Introduction: The surface EKG of typical atrioventricular nodal reentrant tachycardia (AVNRT) shows simultaneous ventricular-atrial (RP) activation with pseudo R’ in V1 and typical heart rates ranging from 150-220/min. Slower rates are suspicious for junctional tachycardia (JT). However, occasionally we encounter typical AVNRT with slow ventricular rates. We describe a series of typical AVNRT cases with heart rates under 110/min. Methods: A total of 1972 patients with AVNRT who underwent slow pathway ablation were analyzed. Typical AVNRT was diagnosed when; 1) evidence of dual atrioventricular nodal conduction, 2) tachycardia initiation by atrial drive train with A-H-A response, 3) septal ventriculoatrial (VA) time < 70 ms, and 4) ventricular-atrial-ventricular (V-A-V) response to ventricular overdrive (VOD) pacing with post pacing interval-tachycardia cycle length (PPI-TCL) > 115ms. JT was excluded by either termination or advancement of tachycardia by atrial extrastimuli (AES) or atrial overdrive (AOD) pacing. Results: We found 11 patients (Age 20-78 years old, 6 female) who met the above-mentioned criteria. The TCL ranged from 560ms to 782ms. Except for one patient showing tachycardia termination, all patients demonstrated a V-A-V response and PPI-TCL over 115ms with VOD. AES or AOD pacing successfully excluded JT by either advancing the tachycardia in 10 patients or by tachycardia termination in one patient. Slow pathway was successfully ablated, and tachycardia was not inducible in all patients. Conclusions: This case series describes patients with typical AVNRT with slow ventricular rate (less than 110/min) who may mimic JT. We emphasize the importance of using pacing maneuvers to exclude JT.

Hamdani, A1, Samankula1, A, Amarasiri2, M., Gunawaedena, A.1, Karunathilake, I21. Ministry of Health, Sri Lanka2. Faculty of Medicine, University of Colombo, Sri Lanka

Abstract:  In recent years, global warming has increased the frequency and severity of extreme storm events, super typhoons, and short-duration and high-intensity rainfall events. Along with the growing awareness of sustainable development, Low Impact Development (LID) techniques are advocated to mitigate the impact on the environment to reduce surface runoff and to reduce the heat island effect.  The main purpose of this study is to investigate the effect of different stormwater facilities for different storm sizes on urban areas. The study areas are the flood-prone areas of Tu-Cheng downstream. In this study, four different cases are designed for comparison with the LID approach, including non-stormwater facilities, drainage channels with lower (silty loam) or higher (sandy clay load) infiltration rates, and drainage channels with lower infiltration rates and retention storage ponds. The FLO-2D model is applied for two-dimension flood distribution on the study areas of different designed cases, and Self-Organizing Map (SOM) is used to categorize the simulation data into a meaningful and visible inundation topology for displaying the regional flood inundation extents and severity of these four cases.Keywords:Artificial Neural Networks, Self-Organizing Map (SOM), Numerical Simulation, FLO-2D, Flood mitigation facilities, Flood InundationOverview:1. IntroductionAbout three to four typhoons hit Taiwan every year and the average annual rainfall is about 2,500 mm. The rainfall is concentrated in May to November each year which brings abundant water to Taiwan. However, due to the high development of Taiwan's cities, the buildings are so dense that the impervious areas are almost covered. In the whole city, the land use has exceeded the load of the natural environment, the soil permeability is poor and the surface runoff has greatly increased, resulting in insufficient drainage facilities to discharge and cause flooding. Therefore, how to increase the urban water retention rate and reduce the impact of urban development on the environment becomes one of the major issues for water resources management.2. PurposeTaking the flooding in the Tu-Cheng area as the research object, the numerical software FLO-2D is used to establish the flooding situation generated by different combinations of Low Impact Development facilities and to explore the best flood reduction effect by LID facilities. In addition, Self-Organizing Map (SOM) is used to carry out the cluster analysis to explore the correlation characteristics of flood mitigation factors with flooding conditions. Finally, it is expected that the results of this analysis can effectively solve the problem of urban flooding.3. Study areaTu-Cheng district is a municipal district of New Taipei City, with a population of about 240,000 and an area of about 30 square kilometers. It is located in the southwest corner of the Taipei Basin, and the northeast corner is adjacent to Banqiao District. The Southeast is backed by mountains and faces the water. Its location map is listed as vulnerable to flooding. Due to the highly developed and densely populated areas, the loss of flooding can be quite heavy.4. Methodology4.1 FLO-2DThis model is a two-dimensional flood disaster simulation model developed by an American company. It uses a one-dimensional variable flow model and a two-dimensional overland flow model to simulate one-dimensional flow, street flow, and two-dimensional overland flow. When the overflow occurs, the interaction mechanism between the channel outside the embankment and the surface of the embankment can be calculated which can effectively simulate the flooding situation. The model channel calculation method is to use the continuous equation and the dynamic wave model to simulate the finite difference method, simulate the speed and depth of fluid flow and estimate the reasonable submerged area as a flood disaster prediction tool.4.2 Self-Organizing Map (SOM)The SOM, introduced by Kohonen (1982), is a useful clustering method that can classify a large set of high-dimensional data to form a meaningful topological map derived from the low-dimensional (usually two-dimensional) output layer of the network. The topological map can be used to visibly conduct an assessment of the behavior of input variables and the multi-relations among variables through the constructed clusters. The SOM has advantages of information extraction and visualization and has been widely used in water resources problems. 4.3 Low Impact Development (LID)The main purpose of LID is to apply flood retention, infiltration and evaporation that are common in current drainage design and planning, and to increase urban park green space, so as to delay the flood peak when floods come and reduce flood volume to maintain the hydrological state before land development as much as possible.5. Expected resultsThis study is to collect the elevation date distributed in the Tu-Cheng urban area, the rainfall data from the Tu-Chung rainfall stations, and the satellite imagery to build houses, roads and channels. Besides, the purpose is to explore the effect of different flood mitigation facilities on urban flooding. Taking the flooding situation in the downstream easily flooded area of Tu-Chung district as the research object, the numerical software FLO-2D simulated the flooding situation of different flood mitigation facilities. The flood reduction effect of the combination of LID facilities, and use the SOM to conduct cluster analysis to observe the interactive relationship between the trend of flooding and the factors of flood mitigation facilities, and provide the lowest environmental damage and can improve its maximum reduction. 6. Reference(1)Batesa, P.D., Horrittb, M.S. and Fewtrella, T.J., 2010. A simple inertial formulation of the shallow water equations for efficient two-dimensional flood inundation modelling. Journal of Hydrology 387(1-2):33-45.(2)Chang, L. C., Shen, H. Y., Wang, Y. F., Huang, J. Y., & Lin, Y. T.(2010).Clustering-based hybrid inundation model for forecasting flood inundation depths. Journal of hydrology, 385(1), 257-268.(3)Chang, F. J., Chang, L. C., Kao, H. S., & Wu, G. R. (2010). Assessing the effort of meteorological variables for evaporation estimation by self-organizing map neural network. Journal of Hydrology, 384(1), 118-129.(4)Chen, A. S., Evans, B., Djordjević, S., & Savić, D. A. (2012).Multi-layered coarse grid modelling in 2D urban flood simulations.Journal of hydrology, 470, 1-11.(5)Davis, A. P. (2005). Green engineering principles promote low-impact development. Environmental science & technology, 39(16), 338A-344A.(6)Dietz, M. E. (2007). Low impact development practices: A review of current research and recommendations for future directions. Water, air, and soil pollution, 186(1-4), 351-363.

