Objective The shape of the sacrum-coccyx was defined and compared in nulliparous, pregnant, and parous women to provide insight into anatomical adaptations that afford vaginal delivery. Design A retrospective study comparing midsagittal anatomical measurements based on MRI of the sacrum and coccyx from 63 subjects. Setting Magee-Womens Research Institute and Northshore University HealthSystem. Population 23 nulliparous, 14 pregnant, and 26 parous women who had an MRI taken that included the necessary bony anatomy. Methods Twelve measurements were taken on scans between the ages of 20 and 49 that had a pelvic MRI scan with or without contrast were analyzed. Subjects were categorized based on parity and gravidity. Main Outcome Measures Length, angles, and curvature indices describing midsagittal sacrum and coccyx shape Results Overall pregnant women had a significantly straighter and more posteriorly oriented coccyx when compared to nulliparous women. This was reflected by a change in 3 measures at the univariate level. The coccygeal curvature index was higher in pregnant (89.2  10.0) women relative to nulliparous (78.7  6.6, p=0.003) and parous (80.0  5.5, p=0.004) women. The sacrococcygeal curvature index and sacrococcygeal angle also increased in the pregnant as compared to the nulliparous group (73.3  5.8 versus 79.2  3.7, p=0.016; 92.8  10.9 versus 109.3  9.4, p=0.002, respectively) with no difference between pregnant and parous groups for these measurements. Conclusions Pregnancy-induced posterior motion of the coccyx, which allowed for the combined sacrum-coccyx shape to straighten, effectively widens the obstetric outlet for vaginal delivery.

Background: Oxygen supplementation is an important component for preterm infants neonatal care. Pulse oximetry (SpO2) is essential to guide oxygen therapy. Evidence on SpO2 values in premature infants previous to discharge is limited. Objectives: To establish SpO2 values in asymptomatic premature infants at 34, 35, and 36 weeks postmenstrual age (PMA). Methods: Longitudinal, multicentric study. From May 2018 to May 2019 premature infants born ≤32 weeks gestational age, from three level III NICUs in Santiago, Chile (altitude 579mt), were enrolled. Healthy children without current apnea of prematurity were included. Continuous SpO2 was obtained with Masimo-Radical 7/8 (USA), averaging time 2-4 seconds. Results: 101 SpO2 recordings (n = 44, 33 and 24 at 34, 35 and 36 weeks PMA respectively) from 62 infants. Twenty eight (45%) male, median (range) gestational age at birth 30 (26-32) weeks, median (range) birth weight 1480 (785-2700) g. Oximetry variables for total recordings: mean SpO2, median (range) 96.9 (93.3-99.3); minimum SpO2, median (range) 74 (51-89); time of SpO2 <90%, median (range) 2% (0-10.6%); time of SpO2 <80%, median (range) 0.1% (0-1.3%); desaturation event by ≥4% (DI4) ≥ 0 and ≥ 10 seconds per sample hour, median (range) 45.2 (5.2-115) and median (range) 15 (3.5-62.5) respectively; desaturation event <80% (DI80), median (range) 0.58 (0-10.8). We found no differences between SpO2 values at different weeks PMA. Conclusions: We described SpO2 values in very preterm infants, asymptomatic at 34, 35 and 36 weeks PMA. These values could be used as a reference to guide oxygen therapy previous to discharge.

Cardiac hemangioma is relatively rare for primary cardiac tumors. The diagnose is mainly based on surgical resection and biopsy, imaging examinations only provide limited diagnostic clues. For those giant cardiac hemangiomas, which may raise a risk of rupture, need thoroughly surgical removal. However, meticulous follow-up is required due to its possibility of recurrence.

