Objective: Caesarean delivery rates continue to rise globally the reasons for which are poorly understood. We aimed to characterize attributable factors for increasing caesarean delivery rates over a 30-year period within our health network. Design: Observational cohort study. Setting: Two hospitals (large tertiary referral hospital and metropolitan hospital) in Sydney, Australia, across two time periods: 1989-1999 and 2009-2016, between which the caesarean delivery rate increased from 19% to 30%. Participants: All women who had a caesarean delivery after 24 weeks gestation Methods: Data were analysed using multiple imputation and robust Poisson regression to estimate the changes in the caesarean delivery rate attributable to maternal and clinical factors. Main outcome measures: Caesarean delivery. Results: Fifty-six percent of the increase in the rate of caesarean delivery was attributed to changes in the distribution of maternal factors including maternal age, body mass index, parity and history of previous caesarean delivery. When changes in the obstetric management of multiple gestation, malpresentation and preterm singleton birth were considered, 66% of the increase in caesarean rate was explained. When pre-labour caesarean deliveries for maternal choice, suspected fetal compromise, previous pregnancy issues and suspected large fetus were excluded, 78% of the increase was explained. Conclusions: Most of the steep rise in the caesarean delivery rate from 19% to 30% is attributable to changes in maternal demographic and clinical factors.

Paediatric multisystem inflammatory syndrome: temporally associated with SARS-COV-2 (PIMS-TS) is a well described rare but severe COVID-19 related syndrome. PIMS-TS have been reported in children from geographical areas of high COVID-19 infection. Most children with PIMS-TS require management in an intensive care unit with variable respiratory involvement. Adults recovering from COVID-19 infection have been reported to suffer from respiratory morbidity but such outcomes are unknown in children. We present the first report of normal short term respiratory outcomes as measured by spirometry in children with SARS-COV-2 antibody positive, PIMS-TS syndrome managed at a specialist children’s hospital in the UK.

Aim: The aim of this study was to assess the efficacy of pre-operative axillary ultrasonography (AUS) and pre-operative axillary fine-needle aspiration biopsy (FNAB) from suspicious lymph nodes in clinically node-negative breast cancer to compare with radiologically positive and sentinel lymph node biopsy (SLNB) positive involvement. Method: Clinically node-negative early-stage breast cancer patients were included in the study. These patients under went pre-operative AUS examination, suspicious lymph nodes were evaluated with FNAB. AUS-FNAB results were compared with those of SLNB or of axillary dissection. Results: Of 181 patients undergoing AUS, 32 were reported to have axillary metastasis, 25 suspicious and 124 benign nodes. The suspicious group underwent FNAB examination and metastasis was found in 9 of them. The sensitivity of AUS-FNAB was found to be 64.06%, specificity 100%, positive predictive value 100% and negative predictive value (NPV) 83.5%. False negativity rate (FN) of this method was 16,4%. Lymphovascular invasion and tumor size were found statistically significant factors for false negativity. Conclusion:It was concluded that axillary AUS-FNAB with its high NPV, low FN rate, may be a clinical alternative to SLNB for early stage breast cancer patients.

Rationale, aims, and objectives The current strategy of searching for an effective drug to treat COVID-19 relies mainly on repurposing existing therapies developed to target other diseases. There are currently more than four thousand active studies assessing the efficacy of existing drugs as therapies for COVID-19. The number of ongoing trials and the urgent need for a treatment poses the risk that false-positive results will be incorrectly interpreted as evidence for treatments’ efficacy and a ground for drug approval. Our purpose is to assess the risk of false-positive outcomes by analyzing the mechanistic evidence for the efficacy of exemplary candidates for repurposing, estimate false discovery rate, and discuss solutions to the problem of excessive hypothesis testing. Methods We estimate the expected number of false-positive results and probability of at least one false-positive result under the assumption that all tested compounds have no effect on the course of the disease. Later, we relax this assumption and analyze the sensitivity of the expected number of true-positive results to changes in the prior probability (π) that tested compounds are effective. Finally, we calculate False Positive Report Probability and expected numbers of false-positive and true-positive results for different thresholds of statistical significance, power of studies, and ratios of effective to non-effective compounds. We also review mechanistic evidence for the efficacy of two exemplary repurposing candidates (hydroxychloroquine and ACE2 inhibitors) and assess its quality to choose the plausible values of the prior probability (π) that tested compounds are effective against COVID-19. Results Our analysis shows that, due to the excessive number of statistical tests in the field of drug repurposing for COVID-19 and low prior probability (π) of the efficacy of tested compounds, positive results are far more likely to result from type-I error than reflect the effects of pharmaceutical interventions.

