Background The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. Methods From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; mean age 45±14 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation – Group 2; mean age 49±13 years. Median follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. Results In-hospital mortality was 1% in group 1, and 2% in Group 2 (p=0.6). The 5- and 10-year survival was 93±2.9% and 81±5.8% in Group 1 and 96±3.1% and 96±3.1% in Group 2, respectively (p=0.31). Eleven patients of Group 1 (1.7% /patient-year) and 5 patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p=0.5). The 5- and 10-year freedom from reoperation were 93.0±2.1% and 77.1±7.1% in Group 1 and 93.0±5.0% and 76.7±9.6% in Group 2 (p=0.83), respectively. At latest follow-up only 2 patients of Group 1 and 1 patient of Group 2 had AR=2° (p=0.7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, reoperation) was 2.9%/patient-year in Group 1 and 4%/patient-year in Group 2, respectively (p=0.6). Conclusions Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.

Acute itch flares in atopic dermatitis via the LTC4-CysLTR2 pathway.

Background: The early detection of COVID-19 patients with interstitial pneumonia at high risk of dismal outcome is necessary to deliver proper care and optimize management of limited resources. Objective: The aim of this study was to analyse the performance of pre-existing scores in predicting in-hospital mortality and ICU transfer at admission in an Acute Medical Unit. Methods: 106 consecutive patients with acute respiratory failure due to COVID-19 interstitial pneumoni admitted to Acute Medical Unit were enrolled. The performances of NEWS, SIRS, RAPS, REMS, qSOFA, APACHE II, CURB-65 and PSI were analysed by the Area Under the Receiver Operator Characteristic (AUROCs) and standard indices of accuracy. Results: Considering in-hospital mortality PSI and APACHE II had the higher AUROCs, 0.83 (95% CI 0.75-0.91) and 0.80 (95% CI 0.71-0.88), followed by REMS, 0.77 (95% CI 0.67-0.86), and CURB-65, 0.73 (95% CI 0.63-0.82), whereas the AUROCs of the other scores were < 0.7. PSI and APACHE II had good sensitivity (0.92 and 0.97), negative predictive value (0.96 and 0.97) and negative likelihood ratio (0.1 and 0.1), accurately identifying patients at low risk to die. However, the low specificity (0.70 and 0.47) and positive likelihood ratio (3.1 and 1.8) could limit their usefulness in predicting in-hospital mortality. Considering ICU admissions all the scores, except NEWS, SIRS and qSOFA, showed a worse performance. Conclusions: PSI and APACHE II showed good prognostic results in predicting in-hospital mortality but no pre- existing score validated for acute care settings was totally satisfactory to predict adverse outcomes in COVID-19 interstitial pneumonia after admission to Acute Medical Unit. The application setting and selected outcome criteria should always be considered to evaluate and compare scoring systems’ performance analysis.

This paper presents an experimental investigation of ordinary concrete under discontinuous cyclic compression tests and numerical simulations for the residual stress. Stress cycles in discontinuous cyclic compression tests were interrupted by zero or very low loading intervals (ZLIs). Fatigue tests showed that the dissipated energy and the unloading deformation modulus of a cycle after the ZLI ( A cycle) were significantly larger than those of the cycle before the ZLI ( B cycle). The dissipated energy and the unloading deformation modulus both increased with the increase of the stress level. The mechanism of discontinuous fatigue results from the effect of the residual stress which is caused by the uncoordinated mechanical response. Simulations showed that stress concentration occurs on the interface between the aggregate and the main material. The greater the elasticity modulus difference between the aggregate and the main material, the larger the residual stress and plastic deformation.