Objectives –Aspiration of synovial fluid from non-effusive joints is undertaken for the diagnosis of crystal-associated arthritis, biomarker analysis, and to confirm intraarticular positioning. We hypothesized that pneumatic compression of the non-effusive knee would mobilize occult synovial fluid and improve arthrocentesis success. Methods – The absence of a knee effusion was determined by physical examination, imaging, and exclusion of confounding disease.  Conventional arthrocentesis was performed in 111 consecutive non-effusive knees and arthrocentesis volume (milliliters) determined. Pneumatic compression was then applied, and arthrocentesis was resumed. Results – Pneumatic compression improved fluid yield: conventional: 0.4±1.0 ml, compression: 1.8±2.5 ml (319% increase, 95% CI  -1.9<-1.4<-0.9; p=0.0001). Pneumatic compression reduced arthrocentesis failure (< 0.1 ml) from 74.8% (83/111) to 41.4% (46/111) (p=0.0001) and improved successful arthrocentesis in terms of adequate synovial fluid yield: 1) ≥ 0.1 ml from 25.2% (28/111) to 58.5% (65/111) (+132%, p=0.0001), 2) ≥ 0.5 ml from 22.5% (25/111) to 57.7% (64/111) (+156%, p =0.0001), 3) ≥ 2.0 ml from 11.7% (13/111) to 47.7% (53/111) (+300%, p =0.0001), and 4) ≥ 3.0 ml from 5.4% (6/111) to 36.0% (40/111) (+319%, p =0.0001). Conclusions: Pneumatic compression of the non-effusive knee improves the extraction of synovial fluid of various requisite volumes for conventional and biomarker analysis.

Aim: In our study we examined whether anthropometric and body composition parameters, i.e. body surface area (BSA), lean body mass (LBM) and total body weight (TBW), are correlated with docetaxel clearance and exposure. In addition, LBM, TBW and a fixed dose were compared to BSA as dosing parameters for dose individualisation of docetaxel. Methods: Thirty-six patients affected by breast or castration-resistant prostate carcinoma receiving docetaxel chemotherapy entered the study. LBM was measured by a Dual Energy Xray Absorptiometry (DEXA) scanner before treatment. Blood samples were collected up to 180 minutes after dosing to analyse docetaxel concentrations and to determine individual pharmacokinetic (PK) parameters. Results: No significant correlations were found between the docetaxel pharmacokinetic parameters clearance and volume of distribution and the anthropometric and body composition variables BSA, LBM and TBW. AUC was significantly but poorly correlated with BSA (r=0.452 [p=0.016]) and with TBW (r=0.476 (p=0.011]). The Mean Absolute Percentage Error and Mean Error of simulated dosing based on LBM and fixed dosing ME were not significant different compared to BSA. For TBW, only the MAPE of dosing was significant higher compared to BSA (24.1 vs. 17.1, P=0.001). Conclusion: There is no correlations between docetaxel pharmacokinetics and the anthropometric and body composition variables BSA, LBM and TBW. Dose individualisation of docetaxel based on LBM or TBW or fixed dosing cannot be recommended over BSA based dosing.

