Background: Quantifying age trends in healthcare costs of pediatric asthma leads to better understanding of the natural history of the disease and informed decision-making on the allocation of healthcare resources. Methods: We identified children with incident asthma from the health administrative data of British Columbia, Canada (Jan 1998 to Dec 2015), and followed them from their first diagnosis of asthma or wheezing until age 18. We estimated direct medical costs (in 2016 Canadian dollars [$]), including inpatient and outpatient encounters and pharmacy costs, attributed to asthma (primary outcome) and other respiratory diseases (secondary outcome). We assessed the impact of sex and socioeconomic status on age trends, adjusting for calendar effect. Results: The final analysis included 44,552 children with asthma (62% boys). From age 0 to 18, costs of asthma/wheezing and other respiratory conditions decreased from $1,036 to $29/child-year, and from $1,145 to $31/child-year, respectively. Children under 3 years of age incurred 4–fold higher costs for asthma/wheezing and other respiratory conditions. In particular, costs of asthma hospitalizations were 10 times higher in this age group compared to older children. Age trends were generally similar between sex groups and across socioeconomic status. However, medication costs for asthma/wheezing decreased in boys, whereas those in girls declined during childhood but increased during adolescence. Conclusions: The highest costs of pediatric asthma are concentrated in children younger than 3. Age trends were generally consistent between sex and across socioeconomic status.

We herein report first Iranian families with spastic paraplegia 35 and 49 and claim that TECPR2 gene causes complicated spastic paraplegia 49 with or without sensory autonomic neuropathy. In addition, we show how coexistence of SPG49 and griscelli syndrome can lead to misdiagnosis.

Here, we present 76-year-old woman, who presented with a history of quadriparesis from three years ago, initially in the lower extremities and ascended towards the upper extremities (symmetrical and progressive). Magnetic resonance imaging revealed bilateral thalamic lesions (Figure 1), which could identify it as a variant of Creutzfeldt-Jakob disease.

Background: Adrenaline auto-injectors (AAIs) are not used correctly by patients and their caregivers because of a lack of training. The aim of this study was to determine how to help patients maintain proper use of AAIs. Methods: Patients prescribed AAIs or their caregivers were recruited. At enrollment, they were asked to demonstrate use of a ‘trainer’ device, and they were given a calendar as a diary. They were asked to mark the days they practice for a year. After one year, their performance was re-evaluated. Their skills were evaluated in five steps that consisted of a) how to hold the AAI, b) removing the cap, c) selecting the mid-anterolateral thigh as the correct site of injection, d) holding firmly in place for 5 seconds, and e) massaging after injection. The primary endpoint was the percentage of participants that correctly used the AAI one year after enrollment. Results: A total of 102 participants were enrolled. At enrollment, of the 82 participants who had previous AAI prescriptions, 38 (46.3%) used it correctly. Except for evaluation items d) and e), 55 of 82 (67.1%) used it correctly. Ninety-seven participants could be confirmed after one year, and 81 of them (83.5%) used the AAI correctly. Conclusion: Distributing the diary was effective in maintaining AAI skill. It is thought that the diary helped participants maintain their motivation to practice using the AAI.

Acute urticaria in children: what can we learn from clinical practice?

Telomere length and DNA methylation (DNAm) are two promising biomarkers of biological age. Environmental factors and life history traits are known to affect variation in both these biomarkers, especially during early life, yet surprisingly little is known about their reciprocal association. Here, we present the first study on a natural population to explore how variation in DNAm, growth rate and early-life conditions are associated with telomere length changes during development. We tested these associations by collecting data from wild, nestling zebra finches in the Australian desert. We found that increases in the level of DNAm were negatively correlated with telomere length changes across early life. We also confirm previously documented effects of post hatch growth rate and clutch size on telomere length in a natural ecological context for a species that has been extensively studied in the laboratory. However, we did not detect any effect of ambient temperature during developmental on telomere dynamics. We also found that the absolute telomere length of wild zebra finches, measured using the in-gel TRF method, was similar to that of captive birds. Our findings highlight exciting new opportunities to link and disentangle potential relationships between environmental, epigenetic and telomere length dynamics during early life.

