Abstract Objectives To estimate the stillbirth rate at 28 or more gestational weeks and associated maternal socioeconomic characteristics among a large internal migrant population in China. Design Retrospective study Setting Shenzhen Birth Registry Database Population or Sample All births Baoan, Shenzhen from January 2010 and December 2019 Methods The associations between stillbirth rate and maternal socioeconomic characteristics were assessed using logistic regression. Spearman’s rank correlation analysis was used to evaluate the relationship between economic status of maternal birthplace and stillbirth rate. Main Outcome Measures Stillbirth rates by maternal socioeconomic characteristics. Results An overall stillbirth rate of 4.5 per 1000 births was estimated in a total of 492,184 births in our final analysis. Migrant women had lower maternal socioeconomic status including younger age at delivery, lower education attainment, lower economic status of birthplace, inadequate prenatal care, and higher risk of stillbirth. The stillbirth rate varied by region of maternal birthplace, from 4.1 per 1000 births in women from East China to 5.7 per 1000 births from West China. The GDP per capita of maternal birthplace was strongly correlated with stillbirth rate (Spearman’s coefficient -0.875, p<0.001). Conclusions Large disparities in stillbirth rate existed between migrant and local population and among regions of maternal birthplace in China. Targeting strategies towards migrant women based on maternal birthplace are needed to further reduce burden of stillbirth. Tweetable abstract Stillbirth rate among internal migrant women in Shenzhen was inversely correlated with economic status of maternal birthplace. Keywords Stillbirth rate, socioeconomic status, internal migrant population, maternal birthplace

Background & Aim The COVID-19 pandemic led to interesting challenges, when delivering outpatient care during the national lockdown. This was especially pertinent in Otolaryngology, which is not only very heavily outpatient based but also very highly procedural focused. It also presented difficulties for patients shielding due to being deemed high risk. Following advice given by both the NHS and ENT UK, all routine clinics were cancelled and telephone consultations introduced to maintain an ENT service for patients. This study looks at the impact of telephone clinics in a district general hospital on patient outcomes and what benefits can be gained from this method of service delivery. Study Design A retrospective study was undertaken examining telephone clinic consultations of newly referred patients over seven days during a nationwide lockdown. This included all adult and paediatric patients referred routinely. Follow-up patients and 2 week wait referrals were excluded. Higher risk patients were identified using guidelines listed by the NHS and the hospital electronic patient database was used to collect patient information. Clinic outcomes were collected and collated on Microsoft Excel. Patients were followed up to 8 months. Results Data was collected from 104 patients. The age ranged from 1 to 91; with 74 patients being seen by consultants, 18 by registrars and 12 by associate specialists. Outcomes of these consultations showed that 17 patients were discharged, 15 had outpatient imaging requested, 11 referred to another specialty, 11 had further telephone clinic follow up, 31 were given patient initiated follow up and 19 were brought back for face-to-face appointments. Overall, 57% of patients avoided a hospital visit and only 17% needed a face-to-face appointment. Of the patients who were higher risk, 49% were managed remotely. After 8 months there was no significant morbidity or mortality. Conclusions Almost half of all higher risk patients avoided coming in to hospital. The majority of patients were managed remotely and thus reduced the risk and spread of infection to patients and staff. This shows that telemedicine has been a significantly useful mode of service delivery during the pandemic and has further scope in routine ENT outpatient care.