Objectives: Our aim was to determine the treatable causes to increase the chance of decannulation success. For this purpose we evaluated the differences between the patients who succesfully decannulated and the patients who still has tracheostomy. Metods: A retrospective cohort study was conducted based on medical records of all pediatric patients with tracheostomy in a single centre. Results: Decannulation was successfully achieved in 59 patients (34.5%) of total 171 patients with tracheostomy between the years 2012-2019. Median duration of tracheostomy was 41.5 and 12 months in patients who remained with tracheostomy and decannulated respectively. Neurological disorders were higher in patients remained with tracheostomy, congenital heart disease and airway abnormalities were higher in decannulated patients. Presence of bacterial colonization (3.8-fold), history of invasive respiratory support following tracheostomy (2.9-fold), and having any neurological disorder and/or comorbidity (5.2-fold) were significantly associated lower rates of decannulation. Almost 33 % of patients had bacterial colonization and colonization rates were higher in patients who needed invasive respiratory support following tracheostomy placement (p<0.001), patients with feeding/swallowing problems (p=0.005) and neurological disorders(0.002). There was significant correlation between duration of tracheostomy and bacterial colonization rates (p=0.008). But after analysing with logistic regression only having a neurological disorder was associated with bacterial colonization (OR= 2.9; 95% Cl: 1.15-7.47 p=0.024). Conclusion: While conducting decanulation assessment, the presence of colonization should be considered. Future prospective researchs are necessary in order to determine the role of chronic colonization on decannulation success.

Objectives: To assess whether adding placental growth factor (PlGF) or replacing pregnancy-associated plasma protein-A (PAPP-A) improves the first trimester combined test performance for trisomy 21. Design: Prospective observation Cohort Setting: The Chinese University of Hong Kong, China Sample: 11,518 women having a singleton pregnancy screened for trisomy 21 between December 2016 and December 2019 using the first trimester combined test. Methods: PlGF was prospectively measured and estimated term risk for trisomy 21 was calculated by 1) replacing PAPP-A with PlGF and 2) adding PlGF to the combined test which includes nuchal translucency, PAPP-A and free β-human chorionic gonadotropin (hCG). Main Outcome Measure: Screening performance, area under curve (AUC), detection rate (DR), screen positive rate (SPR) and false positive rate (FPR) Results: 29 women had trisomy 21. The combined tests DR, FPR and SPR were 89.7%, 5.7% and 6% respectively. DR when replacing PAPP-A or adding PlGF to the combined test remained unchanged. Replacing PAPP-A by PlGF increased FPR and SPR to 6.2% and 6.4% respectively. Adding PlGF to the combined test gave FPR and SPR rates of 5.5% and 5.7% respectively. Adding or replacing PlGF did not give a significant increase in AUC (p>0.48) over that of the combined test. Conclusion: Adding PlGF to the combined test or replacing PAPP-A with PlGF in the combined test did not improve trisomy 21 detection rate. Replacing PAPP-A by PlGF increased SPR, whilst adding PlGF resulted in only a marginal reduction in SPR.

Ultrasound guided venous access Is important to minimize pneumothorax and unnecessary incisions in patients undergoing device implant.

In this article, we set up adequate circumstances for the existence of solutions for boundary value problems of fractional differential equations including the Caputo fractional derivative and nonlocal conditions.

The pupils will learn what solar energy is and how it can be used for various purposes. We will discuss how sunlight heat can be doubled with the use of aluminum and black sheet. This project will open doors to many ideas in students mind regarding the use of solar energy for different purposes in different ways. Solar Oven is a simple project so this will encourage students to create more projects, using solar energy, on their own.