Objective: Many growth charts provide single centile cutoffs for each week of gestation, yet fetuses gain weight throughout the week. We aimed to assess whether using a single centile per week distorts the proportion of infants classified as small and their risk of stillbirth across the week. Design: Retrospective cohort study. Setting: Victoria, Australia. Population: Singleton, non-anomalous infants born from 2005-2015 (529,261). Methods: We applied growth charts to identify small-for-gestational-age (SGA) fetuses on week-based charts (single centile per gestational week) and day-based charts (centile per gestational day). Main outcome measures: Proportions <10th centile by each chart, and stillbirth risk amongst SGA infants. Results: Using week-based charts, 12.1% of infants born on the first day of a gestational week were SGA, but only 7.8% on the final day; ie. an infant born at the end of the week was 44% less likely to be classed as SGA (p<0.0001). The relative risk of stillbirth amongst SGA infants born on the final day of the week compared with the first was 1.47 (95%CI 1.09-2.00, p=0.01). Using day charts, SGA proportions were similar and stillbirth risk equal between the beginning and end of the week (9.5% vs 9.9%). Conclusions: Growth standards using a single cutoff for a gestational week overestimate the proportion of infants that are small at the beginning of the week and underestimate the proportion at the end. This distorts the risk of stillbirth amongst SGA infants based on when in the week an infant is born. Day-based charts should be used

The present study attempts to understand land use dynamics in an area subjected to opencast and underground coal mining for the last few decades in Kotma Coalmines of Anuppur district in Madhya Pradesh, India through geospatial techniques. Land Use and Land Cover (LULC) change detection analysis was performed digitally classifying Landsat 5 (2001) as well as Landsat 8 (2020) satellite data using maximum likelihood algorithm. Results revealed that area under Dense native vegetation decreased drastically (13.74 sq. km) with the gradual and consistent expansion in the activities of coal mines which showed the highest increase in area over time (15.84 sq. km). Bivariate regression analysis showed the positive empirical relationships between vegetation indices and soil physico-chemical parameters. Studies suggested soil and vegetation is degraded over the large mining areas consistently over a long time period. Despite the continuous reforestation activities on mined areas, the decline area under dense vegetation and sparse vegetation over the twenty-year time-scale indicates that the reclamation activities are still in its’ infancy. Land Degradation Vulnerability Index (LDVI) map was generated to understand the extent of decadal land degradation trends and it shows that 8.60 % of the area is highly vulnerable to degradation. The LDI inputs will help the planners to develop alternate strategies to tackle vulnerability zones for safe mining. Monthly estimation of various meteorological parameters was also recorded to generate heat plots for the period 2001-2020. The study concludes that monitoring and assessment of fragile ecosystems are indispensable for holistic environmental management.

Literature was systematically reviewed regarding CO2 exposure and facemask use. Observational and experimental data are helpful for a risk-benefit assessment for masks as a popular non-pharmaceutical intervention against SARS-CoV2 in the populace. Masks impede breathing by increasing the resistance and dead space volume leading to a re-breathing of CO2 with every breath taken. Fresh air has around 0.04% CO2, while wearing masks more than 5 minutes bears a possible chronic exposure to carbon dioxide of 1.41% to 3.2% of the inhaled air. Although the buildup is usually within the short-term exposure limits, long-term consequences must be considered due to experimental data. US Navy toxicity experts set the exposure limits for submarines carrying female crews to 0.8% CO2 based on animal studies indicating an increased risk for stillbirths. Additionally, in mammals chronically exposed to 0.3% CO2 experimental data demonstrates teratogenicity with irreversible damage of neurons and reduced spatial learning caused by brainstem neuron apoptosis and a reduced blood level of the insulin-like growth factor 1. With significant impact on three readout parameters (morphological, functional, marker) this chronic 0.3% CO2 exposure has to be defined as being toxic. Additional data exists on the exposure of chronic 0.3% CO2 in adolescent mammals causing neuron destruction, which includes less activity, increased anxiety and impaired learning and memory. There is a possible negative impact risk by imposing extended mask mandates especially for vulnerable subgroups. Circumstantial evidence exists that extended mask use may be related to current observations of stillbirths and to reduced verbal motor and overall cognitive performance in children born during the pandemic. Extended masking in pregnant women, children and adolescents has not been thoroughly tested and studied. As a result of the animal experimental data available, a risk-benefit analysis is urgent and a need exists to rethink mask mandates, which provide appropriate warnings.

In this paper, we investigate a two-grid weak Galerkin method for semilinear elliptic differential equations. The method mainly contains two steps. First, we solve the semi-linear elliptic equation on the coarse mesh with mesh size H, then, we use the coarse mesh solution as a initial guess to linearize the semilinear equation on the fine mesh, i.e., on the fine mesh (with mesh size $h$), we only need to solve a linearized system. Theoretical analysis shows that when the exact solution u has sufficient regularity and $h=H^2$, the two-grid weak Galerkin method achieves the same convergence accuracy as weak Galerkin method. Several examples are given to verify the theoretical results.

