Background: As an emerging non-pharmacological method of analgesia, there are no uniform conclusions on the effect of virtual reality (VR) technology in labor. Objective: Exploring the effectiveness of VR technology in maternal delivery. Search strategy: We searched Pubmed, Embase, Web of Science, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, Wan-Fang database from building to November 17, 2021. Selection Criteria: Randomized controlled trials (RCTs) that intervened the pregnant women aged 18-35 years with gestational age>34 weeks and without complications with VR technology were contained within this review. Data Collection and Analysis: Two researchers completed the study selection, data extraction, and assessment of study quality. MD or SMD used for quantitative data, and RR (risk ratio) for qualitative data. Random-effects model and 95% confidence interval (95% CI) were used. Main Results: 12 studies were included. Using VR could relieve pain during labor (MD=-1.81, 95% CI (-2.04, -1.57), P< 0.00001) and active period (SMD=-0.41, 95% CI (-0.68, -0.14), P= 0.003), reduce anxiety (SMD=-1.39, 95% CI (-1.99, -0.78), P< 0.00001) and improve satisfaction with delivery (RR = 1.32; 95% CI (1.10, 1.59); P = 0.003), but the effect on the duration of first (SMD=-1.12, 95% CI (-2.38, 0.13), P=0.08) and second (SMD=-0.22, 95% CI (-0.67, 0.24), P=0.35) stage of labor was not statistically significant. Conclusions: Compared with conventional care, VR technology can relieve labor pain and anxiety and improve satisfaction. However, extensive experimental validation is still needed. Funding: None. Keywords: Virtual reality technology, delivery, labor pain, anxiety, meta-analysis, systematic review

Objective Radiofrequency catheter ablation (RFCA) is a standard treatment for idiopathic premature ventricular complexes (PVCs). This study was aimed to determine autonomic nervous system (ANS) activity in patients with low, medium and high PVC burdens pre- and pro-RFCA. Methods We retrospectively analyzed a total of 200 patients underwent radiofrequency ablation surgery for idiopathic PVCS from June 2017 to March 2021. The procedural ablation success was achieved in 179 of the 200 (89.5%). Patients had success ablation was classified into low burden PVC group (PVCs/min ≤15%), medium burden PVC group (15%> PVCs/min <25%) and high burden PVC group (PVCs/min ≥25%). We assessed the clinical data, time and frequency-domain variables, heart rate turbulence(HRV) and deceleration capacity of rate of patients with different PVC burdens and various ablation site. Spearman correlation analysis was performed. Results High burden PVCs had higher mean HR, SDANN, SDNN index, standard deviation of normal to normal intervals (SDNN), root-mean square successive differences (rMSSD), pNN50 and lower ratio of low-frequency (LF)/ high-frequency (HF), compared to low burden PVCs. After ablation, SDNN, SDNN index, SDANN, rMSSD, pNN50, TS (turbulence slope) and DC (deceleration capacity) were significantly decreased (P<0.01), while LF/HF and TO was significantly increased (P<0.01). The burden of preoperative PVCs was positively correlated with LVD, mean HR, SDNN index, SDANN, rMSSD and pNN50, but negatively correlated with TC, LDL-C, LVEF and LF/HF. Regression analysis showed that the burden of PVCs was positively correlated with mean HR ( P=0.000), SDANN ( P=0.000) and rMSSD ( P=0.000). Conclusion With the increase of PVCS burden, both sympathetic and vagus nerve activities are enhanced. The numbers of PVCS may be related to impaired autonomic nerve balance regulation. RFCA reduced parasympathetic activity and sympathetic activity after eradication of PVCS.

The U.S. is the world’s second largest contributor to carbon emissions, with its road transport sector being one of the most significant emission sources. However, few studies have been conducted on factors influencing the emissions changes for the U.S. from the perspective of passenger and freight transport. This study aims to evaluate the carbon emissions from the U.S. road passenger and freight transport sectors, using a Logarithmic Mean Divisia Index approach. Emissions from 2008 to 2017 in the U.S. road transport sector are analysed and key findings include: 1) passenger transport contributes over 70% to total transport carbon emissions, with cars and light trucks contributing the highest share; 2) energy intensity and passenger transport intensity are critical for reducing emissions from road passenger transport, and transport structure change is causing shift of emissions between different passenger transport modes; and 3) the most effective strategies to reduce carbon emissions in the road freight transport sector are to improve energy intensity and reduce freight transport intensity. Several policy recommendations regarding reducing energy and transport intensity are proposed. The results and policy recommendations are expected to provide useful references for policy makers to form carbon emissions reduction strategies for the road transport sector.