IntroductionDuring the nineteenth-century, the Harvard College Observatory performed many photographic spectroscopic surveys of stars. This produced spectral classifications for roughly 225,000 stars, which created the Henry Draper Catalogue. Ejnar Hertzsprung realised that narrow lined stars had smaller proper motions compared to other stars of the same spectral classification. He was then able to estimate the stars’ absolute magnitudes\cite{1} by computing their secular parallaxes as a result of the difference of proper motions.DefinitionsBefore we start constructing and analysing a Hertzsprung-Russell Diagram, we should familiarise ourselves with some of the words used in this paper.Firstly, Absolute Magnitude (\(M\)) is a measure of the luminosity of a celestial object, on an inverse logarithmic astronomical magnitude scale. It is further defined to be equal to the apparent magnitude that the object would have if it were viewed from a distance of exactly 10 parsecs without extinction of its light.Apparent Magnitude (\(m\)) is a measure of the brightness of a celestial object observed from Earth. This value is dependent on factors such as the extinction of the body’s light, its intrinsic luminosity and its distance from Earth. We state a relationship, the brighter an object, the lower its magnitude value.Luminosity (\(L\)\(\circ\) or \(L\)*) refers to the absolute measure of radiated electromagnetic power emitted by a light-emitting object. We are interested in both the solar luminosity, denoted by \(L\)\(\circ\) and the stellar luminosity, denoted by \(L\)* of a particular star.Lastly, we define the Hertzsprung-Russell Diagram as a scatter plot of stars which shows the relationship between the stars’ absolute magnitudes or luminosities versus their stellar classifications or effective temperatures.Absolute MagnitudeWe know that absolute magnitude is measured by a body’s luminosity, which provides us with the relationship between Absolute Magnitude and Luminosity, which states that the more luminous an object is, the smaller the numerical value of its absolute magnitude. In terms of variables, we can express this relationship by the following:A difference of n magnitudes ( in absolute magnitude ) corresponds to a luminosity ratio of \(100^{\frac{n}{5}}\). In a general sense, subscripts are used alongside \(M\) to represent the filter band used for the specific measurement, e.g. \(M\)V for measurements in the V-Band. We generalise this over all wavelengths with an object’s bolometric magnitude. By applying a bolometric correction\cite{2a}, we can convert absolute magnitudes in specific filter bands to its absolute bolometric magnitude.\[M_{bol}=M_v+BC\]Where BC is the Bolometric Correction, needed to factor in specific types of radiation by celestial bodies.Apparent Magnitude A numerical scale by Hipparchus describes the brightness of stars that appear in the night sky, where \(m\) = 1 is assigned to the brightest stars and \(m\) = 6\cite{3} assigned to the dimmest stars.The equation,\[100^{\frac{mM}{5}}=\frac{F}{F_{10}}=\left(\frac{d}{10pc}\right)^2\]relates objects within the neighbourhood of the Sun, where their brightness differs by a factor of 100 for \(m\) and \(M\) from any distance \(d\). The following equation is derived, given that \(d\) is measured in parsecs,\[M=m-5\log_{10}\left(d_{pc}\right)+5\]  Which when simplified produces,\[M=m-5\left(\log_{10}d_{pc}-1\right)\]This equation can also be written in two other forms,In terms of stellar parallax.(1) \[M=m+5\left(\log_{10}p+1\right)\]Where a distance modulus is known:(2) \[M=m-\mu\]For this paper, we will only be concerned with equation (1).Gathering DataThe following table was generated by using data available from VizieR. The Vmag column represents the H5 V Johnson magnitudes, Plx the Trigonometric Parallax, B-V the Johnson B-V Colours and finally SpType to represent all the Spectral Types.

Introduction: The development of right atrial (RA) thrombus (RAT) is a known complication of central venous catheter insertion (CVC). Deeper insertion of CVC within the RA may increase the risk for RAT development versus those placed at the superior vena cava (SVC)-RA junction. We sought to evaluate the incidence of catheter-associated RAT as detected by transthoracic echocardiograms (TTEs), characterize thrombi though multimodal imaging, and evaluate thrombi management with follow-up imaging. Methods: A retrospective analysis was conducted of consecutive TTEs from our institution between October 1, 2018, and January 1, 2020 in which a venous catheter was visualized in the RA. Studies were reviewed in detail to determine presence of suspected RAT. Demographic data, comorbidities, laboratory values, characteristics of the catheter and the thrombus, subsequent imaging and management, and outcomes were collected. Results: A total of 364 TTEs were performed in 290 patients with a venous catheter visualized in the RA. Of these 290 patients, 15 had an imaging suspicion for RAT yielding an incidence of 5.2%. Management strategies included anticoagulation in 13 (86.7%) patients and catheter removal in 11 (73.3%) patients. At eight months follow-up, 11 (73.3%) patients had resolution of RAT based on subsequent imaging. Conclusion: In patients with deeply placed CVC catheters, the incidental detection of RAT by TTE was not trivial. Anticoagulation and catheter removal and replacement, if deemed safe, were effective methods of thrombus management. RAT as a complication of CVCs must be accounted for when addressing factors that influence depth of CVC insertion.

This themed issue follows a meeting held at the Royal College of Physicians in London in November 2019 entitled “Avoiding harm from overprescribing: how to reduce waste and dependence on prescription drugs.” Here we summarize the existing challenges faced by healthcare professionals and attempt to present solutions to the expanding problem associated with a vast therapeutic arsenal and increasing medical complexity.