Objectives: To review surgical outcomes in patients with complex jugular paragangliomas（CJPs）and to refine the surgical strategies for CJPs. Design: A retrospective study . Setting: A single university hospital. Participants: Twelve patients with CJPs diagnosed in our institution from January 2013 to January 2021. Main Outcome Measures: Individualized surgical strategies, tumor control, complications, function of facial nerve (FN) and lower cranial nerves (LCNs), postoperatively. Results: Gross-total resection was achieved for 9 (75%) patients, and subtotal resection was achieved for 3(25%) patients. The surgical tumor control rate was 100% after a mean follow-up of 37.5 months. New FN dysfunction occurred in 33.3% (4/12) of patients, including 3 patients restored to HB grade II postoperatively, and new LCNs deficits occurred in 16.7% (2/12) patients. One patient suffered from mild hemiparesis as a result of postoperative lacunar cerebral infarction resolved two months later. No other obvious complications noted in our series. Conclusion: Our unique refined surgical techniques, including tension-free anterior FN rerouting, sigmoid sinus tunnel-packing and push-packing techniques, were able to achieve maximum tumor control and cranial nerves preservation. A two-stage surgery should be applied to minimize the risk of bilateral cranial neuropathies and impact on cerebral circulation in patients with bilateral paragangliomas. The preoperative endovascular intervention such as coil embolization or internal carotid artery (ICA) stenting can be employed in management paragangliomas with ICA associated lesions.

Our aim was to derive male and female reference limits of left-ventricular functional parameters for patients with low-likehood coronary heart disease using three quantitative methods and determined the effect of gender, age and body weight on cardiac functional parameters. One hundred and seventy-five consecutive patients who defined as low-likehood coronary heart disease patients underwent adenosine or exercise stress 99mTc-MIBI gated myocardial perfusion single photon emission computed tomography (SPECT) imaging, left ventricular (LV) ejection fraction (EF)，end-diastolic volume (EDV)，and end-systolic volume (ESV) were obtained by QGS, ECToolbox and 4D-MSPECT, respectively. LVEF and LV volumes determined by gated SPECT are significantly affected by gender and age, with body weight as a significant predictor for cardiac volumes. The values of EDV and EF determined by three methods could be different although they correlate very well; the reference limit of EDV, ESV and EF calculated by three methods are established.

Acroporidae and Pocilloporidae are the predominant reef-building corals of Indo-Pacific coral reefs. Coral colony is the basic geometric construction of coral reef, while sustained formation of their calcium carbonate skeletons is the heart of healthy reefs. However, the reef forming strategies in coral growth is still obscure. In this study, we reconstructed 32 representative samples using high-resolution computed tomography and created canal networks inside skeletal data to investigate coral growth regulation and related parameters. In Acropora and Montipora colonies, the polyps are connected as an integral network by complex canals that perform and regulate physiological processes including budding, branching, and mineralising. Furthermore, we visualised coral growth axes and rings, revealing colony growth pattern regulation. We also drew a skeleton grey-gradient heat map and calculated coral skeleton ratios to reveal skeletal diversity, devising a method to quantitatively analyse coral growth. On the basis of the canal network reconstructions, we hypothesised coral growth strategies and compared the similarities and differences among the four genera. This work extends the knowledge of how corals grow their skeleton, what the major controls are and how skeletal growth varies amongst species, ensuring further protections of tropical coral reefs.

A document by Paul Muntean. Click on the document to view its contents.

The cellulase cocktail of marine Aspergillus niger exhibited halo-tolerant and thermostable properties, which is of great potential in industrial application. In order to excavate single tolerant cellulase components from the complex cellulase cocktail, constitutive homologous expression was employed for direct obtainment of the endoglucanase (AnEGL). The constitutive expression system seems as “separation factor” to be implanted into cell for conveniently obtaining a single target enzyme. Enzymatic property study revealed that AnEGL exhibited a property of halo-tolerance and an outstanding thermostability in high salt environment. Significantly, its activity increased by 29% and the half-life at 65 °C increased by 26.7-fold with the presence of 4.5 M NaCl. Molecular dynamics (MD) simulation revealed that Na+ and Cl－ could form salt bridges with charged residues, and then influenced the activity of loops and the stability of substrate binding pocket, which accounted for the halo-tolerance and thermostability. Further, site-specific mutagenesis study proved that the residues Asp95 and Asp99 in the pocket were of great concern for the halo-tolerance and thermostability. The halo-tolerant and thermostable AnEGL was of great value in lignocellulosic utilization and the conjectural mechanisms were of referential significance for other tolerant enzymes.