Axonal transport plays a significant role in the establishment of neuronal polarity, axon growth, and synapse formation during neuronal development. The axon of a naturally growing neuron is a highly complex and multifurcated structure with a large number of bends and branches. Nowadays, the study of dynamic axonal transport in morphologically complex neurons is greatly limited by the technological barrier. Here, a sparse gene transfection strategy was developed to locate fluorescent mCherry in the lysosome of primary neurons, thus enabling us to track the lysosome-based axonal transport with a single-particle resolution. Thereby, several axonal transport models were observed, including forward or backward transport model, stop-and-go model, repeated back-and-forth transport model, and cross-branch transport model. Then, the accurate single-particle velocity quantification by TrackMate revealed a highly heterogeneous and discontinuous transportation process of lysosome-based axonal transport in freely orientated axons. And, multiple physical factors, such as the axonal structure and the size of particles, were disclosed to affect the velocity of particle transporting in freely orientated axons. The combined single-particle fluorescence tracking and TrackMate assay can be served as a facile tool for evaluating axonal transport in neuronal development and axonal transport-related diseases.

Jupyter notebooks are very big right now and this article shows off some of what can be done with them and will make a good addition to CISE. The notebooks in this article all look well-made and are a good introduction to the format.  

Aortic valve and root replacements require an in-depth understanding of the aortic root and annulus. Both structures can be asymmetric at times, and this needs to be recognized and taken into consideration when peforming valve-sparing operations or other root-replacement procedures. Moreover, the geometry of the aortic annulus can be altered, and when performing an aortic root replacement this can distort the geometry of a neo-aortic valve for instance, and lead to valve dysfunction, which is difficult to reverse. We are describing an altered aortic annulus, which required modification through annulus elevation before proceeding with aortic root replacement with a graft-reinforced pulmonary-autograft.

Background Different techniques have been reported to prevent perineal lacerations, but the effects of the use of lubricant have been unclear and is still subject of debate. Objective To assess the effect of lubricants on reducing perineal trauma during vaginal delivery. Search strategy PubMed, Embase, the Cochrane Library, CINAHL, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), WanFang databases, ClinicalTrials.gov in 25 June 2021. Selection criteria Randomized controlled trials published in English or Chinese that compared the vaginal application of lubricant with standard care in women with cephalic presentation at vaginal delivery were included . Data collection and analysis Two independent reviewers selected eligible trials and extracted data on perineal trauma, duration of the second-stage labor, postpartum hemorrhage and Apgar score for meta-analysis. Main results Nineteen trials enrolling 5445 pregnant women were included. Compared with standard care, women using lubricants had a lower incidence of perineal trauma (RR 0.84, 95%CI 0.76 to 0.93), second-degree perineal laceration (RR 0.72, 95%CI 0.64 to 0.82) and episiotomy (RR 0.77, 95%CI 0.62 to 0.96), had a shorter duration of the second-stage labor (MD -13.72 minutes, 95%CI -22.68 to -4.77). Subgroup analysis indicated that women with obstetric gel had a shorter duration of the second-stage (MD -16.9 minutes, 95%CI -27.03 to -6.78 vs MD -8.38 minutes, 95%CI -11.11 to -5.65; P interaction=0.02) when compared with liquid wax. Conclusions Compared with standard care, lubricants could reduce the incidence of perineal trauma, especially second-degree perineal laceration, and shorten the duration of the second-stage labor.

The Species-Sorting concept, one of the models developed to explain patterns in metacommunity structure, suggests that relationships between biological communities and environmental conditions is the basic means of the species selection processes. A second concept is Neutral Theory, and the idea of neutral dynamics underpinning metacommunity structure, cannot be overlooked. The third mechanism is the Mass-Effect concept, that focuses on the interaction between environmental condition and neutral effects. In the present study, we partitioned fish communities in streams between niche and neutral theory concepts, identifying the best representation of metacommunity structure, and assessed if linear and hydrographic distance were equivalent in the representation of neutral processes. The result points to the importance of species sorting mechanisms in structuring fish communities with neutral processes best represented by the linear distances. These results are important for the fish fauna conservation leading to three considerations: (i) the variation of the landscape and habitat is important for the stream fish, (ii) the natural barriers are an important landscape component to be considered, and (iii) the artificial barriers (dams and impoundments) need to be planned taking in account the catchment basin as the landscape unit.

Most of our understanding of island diversity comes from the study of aboveground systems, while the patterns and processes of diversification and community assembly for belowground biotas remain poorly understood. Here we take advantage of a relatively young and dynamic oceanic island to advance our understanding of eco-evolutionary processes driving community assembly within soil mesofauna. Using whole organism community DNA (wocDNA) metabarcoding and the recently developed metaMATE pipeline, we have generated spatially explicit and reliable haplotype-level DNA sequence data for soil mesofaunal assemblages sampled across the four main habitats within the island of Tenerife. Community ecological and metaphylogeographic analyses have been performed at multiple levels of genetic similarity, from haplotypes to species and supraspecific groupings. Broadly consistent patterns of local-scale species richness across different insular habitats have been found, whereas local insular richness is lower than in continental settings. Our results reveal an important role for niche conservatism as a driver of insular community assembly of soil mesofauna, with only limited evidence for habitat shifts promoting diversification. Furthermore, support is found for a fundamental role of habitat in the assembly of soil mesofauna, where habitat specialism is mainly due to colonisation and the establishment of preadapted species. Hierarchical patterns of distance decay at the community level and metaphylogeographical analyses support a pattern of geographic structuring over limited spatial scales, from the level of haplotypes through to species and lineages, as expected for taxa with strong dispersal limitations. Our results demonstrate the potential for wocDNA metabarcoding to advance our understanding of biodiversity.

