In this paper, we mainly study the existence of solution of fractional differential equations. Firstly, the existence of the maxmum solution and minmum solution of the differential equation are proved by using the fixed point theorem and the monotone iteration method. Secondly, the existence of the solution of the original equation is proved by using the newly constructed differential equation. Finally, the application of the monotone iteration method is given through an example.

Basophil activation testing is useful for the evaluation of life-threatening radiocontrast media anaphylaxisJamma Li, MBBS, MPhil (USyd)Clinical Immunologist and AllergistDepartment of Clinical Immunology and Allergy, Royal North Shore Hospital, Reserve Road, St Leonards NSW 2065, AustraliaUniversity of Sydney, Sydney, AustraliaJamma.li@health.nsw.gov.auChristopher Weir, PhDUniversity of Sydney, Sydney, AustraliaSuran Fernando, MBBS, PhDDepartment of Clinical Immunology and Allergy, Royal North Shore Hospital, Reserve Road, St Leonards NSW 2065, AustraliaUniversity of Sydney, Sydney, AustraliaConflicts of interest: noneFunding source: noneKeywords: allergy, radiocontrast allergy, drug allergy, drug provocation testing, drug challengeWord Count: 582Figures: 0Tables: 2To the EditorThe mechanism of immediate hypersensitivity reactions (IHR) to radiocontrast media (RCM) is not fully elucidated (1, 2). Allergic (IgE-mediated) mechanisms may account for >50% of life-threatening IHR, as detected by skin testing (ST) (3). Basophil activation testing (BAT) may be useful for demonstrating allergic sensitisation for severe RCM IHR as there is correlation with ST or drug provocation testing (DPT) without the risk profile (3). ST is relatively standardised compared to BAT. DPT is recommended only for ST-negative RCM (3).Our study focusses on the usefulness of BAT for evaluating life-threatening RCM IHR and planning of safe subsequent RCM administration. We sequentially recruited patients at a tertiary institution in Sydney, Australia between July 1, 2019 and June 30, 2020. All patients experienced symptoms consistent with Grade 3 or 4 anaphylaxis within 1 hour of RCM administration (4). Clinical characteristics and mast cell tryptase levels were collected. Testing was performed to RCMs available in our institution; iodixanol (Visipaque, GE Healthcare Australia Pty Ltd, Sydney, Australia), iohexol (Omnipaque, GE Healthcare Australia Pty Ltd), iopromide (Ultravist, Bayer Australia Ltd, Sydney, Australia), meglumine iotroxate (Biliscopin, Bayer Australia Ltd), and sodium diatrizoate and meglumine amidotrizoate (Urografin, Bayer Australia Ltd). ST was performed to EAACI guidelines (1). BAT was performed in line with our protocol (5) at 1:10000-1:10 dilutions. Results were expressed as percentage upregulation above the negative control, and stimulation index (SI) for CD63 and CD203c. If ST to Urografin was negative, the patient proceeded to single-dose oral sodium diatrizoate 100mg and meglumine amidotrizoate 660mg DPT (Gastrografin 100mL, Bayer Australia Ltd) with no premedication. Patients then proceeded to routine RCM administration for contrast radiography, or 0.5ml/kg single-dose intravenous RCM challenge with alternative suitable ST-negative RCM/s with no premedication.Patient characteristics are shown in Table 1. Ten study patients were enrolled, the culprit RCMs were iohexol (n=5), iopromide (n=2), and amidotrizoate (n=1). Two patients did not have RCM anaphylaxis and reserved as controls (RCM extravasation, and vasovagal syncope). Findings are shown in Table 2. Six (75%) had significant change in mast cell tryptase. Five (62.5%) had positive ST to the culprit RCM, all had significant tryptase change. Using standard cut-offs for BAT of 5% and 10% upregulation for CD63 and CD203c respectively, and a SI >2.0 (5,6), there were 4 false positives to amidotrizoate, and 1 to iohexol. Adjusting cut-offs to 10% and 15% reduced false positives to 2 for amidotrizoate, and 0 for iohexol. BAT was positive to the culprit RCM in 5 patients (62.5%), including 2 ST-negative patients. Six of 8 (75%) were only positive to the culprit drug on ST and BAT. Both control patients had negative ST and BAT. There was significant lack of agreement between ST and BAT (P<0.05) (McNemar’s test).Our case series centres on patients with life-threatening RCM IHR. Seven of 8 (87.5%) had a positive ST or BAT suggesting that most Grade 3 or 4 anaphylaxis has an allergic mechanism. Also, the patient with negative ST and BAT was evaluated remotely (1706 days from reaction). In this study, BAT was a useful adjunct to ST as it identified an extra 2 patients with allergic IHR. BAT was not useful for amidotrizoate with a significant false positive rate (29%).Therefore, most life-threatening RCM IHRs may have an allergic mechanism. This is significant, as in allergic IHR there may be less cross-reactivity with other RCM. BAT may be a useful adjunct to ST to demonstrate this allergic mechanism. Further study can optimise performance characteristics of BAT, especially for amidotrizoate.Contribution: JL, CW performed the experiments; J.L, CW, SF analysed the results and constructed the tables; JL, CW and SF developed and designed the research; JL wrote the paper.1. Torres M, Trautmann A, Bohm I, et al. Practice parameters for diagnosing and managing iodinated contrast media hypersensitivity. Allergy 2021;76:1325-39.2. Brockow K, Romano A, Aberer W, et al. Skin testing in patients with hypersensitivity reactions to iodinated contrast media – a European multicenter study. Allergy. 2009;64:234-41.3. Clement O, Dewachter P, Mouton-Faivre C, et al. Immediate Hypersensitivity to Contrast Agents: The French 5-year CIRTACI Study. EClinicalMedicine 2018;1:51-61.4. Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet 1977;1:466-9.5. Li J, Best O, Rose M, Green S, Fulton R, Fernando S. Integrating basophil activation tests into evaluation of perioperative anaphylaxis to neuromuscular blocking agents. Br J Anaesth. 2019;123:e135-43.6. Pinnobphun P, Buranapraditkun S, Kampitak T, Hirankarn N, Klaewsongkram J. The diagnostic value of basophil activation test in patients with an immediate hypersensitivity reaction to radiocontrast media. Ann Allergy Asthma Immunol. 2011;106:387-93.Table 1. Patient characteristics

