BACKGROUND Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and nonischemic cardiomyopathy (NICM) patients. METHODS Multicentric observational registry including 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-days mortality and procedure-related complications. RESULTS Most of the patients were male (85%), with IHD (67%) and mean age of 63±13 years. During a mean follow-up of 3±2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class III/IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The independent predictors of mortality were C-ABL, ES, LVEF, age and NYHA class III/IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction=0.04). Mortality at 30-days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P=0.777), as was complication rate (10.3% vs. 15.1% respectively, P=0.336). CONCLUSION A combined endo-epicardial approach was associated with greater VT-free survival and lower all-cause death in IHD and NICM patients undergoing repeated VT catheter ablations. Both strategies seem equally safe.

Appendiceal mucinous neoplasm (AMN) is defined as a distended, mucous-filled appendix. It is a rare condition seen in only 8% of cases of appendiceal tumors. Appendiceal mucocele associated with endometriosis is extremely rare with only 16 cases described in the literature to date. In view of the scarcity of the finding, few data are available on preoperative assessment of AMN in women with endometriosis. The goal of the present study was to describe the imaging features that could be suggestive of AMN in the context of endometriosis, as well as the specific management and outcomes.

In this paper, we introduce notions of RLA-local modules and locally artinian supplemented modules which are proper generalizations as notions of strongly local modules and ss-supplemented modules, respectively and we study some properties of these module. In particular, we give a characterization of semi perfect rings and left perfect rings.

1. Energetics are a key driver of animal decision-making, as survival depends on the balance between foraging benefits and movement costs. This fundamental perspective is often missing from habitat selection studies, which mainly describe correlations between space use and environmental features, rather than the mechanisms behind these correlations. To address this gap, we present a new modelling framework, the energy selection function (ESF), to assess how moving animals choose habitat based on energetic considerations. 2. The ESF considers that the likelihood of an animal selecting a movement step depends directly on the corresponding energetic gains and costs. The parameters of the ESF measure selection for energetic gains and against energetic costs; when estimated jointly, these provide inferences about foraging and movement strategies. The ESF can be implemented easily with standard conditional logistic regression software, allowing for fast inference. We outline a workflow, from data-gathering to statistical analysis, and use a case study of polar bears (Ursus maritimus) as an illustrative example. 3. We show how defining gains and costs at the scale of the movement step allows us to include detailed information about resource distribution, landscape resistance, and movement patterns. We demonstrate this in the polar bear case study, in which the results show how cost-minimization may arise in species that inhabit environments with an unpredictable distribution of energetic gains.4. The ESF combines the energetic consequences of both movement and resource selection, thus incorporating a key aspect of evolutionary behaviour into habitat selection analysis. Because of its close links to existing habitat selection models, the ESF is widely applicable to any study system where energetic gains and costs can be derived, and has immense potential for methodological extensions.

Background: A computational model demonstrated that atrial fibrillation (AF) rotors could be distributed in patchy fibrotic tissue and play an important role in AF drivers. However, this was not validated in humans. Objective: The purpose of this study was to evaluate the fibrotic tissue properties of AF rotors in patients with persistent AF. Methods: A total of 287 segments in 15 patients with persistent AF (longstanding persistent AF in 9 patients) that underwent AF ablation were assessed. Non-passively activated areas (NPAs), where rotational activation (AF rotor) was frequently observed, were detected by the novel real-time phase mapping (ExTRa Mapping). Atrial fibrosis was detected by late-gadolinium enhancement magnetic resonance imaging (LGE-MRI), and the fibrotic heterogeneity and density were assessed by the entropy (LGE-entropy) and volume ratio of the enhancement voxel (LGE-volume ratio), respectively. Results: NPAs were found in 61 (21%) of 287 segments and were mostly found around the pulmonary vein antrum. A receiver operating characteristic curve analysis yielded an optimal cutoff value of 5.7 and 10% for the LGE-entropy and LGE-volume ratio, respectively. The incidence of NPAs was significantly higher at segments with an LGE-entropy of >5.7 and LGE-volume ratio of >10% than at the other segments (38 [30%] of 126 vs. 23 [14%] of 161 segments, p = 0.001). No NPAs were found at segments with an LGE-volume ratio of >50% regardless of the LGE-entropy. Conclusion: AF rotors are mostly distributed in relatively weak and much more heterogenous fibrotic tissue.