Bloom-forming marine gelatinous zooplankton, including the pelagic tunicate Dolioletta gegenbauri, occur circumglobally and have the potential to significantly influence the structure of pelagic marine food webs and biogeochemical cycling through interactions with microbial communities. Using targeted metabarcoding (16S rRNA genes recovering Bacteria/Archaea) and qPCR approaches associated with laboratory-based feeding experiments, we characterized patterns in doliolid gut microbiomes and microbial communities associated with doliolid fecal pellets and the surrounding seawater. The characterization of starved doliolids provides the first description of the doliolid gut microbiome. At the highest taxonomic levels, doliolid-associated bacterial communities are characteristic of marine bacterioplankton communities around the globe and were dominated by representatives of six major bacterial groups including Gammaproteobacteria, Alphaproteobacteria, Cyanobacteria, Planctomycetes, Bacteroidia and, Phycisphaerae. Comparison between sample types, however, revealed distinct patterns in diversity and biomass supporting the hypothesis that through their presence and trophic activity, doliolids influence the structure of pelagic food webs and biogeochemical cycling in subtropical continental shelf systems where doliolid blooms are common. Bacteria associated with starved doliolids (representative of the resident doliolid gut microbiome) possessed distinct communities, supporting the hypothesis that doliolids possess a unique but low diversity, low biomass microbiome optimized to support a detrital trophic mode. Among potential core microbiome taxa, the genera Pseudoalteromomas and Shimia were the most abundant, similar to patterns observed in other marine invertebrates. Exploratory bioinformatic analyses of predicted functional genes suggest that doliolids, via their interactions with bacterial communities, may affect important biogeochemical processes including nitrogen, sulfur, and organic matter cycling.

Pathogenic bacteria attack their host by secreting virulence factors that in various ways interrupt host defenses and damage their cells. Functions of many virulence factors, even from well-studied pathogens, are still unknown. Francisella tularensis is a class A pathogen and a causative agent of tularemia, a disease that is lethal without proper treatment. Here we report the three-dimensional structure and preliminary analysis of the potential virulence factor identified by the transcriptomic analysis of the F. tularensis disease models that is encoded by the FTT_1539 gene. The structure of the FTT_1539 protein contains two sets of three stranded antiparallel beta sheets, with a helix placed between the first and the second beta strand in each sheet. This structural motif, previously seen in virulence factors from other pathogens, was named the SHS2 motif and identified to play a role in protein-protein interactions and small molecule recognition. Sequence and structure analysis identified FTT_1539 as a member of a large family of secreted proteins from a broad range of pathogenic bacteria, such as Helicobacter pylori and Mycobacterium tuberculosis. While the specific function of the proteins from this class is still unknown, their similarity to the H. pylori Tip-α protein that induces TNF-a and other chemokines through NF-kB activation suggests the existence of a common pathogen-host interference mechanism shared by multiple human pathogens.

A verrucuous tumor of the legA 56-year-old woman, with no medical history, presented with a chronic nodular lesion of the left leg, of two year’s duration. There were no associated systemic symptoms. Physical examination revealed a warty mass with a keratotic surface of measured 2 cm. (Figure 1)A surgical excision was performed. Histological examination showed hyperkeratosis, parakeratosis, papillomatosis and cystic invaginations extending downwards from the epidermis. Two different epithelial cell layers consisting of outer small cuboidal cells and inner columnar cells were present. The papillary projections and dermis had also dense infiltration of plasma cells. (Figure 2) Based on these findings, a diagnosis of Syringocystadenoma Papilliferum (SCAP) of the leg was established.SCAP is a benign adnexal tumor. Most of the cases present with solitary lesion in the head and neck region at birth or in early childhood.1 In fact, only two cases of SCAP on lower leg have been reported in literature.1,2 It is mainly, associated with oragnoid nevus. Histogenesis of this tumor remains controversial.2 Histopathologically, there is no difference between SCAP on different locations.1Despite its rarity, we must consider it in the differential diagnosis of any longstanding nodular lesion with crusted surface. Surgical excision is curative.

Rapp-Hodgkin syndrome is a rare condition that is characterized by ectodermal dysplasia and palatal abnormalities. We describe a 15-year-old male who has Rapp-Hodgkin syndrome that is associated with a palmoplantar keratoderma.

The most common variant of cutaneous T-cell lymphomas (CTCL) is mycosis fungoides (MF).The spontaneous regression (SR) of MF is rare. Here, we are reporting an interesting case of refractory MF after COVID-19. The SARS-CoV-2 could be an essential component in the improvement of clinical features related to MF.