The coronavirus disease 2019 (COVID-19) pandemic started over one year ago and produced almost 3.5 million deaths worldwide. We have been recently overwhelmed by a wide literature on how the immune system recognizes Severe Acute Respiratory Syndrome Coronavirus 2 and contributes to COVID-19 pathogenesis. Although originally considered a respiratory viral disease, COVID-19 is recognized as a far more complex, multi-organ-, immuno-mediated-, and mostly heterogeneous disorder. Though efficient innate and adaptive immunity may control infection, when the patient fails to mount an adequate immune response, a high innate-induced inflammation can lead to different clinical outcomes through heterogeneous compensatory mechanisms. The variability of viral load and persistence, the genetic alterations of virus-driven receptors/signaling pathways and the plasticity of innate and adaptive responses may all account for the extreme heterogeneity of pathogenesis and clinical patterns. As recently done for some inflammatory disorders as asthma, rhinosinusitis with polyposis and atopic dermatitis, herein we suggest to define different endo-types and the related phenotypes along COVID-19. Patients should be stratified for evolving symptoms and tightly monitored for surrogate biomarkers of innate and adaptive immunity. This would allow to preventively identify each endo-type (and its related phenotype) and to treat patients precisely with agents targeting pathogenic mechanisms.

A document by Isabella Annesi. Click on the document to view its contents.

The realization of the enormous potential of stem cells requires development of efficient bioprocesses and optimization drawing drawn from mechanobiological considerations. Here, we emphasize the importance of mechanotransduction as one of the governing principles of stem cell bioprocesses, underscoring the need to further explore the behavioral mechanisms involved in sensing mechanical cues and coordinating transcriptional responses. We identify the sources of the intrinsic, extrinsic, and external noise in bioprocess under uncertainty, and discuss criteria and indicators that might assess and predict cell-to-cell variability resulting from environmental fluctuations. Specifically, we propose a conceptual framework to explain the impact of mechanical forces within cellular environment and identify key cell state determinants in bioprocess and discuss their implementation challenges.