Concomitant surgery on the aortic arch with hypothermic cardiac arrest in the setting of heart transplantation (HTX) is extremely rare. A 67-year-old woman who suffered from ischemic cardiomyopathy was evaluated for HTX. Computed tomography showed diffuse soft and hard atheromatous plaques of the entire aorta. Upon allocation of an appropriate donor organ, the ascending aorta and the proximal aortic arch were replaced using hypothermic cardiac arrest at 28℃ prior to arrival of the donor heart and without clamping of the diseased recipient aorta. After uncomplicated postoperative course the patient was recovered without neurological complications.

Aim The aim of this study is to model the past, current and future distribution of J. phoenicea s.s., J. turbinata and J. canariensis, based on bioclimatic variables using a maximum entropy model (MaxEnt) in the Mediterranean and Macaronesian regions. Location Mediterranean and Macaronesian Taxon Cupressaceae, Juniperus Methods Data on the occurrence of the J. phoenicea complex was obtained from the GBIF, the literature, herbaria, and the authors’ field notes. The bioclimatic variables were obtained from the WorldClim database (http://worldclim.org/) and Paleoclim (http://www.paleoclim.org/). The climate data related to species localities were used for predictions of niches by implementation of MaxEnt and we evaluated the model with ENMeval. Results The potential niches of Juniperus phoenicea during the LIG, LGM and MH covered 30%, 10% and almost 100%, respectively, of the current potential niche. Climate warming could reduce potential niches by 30% and 90% in scenarios RCP2.6 and RCP8.5, respectively. The potential niches of Juniperus turbinata had a broad circum-Mediterranean and Canarian distribution during the LIG and the MH, extending its distribution during the LGM when it was found in more areas than at present; the predicted warming in scenario RCP2.6 and RCP8.5 could reduce the current potential niche by 30% and 50%, respectively. The model did not find suitable niches for J. canariensis during the LIG and the LGM, but during the MH its potential niche was 30% larger than at present. The climate warming scenario RCP2.6 indicates a reduction of the potential niche by 30%, while RCP8.5 does so by almost 60%. Main conclusions This research can provide information to increase the protection of the juniper forest and to try to counteract the phenomenon of local extinctions caused by anthropic pressure and climate changes.

Soil acidification is one of the major soil degradation phenomenon in tropical and subtropical region, which cause reductions in soil fertility, particularly potassium (K), and declines in crop yield. However, it remains unclear whether and how the status of K in soils and crops changes with the application of lime to alleviate soil acidification. Six treatments of long-term experiments (started 1990) in subtropical region were carried out. Regardless of fertilization regime, lime addition markedly increased grain and straw yields compared to those yields without lime application. Lime addition also led to significant decreases in the apparent K balances compared to soils without lime application. The agronomic K efficiency and partial factor productivity of K fertilizer both significantly increased after lime application. Lime addition reduced the soil exchangeable K (EK) content and stock, while increased soil non-exchangeable K (NEK) content and stock. Redundancy analysis showed that K input, lime, pH, and exchangeable calcium all significantly affected the K in soil and crops. Path analysis showed that lime indirectly influenced soil K (EK and NEK) by directly affecting soil pH, exchangeable calcium, K uptake and apparent K balances. These results suggest that lime addition is a viable strategy for improving crop yields and K fertilizer efficiency in degraded soils caused by acidification. Lime significant increased K uptake which lead to decreased soil EK content and stock. Additional, lime also increased soil NEK content and stock which was regulated by soil pH, exchangeable calcium, and crop growth.