Rationale: To explore perception of health trainees in Saudi Arabia towards international voluntary medical missions emphasizing on feasibility, expectations, and barriers. Methods: The study was a cross sectional survey of health trainees across medical, surgical, and allied health field allover Saudi Arabia from March 2017 until February 2018, using a validated standardized questionnaire that was adapted to assess interests, attitude, and perception towards voluntary medical missions. We have also assessed the awareness of available opportunities and the effect of mentorship in improving this interest. Results: A total of 589 responded to the questionnaire with response rate of 83.7%. Most were under 35 years with equal gender distribution. Majority were from medical and surgical specialties and were graduated from the western region of Saudi Arabia. Health Trainees considered volunteering as residents but did not have a previous experience in missions acknowledged that a presence of a staff member with regular participation in missions in their training environment had positive effect on their interest in international health (p= 0.038). Commonest reasons of interest to volunteer were enhancing technical and clinical skills and helping others in need. Moreover, having interest in tourism and learning about new cultures. Only 7 of 589 participants had an actual experience. We expressed the actual barriers they faced during volunteering trips. Interestingly, their colleagues with no similar experience have almost matching perceived barriers. The major barrier faced by those with a previous experience is “Lack of elective time” compared to “Lack of available organized opportunities” in the counterpart group. Conclusion: Exploring challenges and barriers from the Saudi health trainee’s perspectives on medical missions will inform organization for future opportunities. Coordinating medical and surgical missions through a unified authoritative body would allow better opportunity to override challenges and to improve the health trainee’s perception and participation in medical missions.

Primary cardiac lymphoma (PCL) is a very rare neoplasm, which involves only the heart and pericardium without evidence of extracardiac involvement. We herein report a unique case of a 64-year-old man presenting with increasing exertional dyspnea, worsening orthopnea, oxygen desaturation and upper body swelling. Subsequent investigations revealed a large obstructive right atrial (RA) tumor. Due to the patient’s deteriorating clinical condition, urgent surgical removal of the tumor was planned and successfully performed. Histopathological findings were consistent with the diagnosis of primary cardiac lymphoma. The patient subsequently completed his chemotherapy cycles and is currently in remission.

Abstract: Dryland regions cover 41% of the Earth’s land surface and support the livelihood of half of the world’s population. Soil microbes play an important role in carbon (C) and nitrogen (N) cycling, therefore affecting soil health. Soil microbial biomass C (SMBC) and N (SMBN) are indicators of soil microbial activities. A better understanding of patterns and drivers of SMBC and SMBN in global dryland regions can provide important insights to enhance ecosystem functioning services. Here, we compiled 109 observations of SMBC (0-30 cm) and 79 observations of SMBN (0-30 cm) from 100 sites across global dryland regions with aridity index less than 0.65. The results showed that the average amount of SMBC and SMBN in dryland regions were 358.47 ± 25.45 mg kg-1 and 51.86 ± 4.59 mg kg-1. The amount of SMBC and SMBN did significantly vary among different dryland types and ecosystem types. Meanwhile, the ratio of SMBC to SMBN in global dryland regions was 8.73. Soil sand fraction and pH had significant negative effect on the ratio of SMBC to SMBN. Our research has initially explored the pattern and control factors of soil microbial biomass in dryland, and provided basic research data for dryland management in the future.