Left ventricular assist devices (LVADs) provide circulatory support to patients with severe left ventricular systolic dysfunction. Many such patients have a pre-existing implantable cardioverter defibrillator at the time of their LVAD surgery. LVAD implantation can alter ICD lead parameters including R wave sensing, RV capture threshold, and impedance. These changes can in turn affect the ability of the ICD to successfully treat malignant ventricular arrythmias. In most patients who present with ineffective ICD shocks, the failed shock is assumed to be secondary to the patient’s severe cardiomyopathy. Especially the role of physical examination in such patients is often minimized. In our patient a thorough history and history guided physical examination, led us to the root cause of his failed ICD shocks. Our patient was noted to have a metal tongue ring, which was the likely cause of his ineffective ICD shocks. Our case highlights the importance of a comprehensive history and physical examination.

Apple necrotic mosiac virus (ApNMV) is a newly identified causal agent that is highly associated with the occurrence of apple mosaic disease in China. However, resistance gene against this virus has not been identified yet. We reported here that nitrate treatment destablized viral protein 1a via the ubiquitin-proteasome pathways to restrain ApNMV genomic RNA accumulation. A nitrate-responsive BTB/TAZ domain-containing protein MdBT2 was identified in a yeast-two-hybrid screening of apple cDNA library using viral protein 1a as bait, and 1a was confirmed to interact with MdBT2 both in vivo and in vitro. MdBT2 was further verified to promote the ubiquitination and degradation of viral protein 1a through the proteasome pathways in a MdCUL3A-scaffold protein in E3 ligase complex-independent manner. Viral genomic RNA accumulation was decreased in MdBT2 overexpression transgenic apple leaves but enhanced in MdBT2 antisense leaves compared to that in wild type. Moreover, MdBT2 was found to interfere with the interactions between viral replication proteins 1a and 2apol by competing with the latter. Taken together, our work demonstrated that nitrate-inducible MdBT2 functioned as a limiting factor in ApNMV viral RNA accumulation by promoting the ubiquitination and degradation of viral protein 1a and interfering with the interactions between viral replication proteins.

Device Rounds: Misplaced Pacemaker Lead: How can this be practically managed?(1) Michael Coles, MD (corresponding author)- Drafted and assembled the manuscriptAugusta University, Department of Internal Medicine1120 15th StreetAugusta, Georgia, USA, 30912410-553-1893micoles@augusta.edu(2) Mary Caroline TaralloDrafted and assembled the manuscriptAugusta University, Medical College of Georgia1120 15th StreetAugusta, Georgia, USA, 30912(3) Catherine WillDrafted and assembled the manuscriptAugusta University, Medical College of Georgia1120 15th StreetAugusta, Georgia, USA, 30912(4) Nicole BiselDrafted and assembled the manuscriptAugusta University, Medical College of Georgia1120 15th StreetAugusta, Georgia, USA, 30912(5) Victoria MadrayDrafted and assembled the manuscriptAugusta University, Medical College of Georgia1120 15th StreetAugusta, Georgia, USA, 30912(6) Chinmaya MareddyEdited the manuscript for intellectual contentAugusta University, Department of Cardiology1120 15th StreetAugusta, Georgia, USA, 30912(7) Robert SorrentinoEdited the manuscript for intellectual contentAugusta University, Department of Cardiology1120 15th StreetAugusta, Georgia, USA, 30912

Abstract Objectives To comparatively evaluate a low cost ‘frugal’ otoscope in low resource settings with a traditional device amongst health care workers in Malawi. Design A prospective, comparative, qualitative observational survey of healthcare workers opinions using 5-point Likert rating scales and tick box categories. Setting and Participants 25 mixed cadre health care workers from the Ear, Nose and Throat department of the in Malawi were recruited. Main outcome measures A 10-item survey questionnaire was used to compare the low cost ‘frugal’ otoscope with a traditional device. Outcomes measures used were ease of speculum attachment, handling, insertion, stability, the quality of view, colour, build, brightness, overall ease of use and their suitability for local work. Results The low cost ‘frugal’ otoscope scored statistically higher in overall combined performance, as well as in the remaining 4 out of the 9 attributes. Notably, 54.2% of users rated the low-cost device more suitable than the traditional device for use in low-middle income countries, 25% were equivocal and 20.8% preferred the traditional device. Conclusion This study deemed the low-cost frugal Arclight otoscope appropriate as a practical substitute for more expensive traditional otoscopes for the delivery of ENT services in low resource settings.