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection has milder presentation in children than adults, mostly requiring only supportive therapy. The immunopathogenic course of COVID-19 can be divided in two distinct but overlapping phases: the first triggered by the virus itself and the second one by the host immune response. Cytokine storm induces Acute Respiratory Distress Syndrome (ARDS) in 20-30% of adults while less than 1% of children develops severe pulmonary or systemic involvement as Multisystem Inflammatory Syndrome in Children (MIS-C), requiring intensive care. Less severe lung injury in children could be explained by qualitative and quantitative differences in age-related immune response. Evidence on the best therapeutic approach for COVID-19 lung disease in children is lacking. Currently, the approach is mainly conservative and based on supportive therapy. However, in hospitalized children with critical illness and worsening lung function, antiviral therapy with remdesivir and immunomodulant treatment with systemic steroids could be considered the “therapeutic pillars”. In addition, optimal disease control of allergic and asthmatic children and, in the near future, vaccinations are expected to be important as preventive strategies to reduce the COVID-19 burden.

Background: Ineffective erythropoiesis (IE) is the most prominent feature of transfusion-dependent beta-thalassemia (TDT), which leads to extramedullary hemopoiesis. The rejection rate in allogeneic hematopoietic stem cell transplantation (HSCT) is clearly superior in heavily transfused patients (pts) with TDT accompanied by prominent IE. Therefore, a pre-transplantation treatment bridging to HSCT is often used to reduce allosensibilization and IE. Ruxolitinib (RUX) is a JAK-1/JAK-2-inhibitor and has showed its efficacy to suppress IE and the immune system. A previously published study on RUX in adult pts with TDT has revealed that this treatment significantly reduces spleen size and is well tolerated. Procedure: Ten pts (5-14 y.o.) with TDT and an enlarged spleen were enrolled. The dose of RUX was adjusted for age: for pts younger < 11 years: 40 - 100 mg/m2 and for pts >11 years: 20 - 30 mg/m2. HSCT was performed in 8 out of the 10 pts. Results: After the first 3 months of RUX therapy the spleen volume decreased in 9 out of the 10 cases by 9.1 – 67.5% (M = 35.4%) compared to the initial size (р = 0.003). The adverse events of RUX included infectious complications, moderate thrombocytopenia as well as headache and were successfully managed by reducing the dose. The outcomes of HSCT were favorable in 7 out of the 8 cases. Conclusion: RUX is promising as a short-term pre-HSCT treatment for pediatric pts with TDT and pronounced IE.

To analyze the role of Epstein-Barr virus (EBV) in the biological and clinical characteristics of patients treated for classic Hodgkin lymphoma (cHL) in France. Bio-pathological data of 301 patients treated for a cHL in or according to the protocol of the EuroNet PHL-C1 trial between November 2008 and February 2013 were centrally reviewed. Median age at diagnosis was 14 [3-18] years and the F/M ratio 0.86, 0.47 before 10 years and 0.9 from 11 to 18. CHL subtypes were nodular sclerosis for 266/301 (88%) patients, mixed cellularity for 22/301 (7%), lymphocyte rich for 2/301 (1%), and 11/301 were unclassified. EBV expression in situ (EBV cHL) was observed for 68/301 (23%) patients, significantly associated with MC subtype and male gender, and there was a trend with age <10 years, it was particularly overrepresented in boys below 10 years: 15/23 (65%) vs 28/139 among other male patients (20%). Event-free and overall survival were equivalent between EBV and non-EBV cHL patients. EBV viral load was tested for 108/301 patients and detectable in 22/108 (22%) cases. A positive viral load was overrepresented in EBV cHL versus non-EBV cHL patients: 13/28 (46%) vs 9/80 (11%). Detailed semi-quantitative histological analysis showed a high number of B-cell residual follicles in EBV cHL and no significant association with CD 20 or PAX 5 immunostaining in tumoral cells relative to EBV-negative HL. Distribution of EBV cHL in children and adolescents is associated with young age and male gender, suggesting a specific physiopathology and may require a differential therapeutic approach.