Background: Tramadol causing intrapartum maternal anaphylaxis is unknown. Case: A 29-year-old, primigravida at 39+4 weeks pregnancy had an anaphylactic reaction to injection tramadol. She was intubated, caesarean section done and health baby and mother were discharged. Conclusion: Staffs have to be aware of this uncommon anaphylactic reaction to tramadol.

We report a rare case of a large prolapsed pedunculated uterine myoma measuring 15cm in its greater diameter. In order to make a surgical procedure safe and feasible, appropriate clinical predictors should be taken into account and pre- and intraoperative preparations be available to the surgeon's armamentarium.

Monoclonal gammopathy of undetermined significance (MGUS) may be associated with pathologies with severe neuromuscular manifestations such as sporadic late-onset nemaline myopathy (SLONM). We describe a difficult to diagnose case of SLNOM with marked clinical improvement after achieving gammopathy complete hematologic response.

Metronidazole may rarely cause encephalopathy and neuropathy. In this study we report a 30-year-old post-partum, ex-addicted female with leukoencephalopathy due to metronidazole.

Rereading Popper’s “The Logic of scientific discovery”, at his 120th anniversary, brings some thoughts regarding the diagnostic process and decision making in medicine from the viewpoint of the classical scientific method. In recent years physicians are increasingly becoming technical experts who base their decision-making on uniform criteria, guidelines and classifications but unfortunately have moved away from understanding the basic concepts in the philosophy of science. This raises an ethically and philosophically important issue; what does a medical diagnosis mean? Is this an absolute or a relative truth? The implications of this question are enormous in terms of prognosis and treatment. Both patients and physicians should be educated about the nature of the diagnostic process.

Introduction: Little is known about reverse cardiac remodeling (CRR) under the low-dose S/V therapy. Methods: In 37 patients (mean age 64.5±17.5 years, five females) 24/26mg S/V BID was started. After one month of observation, the following CRR parameters improved: LVEDD (-∆2,9±2.6mm, p<0.01), LVESD (-∆ 2,4±2.5mm, p<0.01), LVEDV(-∆14.6±33.1ml, p=0.04), LVESV (-∆13.4±30.6ml, p=0.04), LAVI (-∆8.7±37.7ml/m2, p<0.01), and EROA (-∆ 0.09 ± 0,01cm2; p=0.03). In opposite to LVEF global longitudinal strain (GLS) changed from -6.6% to -7.9% (absolute improvement of 16%, p <0.001). Walked distance in 6-MWT ( +∆65.4 ± 75.8 m, p <0.001), and the quality of life (MLHFQ 22 vs 16 scores, p<0.01) improved. Decreasing NT-proBNP (-∆ 1,203,1±3,121,4pg/ml, p=0.03) and troponin T (-∆ 4.7±9.4pg/ml, p=0.004) were observed. Correlation between GLS and LVESV (r = -0,43, p = 0.027) was found. ROC curve analysis showed that GLS cut-off value -8% is a good predictor of clinical improvement (6MWT: AUC 0.69 p=0.04) and CRR (MRvol: AUC:0.74 p=0.01; LAVI: AUC 0.71 p=0.04). Conclusion: One-month, low-dose (24/26 mg BID) S/V therapy initiates CRR. GLS’s ability to evaluate LV function is better than LVEF’s. S/V should be started early as patients with symptomatic HFrEF and less impaired LV systolic function (GLS <-8%) are more likely to develop CRR and clinical improvement.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID19), is associated with flares of psoriasis in patients with well-documented disease. Both viral infection and medications used for treatment, like hydroxychloroquine, were incriminated. Herein, we report the case of a 25-year-old patient who presented a first-onset guttate psoriasis following COVID19.

We are presenting a newborn with a very rare and most severe form of congenital ichthyosis that is characterized by a thick, heavily keratinized and scaly skin.