Background During automated radiofrequency (RF) annotation-guided pulmonary vein isolation (PVI), respiratory motion adjustment (RMA) is recommended, yet lacks in vivo validation. Methods Following contact force (CF) PVI (continuous RF, 30W) using general anaesthesia and automated RF annotation-guidance (VISITAG™: force-over-time 100% minimum 1g; 2mm position stability; ACCURESP™ RMA “off”) in 25 patients, we retrospectively examined RMA settings “on” versus “off” at the left atrial posterior wall (LAPW). Results Respiratory motion detection occurred in 8, permitting offline retrospective comparison of RMA settings. Significant differences in LAPW RF auto-annotation occurred according to RMA setting, with curves displaying catheter position, CF and impedance data indicating “best-fit” for catheter motion detection using RMA “off”. Comparing RMA “on” versus “off”, respectively: Total annotated sites 82 versus 98; median RF duration per-site 13.3s versus 10.6s (p<0.0001); median force time integral 177g.s versus 130g.s (p=0.0002); mean inter-tag distance (ITD) 6.0mm versus 4.8mm (p=0.002). Considering LAPW annotated site 1-to-2 transitions resulting from deliberate catheter movement, 3 concurrent with inadvertent 0g CF demonstrated <0.6s difference in RF duration. However, 13 deliberate catheter movements during constant tissue contact (ITD range 2.1 – 7.0mm) demonstrated (mean) site-1 RF duration difference 3.7s (range: -1.3 to 11.3s): considering multiple measures of catheter position instability, the appropriate indication of deliberate catheter motion occurred with RMA “off” in all. Conclusions ACCURESP™ respiratory motion adjustment importantly delayed the identification of deliberate and clinically relevant catheter motion during LAPW RF delivery, rendering auto-annotated RF display invalid. Operators seeking greater accuracy during auto-annotated RF delivery should avoid RMA use.

In this paper, we introduce the notion of generalized fractional integrals for the interval-valued functions of two variables. We establish Hermite-Hadamard type inequalities and some related inequalities for co-ordinated convex interval-valued functions by using the newly defined integrals. It is also proved that the results given in this paper are the strong generalization of already published ones.

The numerical simulations of the uniform circular rotation of paddles on circular cylinder results natural convection flow of Al2O3-water in a cross-shaped porous cavity were performed by incompressible representation of smoothed particle hydrodynamics entitled ISPH method. The two vertical area of a cross-shaped cavity is saturated with homogeneous porous media and the whole horizontal area of a cross-shaped cavity is saturated with heterogeneous porous media. The inner paddles on the circular cylinder are rotating around their center by a uniform circular velocity. The whole embedded body of paddles on a circular cylinder has temperature Th. The wall-sides of a cross-shaped cavity are positioned at a temperature Tc. The current geometry can be applied in analysis and understanding the thermophysical behaviors of the electronic motors. The angular velocity is taken as ! = 7:15 and consequently the natural convection case is only considered due to the low speed of inner rotating shape. The performed simulations are represented in the graphical for the temperature distributions, velocity fields and tabular forms for average Nusselt number. The results revealed that an augmentation on paddle length rises the heat transfer and speed of fluid flow inside a cross shaped cavity. Also, an incrementation on Rayleigh number augments the heat transfer and speed of the fluid flow inside a cross-shaped cavity. The fluid flow is circulated only around the rotating inner shape when Darcy parameter decreases to Da = 105. Average Nusselt number Nu enhances by an increment on the paddle lengths and nanoparticles volume fraction