Aims: In a previous study, Singaporean Asians were found to have lower rivaroxaban plasma concentrations than Caucasians. This study attempts to identify predictors that may be associated with bleeding and stroke and systemic embolism (SSE) in Singaporean Asians taking rivaroxaban and apixaban. Methods: A total of 134 Singaporean patients on either rivaroxaban or apixaban for non-valvular atrial fibrillation were included for this study. Baseline characteristics were recorded at recruitment while bleeding and SSE events were recorded during a 1-year follow-up. Characteristics of patients with or without bleeds were compared using relevant statistical tests. Multivariable regression that included covariates with p < 0.1 from an initial univariable regression was performed to analyze predictors that resulted in higher risk of bleeding in patients. Results: Median creatinine clearance (CrCl) was significantly lower in patients on rivaroxaban who experienced bleeds as compared to patients who did not experience bleeds (61.5 vs 70.8 mL/min, p = 0.047), while concomitant simvastatin use was found to be independently associated with a six-fold increased risk of bleeding [Adjusted OR = 6.14 (95% CI: 1.18 – 31.97), p = 0.031] for rivaroxaban after controlling for body mass index, CrCl and having experienced a previous SSE. Conclusion: Our findings suggest that concomitant use of simvastatin with rivaroxaban may be associated with bleeding events in an Asian cohort. Further studies using physiologically-based pharmacokinetic modeling are required to investigate the drug-drug interactions between these drugs. Keywords: Atrial Fibrillation, Bleeding, Rivaroxaban, Simvastatin

Transient abnormal myelopoiesis (TAM) is a pre-leukaemic syndrome associated with Trisomy 21 (Down syndrome). TAM typically regresses without treatment, but if needed TAM cells are exquisitely sensitive to a short course of low-dose cytarabine (LDAC). A significant minority of TAM patients progress to myeloid leukaemia of Down Syndrome (MLDS) requiring intensive chemotherapy. We describe a neonate with unusually recalcitrant TAM who required four 7-day courses of LDAC. Neonates with Down syndrome are at significant risk of severe toxicity from chemotherapy but this was mitigated by the use of repeated courses of LDAC, without the need for more intensive MLDS treatment.

Ecosystems can exhibit rich equilibrium behaviors, including alternative stable states (ASS), for which ecosystems dramatically differ in structure and functions. Therefore, it is critical to understand system equilibrium behavior. Positive feedback has been recognized as a critical process to induce ASS. However, it is largely unclear whether and to which extent increasing number of positive feedbacks will be easier to produce ASS. Using a generalized Lotka-Volterra model and two functional forms of positive feedback, this study found that positive feedback was largely necessary to produce ASS, and more positive feedbacks generally more likely produced ASS. However, above results depended on the functional form of positive feedback and interaction types. This work can help predict ecosystem dynamics under global change and intensified anthropogenic activities, both which may activate previously “dormant” positive feedbacks and make this issue more visible and important.

A non-responder heart failure patient to conventional cardiac resynchronization therapy (CRT) received novel mid-septal pacing (MSP) optimized CRT (MOT-CRT) by pacing at middle part of septum which captured both right and left ventricular septum in combination with coronary venous pacing (CVP). The QRS duration was shortened from 142 ms of the conventional CRT to 110 ms with improved cardiac function. MSP bypassed slow transseptal conduction and reduced 31 ms of left ventricular activation delay compared with right ventricular septal pacing. This case demonstrates for the first time that the MOT-CRT might serve as a valuable alternative to CRT.

Objective: The traditional outcomes of the Fontan Operation (FO) in Endocardial Cushion Defect (ECD) patients have been suboptimal. Previous studies have been limited by the smaller number of ECD patients, longer study period with an era effect and do not directly compare short-term outcomes of FO in ECD patients with non-ECD patients. Our study aims to address these shortcomings. Methods: A retrospective analysis of the Kids Inpatient Database (2009, 2012, and 2016) for the FO was done. The groups were divided into those who underwent FO with ECD as compared to non-ECD diagnosis. The data was abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used. Results: 3380 patients underwent the FO of which 360 patients (11%) were FO-ECD. ECD patients were more likely to have Down syndrome, Heterotaxy syndrome, transposition/DORV, and TAPVR as compared to non-ECD patients. FO-ECD had a higher discharge-mortality (2.84% vs. 0.45%, p=0.04). The length of stay (16 vs. 13 days, p=0.05) and total charges incurred ($ 283, 280 vs. 234, 106, p=0.03) for the admission were higher in the FO-ECD as compared to non-ECD patients. In multivariable analysis: ECD diagnosis, cardiac arrest, acute kidney injury, and post-operative hemorrhage were predictors of mortality. Conclusion: Contemporary outcomes for FO are excellent with very low overall operative mortality. However, the outcomes in ECD patients are inferior with higher operative mortality than non-ECD patients. Occurrence of post-operation complications, associated TAPVR and a diagnosis of ECD were predictive of a negative outcome.