In this study, a theoretical investigation of the photoinduced charge transfer (CT), electron injection, regeneration and Non-linear optical (NLO) of the A1-A4 structures were carried out for optoelectronic applications based on tetrahydroquinoline (C1-1) dye. Besides, a detailed assessment of the association among the electronic structures, chemical hardness, spectral and photovoltaic (PV) presentation were defined in DSSCs. Furthermore, this exploration purposes improved the electron-injection procedure, as well as the light-harvesting efficiency (LHE) of the dyes. For the research purpose, PO3H2, CONHOH, SO2H and OH (A1-A4) chromophores effects among the tetrahydroquinoline moieties related via a thiophene group were used as the electron acceptor group. The density functional theory (DFT) and time-dependent DFT (TD-DFT) calculations were executed on the designing dye molecules. The presentation of three functional groups (Becke’s three-parameter and Lee-Yang-Parr (B3LYP), coulomb-attenuating method-B3LYP (CAM-B3LYP) and Head-Gordon model (ωB97XD) were analyzed maximum absorption peak for C1-1. Here, TD-ɷB97XD with the 6-31G(d) combined functional and basis set were provided reliable effects to the C1-1. Therefore, newly designed A1-A4 dyes in absorption spectra were followed by TD-ɷB97XD method. Among these results, A1 dye displays red-shift and higher molar extinction coefficient than the other dyes and C1-1. It is specified that the PO3H2 have better PV properties, compared to literature. The NLO belongings of the A1-A4 sensitizers were derived in the polarizability and first-order hyperpolarizability. The calculated value of A1 dye has best for NLO presentation. The theoretically outcomes were intensely recommended that molecular proposal of the sensitizer has a vital role for the optoelectronic properties.

The initial configuration of Yttrium oxide clusters (Y2O3)n(n=1-15) was creatively constructed by combining artificial bee colony algorithm with density functional theory. The structures of large and medium-sized yttrium oxide clusters with molecular number greater than 10 were established for the first time, and many new structures that are different from existing research have been obtained. The average binding energy, second-order difference energy, HOMO-LUMO gap, density of states and other properties of the clusters were analyzed. The thermodynamic properties and behavior of nano yttrium oxide clusters at different temperatures and sizes were discussed. Studies have shown that for small-sized clusters, the atomic stacking structure is cage-like, while for medium-sized and large-sized clusters, the composite trapezoidal structure and ellipsoid-like structure are more stable. The nanoclusters tend to be stable as a whole, and the relative stability of the cluster structure is higher when n = 2,4,7,9. The effect of yttrium oxygen atomic orbital on bonding is analyzed. The heat capacity (Cp), enthalpy change (H) and entropy (S) of (Y2O3)n (n=1-15) clusters increase with the increase of temperature (T), and the vibration free energy (Gv) decreases with the increase of T. The stability of the clusters changes in the temperature range of 300K-500K.

Estimating the distribution of phenotypes in populations and communities is central to many questions in ecology and evolutionary biology. These distributions can be characterized by their moments: the mean, variance, skewness, and kurtosis. Typically, these moments are calculated using a community-weighted approach (e.g. community-weighted mean) which ignores intraspecific variation. As an alternative, bootstrapping approaches can incorporate intraspecific variation to improve estimates, and also quantify uncertainty in the estimate. Here, we compare the performance of different approaches for estimating the moments of trait distributions across a variety of sampling scenarios, taxa, and datasets. We introduce the traitstrap R package to facilitate inferences of trait distributions via bootstrapping. Our results suggest that randomly sampling ~9 individuals per sampling unit and species, focusing on covering all species in the community, and analysing the data using nonparametric bootstrapping generally enables reliable inference on trait distributions, including the central moments, of communities.

Background Real-life data on the predialysis management of chronic kidney disease (CKD) is scarce. We aimed to investigate the current clinical practice and compliance among nephrologists with KDIGO CKD mineral bone disorders (MBD) guidelines. Methods We performed a multicenter cross-sectional study. We recruited stage 3-5 non-dialysis (ND) CKD patients and recorded data related to CKD MBD from two consecutive outpatient clinical visits apart 3 to 6 months. We calculated therapeutic inertia for hyperphosphatemia, hypocalcemia, hyperparathyroidism, and hypovitaminosis D and overtreatment for hypophosphatemia, hypercalcemia, hypoparathyroidism, and hypervitaminosis D. Results We examined a total of 302 patients (male: 48.7%, median age: 67 years). The persistence of low 25-OH vitamin D levels (61.7%) was the most common laboratory abnormality related to CKD-MBD, followed by hyperparathyroidism (14.8%), hyperphosphatemia (7.9%), and hypocalcemia (0.0%). According to our results, therapeutic inertia seems to be a more common problem than overtreatment for all the CKD-MBD laboratory parameters that we examined. Therapeutic inertia frequency was highest for hypovitaminosis D (81.1%), followed by hypocalcemia (75.0%), hyperparathyroidism (59.0%), and hyperphosphatemia (30.4%), respectively. Conclusion We found that CKD-MBD is not optimally managed in CKD stage 3-5 ND patients. Clinicians should have an active attitude regarding the correction of MBD even at the earlier stages of CKD.