Background: The COVID 19 infection, which is caused by the novel coronavirus SARS-CoV-2, has rapidly emerged as a global public health issue. This study aimed to evaluate whether subclinical myocardial dysfunction using left ventricular global longitudinal strain (LVGLS) in non-hospitalized mildly symptomatic COVID-19 patients. Methods: Fifty (26 male, 24 female) non-hospitalized COVID-19 patients and 50 age- and sex-matched healthy volunteers have included in the study. Apical four-, three-, and two-chamber images were analyzed longitudinally by conventional methods and speckle tracking echocardiography (STE) for left ventricle functions. Results: The mean age of the COVID-19 patients was 39.55±8.96, 52% of them were male. The most prevalent presenting symptoms were fever (in 34 (68%)), asthenia (in 30 (60%)), loss of appetite (in 21 (42%)), myalgia (in 20 (40%)), and cough (in 13 (26%)). Plasma levels of C-reactive protein (CRP) were significantly higher in the COVID-19 patients than in the controls (10.84±12.44 vs. 4.50±2.81, p < 0.001). There was no significant difference between the groups in terms of standard echocardiography and Doppler parameters (p>0.05). Left ventricular longitudinal strain and strain velocity parameters were significantly decreased in COVID-19 patients compared to healthy individuals. LV-GLS values (-21,72 ± 3,85% vs. -23,11 ± 4,16%; P =0,003) were significantly lower in COVID-19 patients when compared with the healthy controls. Conclusion: Mildly symptomatic COVID-19 patients also have subclinical myocardial dysfunction similar to hospitalized patients. STE has the potential for detecting subclinical LV systolic dysfunction and can provide useful information on the risk stratification in the mildly symptomatic COVID-19 population.

Non-small cell lung cancer constitutes one the most frequent and lethal forms of the disease. The antitumor peptide CIGB-552 is a new targeted anticancer therapy which molecular mechanism is associated with the inhibition of the transcription factor NF-kB, mediated by COMMD1 protein stabilization. However, its pharmacological potential in combination with chemotherapy is unknown. In this study, we examined the antiproliferative capacity of CIGB-552 in combination with chemotherapeutic agents in the non-small cell lung cancer cell line NCI-H460 and we confirmed drug interactions in vivo, in a mouse model of TC-1 lung cancer. We focus our research in the combination of CIGB-552 and the antineoplastic agent Cisplatin (CDDP) in a concomitant treatment. Our results demonstrate a clear synergic effect between 37.5 μM of CIGB-552 and 5 μM of CDDP under concomitant scheme, on proliferation inhibition, cell cycle arrest, apoptosis induction and oxidative stress response. The effect of CIGB-552 (1 mg/kg) and CDDP (0.4 mg/kg) administrated as a combined therapy was demonstrated in vivo in the TC-1 murine model where the combination achieved an effective antitumor response, without any deterioration signs or side effects. These findings demonstrate the efficacy of the concomitant combination of both drugs in preclinical studies and support the use of this therapy in clinical trials.