Objectives: This study investigated the effects of socioeconomic changes and health system improvements in the past two decades on the epidemiology of community-acquired pneumonia (CAP) in Turkey. Methods: In total, 1488 children treated with a diagnosis of pneumonia in XXXX Training and Research Hospital Pediatrics Department between 2016 to 2021 were included in the present study. The patients’ demographic data, personal and family histories, and socioeconomic status were recorded. Results: Of the 1488 pediatric patients (46.8% girls; mean age:43.20 ± 41.04 months), 108 were aged 0–6 months (7.3%), 672 were aged 6–24 months (45.2%), 444 were aged 24–60 months (29.8%), and 264 were aged ≥ 60 months (17.7%). In total, 98% of patients underwent routine vaccination and the rate of seasonal influenza vaccination was 5.6%. Additionally, 444 patients (29.8%) had chronic disease and 276 of these had asthma. Furthermore, asthma and cerebral palsy were the most common chronic diseases. A family history of asthma in first-degree relatives was present in 396 patients (26.6%). Conclusion: In the past two decades, there have been substantial changes in the epidemiology of CAP in Turkey, due to socioeconomic changes, increasing urbanization, and health system improvements.

Introduction Breathing mechanic is determined by tonus and flexibility, correct contraction amplitude of the thoracic diaphragm, relaxation, and the activity of auxiliary muscles. Respiratory muscle strength is evaluated by measuring the static maximal inspiratory (MIP) and expiratory (MEP) pressures. The aim of this research was to determine the relationship between MIP and MEP and body posture in female soccer players. Material and methods The research involved a group of 57 women aged 16-20 years (42 soccer players and 15 controls) without disorders in the movement apparatus, cardiovascular system, or respiratory system. MIP and MEP were measured and analyzed with respect to body posture in three different positions. MIP and MEP values were evaluated with Micro Respiratory Muscle Analyzer (CareFusion). The body posture in the coronal plane from the back measured with a non-contact 3D photogrammetry system. Results Asymmetries in body posture were also measured and compared between groups. Asymmetry was observed at all anatomical locations in each of the postural positions, with an increase in asymmetry of the scapulae in the soccer players (p = 0.008). The control group had increased asymmetry at the skull nuchal line. Conclusions These results draw attention to the need for standardizing the evaluation procedure for respiratory muscle strength and interpretation of results. Postural measurements allow linkage of specific postural errors to the maximum strength of inspiratory and expiratory muscles. The asymmetrical location of the scapulae may be followed by a disturbance in the maximum strength of the inspiratory muscles.

The common vole is a temperate rodent widespread across Europe. Phylogeographic studies of its extant populations suggested the Last Glacial Maximum (LGM) as one of the main drivers of the species’ population history. However, analyses based solely on extant genetic diversity may not recover the full complexity of Late Pleistocene population dynamics. To reconstruct the population history of the common vole through the Last Glacial Period, we analysed a 4.2 kb-long fragment of mitochondrial DNA of 148 ancient and 51 modern specimens, sampled from across Europe, and covering the last 60 thousand years (ka). We estimate the time to the most recent common ancestor of Last Glacial common vole lineages to 90 ka ago and the diversification of the main extant lineages to between 55 and 40 ka ago, substantially earlier than previously estimated. Our data suggests multiple lineage turnovers in Europe at the end of Marine Isotope Stage (MIS) 3 and around the Pleistocene/Holocene transition. Conversely, data from the Western Carpathians suggest continuity throughout the LGM. This further suggests that climate amelioration during MIS 2 had little impact on common voles and that the main driver of population dynamics was the reduction of open habitats during the interstadial periods.