Background: The association of double aortic arch and common arterial trunk is extremely rare. The initial surgical approach depends on the patient’s clinical condition and associated cardiac anomalies. Aim: To report a rare association of common arterial trunk with double aortic arch in a 4-month-old female infant. Methods: description of case of a rare association where double aortic arch was not diagnosed initially, surgical repair was done successfully. Results and conclusions: associated cardiovascular anomalies may have an impact on management and outcome. Magnetic resonance imaging and computed tomography may be useful in assessment of this rare association. Complete repair has favorable outcome.

Background: Insomnia is a very common sleep disorder which is encountered to a greater extent in cohorts of the population as they get older. The author of this paper has suffered from the effects of insomnia. He has performed some experimentation on himself with a number of publicly available supplements including Melatonin with a view to ameliorating the insomnia with some success. He will be writing papers which report his conclusions. This is the first. Methods: Over a period of 3 years the author has tried a range of different strategies for reducing the effects of insomnia with supplements including Melatonin and measured the effects on his sleep using a sleep monitor and otherwise. Results: It is clear for the test subject that relatively substantial doses of Melatonin (15-110mg) taken during the night can assist with the failure of sleep maintenance and thereby improve the ability of the subject to function intellectually during the day rather than suffer from afternoon fatigue. There may be other people that this approach could benefit. Caution and further research is, however, needed as there may be side effects. An alternative strategy is to clear down the melatonin system and restart it.

The present work focuses on the synthesis and characterization of four hydrazone derivatives. The structures of the synthesized compounds were determined through spectroscopic techniques via., EI MS, &1H NMR. The experimental results demonstrate that the obtained compounds successfully synthesize and screened for DPPH free radical scavenging activity, ferrous ion-chelating activity, ferric ion reducing activity, total antioxidant activity, and hydroxyl radical scavenging activity. Density Functional Theory (DFT) calculations were carried out by the Gaussian 09 package by using a hybrid density functional B3LYP (at 6-31G, 6-311G, and 6-31G++(d,p) basis sets) to investigate the electronic, molecular structures and provide useful spectroscopic and structural information. The computational data obtained from 1H NMR calculations were quite compatible with the experimental results. DFT calculations optimized the molecular geometry and estimated the highest occupied molecular orbital (HOMO) and lowest unoccupied molecular orbital (LUMO) energy of these compounds. Additionally, the charge transfer within the molecule and favorable sites for the electrophilic and nucleophilic attack was explored. Furthermore, the frontier molecular orbital (FMO) calculations were used to calculate different reactivity parameters, i.e., ionization potential, electron affinity, electronegativity, chemical hardness, chemical softness, and electrophilicity index.

Background Use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (e.g. acute Type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favour of improved surgical access and outcomes. This review seeks to elucidate whether proximalisation of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes. Methods We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. Results Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. Conclusion Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review therefore recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalisation of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.