Background: Currently there are no effective licensed anti-tussive therapies. Understanding how the neuronal mechanisms mediating the cough reflex in animal models translate to humans is important for the development of effective therapies. Pre-clinical studies suggest that the activation of GABAB receptors in both the peripheral and central nervous systems inhibit cough. Objective: To compare the effect of central and peripherally acting GABAB agonists (lesogaberan and baclofen) on the cough reflex in healthy volunteers. Methods: We performed a single center, double-blind, double-dummy, three-way crossover trial in healthy controls comparing single doses of lesogaberan (120mg MR), with baclofen (40mg) and placebos. Cough responses to inhaled capsaicin were assessed at screening and 2h post-dose on each study day. The primary endpoint was the maximum number of coughs evoked at any concentration of capsaicin (Emax) and the secondary endpoint was the concentration evoking 50% of the maximal response (ED50). Results: Fifteen patients enrolled onto the study (median age 29 (IQR 25-44) years; 7 females, mean BMI 24.6(±3.0). Lesogaberan treatment produced a small, statistically significant increase in Emax compared with placebo [mean 13.4coughs (95%CI 10.1-17.9) vs. 11.8coughs (8.8-15.9), p=0.04], but had no effect on ED50 [geometric mean 47.4µM (95%CI 24.4-91.7) vs 37.6 µM (95%CI 19.2-73.5), p=0.37]. In contrast, baclofen had no significant effect on Emax (11.1, 95%CI 8.1-15.4) (p=0.23), but significantly increased ED50 compared with placebo (geometric mean 75.2µM (95%CI 37.2-151.8), p=0.002). Conclusion: This data suggests the anti-tussive actions of GABAB agonists, in healthy volunteers, occur in the central rather than the peripheral nervous system.

Intensive respiratory management under extracorporeal membrane oxygenation (ECMO) is essential for patients with severe respiratory failure; however, critical complications during ECMO management are a matter of concern. We report the case of an adolescent with T-cell lymphoblastic lymphoma with a respiratory emergency due to compression of the trachea by an anterior mediastinum tumor, for whom ECMO followed by endotracheal stent (ES) was urgently introduced. Biopsy and initial chemotherapy were introduced under short-term management by ECMO for 23 hours. Transient ECMO followed by ES would be a robust option for the patients at risk of respiratory crisis due to mediastinal tumors.

Background: Cytokine release syndrome (CRS) is a major complication after chimeric-antigen receptor (CAR) T cell treatment, characterized by an uncontrolled sistemic inflammatory reaction. The potential role of diclofenac in the management of CRS has been investigated in five pediatric patients treated for relapsed/refractory B-lineage acute lymphoblastic leukemia. Procedure: in case of persistent fever with fever-free intervals shorter than 3 hours, diclofenac continuous infusion was initiated, at the starting dose of 0.5 mg/Kg/day, the lowest effective pediatric dose, in our experience, possibly escalated up to 1 mg/Kg/day, as per institutional guidelines. Vital signs, O2 requirement, SpO2/FiO2 ratio and dosage of diclofenac and vasopressors until CRS resolution were recorded. Results: CRS occurred at a median of 20 hours (range 8-27) after tisagenlecleucel infusion. Diclofenac was started at a median of 20 hours (range 13-33) after fever onset. A mean of 3,07 febrile peaks without diclofenac and 0,95 with diclofenac were reported (p-value 0.02). A clinical benefit was achieved by hampering the progression of tachypnea and, mainly, tachycardia. Despite fever control, CRS progressed in four of the five patients and hypotension requiring vasopressors, fluid retention, besides hypoxia, occurred. Vasopressors were followed by 1-2 doses of tocilizumab (one in patient 2 and two in patients 3, 4, and 5), plus steroids in patients 4 and 5. Conclusion: based on a limited number of patients, diclofenac leads to a better fever control, which translates into symptom relief and improvement of tachycardia, but could not prevent the progression of CRS.

Objective: To gain insight into pregnant women’s preference if given a choice between getting antibiotic prophylaxis before or after cord clamping during caesarean delivery. Design: A qualitative semi-structured interview-study Setting: The interviews were conducted at a Danish Hospital, with about 4000 births a year. Sample: Fourteen pregnant women, either considering or having a planned caesarean section, or scheduled for induction due to post-term gestational age. Methods: Fourteen individual semi-structured interviews were conducted, and a systematic text condensation approach was used to analyse the transcribed interviews. Main Outcome Measures: Patient perspectives. Results: Ten of the fourteen women favoured antibiotic administration after cord clamping. Despite any adverse effects to the infant’s microbiota and increased risk of long-term health outcomes were only hypothetical and the risk reduction in postpartum infections being well documented, they did not want to expose their offspring to antibiotics. Those who preferred antibiotic prophylaxis before cord clamping were concerned, if they would be able to care for the infant in case of a maternal infection. Three of the women preferring antibiotics after cord clamping said they would potentially change preference, if the maternal risk was higher. Most women preferred to be informed of the use of prophylactic antibiotic and that the timing has consequences for trans-placental exposure to the infant. Conclusions: With most of the interviewed women preferring antibiotic administration after cord clamping, we suggest patients should be involved in the decision regarding timing of prophylactic antibiotics before caesarean section. Funding: None.