Teacher evaluation can be an underused resource for teaching improvement, as it is reduced to a single questionnaire to be answered by students. The lack of flexibility and adaptability prevents them from developing their potential.This paper provides a record of the protocol that is being applied in a relation to an educational innovation project that aims to develop a contextualized alternative to the current system of teaching assessment that is being carried out at the University of Malaga (Spain).For this purpose, an evaluation based on the Contribution Analysis is being carried out (Mayne, 2008). This procedure is based on the project's Theory of Change (Roger, 2014) from which a procedure is established to confirm the causality of the changes observed. The procedure is currently underway and the first partial results are expected by the end of 2021.The results of the evaluation will make it possible to assess the efficiency of the project, as well as its capacity to solve the problems of questionnaire-based teaching evaluation.ResumenLa evaluación docente puede ser un recurso infrautilizado para la mejora de la enseñanza, ya que se reduce a un solo cuestionario para ser respondido por los estudiantes. La falta de flexibilidad y adaptabilidad les impide desarrollar su potencial.Este artículo proporciona un registro del protocolo que se está aplicando en relación a un proyecto de innovación educativa que tiene como objetivo desarrollar una alternativa contextualizada al actual sistema de evaluación docente que se está llevando a cabo en la Universidad de Málaga (España).Para ello, se está realizando una evaluación basada en el Análisis de Contribuciones (Mayne, 2008). Este procedimiento se basa en la Teoría del Cambio del proyecto (Roger, 2014) a partir del cual se establece un procedimiento para confirmar la causalidad de los cambios observados. El procedimiento está actualmente en curso y se esperan los primeros resultados parciales para finales de 2021. Los resultados de la evaluación permitirán valorar la eficacia del proyecto, así como su capacidad para resolver los problemas de evaluación docente mediante cuestionarios.

Infective endocarditis is nowadays one of the main indications for valvular surgery. When occurring in the right chambers of the heart, the tricuspid valve is the most commonly affected. Although this disease is usually present in injecting-drug abusers or patients with other predisposing risk factors, the incidence of native pulmonary valve infective endocarditis is the least frequent. This case report presents a 51-year-old patient with no relevant medical history that was admitted to our institution with sepsis. Further studies revealed a native pulmonary valve infective endocarditis complicated with infra-annular abscess and pulmonary septic embolisms. The following describes the clinical presentation of the case, echocardiograms, the surgical procedure, and the postoperative period. To date, few cases of native pulmonary valve infective endocarditis with no previous risk factors have been reported.

Multi-channel food webs are shaped by the ability of apex predators to link asymmetric energy flows in mesohabitats differing in productivity and community traits. While body size is a fundamental trait underlying life histories and demography, its implications for structuring multi-channel food webs are unexplored. To fill this gap, we develop a framework that links population responses to predation and resource availability to community-level patterns using a tri-trophic food web model with two populations of intermediate consumers and a size-selective top predator. We show that asymmetries in mesohabitat productivities and consumer body sizes drive food web structure, merging previously separate theory on apparent competition and emergent Allee effects (i.e., abrupt collapses of top predator populations). Our results yield theoretical support for empirically observed stability of asymmetric multi-channel food webs and discover three novel types of emergent Allee effects involving intermediate consumers, multiple populations or multiple alternative stable states.