Introduction:It has been known that there is a complex interaction between asthma and cardiovascular physiology.Some investigations on echocardiography and electrocardiography(ECG) in asthmatic patients revealed many findings such as pulmonary hypertension(PHT) and arrhythmia.In this study,we aimed to perform tissue doppler imaging(TDIE) and conventional echocardiographic(CEI) assessment with many indexes of arrhythmia on electrocardiography(ECG) in asthmatic patients.Methods:A total of 89 patients,63 female(70.8%) and 26 male(29.2%),was included in this study.Patients were divided into three groups and then each group was separated in two 2 groups as mild-moderate and severe asthma.Results:There is no difference among groups with respect to age,gender and anthropometric data and no difference between groups with respect to indexes of arrhythmia on ECG(p> 0.05).It was determined that ventricular outflow systolic velocity recordings at aortic and pulmonary valve were similar(p> 0.05).MAPSE,TAPSE and both ventricular diastolic velocities on CEI were similar between groups,except for left ventricular A wave velocity which was higher in severe asthmatic patients(p< 0.05).No difference between groups was detected in left atrium(LA) TDIE diastolic velocities(p> 0.05).Investigation of time intervals of both ventricular diastolic filling velocities(e’ and a’) at the mitral lateral,septal and tricuspid lateral annulus revealed significant difference at Pa’m- 3 and Pa’s- 3 intervals based on TDEI(p<0.05).Investigation of the LA volumes determined that only maximal volume of the LA was higher in severe asthmatic patients(p< 0.05).However, there is no significant difference between LA-VpreA and LA-Vmin(p> 0.05).Conclusions:Based on these results, it can be suggested that LA mechanical functions and intra-atrial LA electromechanical durations were impaired in severe asthmatic patients.

Aneurysms of the sinus of Valsalva are rare, with dissecting aneurysms of the sinus of Valsalva that extend into the interventricular septum being even more rare. This report describes a young patient with syphilis and a quadricuspid aortic valve who experienced a spontaneously dissecting aneurysm of the sinus of Valsalva and the basal interventricular septum.

Introduction: Several homeostatic changes like an increase in sympathoadrenal response and oxidative stress occur in hypoglycemia. As a result of these findings, an increase in inflammation and pre-atherogenic factors is observed and these changes may lead to endothelial dysfunction. Aim: Our study aims to reveal possible cardiac risks (systolic-diastolic functions and endothelial dysfunctions) in patients who have applied to the emergency department with hypoglycemia. Methods: This cross-sectional, case-control study included 46 hypoglycemia patients who admitted to the emergency with symptoms compatible with hypoglycemia and diagnosed with hypoglycemia and 30 healthy volunteers. All patients were evaluated with baseline echocardiography, tissue-doppler imaging(carotid and brachial artery). Also, the fasting blood tests of the patients referred to the internal medicine department were examined. Results: There were no differences between the groups regarding age, weight, body mass index, and systolic blood pressure. Total cholesterol, LDL, HDL, Vitamin B12, TSH, and fasting blood glucose levels were similar in the groups’ blood tests (all p values>0.05). We observed a statistically significant decrease in diastolic dysfunction parameters: E/A and E/e’ ratios (respectively, p=0.020 and 0.026). It was shown that insulin resistance was influential in forming these considerable differences. The patient group observed that the carotid intima-media thickness was more remarkable(p=0.001), and the brachial flow-mediated dilatation value was smaller(p=0.003), giving an idea about endothelial functions.

Described is an atypical presentation of a rare condition. It highlights the importance of thorough algorithm of medical and family history, physical examination, appropriate investigations and perioperative workup and for surgery. This case raises the awareness that a lateral neck mass (or lateral ectopic thyroid mass) can be benign.

This report describes the case of a 53-year-old man with SARS-CoV-2 infection and occurrence of complete unilateral sensorineural hearing loss, adding new evidence to the association between COVID-19 and hearing loss. Whether this is the result of endothelial cell dysfunction in the cochlea or central auditory pathways remains unclear.