Increases in soil salinity impact growth and agricultural yield by inhibiting plant functions. Interactions of fungal endophytes with crop plants can improve tolerance and is a less expensive approach. Here, the role of Trichoderma harzianum T-22 in alleviating NaCl-induced stress in two barley genotypes (cv. Vlamingh and cv. Gairdner) has been investigated. Metabolomics using GC-MS for polar metabolites and LC-MS for lipids was employed to provide insights into the biochemical changes in inoculated roots during the early stages of interaction. T. harzianum improved root growth of both genotypes in saline conditions whereas uninoculated roots were significantly shorter after salt treatment. The fungus reduced relative concentration of sugars in both genotypes under saline conditions but there was no change in organic acids. Amino acids decreased only in cv. Gairdner in fungus-inoculated roots under saline conditions. Lipid analysis suggested that salt stress causes large changes in roots but that inoculation with fungus greatly reduces the extent of these changes. By studying a tolerant and a sensitive genotype and their responses to salt and inoculation we have been able to develop hypotheses that explain the tolerance of Vlamingh to salt and how fungal inoculation changes the response of Gairdner to improve its tolerance.

Response surface methodology (RSM) was used to optimize the oxidizing the omeprazole sulfide to (S)-omeprazole catalyzed by environmentally friendly catalyst soybean pod peroxidase (SPP) in cetyltrimethylammonium bromide (CTAB)/isooctane/n-butyl alcohol/water water-in-oil microemulsions. With the initial concentration of SPP of 3200 U ml-1, the conversion of the omeprazole sulfide, the (S)-omeprazole yield and ee were 93.75%, 91.56% and 96.08%, respectively, under the optimal conditions: Wo of 15.85, the concentration of H2O2 of 22.44 mM and reaction temperature of 49.68 °C, respectively. The proposed mechanism of asymmetric sulfoxidations catalyzed by SPP involves three concomitant mechanisms as follows: (1) a two-electron reduction of SPP-I, (2) a single-electron transfer to SPP-I and (3) nonenzymatic reactions, including five enzymatic and two nonenzymatic reactions, which is reasonable and can express the oxidations. With 5.44% of the average relative error, a kinetic model based on the mechanisms fitting observed data very well was established, and the SPP-catalyzed reactions including both the two-electron reduction and the single-electron transfer mechanisms obey ping-pong mechanism with substrate and product inhibition, while nonenzymatic reactions follow a power law. This study has also demonstrated the feasibility of SPP as a substitute with low cost, excellent enantioselectivity and better thermal stability.

: A right atrial myxoma extending to inferior vena cava (IVC) with associated right-to-left shunting leading to systemic desaturation is an exceedingly rare clinical entity. The number of such cases reported in literature till date is not more than five. This case study presents a 45-year lady who was referred to our Centre with symptoms of breathlessness, easy fatigability, generalized weakness and bluish discoloration of lips, fingers and skin. On routine blood investigation, polycythemia was noted. On preoperative 2D-Transthoracic Echocardiography (TTE), the diagnosis of right atrial myxoma was confirmed but the reason for cyanosis was not revealed. Tumor thrombus in a branch of right lower pulmonary artery with small locoregional pulmonary infarct along with right atrial myxoma was reported in CT angiography of heart and great vessels and CT pulmonary angiography. On-table Transesophageal Echocardiography (TEE) showed patent foramen ovale (PFO) with right-to-left shunting because of raised right atrial pressure and dynamic obstruction of the tricuspid valve by the myxoma. The myxoma was resected completely via right atrial approach along with primary closure of PFO. The postoperative period was uneventful and the saturation at room air of the patient was 100% and she was discharged on day 7. The Patient is doing well during the 3-month follow-up.