Title PageTitle: A commentary on the need for support with mental as well as physical health for people with endometriosis during the COVID-19 pandemic and beyond.Authors:Lysia Demetriou, Emma Cox, Claire E. Lunde, Christian M Becker, Adriana L. Invitti, Beatriz Martínez-Burgo, Marina Kvaskoff, Kurtis Garbutt, Emma Evans, Elaine Fox, Krina T Zondervan, Katy Vincent.Corresponding author contact information:Prof Katy VincentNuffield Department of Women’s & Reproductive HealthUniversity of OxfordJohn Radcliffe HospitalOxfordOX3 9DUTel: 01865 220024Fax: 01865 769141 katy.vincent@wrh.ox.ac.ukAuthor information:Lysia Demetriou , PhD, lysimachi.demetriou@wrh.ox.ac.uk , Nuffield Department of Women’s and Reproductive Health, University of Oxford.Emma Cox , MSc, MBA, ceo@endometriosis-uk.org, Endometriosis UKChristian Becker , MD; christian.becker@wrh.ox.ac.uk; Nuffield Department of Women’s and Reproductive Health, University of OxfordClaire E. Lunde , BS, BA; claire.lunde@spc.ox.ac.uk; (1) Nuffield Department of Women’s and Reproductive Health, University of Oxford. (2) Biobehavioral Pediatric Pain Lab, Department of Psychiatry, Boston Children’s Hospital; (3) Center for Pain and the Brain (P.A.I.N. Group), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s HospitalAdriana Invitti , PhD, adriana.invitti@wrh.ox.ac.uk; (1) Nuffield Department of Women’s and Reproductive Health, University of Oxford; (2) Departamento de Ginecologia, Universidade Federal de São Paulo.Beatriz Martínez-Burgo , PhD, beatriz.martinezburgo@wrh.ox.ac.uk, Nuffield Department of Women’s and Reproductive Health, University of OxfordMarina Kvaskoff , PhD, marina.kvaskoff@inserm.fr, Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy, ”Exposome and Heredity” Team, CESP, F-94805, Villejuif, FranceKurtis Garbutt, EngD, kurtis.garbutt@wrh.ox.ac.uk, Nuffield Department of Women’s and Reproductive Health, University of Oxford.Emma Evans , DClinPsych, emma.evans@ouh.nhs.uk, Oxford University Hospitals NHS Foundation TrustElaine Fox, PhD, elaine.fox@psy.ox.ac.uk, Department of Experimental Psychology, University of Oxford.Krina Zondervan , DPhil, krina.zondervan@wrh.ox.ac.uk, (1) Nuffield Department of Women’s and Reproductive Health, University of Oxford; (2) Wellcome Centre for Human Genetics, University of OxfordKaty Vincent , DPhil, katy.vincent@wrh.ox.ac.uk, Nuffield Department of Women’s and Reproductive Health, University of Oxford.Running Title: Support for people with endometriosisManuscript word count: 1282 wordsThe coronavirus disease 2019 (COVID-19) pandemic meant an abrupt change in healthcare provision around the world. Whilst the primary focus was (rightly) on the care of those infected with SARS-CoV-2 and public health measures to prevent transmission/identify those most at risk, individuals with chronic conditions saw their treatments halted, cancelled or changed, with little information available and extremely limited access to clinicians1-3. As the first wave settled, many units began to restart their benign gynaecology services, however, this was within the limitations of social distancing, reduced staffing (due to sickness, shielding or COVID-19 contact) and the continued need for personal protective equipment (PPE). At a global level, the focus remained on public health measures and the search for a vaccine4.Everyone had their own personal experience of the initial lockdowns and ongoing restrictions, the extent and timing of which varied throughout the world. Many were able to find at least some positives to contrast with the limitation on freedom and continuing background threat from the virus. These included more time to spend with their nuclear family, reigniting interest in or starting new hobbies, the opportunity to tackle home improvements and more time to exercise. However, data also began to emerge on the significant impact the pandemic was having on mental health5, 6. Of particular relevance to Obstetricians and Gynaecologists was the finding that along with young people and those with small children at home, mental health was deteriorating most in women6.As endometriosis is a chronic disease, many of those affected rely on long term medication, whilst others require one or more procedures (surgery or fertility treatment). We were concerned as to the impact the pandemic might be having on the access to treatment for those with endometriosis. We therefore conducted an online survey study to determine this impact and understand priorities going forwards. The survey (open 11th May to 8th June 2020; University of Oxford Central University Research Ethics Committee approval reference: R69636/RE001) was available in English, French, German, Spanish and Portuguese and had 7246 respondents. 6729 of these met inclusion criteria (\(\geq\)18 years old; self-reported endometriosis diagnosis by surgery or imaging) covering most regions of the world (Europe: n=4502; North America: n=973; Latin America and Caribbean: n=662; Oceania: n=379; Asia: n=35; Africa: n=28; Unknown: n=150).Overall, 80.7% (95% CI [79.7, 81.6]) reported an impact on their current or planned treatments. Based on enquiries to Endometriosis UK and what we were hearing clinically, we had expected many challenges with accessing medications especially injectables. However, 64.6% reported no impact of the pandemic on the availability of their usual treatments for endometriosis (n=4267). Although 20.3% (n=1337) did report difficulty obtaining repeat prescriptions, 10.5% having to change their hormone and/or painkiller (4.5% and 7.0% respectively), whilst 