Four divergent groups of duck astroviruses (DAstVs) have been identified that infect domestic ducks. In March 2021, a fatal disease characterized by visceral urate deposition broke out in 5-day-old Beijing ducks on a commercial farm in Guangdong province, China. The pathogen was confirmed to be a duck astrovirus. The complete genome sequence of this DAstV was obtained by virome sequencing and amplification. Phylogenetic analyses and pairwise comparisons demonstrated that this DAstV represented a novel group of avastrovirus. Thus, we designated this duck astrovirus as DAstV-5 JM strain. DAstV-5 JM shared genome sequence identities of 15–45% with other avastroviruses. Amino acid identities with proteins from other avastroviruses did not exceed 59% for ORF1a, 79% for ORF1b, and 60% for ORF2. The capsid region of JM shared genetic distances of 0.596 to 0.695 with the three official avastrovirus species. In summary, we determined that the DAstV-5 JM strain, causing gout in ducklings, is a novel species of avastrovirus.

Hyoscine butylbromide associated psychosisDurga Neupane1, Nimesh Lageju1, Lokesh Shekher Jaiswal2B.P. Koirala Institute of Health Sciences, Dharan, NepalDepartment of Surgery(Division of CTVS), B.P. Koirala Institute of Health Sciences, Dharan, NepalAuthorsDurga NeupaneEmail: neupanedurga26@gmail.comORCID iDhttps://orcid.org/0000-0002-9736-9335

In children, all medications and fluids are calculated by body weight or surface area, mostly by mobile phones, written on paper or a pre-filled form, or entered into the hospital information system. The complexity and risks of chemotherapy forces healthcare professionals to follow standard practices. In medical procedures, Microsoft Excel is generally used for data collection and statistical calculation. In this article, we aimed to introduce the use of Excel to facilitate cancer treatment and follow-up procedures, save on time, increase consistency, minimize errors, and eliminate hesitations and contribute to the scientific community.

Most industrial batch processes involve inherent dynamic characteristics in both within-batch time direction and batch-wise direction. In order to ensure process safety and improve process performance, the two-dimensional dynamics should be analyzed during batch process monitoring. In this work, Firstly, two-dimensional region of support (2D-ROS) is constructed to select and preserve the relevant samples for the current measured sample by calculating autoregressive orders with Akaike Information Criterion (AIC) in time direction and measuring the similarity with weighted Euclidean distance in batch-wise direction. Afterward, sparse canonical variate analysis (SCVA) algorithm is performed to yield sparse canonical vectors, which is especially advantageous for eliminating the irrelevant variables and facilitating the interpretation of underlying relationships of process variables. The upper control limits (UCLs) in 2D-SCVA can be estimated using kernel density estimation (KDE). The achieved results clearly verify that the proposed method performs well for detecting abnormal operation for the batch process.

Water with three structures was compared for solar-steam generation: a) copper/silica nanoshells (CuSiN) having a plasmonic resonance in the visible region; b) thermal reduced graphene oxide (TrGO) having π-band optical transition; and c) an oxidized carbon foam (OCF) on the top allowing a localized heating. By using an open direct absorbing solar collector under simulated solar radiation, the evaporation rate (in kg/m 2 s) under 3 Suns was 2.1 x 10 -4 for pure water, while values of 5.1, 5.5 and 6.0 were reached for water with CuSiN, TrGO and OCF systems, respectively. Under natural sunlight (60 suns), for pure water an evaporation rate of 7.5 x 10 -4 was obtained after only 10 minutes of irradiation. Noteworthy, this value increased to 1.0 x 10 -2 for the system having the OCF while for all the nanoparticles systems the values were around 8.4 x 10 -3 .

We report the case of a child with T-cell ALL who presented with clinical features of SMA syndrome and Wernicke's encephalopathy, concurrently, in the setting of malnutrition and significant weight loss. We highlight the importance of an early clinical diagnosis of these two uncommon but treatable complications of malnutrition in childhood cancer.