The Ensembl Variant Effect Predictor (VEP) is a freely available, open source tool for the annotation and filtering of genomic variants. It predicts variant molecular consequence using the Ensembl/GENCODE or RefSeq gene sets. It also reports phenotype associations from databases such as ClinVar, allele frequencies from studies including gnomAD, and predictions of deleteriousness from tools such as SIFT and CADD. Ensembl VEP includes filtering options to customise variant prioritisation. It is well supported and updated roughly quarterly to incorporate the latest gene, variant and phenotype association information. Ensembl VEP analysis can be performed using a highly configurable, extensible command-line tool, a Representational State Transfer (REST) application programming interface (API) and a user-friendly web interface. These access methods are designed to suit different levels of bioinformatics experience and meet different needs in terms of data size, visualisation and flexibility. In this tutorial, we will describe performing variant annotation using the Ensembl VEP web tool, which enables sophisticated analysis through a simple interface.

Cylas formicarius is one of the most important pests of sweet potato worldwide, causing considerable ecological and economic damage. To improve the effect of comprehensive management and understanding of genetic mechanisms, the genetic functions of C. formicarius have been the subject of intensive study. Using Illumina and PacBio sequencing, we obtained a chromosome-level genome assembly of adult weevils from lines inbred for 15 generations. The high-quality assembly obtained had a size of 338.84 Mb, with contig and scaffold N50 values of 14.97 Mb and 34.23 Mb, respectively. In total, 157.51 Mb of repeat sequences and 11,907 protein-coding genes were predicted. A total of 337.06 Mb of genomic sequences was located on the 11 chromosomes, and the sequence length that could be used to determine the sequence and direction accounted for 99.03% of the total length of the associated chromosome. Comparative genomic analysis showed that C. formicarius was sister to Dendroctonus ponderosae, and C. formicarius diverged from D. ponderosae approximately 138.89 million years ago (Mya). Many important gene families that were expanded in the C. formicarius genome were involved in the chemosensory system. In an in-depth study, the binding assay results indicated that CforOBP4-6 had strong binding affinities for sex pheromones and other ligands. Overall, the high-quality C. formicarius genome provides a valuable resource to reveal the molecular ecological basis, genetic mechanism and evolutionary process of major agricultural pests, deepen the understanding of environmental adaptability and apparent plasticity, and provide new ideas and new technologies for ecologically sustainable pest control.

Aims: KA2237, an oral, potent and selective, inhibitor of the PI3K β and δ isoforms, was evaluated for safety, tolerability and pharmacokinetics (PK) in patients with B-cell lymphoma. KA2237 is metabolised by CYP3A4/5 but also demonstrated mechanism-based inhibition (MBI) of CYP3A4/5. An MBI mechanistic dynamic model was used to predict drug accumulation after repeat dosing of KA2237. This model, along with clinical safety data, was used to guide safe dose escalation. Methods: An open-label, single arm, dose escalation study was carried out in patients, dosed orally with KA2237 at 50, 100, 200 and 400 mg once daily. Complete plasma profiles were obtained on Day 1 and Day 14 of dosing and pre-dose (Cmin) samples were obtained on Days 2-7. The MBI model was validated and used to calculate drug levels and predict potential drug accumulation during dose escalation. Results: KA2237 elimination half-life was around 20-30 h, compatible with once daily dosing regimens. The accumulation of KA2237 was around 4-fold after the highest dose of 400 mg and around 3-fold after administration of 200 mg, which is considered the maximum tolerated dose (MTD). The MBI model accurately predicted this accumulation. Conclusions: Drugs that demonstrate MBI and potential auto-inhibition can be successfully developed, provided that models are developed to assess the extent of accumulation prior to the start of FIH clinical studies. This, along with the close monitoring of drug levels and clinical safety data can be used to guide dose escalation and lead to the safe conduct of clinical studies.

Lake eutrophication and cyanobacterial blooms have become worldwide environmental issues. Under cyanobacterial blooms (especially Microcystis), Daphnia spp. can transfer beneficial information to their offspring in order to improve adaptability. Hox genes are important regulatory factors of transcription in metazoans, and are involved in the growth and development of organisms. In this study, the effects of Microcystis aeruginosa on Hox gene expression in the mothers and offspring of Daphnia similoides sinensis were investigated using a mixed diet of M. aeruginosa and Scenedesmus obliquus, in two clones. There were significant differences in the survival rates of D. similoides sinensis under different food treatments. Our results suggest that the offspring produced by D. similoides sinensis mother pre-exposed to toxic M. aeruginosa had stronger adaptability to M. aeruginosa than those produced by previously unexposed mother. Additionally, Hox gene expressions of D. similoides sinensis had obvious differences between clones under stress of toxic M. aeruginosa.