          There is a strong coordinated effort by vaccination groups all over the world to put an end to the current crisis of COVID-19. The Mass vaccination first started in the UK on 8th December 2020 and soon afterward covered all of the globe. Now sufficient data are available to analyse and compare some results to explore many aftereffects of vaccination. Some influence variables on transmissions of the disease were discussed e.g., mass vaccination, lockdown and seasonality. To address seasonality, similarities between COVID-19 and seasonal Flu are discussed to gain useful insight. Like Flu, seasonality was shown to play a dominant role in transmissions of COVID-19 in the Eu-rope and US. In terms of mass vaccination, adverse reactions after vaccination received attention, as health and safety issues of the general public are of prime importance. Apart from direct side effects, the secondary effect of mass vaccination needs attention too. After the initiation of vaccination programme , almost all countries experienced a sudden surge of transmission and most countries had to impose strict lockdown measures. Many countries, those showed a low prevalence of the disease, suddenly showed a steep jump after the onset of mass vaccination. Some countries even followed a synchronized pattern between the rate of transmissions and the variation of vaccine doses; the pattern seemed distinct with the sudden steep rise/fall in vaccine doses (e.g., countries India, Indonesia among others). In that context, fast mutation of the virus and new variants after mass vaccination and possible mechanisms/consequences were discussed.                        Balanced discussion, critical and open analyses are desperately needed in the current crucial stage. Debating, questioning and criticism are always the foundation of good science and the main pillars to its progress. Following that objective, it is an effort to explore pragmatically, areas relating to the effectiveness of the COVID-19 vaccine and the exit strategy via the pathway of vaccination. Policymakers, academics, patients and common people will be greatly benefitted from such critical, transparent and balanced analyses.

Accurate simulation of plant water use across agricultural ecosystems is essential for various applications, including precision agriculture, quantifying groundwater recharge, and optimizing irrigation rates. Previous approaches to integrating plant water use data into hydrologic models have relied on evapotranspiration (ET) observations. Recently, the flux variance similarity approach has been developed to partition ET to transpiration (T) and evaporation, providing an opportunity to use T data to parameterize models. To explore the value of T/ET data in improving hydrologic model performance, we examined multiple approaches to incorporate these observations for vegetation parameterization. We used ET observations from 5 eddy covariance towers located in the San Joaquin Valley, California, to parameterize orchard crops in an integrated land surface – groundwater model. We find that a simple approach of selecting the best parameter sets based on ET and T performance metrics works best at these study sites. Selecting parameters based on performance relative to observed ET creates an uncertainty of 27% relative to the observed value. When parameters are selected using both T and ET data, this uncertainty drops to 24%. Similarly, the uncertainty in potential groundwater recharge drops from 63% to 58% when parameters are selected with ET or T and ET data, respectively. Additionally, using crop type parameters results in similar levels of simulated ET as using site-specific parameters. Different irrigation schemes create high amounts of uncertainty and highlight the need for accurate estimates of irrigation when performing water budget studies.

Il riutilizzo delle acque reflue opportunamente trattate è stato identificato come una delle soluzioni per sopperire alla carenza di risorse idriche. Al riutilizzo sono associati anche ulteriori vantaggi, tra i quali la riduzione dello scarico delle acque reflue depurate nell’ambiente con conseguente riduzione della contaminazione dell’ambiente stesso. Tuttavia, le acque destinate al riutilizzo devono presentare elevata qualità in termini di concentrazioni di contaminanti al di sotto di valori limite. Crescente preoccupazione si ha nei confronti della presenza di metalli pesanti a causa dalla loro potenziale capacità di causare effetti tossici già a basse concentrazioni, rappresentando una minaccia sia alla salute dell’uomo sia alla qualità degli ecosistemi. Tra le tecnologie applicabili per la rimozione dei metalli pesanti, la combinazione di processi elettrochimici e adsorbimento (sistema ibrido EC-AD) e diversi processi a membrana, tra cui le tecniche MEUF e PEUF e l'impiego di membrane nanocomposite adsorbenti, hanno fornito risultati interessanti.