A six-year old boy presented with mycoplasmal pneumonia combined with recurrent pneumothorax. The patient had been treated with azithromycin and methylprednisolone for mycoplasmal pneumonia after admission, however his condition deteriorated. We increased the dosage of methylprednisolone and changed to erythromycin from azithromycin, his condition improved progressively. He presented pneumothorax twice during recovery phase. He was put on thoracic closed drainage and was cured. Pneumothorax is rare complication of mycoplasmal pneumonia. Here we reported the case to raise awareness of this condition.

Adoptive immunotherapy using Epstein-Barr Virus (EBV)-specific T cells is a potentially curative treatment for patients with EBV-related malignancies where other clinical options have proved ineffective. We describe improved GMP-compliant culture and analysis processes for conventional lymphoblastoid cell line (LCL)-driven EBV-specific T cell manufacture, and describe an improved phenotyping approach for analyzing T cell products. We optimized the current LCL-mediated clinical manufacture of EBV-specific T cells to establish an improved process using xenoprotein-free GMP-compliant reagents throughout, and compared resulting products with our previous banked T cell clinical therapy. We assessed effects of changes to LCL: T cell ratio in T cell expansion, and developed a robust flow cytometric marker panel covering T cell memory, activation, differentiation and intracellular cytokine release to characterize T cells more effectively. These data were analyzed using t-Stochastic Neighbour Embedding (t-SNE) algorithm. The optimized GMP-compliant process resulted in reduced cell processing time and improved retention and expansion of central memory T cells. Multi-parameter flow cytometry determined the optimal protocol for LCL stimulation and expansion of T cells and demonstrated that cytokine profiling using IL-2, TNF-α and IFN-γ was able to determine the differentiation status of T cells throughout culture and in the final product. We show that fully GMP-compliant closed-process culture of LCL-mediated EBV-specific T cells is feasible and profiling of T cells through cytokine expression gives improved characterization of start material, in-process culture conditions and final product. Visualization of the complex multi-parameter flow cytometric data can be simplified using t-SNE analysis.

We aimed to test the hypothesis that a lung ultrasound severity score (LUS) and assessment of left ventricular eccentricity index of the interventricular septum (LVEI) by focused heart ultrasound can predict extubation success in mechanically ventilated infants. We conducted a prospective study on premature infants <34 weeks’ of gestation. LUS was performed on postnatal days 3 and 7 by an investigator who was masked to infants’ ventilator parameters. LVEI and pulmonary artery pressure (PAP) were measured at postnatal day 3. A receiver operator curve was constructed to assess the ability to predict extubation success. Spearman correlation was performed between LVEI and PAP. A total of 104 studies were performed to 66 infants; of them 39 had mild and 65 had moderate-severe lung disease. LUS predicted extubation success with a sensitivity and a specificity of 91% and 69%, respectively. Area under the curve was 0.83 (CI: 0.75-0.91). LVEI did not differ between infants that succeeded and failed extubation. It correlated with PAP during systole (r=0.66). We conclude that LUS predicts extubation success in mechanically ventilated preterm infants whereas LVEI correlates with high PAP.

Aerococcus urinae is rare in infective endocarditis. The best known risk factors are urogenital comorbidities. We report the case of a 46-year-old male with Down’s syndrom with infective endocarditis. The patient underwent successful treatment with amoxicillin and heart surgery with valve replacement.He had an unknown ventricular septal defect

As the clinical course of COVID-19 infection in SCD patients is not clear, close monitoring is essential. We emphasize that RBC exchange should be offered early to avoid possible deterioration. We present a case of COVID-19 infection in a SCD patient causing severe hemolysis, that improved after RBC exchange.

The case of ischemic upper extremity disease caused by guide catheter-induced injury is rare. We present a case of right axillary artery occlusion, after percutaneous coronary intervention (PCI), treated by endovascular stent-grafting successfully.

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Large occurrence datasets provide a sizable resource for ecological analyses, but have substantial limitations. Phenological analyses in Fric et al. (2020) were misleading due to inadequate curation and improper statistics. Our reanalysis of 22 univoltine species with sufficient data for independent analysis found substantive differences in macroscale phenological patterns.