The assessment of climate change impacts on water resources and flood risk is typically underpinned by hydrological models calibrated and selected based on observed streamflow records. Yet, changes in climate are rarely accounted for when selecting hydrological models, which compromises their ability to robustly represent future changes in catchment hydrology. In this paper, we test a simple framework for selecting an ensemble of calibrated hydrological model structures in catchments where changing climatic conditions have been observed. We start by considering 78 model structures produced using the FUSE modular modelling framework and rely on a Pareto scheme to select model structures maximizing model efficiency in both wet and dry periods. The application of this approach in three case study basins in Peru enables the identification of structures with good robustness, but also good performance according to hydrological signatures not used for model selection. We also highlight that some model structures that perform well according to traditional efficiency metrics have low performance in contrasting climates or suspicious internal states and fluxes. Importantly, the model selection approach followed here helps to reduce the spread in precipitation elasticities and temperature sensitivities, providing a clearer picture of future hydrological changes. Overall, this work demonstrates the potential of using contrasting climatic conditions in a multi-objective framework to produce robust and credible simulations, and to constrain structural uncertainties in hydrological projections.

Although pneumothorax is a well-known complication of COVID-19 pneumonia especially in patients requiring mechanical ventilation, bronchopleural fistula causing persistent pneumothorax in sole COVID-19 pneumonia is extremely rare. In this case, we illustrate that bronchopleural fistula can be found in COVID-19 pneumonia, even with no risk factors nor mechanical ventilation administration.