Tubulointerstitial nephritis and uveitis syndrome post-COVID-19: a paediatric case and literature review To the Editor.The angiotensin-converting-enzyme-2 receptor is expressed in many extrapulmonary organs: eyes (conjunctival, corneal and limbal epithelial cell, retina), nerves, vessels, enterocytes of the small intestine, the kidney proximal tubules, with possible involvement of these districts by SARS-CoV-2 infection. Positive conjunctival swab tests are documented, as well (1). Furthermore, a transmembrane serine protease (TMPRSS2) cleaves the S protein into S1 and S2 domains upon virus binding to ACE2 and consequently allows the fusion of the viral membrane with the host cellular membranes permitting the viral entry. The cornea is a potential site for SARS-CoV-2 infection: the co-expression of ACE2 and TMPRSS2 are documented in corneal epithelium and endothelium. However, the expression of both ACE2 and TMPRSS2 in superficial conjunctival epithelium is much lower than in lung and kidney tissues, as only 6.6% of cells of the superficial conjunctival epithelium express both entry proteins TMPRSS2 and ACE2 . Recently, some cases of uveitis and optic neuritis as an uncommon presentation of ocular involvement in COVID-19 were described (2). Furthermore, the phlogistic involvement of renal interstitium and uveal tissue characterizes the two components of tubulointerstitial nephritis and uveitis (TINU) syndrome. Eyes and kidneys involvement can persist as asymptomatic and can have an independent outcome. TINU usually shows bilateral anterior uveitis and may evolve into a chronic disease. TINU syndrome accounts for approximately 1%-2% of uveitis in tertiary referral centres (3). Renal and ocular manifestations in some patients do not occur simultaneously, making the diagnosis challenging. Treatment includes topical and oral corticosteroids. Renal disease shows as acute kidney injury and resolves spontaneously with full recovery of kidney function or evolves into permanent renal insufficiency. However, uveitis can persist, or it recurs years after its first presentation (4).A 7-years-old girl was admitted in our Children Hospital for persistent fever and bilateral red eyes, photophobia, eye pain, during the COVID-19 pandemic. The nasopharyngeal swab for SARS-CoV-2, diagnosed by a reverse transcription-polymerase chain reaction - RT-PCR diagnostic on 2 molecular targets (E, N2) (Xpert Xpress SARS-CoV-2, Cepheid, Maurens-Scopont, France), was positive in two different swabs, confirming SARS-CoV-2 infection. The swab for other respiratory viruses was negative. The ophthalmologist diagnosed bilateral, anterior uveitis and she started a course of eye drops 0.1% dexamethasone (to both eyes at an initial schedule of once every 2 h for 3 days), and a 1-week course of eye drops to both eyes twice daily. Treatment was tapered over a 2-week period and the patient’s symptoms resolved. Furthermore, she showed nocturia, polyuria and polydipsia.14 days after the end of steroids’ treatment and a negative swab, she showed a relapse of uveitis, with a reduction of visual acuity in the right eye (4/10), ipsilateral conjunctival hyperaemia, bilateral irido-capsular synechiae, papilledema and macular edema. The optical computerized tomography (OCT) confirmed the diagnosis. The encephalic computerized axial tomography was negative, and the magnetic resonance showed a bilateral slight distension of the perioptic sheath in the retrobulbar area. Cerebrospinal fluid (CSF) analysis showed normal chemical-physical examination and cell count, with concordance between the CSF and serum bands, excluding an intrathecal production of IgG. Specific PCR analysis for viruses and microbic agents was conducted on CSF and was negative. Furthermore, autoimmune tests, the anti-NMDA, anti-MOG and anti-aquaporin 4 antibodies were negative. Blood tests revealed: C-reactive protein (CRP) 1.79 mg/dl (n.v. < 0.5), erythrocyte sedimentation rate (ESR) 56 mm/h, serum amyloid A (SAA) 30 ng/dl (< 6.4), fibrinogen 460.3 mg/dl, ferritin, IL-6, lymphocyte subpopulation analysis in the normal range, creatinine 0.83 mg/dl; hyponatremia: 134 mmol/L; mild increase of C3: 150 mg/dl (n.v. < 140); blood urea and C4 were in the normal range. The kidney involvement was confirmed by the creatinine values above the normal range (0.83 mg/dl), with a glomerular filtration rate of 60 ml/min/1.73 m2, according to Scwartz’s formula. The chemical-physical examination of the urine shows glycosuria (172 mg/dl), albuminuria (101 mg/l), proteinuria (130 mg/dl). The diagnosis of tubulointerstitial nephritis was done and confirmed by the increased serum and urinary levels of tubular enzymes beta2 microglobulin, alpha1 microglobulin, alpha2 macroglobulin. The Human Leukocyte Antigens (HLA) -B27, -B51, -B57 were not expressed in the patient. Specific anti-SARS-CoV-2 IgG were significantly increased: 8080.7 UA/ml (n.v. < 50). She was treated with prednisone (1 mg/kg/day) for 1 month, with a gradual tapering of the steroid dose.She started a second course of topic 0.1% dexamethasone and mydriatics.During the follow-up, creatinine and glomerular filtration rate normalized, with the resolution of uveitis, as well.However, 3 months after the stop of steroids, she showed a relapse of bilateral uveitis, treated again with steroids (prednisone: 0.75 mg/kg/day) for 1 month, with a gradual tapering. A new relapse occurred 2 months later, and the patient started anti-TNF-alfa treatment (adalimumab) (40 mg/every 14 days), with the complete resolution of the eye involvement. The diagnosis of TINU syndrome was done, in conformity of the clinical outcome of the patient.TINU syndrome is a rare disease with kidney and eyes inflammatory involvement. The prevalence of TINU syndrome between patients attending specialist uveitis centres, is < 0.1- 2% in the general populations and 1.1-2.3% in paediatric populations (5), with variation reflecting many factors