The hybrid impression technique consists of an initial alginate impression that provides a pre-operative cast upon which a diagnostic wax-up and a silicone index impression are made. This work is digitized; thus, the altered final digital impression is limited to absolute minimum time, effort and ensures comfort for the patient.

Objective All cancer sites show considerable social inequality in risk and patient survival. Despite the advantages of healthcare professionals (HPs) systematically registering information about patients’ social circumstances, this is not routine practice. Our aim was to understand the barriers to registering patients’ social histories. Methods We observed 104 outpatient encounters and interviewed 30 HPs treating malignant melanomas, urological cancer or lung cancer. We explored interactive (e.g. processes and activities) and interpretative (e.g. perspectives and meanings) aspects of barriers to recording patients’ social data. Using Kirk´s theoretical framework developed in hospital settings, we conducted a qualitative analysis to address organizational and professional barriers. Results Unevenness in registration was due to 1) organizational barriers (interdisciplinarity, time and technical challenges), 2) professional barriers (prioritization, meeting patients where they are, and reliance on HP’s own judgements). HPs neglected to use medical records, preferring to form their own pictures of patients´ needs to avoid prejudices and to promote equality. However, HPs did not systematically verify these impressions with the patients. Conclusion To facilitate systematic recording of patients’ social histories and address the barriers identified in our study, there is a need to: 1) develop a electronical tool for recording patients’ social circumstances that is aligned with HP’s daily practices 2) introduce training programmes targeting all barriers, and 3) provide time and opportunities to support patients.

Introduction: Left bundle branch pacing is a recently described form of conduction system pacing which can correct left-bundle branch block and deliver cardiac resynchronization therapy (CRT). The WiSE-CRT system delivers leadless endocardial pacing and can improve symptoms and left ventricular remodelling in CRT non-responders. Case Report: We describe the case of a 57 year old male who underwent implantation of the WiSE-CRT system after failed conventional CRT. Pacing the left bundle during implant achieved superior electrical resynchronization and equivalent hemodynamic response compared to pacing the lateral wall. Conclusion: This case demonstrates the potential for leadless left bundle branch pacing.

BACKGROUND: Hoarseness in school-aged children may affect their educational achievement and interfere with their communication and social skills development. The global prevalence of hoarseness in school-aged children ranges between 6% and 23%. OBJECTIVE: Measure the prevalence of hoarseness among school-aged children and identify its associated factors. DESIGN: Cross-sectional questionnaire-based survey. SETTING: Randomly selected primary and early childhood schools in Saudi Arabia. PATIENTS AND METHODS: Data were collected using a questionnaire completed by the children’s parents, which included sociodemographic aspects, health and related comorbidities, history of frequent crying during, history of letter pronunciation problems and stuttering, history of vocal fold surgery, the Reflux Symptom Index (RSI), and Children’s Voice Handicap Index-10 for parents (CVHI-10-P). MAIN OUTCOME MEASURES: Determinants of hoarseness were investigated using the chi-square test, Fisher exact test, and adjusted and unadjusted logistic regression models SAMPLE SIZE: 428 children RESULTS: The mean age of the study children was 9.05 ± 2.15 years, of whom 69.40% were male. The rate of hoarseness in the participants was 7.5%, 9.90% were female and 6.40% were male. Hoarseness was found to be significantly associated with a history of excessive crying in infancy (12.24%, x2=7.54, p=0.006), letter pronunciation issues, especially ‘R’ and ‘S’ (13.56%, x2=8.71, p=0.003), stuttering (16.39%, x2=8.08, p=0.004), and those with a previous history of hoarseness (p=0.023). In addition, having symptoms of gastrointestinal reflux increased the risk of hoarseness by four times (OR=4.77, 95% CI= 2.171, 10.51) after adjustment for age and gender. CONCLUSIONS: Hoarseness in children may be underestimated as it may reflect the presence of speech problems (i.e., letter articulation and stuttering) in addition to the presence of laryngopharyngeal reflux. Hoarseness was assumed on the basis of parental complaints. Therefore, further research with diagnosis based on clinical assessment is needed to understand the magnitude of the hoarseness and its consequences