A case of acute necrotising pancreatitis following the second dose of Pfizer-BioNTech COVID-19 mRNA vaccineAs of 22 June 2021, there have been about 400,000,000 doses of the Pfizer-BioNTech COVID-19 mRNA vaccine administered world-wide. At this time, 176 cases of pancreatitis have been reported in pharmacovigilance reports submitted to the WHO.1 No epidemiological link between the Pfizer-BioNTech COVID-19 mRNA vaccine and pancreatitis has been reported. We report a case of acute necrotising pancreatitis following the second dose of the Pfizer-BioNTech COVID-19 mRNA vaccine. This case has been reported to the New Zealand Pharmacovigilance Centre and the patient has consented to publication of the case report.A 43-year-old, NZ European male was diagnosed with acute necrotising pancreatitis 10 hours following the administration of his second Pfizer-BioNTech COVID-19 mRNA vaccine. He has a background of atopy with seasonal rhinitis, eczema and asthma, all of which are ‘mild’. He takes no regular medications and takes as needed melatonin 2 mg nocte, cetirizine 10 mg for hay fever, and betamethasone and emollient cream for dermatitis. He has no family history of note and works in a senior professional role. He drinks six standard units of alcohol per week, has never been a tobacco smoker and does not use recreational drugs – and his employer undertakes regular drug testing.He had a previous episode of pancreatitis in 2011, precipitated by high alcohol intake during a holiday abroad. He is otherwise previously well. There is no family history of note, his father was a smoker and died of lung cancer in his 60s, his mother is well, he has two siblings and three children all of whom are well. He is not aware of any diseases of note in his extended family.In May 2021 he received his second dose of Pfizer-BioNTech COVID-19 mRNA vaccine, he was well at that time. Four hours after the dose he had two 330ml bottles of 5% alcohol beer with his dinner. Six hours after the dose he became unwell with nausea, epigastric pain, and vomiting. Ten hours after the dose blood tests on admission to hospital included: white cell count 18.5 x109/L (4 - 11), neutrophils 15.5 x109/L (1.9 - 7.5), lymphocytes 0.8 x109/L (1.0 - 4.0), CRP <3 mg/L (<5), lipase 23,750 U/L (10 – 70), and triglycerides 3.3 mmol/L. Acute pancreatitis was diagnosed. An ultrasound scan showed pancreatitis without evidence of cholelithiasis. He subsequently deteriorated and a computer tomography (CT) scan on 17 May, day 9 of the illness, showed severe necrotising pancreatitis with collections.During the admission under a specialist hepatobiliary surgical team, known causes of pancreatitis were excluded including: steroid use, trauma, family history of autoimmune conditions, and infection. He did not have the risk factors of obesity, smoking or heavy alcohol consumption. He had the risk factor of a previous episode of acute pancreatitis. The incidence of pancreatitis in New Zealand Europeans in this age group is approximately 50 per 100,000 per year.2 Idiopathic cases represent about 15% of these.Using the Naranjo criteria, the pancreatitis being ’caused’ by the Pfizer-BioNTech COVID-19 mRNA vaccine score was 6 ‘probable’.3 Clinical case discussion (including a hepatobiliary surgeon, gastroenterologist and clinical pharmacologist) concluded that while idiopathic pancreatitis could not be excluded, the onset of symptoms and findings were consistent with an acute precipitating event around the time the second vaccine dose was administered.In addition to the 176 cases reported in VigiBase™, searches of PubMed and Google Scholar™ identified two published case reports of pancreatitis following the Pfizer-BioNTech COVID-19 mRNA vaccine. These were following administration of the first dose of the Pfizer-BioNTech COVID-19 mRNA vaccine. In one case symptoms developed several hours after vaccine administration and the other several days after vaccine administration.4,5Acute pancreatitis is a rare in patients with COVID-19 but characteristic patterns of illness have been reported.6 This raises the possibility that an immune response to either the virus or the vaccine could have common sequalae.This case of acute pancreatitis was temporally associated with the Pfizer-BioNTech COVID-19 mRNA vaccine suggesting a causal link. The characteristics of pancreatitis cases associated with the Pfizer-BioNTech COVID-19 mRNA vaccine should be examined to see if a consistent pattern is present.VigiAccess™ http://www.vigiaccess.org/ - accessed June 24, 2021.Pendharkar SA, Mathew J, Zhao J, Windsor JA, Exeter J, Petrov MS. Ethnic and geographic variations in the incidence of pancreatitis and post- pancreatitis diabetes mellitus in New Zealand: a nationwide population- based study. 2017;130(1450):14.Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther . 1981;30(2):239-245. doi:10.1038/clpt.1981.154Cieślewicz A, Dudek M, Krela-Kaźmierczak I, Jabłecka A, Lesiak M, Korzeniowska K. Pancreatic Injury after COVID-19 Vaccine—A Case Report. Vaccines . 2021;9(6):576. doi:10.3390/vaccines9060576Parkash O, Sharko A, Farooqi A, Ying GW, Sura P. Acute Pancreatitis: A Possible Side Effect of COVID-19 Vaccine. Cureus . Published online April 28, 2021. doi:10.7759/cureus.14741Bircakova B, Bruha R, Lambert L, Grusova G, Michalek P, Burgetova A. A bimodal pattern of the onset of COVID-19 related acute pancreatitis supports both the cytotoxic and immune-related pathogenesis – a systematic review. Scand J Gastroenterol . 2021;56(7):870-873. doi:10.1080/00365521.2021.1922751

Introduction: Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) is a highly effective cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy (HEMT) originally approved in 2019 for use in patients 12 years of age and older with at least one F508del mutation or a mutation in the CFTR gene that is responsive based on in vitro data. This report describes coverage of ELX/TEZ/IVA for CF in children 6 to 11 years of age prior to the recent age expansion by the Food and Drug Administration (FDA). Methods: An email was sent to pharmacists and pharmacy technicians through the CF Foundation LISTSERV and all responses regarding ELX/TEZ/IVA use in children 6 to 11 years of age were collected. Results: A total of 65 children from 15 CF care centers were included in the study. A total of 55 children had early coverage of ELX/TEZ/IVA for an overall approval rate of 84.6%. The median time to approval was 15 days. Lung function and weight outcomes were also positive. Conclusions: Early insurance coverage of ELX/TEZ/IVA for CF in children 6 to 11 years was achieved regardless of insurance type and should be considered an option for patients in need of HEMT therapy.