9.5% had to stop a medication altogether (hormones: 3.4%; painkillers 6.6%). The impact on planned care was much greater: 50.0% of responders reported cancelled/postponed appointments with gynaecologists and 14.7% described cancelled/postponed primary care appointments; 37.2% had procedures cancelled/postponed (surgery: 27.0%; fertility: 12.0%). These proportions were similar around the world (Table 1).Our data demonstrate the considerable impact the COVID-19 pandemic has had on the care of people around the world with endometriosis. These findings agree with studies in Urology7, Dermatology2 and a smaller Turkish endometriosis cohort (n=261)3, suggesting a significant impact on benign services. Concerns have also been expressed about the impact on those with chronic pain, both in terms of difficulties accessing treatments including physiotherapy and psychology and the possibility of medication issues due to telephone prescribing8. During this second wave and as we move forwards, it is essential that we minimise the impact on those with chronic conditions. Redesigning services with the priorities of those suffering with the conditions in mind will be essential to achieving this aim.In our survey we also asked “During the pandemic, what one thing would be most helpful to you, relating to endometriosis? ” and “As restrictions begin to ease and healthcare starts to go back to normal, what one thing do you think should be prioritised with regards to endometriosis? ”. Respondents considered that during the pandemic the most helpful things would be: contact with their gynaecologist (32.6%); dates booked for future surgery/fertility treatments (20.5%); and mental health support (20.3%). Improving availability of medication and contact with primary care were less popular (11.1% and 8.6% respectively). As restrictions ease, priorities are: arranging cancelled/postponed procedures (42.7%) or appointments with their gynaecologists (32.1%) and mental health support (13.0%). Considerably less chose medication availability (5.3%) or primary care appointments (3.8%). Figure 1 illustrates how similar these priorities were around the world.It was notable that the top three priorities during and immediately after the pandemic were remarkably consistent around the world. Given how rapidly telemedicine has been adopted globally, it should not be a challenge to arrange contact between patients and their gynaecologists by either telephone or video. However, this does necessitate gynaecologists being available to provide this service and argues against them being redeployed to cover emergency services as commonly occurred during the height of the first wave. We do not believe that primary care appointments should be recommended as a substitute for gynaecology appointments. These are clearly not the priority for those with endometriosis and primary care services have been placed under considerable pressures during the pandemic9. Whilst little can be done to reduce waiting times for procedures (both surgical and fertility treatments), we should at least be open with patients, giving a realistic timeframe in which we expect to be able to offer these.Although these first two priorities were not surprising, we did not expect to see such a high proportion prioritising mental health over and above all other aspects of their endometriosis care. There has been an increasing focus on comorbid mental health conditions in people with endometriosis over recent years, including two high profile UK investigations10, 11, yet guidance on the management of the condition does not reflect this. Whilst the pandemic continues, mental health support can be delivered virtually, both standalone and in the context of pain management12. However, this is one change we believe should continue for the long-term and therefore investment in psychology, ideally embedded within gynaecology services, will be essential. Integrating mental health support into the standard of care for endometriosis could be one positive to come out of this pandemic and might be expected to have a real impact on quality of life.Finally, we were concerned to see that more than half of respondents worried that their endometriosis makes them more vulnerable to COVID-19 (n=3635, 54.2% 95% CI [53.0, 55.4]; only n=22 did not answer this question). This may be because the known link to altered immunological responses has been misinterpreted as endometriosis being an autoimmune condition7, with additional concerns for those with thoracic endometriosis. Given that so far there is no evidence to support this belief, we consider it essential that clinicians address this issue with their patients, and education campaigns should be considered. Worries about their vulnerability to COVID-19 may add to the feelings of threat experienced during the pandemic and thus contribute to worsening mental health.In conclusion, COVID-19 has clearly had a devastating effect on health and healthcare around the world. At least in the initial phases, those with chronic conditions (including endometriosis) experienced a significant impact on their care, the longer-lasting effects of which remain to be determined. Moving forwards, it will be essential to take patient priorities into consideration as financially-strained healthcare providers redesign their services. We hope that this additional evidence of the desire for support with mental health in combination with other work highlighting this as an area of real need leads to a sustained change in the availability of psychologists within gynaecology services.

