 0.01). On multivariate analysis, lower Δheart rate was a significant independent predictor of early peri-procedual DHF, while early recurrence of AF was a significant independent predictor of late peri-procedual DHF. Conclusion: In patients with AF, lower Δheart rate was an independent predictor of early peri-procedual DHF, and early recurrence of AF was an independent predictor of late peri-procedual DHF.