Background and Purpose: Boerhavia diffusa is an herbaceous member of the Nyctaginaceae family which has been widely used in folk medicine to treat several illnesses. Experimental Approach: A validated HPTLC method has been newly developed for the quantification of eupalitin 3-O- β-D-galactopyranoside in hydroalcoholic extracts of B. diffusa. A three-level factor Box-Behnken statical design was used for optimization, extraction time (min), temperature (ºC), and methanol: water ratio (% v/v) are independent variables while bioactive compounds as the dependent variable. This study was aimed to investigate the pretreatment of HepG2 cells with hepatoprotective agents against the damage induced by galactosamine (GalN) and evaluate in vivo antihypertensive activity of eupalitin 3-O- β-D-galactopyranoside in rats by prednisolone inducing hypertension. Key Results: The separation was achieved on silica gel 60F254 HPTLC plate using: toluene: acetone: water (5: 15:1) as mobile phase. Densitometric analysis of eupalitin 3-O- β-D-galactopyranoside was carried out in the absorbance mode at 366 nm. A study has shown that optimized eupalitin 3-O-β-D-galactopyranoside can be used as an antihypertensive drug in rats by prednisolone inducing hypertension and In-vitro Hepatoprotective Activity of optimized eupalitin-O- β-D-galactopyranoside was checked in HPG2 cell line compared with silymarin by ANOVA technique. Conclusion and Implications: It is concluded that A new method for a method of validation and quantification of eupalitin-O-β-D-galactopyranoside in Boerhavia diffusa has been developed, In vivo antihypertensive and in-vitro hepatoprotective activity of optimized eupalitin O- β-D-galactopyranoside was done in intoxicated rats and in HepG2 cells induced by galactosamine (GalN).

Background and Purpose: Cystic fibrosis (CF) is associated with a myriad of respiratory complications including increased susceptibility to lung infections and inflammation. Progressive inflammatory insults lead to airway damage and remodelling, resulting in compromised lung function. Treatment with ivacaftor significantly improves respiratory function and reduces the incidence of pulmonary exacerbations; however, its effect on lung inflammation is yet to be fully elucidated. Experimental approach: This study investigates the anti-inflammatory effects of ivacaftor in the lung post lipopolysaccharide (LPS) exposure and compare effects of prophylactic and therapeutic ivacaftor treatment in a C57BL/6 mice model. All groups received intratracheal (IT) administration of LPS (10 ug). Prophylactic treatment involved intraperitoneal injections of ivacaftor (40mg/kg) once a day beginning 4 days prior to LPS challenge. The therapeutic group received a single intraperitoneal ivacaftor injection (40mg/kg) directly after LPS. Mice were culled either 24h or 72h post LPS challenge and serum, bronchoalveolar lavage fluid (BALF) and lung tissue samples were collected. The degree of inflammation was assessed through cell infiltration, cytokine expression and histological analysis. Key Results: Ivacaftor did not alter the total number of immune cells within the BALF, however, prophylactic treatment did significantly alter macrophage and lymphocyte infiltration. Prophylactic treatment saw a significant negative correlation between immune cell number and ivacaftor concentrations in BALF, however, no significant changes in cytokine expression nor histological parameters were determined. Conclusion & Implications: Ivacaftor possesses some inherent immunomodulatory effects within the lung following LPS inoculation, however, further analysis of larger sample sizes is required to confirm results.

Evans syndrome: A rare complication of a living related pediatric liver transplantationIbrahim E I Hassan¹˒², Christina Hajinicolaou¹˒³, Priya Walabh¹˒²˒⁴

Study Objective: To evaluate how COVID-19 has affected the management of women who presented with suspected adnexal torsion. Design: A retrospective case-controlled cohort study. Setting: A tertiary hospital. Population: 25 women in the control group (surgical date 24th March 2019 to 23rd March 2020) and 36 women in the pandemic group (24th March 2020 to 23rd March 2021) with confirmed adnexal torsion. Methods: Electronic patient record reviewed looking at women that had confirmed adnexal torsion in surgery. Main outcome measures: Time taken between clinical diagnosis of suspected adnexal torsion and surgical confirmation. Results: The median number of hours between suspected diagnosis and operating time was 7 hours (range 0.5-45 hours) and 4 hours (range 1-53 hours) respectively, with no statistical difference between the two groups (p>0.05, p=0.27). Out of hours operating was 6.5 times (OR 6.5 95%CI 1.36-31.09, p=0.01) more likely in the pandemic group when compared to the control group. Surgical outcome demonstrated 60% (n=15) of patients required oophorectomy in the control group, compared with 38% (n=14) in the pandemic group. Conclusions: Whilst there was an increase in the likelihood of out of hours operating during the pandemic; we have demonstrated that our ability to undertake diagnostic test and to perform emergency surgery safely was not delayed overall due to the impacts of COVID-19. Funding: None Keywords: adnexal torsion; ovarian torsion; COVID-19