Objective: In ranula etiology, trauma in submandibular and sublingual glands and trauma in secretory ducts have role. There are many different treatment strategies ranging from drainage to ekcision of sublingual gland with ranula. Aim of this study is evaluation of the effects of usage of surgicel in ranula surgery instead of marsupialization with gauze ped. Materials and methods: We included 26 patients to our study who had sublingual ranula surgery and fulfil study criteria Results: Significant differences were not determined according to age,sex, anesthesia type and ranula size. Infection signs were not seen in post-operative one week control of patients. In six months controls, oral base wound was healed totally and there were no relapse cases. Conclusions: In result of this study, We showed that using of surgicel with marsupialization is an effective therapeutic method and it decreases relaps rates in ranula patients.

Introduction: Prevalence of insomnia is higher in females and increases with higher age. Besides primary insomnia, comorbid sleep disorders are also common, accompanying different conditions. Considering the possible adverse effects of commonly used drugs to promote sleep, a nonpharmacologic approach should be preferred in most cases. Although generally considered first-line treatment, the nonpharmacologic approach is often underestimated by both patients and physicians. Objective: To provide primary care physicians an up-to-date approach to the nonpharmacologic treatment of insomnia. Methods: PubMed, Web of Science, and Scopus databases were searched for relevant articles about the nonpharmacologic treatment of insomnia up to December 2020. We restricted our search only to articles written in English. Main Message: Most patients presenting with sleep disorder symptoms can be effectively managed in the primary care setting. Primary care physicians may use pharmacologic and nonpharmacologic approaches, while the latter should be generally considered first-line treatment. A primary care physician may opt to refer the patient to a sleep medicine specialist for refractory cases. Conclusions: This paper provides an overview of current recommendations and up-to-date evidence for the nonpharmacologic treatment of insomnia. This article emphasizes the importance of cognitive-behavioral therapy for insomnia, likewise, exercise and relaxation techniques. Complementary and alternative approaches are also covered.

Background: The pathogenesis of atopic dermatitis (AD) results from complex interactions between environmental factors, barrier defects, and immune dysregulation resulting in systemic inflammation. Therefore, we sought to characterize circulating inflammatory profiles in pediatric AD patients and identify potential signaling nodes which drive disease heterogeneity and progression. Methods: We analyzed a population of 87 infants that were at high risk for atopic disease based on dermatitis diagnoses. Clinical parameters, serum, and peripheral blood mononuclear cells (PBMCs) were collected upon entry, and at one and four years later. Within patient serum, 126 unique analytes were measured using a combination of multiplex platforms and ultrasensitive immunoassays. Results: We assessed the correlation of inflammatory analytes with AD severity (SCORAD). Key biomarkers, such as IL-13 (corr=0.47) and TARC (corr=0.37), among other inflammatory signals, significantly correlated with SCORAD across all timepoints in the study. Flow cytometry and pathway analysis of these analytes implies that CD4 T cell involvement in type 2 immune responses were enhanced at the earliest time point (year 1) relative to the end of study collection (year 5). Importantly, forward selection modeling identified 18 analytes in infant serum at study entry which could be used to predict change in SCORAD four years later. Conclusions: We have identified a pediatric AD biomarker signature linked to disease severity which will have predictive value in determining AD persistence in youth and provide utility in defining core systemic inflammatory signals linked to pathogenesis of atopic disease.

    Bu haftaki yazımızda, ünlü matematikçi Fibonacci'nin varsayımsal bir tavşan popülasyonunu modelleyerek elde ettiği Fibonacci dizisini C, Python ve MATLAB'de kodlayarak inceledik.  

Introduction Inhaled nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale and warrants urgent investigation of its therapeutic potential for COVID-19. UFH has antiviral effects and prevents the SARS-CoV-2 virus’ entry into mammalian cells. In addition, UFH has significant anti-inflammatory and anti-coagulant properties, which limit progression of lung injury and vascular pulmonary thrombosis. Methods and intervention This meta-trial is a prospective collaborative individual patient data meta-analysis of randomised controlled trials and early phase studies. Individual studies are conducted in multiple countries. Adult patients admitted to the hospital with confirmed SARS-CoV-2 infection, who do not require immediate mechanical ventilation, are randomised to inhaled nebulised UFH or standard care. All studies collect a minimum core dataset. The primary outcome is intubation (or death, for patients who died before intubation) at day 28, assessed in a time-to-event analysis. The secondary outcomes are oxygenation, clinical worsening and mortality, assessed in time-to-event analyses. Individual studies may have specific outcome measures in addition to the core set. Ethics and dissemination: The meta-trial is registered at ClinicalTrials.gov, ID NCT04635241. Results of this study will be shared with the WHO, published in scientific journals and presented at scientific meetings.

The aim of this article is to present stability results of some Caputo fractional differential equations in the sense of Ulam-Hyers, Ulam-Hyers-Rassias and generalized Ulam-Hyers-Rassias. In this way, we generalize some recent interesting results.