Title: Cardiac surgery and healthcare quality: Is the right question being asked?Authors : Abdullah Nasif, MD1/ Saqib Masroor, MD1 1Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo Medical Center Toledo, OH USAManuscript: Minimally Invasive Mitral Valve Surgery After Previous Sternotomy: A Propensity-Matched Analysis.Disclosure : NoneWord Count : 1381Even though by 2003, Casselman (and many others) had concluded that totally endoscopic mitral valve repair can be performed safely with excellent results and a high degree of patient satisfaction1, less than a quarter of all isolated mitral valve procedures were performed using minimally invasive approach (MIS) by 20162. Conventional sternotomy (ST) remains the approach of choice in the majority of cardiac surgery centers. Since 2011, partial sternotomy has fallen out of favor and right mini thoracotomy (RMT) approach has been the major MIS approach (with or without robotics) for both primary as well as re-operative mitral valve surgery. At experienced centers, the indications for MIS surgery have been expanded to include complex pathologies, reoperative surgery, endocarditis, as well as a hybrid open approach for severely calcified mitral annuli using an open deployment of transcatheter aortic valve3-5.One reason for the slow adoption of MIS has been the lack of randomized prospective trials comparing the conventional sternotomy approach with MIS. Most literature supporting the use of MIS has consisted of retrospective review of series of individual surgeons or centers, which have shown a shorter length of stay, reduced need for transfusions and a quicker recovery2,3. Since these reports came from centers with extensive experience and the fact that initial cohorts of patients undergoing MIS were relatively lower risk patients, these retrospective observational studies were not as convincing in their conclusions, because the two groups of patients were not similar. Only a few propensity-matched analyses comparing MIS vs sternotomy have so far been reported in patients undergoing primary surgery4-6.For re-operative mitral valve surgery, there has been one propensity-matched comparison of 42 pairs of patients undergoing right mini-thoracotomy MIS vs sternotomy from China7. MIS patients had lower transfusions, shorter length of stay and lower costs, while having similar mortality. However, the study had a mean length of stay of 22 days vs 16 days and mortality of 11% vs 7 % for sternotomy and MIS patients, respectively and thus the results cannot be reliably generalized.In this issue of the Journal , Hamandi et al8, reviewed 305 isolated MV reoperations that were performed in a single institution between 2007-2018. Patients who underwent MIS MV reoperation totaled 199, while sternotomy operations were 106. The primary endpoints were operative mortality and 1-year survival with operative complications and length of stay being secondary endpoints. Median age of patients was 69 years with an equal gender distribution. The team performed propensity-matched analysis to compare the two groups.There were 88 well-balanced matched pairs. There was no statistically significant difference in mortality among the matched groups at 30 days (3.4% vs 8.0%, p=0.19) or at 1-year (15.9% vs. 16.5%, p=0.9). Comparing long-term survival rates, no statistically significant difference was found up to 5 years postoperatively. Also, the incidence of post-operative complications such as atrial fibrillation, valve dysfunction or renal failure didn’t show any statistically significant difference. However, intraoperative blood utilization was significantly lower among the MIS cohort (p<0.01). Patient satisfaction was not evaluated as is not possible in a retrospective analysis. Neither was readmission rates and other similar measures which would be important in a value-based care system.The 30-day mortality difference (3.4% vs 8%), while not statistically significant, tended to be lower in MIS patients. 4 patients in the MIS group converted to sternotomy due to adhesions. It is not clear from the manuscript, if the mortality in the MIS group was in some way related to the conversions or not. But based on our experience over the years and from the analysis of this manuscript, we recommend an early conversion to sternotomy if one is dealing with difficult adhesions, rather than risking a long tedious operation and possibly emergently converting to sternotomy. It is also important to note that 75% of patients were discharged home, however readmission rate is unknown. With the advent of value-based purchasing, readmission rates should also be looked at. Overall, the authors should be congratulated on their excellent management of this subset of patients and for taking the time share their experience with us.Propensity score matching is commonly used in evaluation research to estimate average treatment effects.9 The main benefit in using this statistical method is to remove confounding bias from observational cohorts. It attempts to reduce the effects of confounders by matching already treated subjects with control subjects who exhibit a similar propensity for treatment based on preexisting covariates that influence treatment selection. However, it is limited in that it requires the removal of data and works primarily on binary treatments. In this study, by including standardized mean difference (SMD), the authors were able to balance the covariates in this propensity-matched analysis.Other than being a single-center retrospective study, this study suffered from other short-comings of a propensity match study, such as the loss of study power due to the decreased sample size after performing propensity matching. Also, “the surgeon effect” was noted. Since the MIS MV reoperative surgeries were performed by the same surgeons who performed the sternotomy cases, the results may not be generalizable.The question being addressed by this manuscript (and by most other similar comparisons of one therapy vs another) is, “Is MIS better than sternotomy?”Unfortunately, that question cannot be satisfactorily addressed with this or similar studies. Healthcare quality has evolved since its inception in 1999 with the Institute of Medicine report, titled “To Err is human”. In the subsequent report “Crossing the Quality Chasm”11, a high-quality care is defined as beingsafe, effective, patient-centered, timely, efficient and equitable. Our healthcare delivery system is changing, and so should our research methodologies. Our analyses should go deeper than scratching the surface with mortality and morbidity data. Most studies, including this one by Hamandi et al, do not even address “effectiveness” adequately in the context of healthcare quality. Having similar mortality and morbidity means that both approaches are equally ‘safe ’. We have little information about other measures of safety, such as readmissions, central line associated blood borne infections. We have not evaluated whether the two approaches were patient centered (Did the patient participate in choosing the approach?), efficient (Cost of care) or equitable.As cardiac surgeons dealing with life and death from up close, we are not used to viewing healthcare from the rather distant 6-pronged quality viewpoint mentioned above. But this is important for a very important reason which I explain below.Individual surgeons and patients may not have the power to bring about a meaningful change in the way we do business everyday. But just like state pension funds pressured oil companies into facing climate change10, big stakeholders like insurance companies and other payers may be able to convince the cardiac surgeons to face the future. For that to happen, quality metrics such as readmission rates, cost of care and patient satisfaction must be looked at and reported, because that is how these stakeholders assess quality. According to some studies7 MIS approach is better in terms of cost and patient satisfaction. Such comprehensive analyses of quality will go a long way in answering a slightly different question than the one posed earlier; “Does MIS offer better quality than sternotomy?”If we want to influence healthcare delivery and have a passion for quality, then our research methodology must reflect the high standards, that we have set for our clinical work. We should also develop new measures of quality besides morbidity and mortality. We have to look at those metrics that have traditionally been ignored by surgeons, but are important for the payers and the hospitals that rely on these payers for their success. As far a minimally invasive vs sternotomy approach is concerned, that question is not going to last for long. Not because one side would have won or the other lost, but because for those that have not yet boarded the train of minimally invasive mitral valve surgery, that train may have already left the station, moving at full speed ahead towards the “percutaneous station”. It is not a matter of if , but when , sternotomy would not be the standard of care for mitral valve surgery. Today’s vascular surgeons save open repair of abdominal aortic aneurysm for a very small subset of patients. There is no reason to believe that tomorrow’s mitral valve surgeons will consider open sternotomy any differently for mitral valve surgery.