Acute respiratory distress syndrome (ARDS) is a disabling and potentially lethal syndrome requiring prompt recognition and urgent interventions to prevent morbidity and mortality[1]. Although constipation is not generally recognized as a cause for ARDS or usually listed within the differential diagnosis, there have been case reports describing such an association[2,3]. We present the case of a patient with history of intermittent constipation presenting with progressive abdominal pain and an acute abdomen that required emergent surgical fecal decompaction. This was followed by hypoxemic respiratory distress leading to respiratory failure in the setting of severe constipation and aspirated feculent material. To our knowledge, this is the first published case report describing aspirated feculent material in a child with respiratory failure due to ARDS.

Masting, the synchronous highly variable flowering across years by a population of perennial plants, has been shown to be precipitated by many factors including nitrogen levels, drought conditions, spring and summer temperatures. However, the molecular mechanism leading to the initiation of flowering in masting plants in particular years remains largely unknown, despite the potential impact of climate change on masting phenology. We studied genes controlling flowering in Chionochloa pallens, a strongly masting perennial grass. We used a range of in situ and manipulated plants to obtain leaf samples from tillers (shoots) which subsequently remained vegetative or flowered. Here, we show that a novel orthologue of TERMINAL FLOWER 1 (TFL1; normally a repressor of flowering in other species) promotes the induction of flowering in C. pallens (hence Anti-TFL1), a conclusion supported by structural, functional and expression analyses. Global transcriptomic analysis indicated differential expression of CpTPS1, CpGA20ox1, CpREF6 and CpHDA6, emphasising the role of endogenous cues and epigenetic regulation in terms of responsiveness of plants to initiate flowering. Our molecular-based study has provided insights into the cellular mechanism of flowering in masting plants and will supplement ecological and statistical models to predict how masting will respond to global climate change.

Food Allergy (FA) is now one of the most common chronic diseases of childhood often lasting throughout life and leading to significant worldwide healthcare burden. The precise mechanisms responsible for the development of this inflammatory condition are largely unknown; however, a multifactorial aetiology involving both environmental and genetic contributions is well accepted. A precise understanding of the pathogenesis of FA is an essential first step to developing comprehensive prevention strategies that could mitigate this epidemic. As it is frequently preceded by atopic dermatitis and can be prevented by early antigen introduction, the development of FA is likely facilitated by the improper initial presentation of antigen to the developing immune system. Primary oral exposure of antigens allowing for presentation via a well-developed mucosal immune system, rather than through a disrupted skin epidermal barrier, is essential to prevent FA. In this review, we present the data supporting the necessity of 1) an intact epidermal barrier to prevent epicutaneous antigen presentation, 2) the presence of specific commensal bacteria to maintain an intact mucosal immune system and 3) maternal/infant diet diversity, including vitamins and minerals, and appropriately timed allergenic food introduction to prevent FA.

Background: Uncontrolled chronic rhinosinusitis (CRS) needing consideration of surgery is a growing health problem yet its risk factors at individual level are not known. Our aim was to examine risk factors of revision endoscopic sinus surgery (ESS) at the individual level by using artificial intelligence. Methods: Demographic and visit variables were collected from electronic health records (EHR) of 790 operated CRS patients. The effect of variables on the prediction accuracy of revision ESS was examined at the individual level via machine learning models. Results: Revision ESS was performed to 114 (14.7%) CRS patients. The logistic regression, gradient boosting and random forest classifiers had similar performance (AUC values .746, .745 and .747, respectively) for predicting revision ESS. The best performance was yielded by using logistic regression and long predictor data retrieval time (AUC .809, precision 36%, sensitivity 70%) as compared with data collection time from baseline visit until 0, 3 and 6 months after the baseline ESS (AUC values .668, .717 and .746, respectively). The number of visits, number of days from the baseline visit to the baseline ESS, age, CRS with nasal polyps (CRSwNP), asthma, NERD and immunodeficiency or its suspicion were associated with revision ESS. Age and the number of visits before baseline ESS had non-linear effects for the predictions. Conclusions: Intelligent data analysis found important predictors of revision ESS at the individual level, such as visit frequency, age, Type 2 high diseases and immunodeficiency or its suspicion.