Objectives: To externally validate and compare Resorlu-Unsal stone score(RUSS), modified Seoul National University Renal Stone Complexity Score(S-ReSC), Ito’s nomogram and R.I.R.S. scoring systems for predicting capabilities of both the stone-free status and complications in a multi-institutional study. Materials and Methods: We performed a retrospective analysis of 949 patients who were underwent flexible ureterorenoscopy (f-URS) and laser lithotripsy for renal stones in two institutions between March-2015 and June-2020. The RUSS, modified S-ReSC, Ito’s nomogram and R.I.R.S. scores were calculated for each patient by same surgeon on imaging methods. Results were compared for their predictive capability of stone-free status and complications. Results: Of 949 patients 603 were male and 346 were female with a mean age of 47.2±14.3 (range 2-84years). Mean stone burden was 102.6±42.2 (48-270mm2). All nomograms predicted stone-free status (AUC were 0.689, 0.657, 0.303 and 0.690, respectively). All four scoring systems predicted complications with AUC values of 0.689, 0.646, 0.286 and 0.664 for RUSS, modified S-ReSC, Ito’s nomogram, R.I.R.S., respectively. Although all scoring systems were able to predict complications only Ito’s nomogram was able to predict Clavien ≥2 complications. Conclusion: All four scoring systems (RUSS, modified S-ReSC, Ito’s nomogram and R.I.R.S.) could predict stone-free status after f-URS, however the AUC values are not satisfactory in our large patient cohort. Although these scoring systems were not developed for predicting post-operative complications, they were associated with complications in our study. However, these four scoring systems have some significant limitations. The ideal scoring system is yet to be developed.

Abstract Aims of the study: The aim of this study was to investigate the impact of testosterone deficiency on cognitive functions in metastatic prostate cancer patients receiving androgen deprivation therapy (ADT). Methods: In this multicentric prospective study, 65 metastatic prostate cancer patients were evaluated. Demographic and clinical data were recorded. Cognitive functions were assessed using the Symbol Digit Modalities Test, the California Verbal Learning Test Second Edition, the Brief Visuospatial Memory Test - Revised, and the Trail Making Test. Depressive symptoms were assessed using the Beck Depression Inventory. Cognitive functions and depressive symptoms were recorded before the androgen deprivation therapy and at the 3- and 6-month follow ups. Results: At the basal cognitive assessment, the mean Symbol Digit Modalities Test, the California Verbal Learning Test Second Edition, the Brief Visuospatial Memory Test - Revised scores were 25.84 ± 17.54, 32.68 ± 10.60, and 17.63 ± 11.23, respectively, and the mean time for the Trail Making Test was 221.56 ± 92.44 s., and were similar at the 3-month, and 6-month controls (p > 0.05). The mean pretreatment, third and sixth month testosterone levels were 381.40 ± 157.53 ng/dL, 21.61 ± 9.09 ng/dL, and 12.25 ± 6.45 ng/dL (p < 0.05), and the total PSA levels were 46.46 ± 37.83 ng/mL, 1.41 ± 3.31 ng/mL, and 0.08 ± 0.14 ng/mL (p < 0.05), respectively. Conclusion: The ADT in patients with metastatic prostate cancer does not affect patients’ cognitive functions and depressive symptoms. However, further prospective randomized studies with higher cohorts and longer follow up periods are needed.

Recovery from SARS-CoV-2 infection requires a solid first line of innate immunity defense, namely release of interferon-alpha and beta, which interfere with viral replication. These critical defense factors are produced upon encounter of the RNA of the virus that succeeded in host cell invasion with the cytoplasmic innate immunity receptors, notably retinoic acid-inducible gene I (RIG-1). A second line of defense would be the host generation of neutralizing and opsonic antibodies capable of preventing virus entry and virus spread, respectively. We need to avoid or dampen host generation of powerful cytotoxic T cells, which lead to destruction of the host heart, lung, kidney, and small intestine cells presenting the viral peptides on their surface membrane, and potential organ failure and destruction. We herein wish to demonstrate that the vaccine should be based uniquely on SARS-CoV-2 spike glycoprotein subunit 1 polypeptide, because that subunit is released upon virus invasion, and does not penetrate host critical cells in the heart, lung, liver, kidney and 2 small intestine. Differently from all other viral peptides, subunit 1 peptides are not readily processed for presentation on the surface of the host structural cells, rendering them targets for the destructive action of cytotoxic T lymphocytes and natural killer cells.