The coronavirus 2019 disease (COVID-19) affected 125 million people worldwide and caused 2.7 million deaths. Some comorbidities are associated with worse prognosis and left ventricular assist device (LVAD) recipients are probably part of this high-risk population. We report a 31-year-old male patient who developed COVID-19 during LVAD implantation. His postoperative period was complicated by severe pneumonia and mechanical ventilation leading to right ventricular failure (RVF) and inotrope necessity. He experienced multiple complications, but eventually recovered. We present a systematic review of LVAD recipients and COVID-19. Among 14 patients, the mean age was 62.7 years, 78.5% were male. Five patients (35.7%) required mechanical ventilation and 3 patients (21.4%) died. Two patients (14.2%) had thromboembolic events. This case and systematic review suggest LVAD recipients are at particular risk of unfavorable outcomes and they may be more susceptible to RVF in the setting of COVID-19, particularly during perioperative period.

Background: Recent randomized controlled trials (RCT) suggest that ablation is superior to antiarrhythmic drugs (AAD) as an initial therapy for paroxysmal atrial fibrillation (pAF) to prevent arrhythmia recurrences. We performed an updated meta-analysis of RCTs, to include recent data from cryoballoon-based ablation, and to compare arrhythmia-free survival and adverse events between ablation and AAMs. Methods: We searched MEDLINE and EMBASE from inception to December 2020. We included RCT comparing patients with pAF undergoing ablation or receiving AADs as an initial therapy. We combined data using the random-effects model to calculate hazards ratio (HR) for arrhythmia-free survival and odds ratio (OR) for adverse events. Results: Five studies from 2005-2020 involving 985 patients were included (495 patients and 490 patients underwent ablation and medication as initial therapy, respectively). Patients who underwent ablation had higher freedom from atrial tachyarrhythmias (AT) during the 12-24 months follow-up period (pooled HR=0.48, 95% CI:0.40-0.59, p<0.001) (Figure 2). In a subgroup analysis of ablation method used, both cryoablation group (pooled HR=0.49, 95% CI:0.38-0.64, p<0.001) (Figure 2A) and radiofrequency ablation group (pooled HR=0.47, 95%CI:0.35-0.64, p<0.001) (Figure 2B) showed reduction in AT recurrence compared to AAD group. There were no differences in adverse events including cerebrovascular accident, pericardial effusion or tamponade, pulmonary vein stenosis, acute coronary syndrome, deep vein thrombosis and pulmonary embolism, and bradycardia requiring a pacemaker. Conclusion: Catheter ablation (both cryoablation and radiofrequency ablation) is superior to AAD as an initial therapy for pAF in efficacy for reducing AT recurrences without a compromise in adverse events.

Phosphate (Pi) and jasmonic acid (JA) play critical roles in plant growth and development. In particular, crosstalk between JA and Pi starvation signaling has been reported to mediate insect herbivory resistance in dicot plants. However, its roles and mechanism in monocot-bacterial defense systems remain obscure. Here, we report that Pi starvation in rice activates the JA signaling and enhances resistance to Xanthomonas oryzae pv. oryzae (Xoo) infection. The direct regulation of OsPHR2 on the OsMYC2 promoter was confirmed by yeast one-hybrid, electrophoretic mobility shift, dual-luciferase, and chromatin immunoprecipitation assays. Molecular analyses and infection studies using OsPHR2-Ov1 and phr2 mutants further demonstrated that OsPHR2 enhances JA response and antibacterial resistance via transcriptional regulation of OsMYC2 expression, indicating a positive role of OsPHR2-OsMYC2 crosstalk in modulating the JA response and Xoo infection. Genetic analysis and infection assays using myc2 mutants revealed that Pi starvation-induced JA signaling activation and consequent Xoo resistance depends on the regulation of OsMYC2. Together, these results reveal a clear interlink between Pi starvation signaling and the JA signaling in monocot plants, and provide new insight into how plants balance growth and defense by integrating nutrient deficiency and phytohormone signaling.

Introduction: Nurses provide long-term care to patients diagnosed or suspected of COVID-19 during the epidemic. This situation may cause nurses to experience more fear and death anxiety and increase the fear levels of their children. This study was conducted to determine the effect of death anxiety levels of nurses on the fear level of their children during the COVID-19 pandemic. Methods: This descriptive and cross-sectional study was carried out online with 362 nurses. Data were collected using an introductory information form, the Death Anxiety Scale, and the Children’s Fear Scale. Results: It was found that the death anxiety levels of nurses and fear levels of their children were high. It was determined that the children of nurses who had high death anxiety had higher fear levels. Conclusions: The findings emphasize the importance of screening nurses’ death anxiety and children’s fear levels during the pandemic period and providing psychological support when necessary. Keywords: COVID-19, Pandemic, Nurse, Child.