Generalized polarizabilities and the molecular charge distribution can describe the response of a molecule in an arbitrary static electric field up to second order. Depending on the expansion functions used to describe the perturbing potential, the generalized polarizability matrix can have rather large dimension (~1000). This matrix is the discretized version of the density response function or electronic susceptibility. Diagonalizing and truncating it can lead to significant (over an order of magnitude) speed-up in simulations. We have analyzed the convergence behavior of the generalized polarizability using a plane wave basis for the potential. The eigenfunctions of the generalized polarizability matrix are the natural polarization potentials. They are potentially useful to construct efficient polarizability models for molecules.

Aims: A commonly encountered problem in emergency care is pneumothorax, identified by air present in pleural space, occurring spontaneously, principally because of trauma or pathogenic factors like a central venous catheter, mechanical ventilation, and biopsy. Employing Chest ultrasound for diagnosing pneumothorax in an emergency is currently investigated by many researchers. The present meta-analysis aimed to assess Chest ultrasound’s diagnostic accuracy in diagnosing the pneumothorax during emergencies. Material and Methods: Literature search of published articles in MEDLINE, Embase, Ovid, Scopus, and Journal on web databases from 2000 up to November 2020 were reviewed for the pre-described outcomes. Results: 12 articles were finally chosen for quantitative analysis. The overall sensitivity of ultrasound scan in pneumothorax diagnosis was 89% (95 % CI – 86 – 91%). Specificity was 96% (CI – 95% – 97%). The diagnostic odds ratio was 193.94 (59.009 – 637.40) at 95% CI, thus demonstrating greater chest ultrasound accuracy in diagnosing pneumothorax. Conclusion: A definite evidence of chest ultrasound accuracy was noted in pneumothorax.

Phosphate is essential for plant growth and development. Root architecture alternations induced by phosphate starvation (-Pi), including primary root and lateral root growth, are mediated by iron (Fe). However, whether and how Fe participates in the -Pi-induced root hair growth (RHG) remains unclear. Here, with morphological, proteomic, and pharmacological analysis, we investigate the impacts of Fe on RHG under -Pi and the underlying mechanisms. We found that -Pi-induced RHG was affected by the local Fe availability. Reduced sensitivity to Fe was found in aux1-7, arf10arf16, and phr1 under -Pi, indicating auxin and phosphate starvation-induced responses were required for the Fe-triggered RHG under -Pi. Fe availability was then found to affect the auxin distribution and expression of phosphate starvation-responsive (PSR) genes. Proteomic analysis indicated vesicle trafficking was affected by Fe under -Pi. With the application of brefeldin A, we found the vesicle trafficking was affected by Fe, and root hairs displayed reduced sensitivity to Fe, indicating the vesicle trafficking is critical for Fe-triggered RHG under -Pi. Our data suggested that Fe is involved in RHG under -Pi by integrating the vesicle trafficking, auxin distribution, and PSR. It further enriches the understanding of the interplay between phosphate and iron on RHG.