Right atrial papillary fibroelastomas (PFE) originated from the Chiari network (CN) are exceedingly rare. Only 2 cases have been reported in the worldwide literature. We present a case of PFE arising from the right atrial CN detected by transesophageal echocardiography (TEE) with a previous vertebral aneurysm history and underwent a complete surgical removal. In this report, we describe our clinical observations to improve our understanding of the tumor and provide evidence for its treatment and prognosis.

Rationale, aims and objectives: A review of studies published over the last six years gives update about this hot topic. In the middle of COVID-19 pandemic, this study findings can help understand how population may perceive vaccinations. The objectives of this study were to review the literature covering the perceptions about influenza vaccines and to determine factors influencing the acceptance of vaccination using Health Belief Model (HBM). Methods: A comprehensive literature search was performed utilizing PubMed and Google Scholar databases. Three keywords were used: Influenza vaccine, perceptions, and Middle East. Empirical studies that dealt with people/ HCW perceptions of influenza vaccine in the Middle East and written in English were included. The search covered articles published between January 2015 and November 2020. Results: A total of 34 cross-sectional studies from of 22 countries were included in this review. The vaccination rates in Middle East varied widely. However, the overall influenza vaccination rates were generally low (<50%) among general population, particularly among pregnant women and children. HCWs had relatively higher vaccination rates compared to general population. Old age, health comorbidities or working in high-risk environments were noted as major motivators to receive the vaccine. Concerns about adverse reactions and the lack of vaccine efficacy were the most predominant reported barriers to receiving the vaccines. Lastly, cues to actions included receiving advice from HCWs, influence of institutional requirement, awareness/ educational pamphlets and influence from the media. Conclusions: The HBM can be helpful in identifying and analyzing motivators and barriers to vaccination. Additionally, by looking at the root causation, this model can help plan campaigns to increase vaccination rates in the region. Finally, we recommend empowering HCWs to proactively advocate for vaccination as part of preventive care.

Feature selection is one of the issues in machine learning as well as statistical pattern recognition. This is important in many fields (such as classification) because there are many features in these areas, many of which are either unused or have little information load. Not eliminating these features does not make a problem in terms of information, but it does increase the computational burden for the intended application. Besides, it causes to store of so much useless information along with useful data. A problem for machine learning research occurs when there are many possible features with few attributes of training data. One way is to first specify the best attributes for prediction and then to classify features based on a measure of their dependence. In this study, the Fuzzy- Rough subset evaluation has been used to take features in core of similar features. Fuzzy-rough set-based feature selection (FS) has been demonstrated to be extremely advantageous at reducing dataset size but has various problems that yield it unproductive for big datasets. Fuzzy- Rough subset evaluation algorithm indicates that the techniques greatly decrease dimensionality while keeping classification accuracy. This paper considers classifying attributes by using fuzzy set similarity measures as well as the dependency degree as a relatedness measure. Here we use Artificial Neural Network, Naïve Bayes as classifiers, and the performance of these techniques are compared by accuracy, precision, recall, and F-measure metrics.

Castleman’s disease (CD) is a rare lymphoproliferative disease. In clinical practice, the first-line treatment of multicentric Castleman disease (MCD) includes glucocorticoid, conventional chemotherapy, immunomodulators, and anti-IL-6. However, not all patients benefited from the first-line regimen, a subset of patients does not respond to front-line therapy and is considered to have primary refractory MCD. Thus, it is urgent to explore alternative treatments to provide new hope for the treatment of MCD. We report two cases of refractory MCD who achieved complete remission by thalidomide combined with interleukin-2 and interferon α-2b. The literature on the treatment of refractory MCD is reviewed.