Widespread screening of asymptomatic people leads to high numbers of false positives when background prevalence is low, even with accurate tests. During the Covid-19 pandemic, not only has the background prevalence been low (vaccine clinical trial baseline testing finds 0.5-0.6% even during periods of higher prevalence), but the various COVID-19 tests are not very accurate. When inaccurate tests are combined with a low background prevalence, this results in a massive and unacknowledged problem of far more false positive test results than true positive test results, leading also to inaccurate characterization of COVID-19 hospitalizations and deaths.

Global climate change is already contributing to the extirpation of numerous species worldwide, and sensitive species will continue to face challenges associated with rising temperatures throughout this century and beyond. It is especially important to evaluate the thermal ecology of endangered ectotherm species now so that mitigation measures can be taken as early as possible. A recent study of the thermal ecology of the federally endangered Blunt-Nosed Leopard Lizard (Gambelia sila) suggested that they face major activity restrictions due to thermal constraints in their desert habitat, but that large shade-providing shrubs act as thermal buffers to allow them to maintain surface activity without overheating. We replicated this study and also included a population of G. sila with no access to large shrubs to facilitate comparison of the thermal ecology of G. sila in shrubless and shrubbed populations. We found that G. sila without access to shrubs spent more time sheltering inside rodent burrows than lizards with access to shrubs, especially during the hot summer months. Lizards from a shrubbed population had higher midday body temperatures and therefore poorer thermoregulatory accuracy than G. sila from a shrubless population, suggesting that greater surface activity may represent a thermoregulatory tradeoff for G. sila. Lizards at both sites are currently constrained from using open, sunny microhabitats for much of the day during their short active seasons, and our projections suggest that climate change will exacerbate these restrictions and force G. sila to use rodent burrows for shelter even more than they do now, especially at sites without access to shrubs. The continued management of shrubs and of burrowing rodents at G. sila sites is therefore essential to the survival of this endangered species.

Background: Premature infants who cannot achieve full oral feeds may need a gastrostomy tube (GT) to be discharged from the neonatal intensive care unit (NICU). We previously developed a model to predict which infants born <30 weeks (w) gestational age (GA) will require a GT before discharge. Here we report the detailed respiratory variable data to describe the general respiratory course for infants in the NICU <30w GA at birth and the association between different levels of respiratory support with postmenstrual age (PMA) at the time of first oral feeding attempt (PMAff), including later need for GT for discharge. Methods: Retrospective chart review of 391 NICU admissions comprising test (2015-2016) and validation (2017-2018) cohorts. Data, including respiratory support, were collected on 204 infants, 41 GT and 163 non-GT, in the test cohort, and 187 infants, 37 GT and 150 non-GT, in the validation cohort. Results: Respiratory data were significantly different between GT and non-GT infants. Infants who required GT for discharge were on significantly higher respiratory support at 30 days of age, 32w PMA, and 36w PMA. Respiratory parameters were highly correlated with PMAff. Conclusion: Respiratory status predicts PMAff, which was the variable in our previously described model that was most predictive of failure to achieve full oral feeing. These data provide a catalyst to develop strategies for improving oral feeding outcome for infants requiring prolonged respiratory support in the NICU.