including level of diagnostic certainty necessary to recognize the disease, otherwise underdiagnosed. The epidemiological and etiological data do not permit the real definition of genetic, epigenetic and environmental factors implicated in the pathogenesis of the disease (5).The limited number of patients and studies do not support the identification of a HLA haplotype and a genetic pattern that predispose to TINU syndrome. Some studies propose infectious triggers or drugs as the principal acquired risk factors for the syndrome. Furthermore, there is an evident different approach between studies on renal diseases, highlighting the role of a drug-induced hypersensitivity reaction in most of the cases, and ophthalmic studies, with no clear supported triggers (5). The most frequent drugs correlated to TINU syndrome are antibiotics and non-steroidal anti-inflammatory drugs. It is essential to exclude systemic diseases proven to trigger an overlap of ocular and renal inflammation, especially Behçet disease, systemic lupus erythematosus (SLE), Sjogren’s syndrome, sarcoidosis and tuberculosis (TB), atypical Kawasaki disease (6-9). COVID-19 and MIS-C can show eyes involvement. Ocular symptoms in adults with COVID-19 are polymorphous: conjunctival hyperaemia, epiphora, chemosis, anterior uveitis, visual impairment, abducens nerve palsy. Most of children with MIS-C or with Kawasaki disease, show conjunctivitis, less frequently anterior uveitis or corneal punctate epitheliopathy (10). COVID-19-related uveitis show multifactorial pathogenetic mechanisms, including: 1) direct cytopathic effect of the virus: the ACE-2 and TMPRSS2 are in the cornea and limbus; 2) the eyes thrombotic vasculopathy; 3) the antigen mimicry between virus and self-antigens of the eyes, especially in patients with HLA-B27; 4) activation of the cytokine secretion, especially of TNF-alfa, IL-1, IL-18.The clinical course of our patient showed a recurrence of uveitis, with full recovery of kidney function after a course of steroids therapy. However, uveitis recurred several times, after its initial presentation, and resolved with adalimumab.The prompt diagnosis and treatment of uveitis is of great consequence, due to the unfavourable ocular complications, as band keratopathy, posterior synechiae, cataract, increased intraocular pressure with secondary glaucoma, cystoid macular oedema, visual impairment. To our knowledge, this is the first paediatric case with TINU syndrome and SARS-CoV-2 in the international literature.Keywords: tubulointerstitial nephritis and uveitis (TINU) Syndrome; SARS-CoV-2; adalimumab; COVID-19.References1) Zhong Y, Wang K, Zhu Y, Lyu D, Yu Y, Li S, Yao K. Ocular manifestations in COVID-19 patients: A systematic review and meta-analysis. Travel Med Infect Dis. 2021 Nov-Dec;44:102191. doi: 10.1016/j.tmaid.2021.102191. Epub 2021 Nov 8. PMID: 34763068; PMCID: PMC8574127. 2) Boz AAE, Atum M, Çakır B, Karabay O, Çelik E, Alagöz G. Outcomes of the Ophthalmic Examinations in Patients Infected by SARS-CoV-2. Ocul Immunol Inflamm. 2021 May 19;29(4):638-641. doi: 10.1080/09273948.2020.1844904. Epub 2020 Nov 23. PMID: 33226284. 3) Amaro D, Carreño E, Steeples LR, Oliveira-Ramos F, Marques-Neves C, Leal I. Tubulointerstitial nephritis and uveitis (TINU) syndrome: a review. Br J Ophthalmol. 2020 Jun;104(6):742-747. doi: 10.1136/bjophthalmol-2019-314926. Epub 2019 Nov 12. PMID: 31719109. 4) Pereira C, Costa-Reis P, Esteves da Silva J, Stone R. A child with tubulointerstitial nephritis and uveitis (TINU) syndrome. BMJ Case Rep. 2018 Feb 17;2018:bcr2017222766. doi: 10.1136/bcr-2017-222766. PMID: 29455181; PMCID: PMC5836612. 5) Okafor LO, Hewins P, Murray PI, Denniston AK. Tubulointerstitial nephritis and uveitis (TINU) syndrome: a systematic review of its epidemiology, demographics and risk factors. Orphanet J Rare Dis. 2017 Jul 14;12(1):128. doi: 10.1186/s13023-017-0677-2. PMID: 28709457; PMCID: PMC5513333.) 6) Gallizzi R, Pidone C, Cantarini L, Finetti M, Cattalini M, Filocamo G, Insalaco A, Rigante D, Consolini R, Maggio MC, Civino A, Martino S, Olivieri AN, Fabio G, Pastore S, Mauro A, Sutera D, Trimarchi G, Ruperto N, Gattorno M, Cimaz R. A national cohort study on pediatric Behçet’s disease: cross-sectional data from an Italian registry. Pediatr Rheumatol Online J. 2017 Dec 21;15(1):84. doi: 10.1186/s12969-017-0213-x. Erratum in: Pediatr Rheumatol Online J. 2018 Apr 23;16(1):29. PMID: 29268757; PMCID: PMC5740899. 7) Maggio MC, Corsello G, Prinzi E, Cimaz R. Kawasaki disease in Sicily: clinical description and markers of disease severity. Ital J Pediatr. 2016 Nov 2;42(1):92. doi: 10.1186/s13052-016-0306-z. PMID: 27806720; PMCID: PMC5094032. 8) Maggio MC, Cimaz R, Failla MC, Dones P, Corsello G. Typical Kawasaki disease with atypical pneumonia: a paediatric case report. Scand J Rheumatol. 2021 May;50(3):248-249. doi: 10.1080/03009742.2020.1784458. Epub 2020 Aug 17. PMID: 32804000. 9) Maggio MC, Cimaz R, Alaimo A, Comparato C, Di Lisi D, Corsello G. Kawasaki disease triggered by parvovirus infection: an atypical case report of two siblings. J Med Case Rep. 2019 Apr 24;13(1):104. doi: 10.1186/s13256-019-2028-5. PMID: 31014402; PMCID: PMC6480815. 10) Islam M, Chou M, Braithwaite T, Siddiqui A. Bilateral anterior non-necrotising scleritis, anterior uveitis, and unilateral facial nerve palsy in paediatric inflammatory multisystem syndrome temporally associated with COVID-19. Lancet Rheumatol. 2021 Nov;3(11):e818. doi: 10.1016/S2665-9913(21)00272-1. Epub 2021 Sep 13. PMID: 34541553; PMCID: PMC8437677.Authors:Maria Cristina Maggio Professor 1; Filippo Collura M.D. 1; Maria Michela D’Alessandro M.D. 2; Barbara Gramaglia, M.D. 1; Giovanni Corsello Full Professor 1.1) University Department PROMISE “G. D’Alessandro, University of Palermo - Children Hospital “G. Di Cristina”, A.R.N.A.S. Palermo, Italy2) U.O.C. of Paediatric Nephrology, Children Hospital “G. Di Cristina”, A.R.N.A.S. Palermo, Italy