Prediction from models and data in Ecology has a long history and can be made from many types of statistical, simulation, and other classes of models. To date, our ability to use the predictive approach as a tool for developing, validating, updating, integrating and applying models across scientific disciplines and to influence management decisions, policies and the public has been hampered by disparate perspectives on prediction and inadequate tools. We present a coherent perspective that follows a Predictive Ecology approach based on 5 principles: Reusable, Freely available and Interoperable models, built around a Continuous workflow, which are Tested automatically (PERFICT). We describe the SpaDES toolkit that helps implement these principles. We outline some benefits for society of working with these principles, including 1) speeding up scientific advances; 2) data science advances; and 3) improving science-policy integration.

Pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that has increased in incidence with the novel coronavirus disease 2019 pandemic. Although traditionally managed with conservative measures, we present the indications and methods for the first operative management of tension pneumomediastinum with concomitant SARS-CoV-2 infection.

Mountain regions are an important regulator in the global water cycle through their disproportionate water contribution. Often referred to as the “Water Towers of the World”, mountains contribute 40 to 60% of the world’s annual surface flow. Shade is a common feature in mountains, where complex terrain cycles land surfaces in and out of shadows over daily and seasonal scales. This study investigated turbulent water and carbon dioxide fluxes over the snow-free period in a subalpine wetland in the Canadian Rocky Mountains, from June 7th to September 10th, 2018. Shading had a significant and substantial effect on water and carbon fluxes at our site. Each hourly increase of shade per day reduced evapotranspiration (ET) and gross primary production (GPP) by 0.42 mm and 0.77 gCm-2, equivalent to 17% and 15% per day, respectively, over the entire study period. However, during only peak growing season, when leaves were fully out and mature, shade caused by the local complex terrain, reduced ET and increased GPP, likely due to enhanced diffuse radiation. The overall result was increased water use efficiency at the site during periods of increased shading during the peak growing season. In addition to incoming solar radiation (Rg), temporal variability in ET was found to relate to temporal variability in soil temperature, moisture and vapour pressure deficit. Shade impacted the curvature and intercept of the nonlinear ET-Rg relationship at our site. In contrast, temporal variability in GPP at our site was dependent largely on Rg only. Our findings suggest that shaded subalpine wetlands can store large volumes of water for late season runoff and are productive through short growing seasons.

Abstract: The scientific evaluation of regional flood risk is particularly important for flood management. Past studies build a hierarchy evaluation index system with two factors and ten sub-factors to assess flood hazard risk, each factor contains five sub-factors. The weights of the sub-factors in their respective evaluation systems are (0.065, 0.129, 0.210, 0.215, 0.378) and (0.399, 0.152, 0.155, 0.180, 0.109) respectively, from expert scoring results optimized by Analytic Hierarchy Process (AHP) modified by Trapezoidal Fuzzy Number (TFN). Variable Fuzzy Set Theory (VFST) is adopted to calculate the risk values of the two factors, the weighted average of two factors risk values is used as flood disaster risk value. Based on above steps, a flood disaster evaluation model is established and applied to evaluate regional flood risks in Zhejiang Province. Extremely low risk, low risk, moderate risk, high risk, extremely high risk areas are 51017 km2,10090 km2,10112 km2,13428 km2 and 19153 km2, respectively occupy with 49.15%, 9.72%, 9.74%, 12.94%, and 18.45% of study region. TFN-modified AHP calculates the weights of sub-factors, considering the subjective cognition of experts and the objective response of factors, which makes the results more representative and scientific. Application of VFST decreases the randomness and uncertainty of flood risk assessment, which improves the stability of evaluation process and reliability of evaluation results. Meanwhile, 30×30m basic evaluation unit adopted in this study accurately and objectively represent the spatial distribution of flood hazard in Zhejiang Province, China. The evaluation results of the model are validated to be consistent with the actual situation of flood disaster.

Using an Accelerated Junctional Rhythm to Predict the Success and Safety of Slow AV Nodal Pathway Ablation G. Neal Kay MD

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