We evaluated the response of liana community structure and the patterns of liana-tree interaction structure to forest edge in two moist semi-deciduous forests in Ghana (Asenanyo and Suhuma Forest Reserves: AFR and SFR, respectively). Liana community structure and liana-tree interactions were assessed in 24 50 × 50 m randomly located plots in three forest sites in each forest: edge, interior and deep-interior established at 0-50 m, 200 m and 400 m from edge. Edge effects positively and negatively influenced liana diversity in forest edges of AFR and SFR, respectively. There was a positive influence of edge disturbance on liana abundance in both forests. More liana species experienced positive magnitude of edge influence (MEI) on their abundance. We observed anti-nested structure in all the liana-tree networks in AFR, while no nestedness was observed in the three networks in SFR. The networks in both forests were less connected, and more modular and specialised than their null models. Many liana and tree species were specialised, with the specialisation tending to be symmetrical. Topologically, most of the species were peripherals, with only a few connectors, module hubs, and network hubs. Some of the species showed consistency in their topological roles from one site to another, while the roles of other species changed. Generally, liana species co-occurred randomly on tree species in all the forest sites except edge site in the Asenanyo Forest Reserve. The findings of the study deepen our understanding of liana-tree interactions, provide implications for conservation, and may contribute to development of a robust edge theory.

This article used three diversion power stations with different operating years along Dicun stream of the source of Jiulong River to study the riparian plant community and discussed the impact of power station development on riparian plants. The results showed that:(1)There were significant differences in the plant diversity of herbs, shrubs and trees among all sample plots in the study area (P < 0.05).(2) The species number of the second and third diversion power stations with longer operation time was larger than that of the fourth diversion power station with short operation time.(3) The water-borne plants were concentrated in the herb layer in the influence area of the diversion power station, and the Richness, Shannon- Wiener, Simpson and Pielou indexes of water-borne plants in the study area were significantly different (P < 0.05). (4) The appearance of diversion power station leaded to the change of environmental factors, and the river depth and flow rate had significant positive correlation with the diversity index of riparian plants and water water-borne plants (P < 0.05). In general, with the increase of the operation time of the power station, the surrounding riparian plant will form a new stable community.

Carotenoids are important pigments producing integument coloration; however, their dietary availability may be limited in some environments. Many species produce red to yellow hues using a combination of carotenoids and self-synthesised pteridine pigments. A compelling but untested hypothesis is that pteridines replace carotenoids in environments where carotenoid availability is limited. Based on a phylogenetic comparative analysis of pigment concentrations in agamid lizards, we show that environmental gradients predict the ratio of carotenoids to pteridines; carotenoid concentrations are lower and pteridine concentrations higher in arid environments with low vegetation productivity. Both carotenoid and pteridine pigments were present in all species, but only pteridine concentrations explained colour variation among species and there were no correlations between carotenoid and pteridine pigments with similar hue. These results suggest that pteridine pigments replace carotenoids in carotenoid-limited environments, irrespective of skin hue, presumably because it is metabolically cheaper to synthesise pteridines than to acquire and sequester carotenoids when carotenoids are rare.

The transfer process and variation characteristics of water and heat fluxes play an important role in both ecosystems function and climatic patterns of arid and semi-arid areas. However, both water (latent heat flux, Fe) and heat (sensible heat flux, Fh) fluxes and the impact factors have different time scales. Therefore, the wavelet transformation was used to reconstruct water and heat flux data measured by an eddy covariance system installed in Horqin sandy land, China. Then the distribution and response regularity of water and heat flux to the control factors were analyzed under different time scales. The results indicated that the responses of Fe and Fh to controlling factors were similar on 30min and daily scales, in which the energy terms (net radiation, Fn and available energy, Fa) showed extremely significant positive contribution. The part of water condition (vapor pressure deficit, VPD and relative humidity, RH) were the main influencing factors at monthly scale. At the seasonal scale, Fe was positively correlated with Fa and Fn, but negatively correlated with soil heat flux (Fg), RH and wind speed (WS). On the contrary, Fh was positively correlated with RH, but negatively correlated with Fn. At the annual scale, Fe and Fh showed a significant positive correlation with all factors. Generally, at the daily and annual scales, there is a high correlation between Fe, Fh and the control factors, and exhibits pronounced periodicity. These results suggest that the time scales of flux and impact factors should be both considered when doing water and heat fluxes analysis of sandy land or others ecosystem.