Rabbit Haemorrhagic Disease (RHD) is a significant viral disease affecting lagomorphs. The first documented cases of RHD in Singapore occurred in adult pet European rabbits in September 2020. Singapore subsequently declared the outbreak resolved in December 2020. Epidemiological investigations ruled out introductions via importation of infected rabbits and contaminated feed. The source could not be definitively determined. However, the findings suggest that the incident involved both inter- and intra-household transmission and veterinary clinic-household transmission. This incident demonstrated the importance of sustained application of biosecurity measures, epidemiological investigations, and control, including active case finding, expedient vaccine dissemination, and risk communications. It shows that Singapore, an urbanised city-state, without a significant lagomorph population, could still encounter emerging diseases such as rabbit haemorrhagic disease. Given its social impact on rabbit owners, the National Parks Board Singapore and the private veterinarians worked together to communicate and urge the adoption of biosecurity measures and assuage the concerns of rabbit owners.

Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence and has variable presentation. Due to rarity, it may often be misdiagnosed as post-dural puncture headache. In this report, we describe a case of a 25-year-old woman who presented with a headache following lower segment cesarean section after spinal anesthesia.

We recommend carrying out a detailed history and evaluation for recent or past COVID-19 infection in patients presenting with Sudden Sensorineural Hearing Loss (SSNHL) since SSNHL could be a sequelae of COVID-19 as in our case and timely diagnosis and intervention could significantly improve hearing and quality of life.

Climate change is altering the relative timing of species interactions by shifting when species appear in a community and by accelerating developmental rates. However, phenological shifts may be mediated through community contexts, such as intraspecific competition and alternative resource species, which can prolong the otherwise shortened windows of availability. Using a combination of laboratory experiments and dynamic simulations, we quantified how the effects of phenological shifts in Drosophila-parasitoid interactions differed with concurrent changes in temperature, intraspecific competition, and the presence of alternative host species. We found that community context, particularly the presence of alternative host species, supported interaction persistence across a wider range of phenological shifts than pairwise interactions. Parasitism rates declined under warming, which limited the ability of community contexts to manage mismatched interactions. These results demonstrate that ongoing declines in insect diversity may exacerbate the effects of phenological shifts in ecological communities under future global warming temperatures.

Objective: Compare the risk of recurrent adverse delivery outcome (ADO) or adverse neonatal outcome (ANO) between consecutive gestational diabetes (GDM) pregnancies. Design: Retrospective cohort Setting: Sydney, Australia Population or Sample: 424 pairs of consecutive singleton GDM pregnancies, 2003-2015 Main Outcome Measures:. ADO: instrumental delivery and emergency Caesarean. ANO: large for gestational age (LGA), small for gestational age (SGA), and composite ANO (LGA/SGA/stillbirth/neonatal death/shoulder dystocia). Methods: Using each pregnancy pair (“index” and “subsequent” pregnancy), we calculated ADO and ANO rates and determined risk factors for subsequent pregnancy outcomes (multivariate regression). Results: Subsequent pregnancies had higher rates of elective Caesarean (30.4% vs 17.0%, p<0.001) and lower rates of instrumental delivery (5% vs 13.9%, p<0.001), emergency Caesarean (7.1% vs 16.3%, p<0.001) and vaginal delivery (62.3% vs 66.3%, p=0.01). ANO rates in index and subsequent pregnancies did not differ. Index pregnancy adverse outcome was associated with a higher risk of repeat outcome: RR 3.09 (95%CI:1.30, 7.34) for instrumental delivery, RR 2.20 (95%CI:1.06, 4.61) for emergency Caesarean, RR 4.55 (95%CI:3.03, 6.82) for LGA, RR 5.01 (95%CI:2.73, 9.22) for SGA and RR 2.10 (95%CI:1.53, 2.87) for composite ANO). The greatest risk factor for subsequent LGA (RR 3.13 (95%CI:2.20, 4.47)), SGA (RR 4.71 (95%CI:2.66, 8.36)) or composite ANO (RR 2.01 (95%CI:1.46, 2.78)) was having the same outcome in the index pregnancy. Conclusions: Women with GDM and an adverse outcome are at very high risk of the same complication in their subsequent GDM pregnancy, representing a high-risk group that should be targeted for directed management over routine care.