Introduction: Catheter ablation is superior to drugs regarding atrial fibrillation (AF) recurrence, symptoms improvement, and mortality reduction in heart failure. POLARx™ is a novel cryoballoon, with technical improvements seeking to improve outcomes. So far, its clinical evidence is restricted to a case report. Methods: To compare the POLARx™ cryoballoon procedural safety and efficacy to the already established Arctic Front Advance PRO™ (AFAP) in a single-center cohort study, consecutive patients undergoing AF cryoablation with the POLARx™ were enrolled. Data were prospectively gathered. POLARx™ patients were compared to a historical cohort of patients submitted to AF cryoablation with the AFAP. Results: Seventy patients were analyzed, 20 in POLARx™, and 50 in the AFAP group. They all underwent first-time pulmonary vein isolation, 77% were male, 94% had paroxysmal AF, median age was 62.5 years, median CHA2DS2-VASc 1, left-atrium size 34ml/m², and 65% were receiving anticoagulation. The primary end-point, all pulmonary veins isolation, was 100% in both groups. The complication rate was similar (0% POLARx™ vs. 5.7% AFAP, p=0.39). The median total procedural time was longer in the POLARx™ group (90min vs. 60min, p<0.001), but the overall time-to-isolation (TTI) (44.8sec vs. 39sec, p=0.253) and ablation time (15min vs. 13.7min, p=0.122) was similar between POLARx™ and AFAP groups, respectively. Despite equal TTI, the POLARx™ had a lower minimal temperature reached (-57ºC vs -47ºC, p<0.001). Conclusion: The novel POLARx™ cryoballoon had similar efficacy and safety compared to the AFAP. It was also associated with longer procedural times, similar TTI, and lower minimum temperature reached.

Subclavian venous obstruction is a common complication after cardiac device placement. Patients typically remain asymptomatic but at times may present with acute symptoms due to thrombus formation immediately after device placement or years later, due to chronic obstruction, with pain and swelling. Various techniques have been attempted to resolve symptoms in patients with chronic lead-related subclavian obstruction but are associated with a high recurrence of restenosis. Drug coated balloons (DCB) have been used subsequently after pre-dilation with high-pressure balloons, of the stenosed region, in patients with arteriovenous fistula obstruction, and have shown promising results. We discuss the utilization of DCB in our patient with chronic subclavian obstruction due to a permanent pacemaker lead.

Background: Many studies have reported the predictors of atrial fibrillation (AF) recurrence after persistent AF (peAF) ablation. However, the correlation between the atrial defibrillation threshold (DFT) for internal cardioversion (IC) and AF recurrence rate is little-studied. We investigated the relationship between DFT prior to catheter ablation for peAF and the AF recurrence. Method and Results: From June 2016 to May 2019, we enrolled 82 consecutive patients (mean age 65.0 ± 12.4 years), including 45 patients with peAF and 37 with long-standing peAF, at Hamamatsu medical center. In order to assess the DFT, we performed IC with gradually increasing energy prior to radiofrequency application. Forty-nine and 33 patients showed DFT values less than or equal to 10 J (group A) and greater than 10 J or unsuccessful defibrillation (group B), respectively. During the mean follow-up duration of 20.5 ± 13.1 months, patients in group B showed significantly higher AF recurrence rates than those in group A after the ablation procedure (P = 0.017). Multivariate analysis revealed that the DFT was the only predictive factor for AF recurrence (OR=1.07; 95% CI: 1.00-1.13, P = 0.047). Conclusions: The DFT for IC was one of the strongest prognostic factors in the peAF ablation procedure.

We previously introduced the Inverse Solution Guidance Algorithm (ISGA) methodology using a Single Equivalent Moving Dipole model of cardiac electrical activity to localize both the exit site of a re-entrant circuit and the tip of a radiofrequency (RF) ablation catheter. The purpose of this study was to investigate the use of ISGA for ablation catheter guidance in an animal model. Ventricular tachycardia (VT) was simulated by rapid ventricular pacing at a target site in eleven Yorkshire swine. The ablation target was established using three different techniques: a pacing lead placed into the ventricular wall at the mid-myocardial level (Type-1), an intracardiac mapping catheter (Type-2), and an RF ablation catheter placed at a random position on the endocardial surface (Type-3). In each experiment, one operator placed the catheter/pacing lead at the target location, while another used the ISGA system to manipulate the RF ablation catheter starting from a random ventricular location to locate the target. The average localization error of the RF ablation catheter tip was 0.31 ± 0.08 cm. After analyzing ~35 cardiac cycles of simulated VT, the ISGA system’s accuracy in locating the target was 0.4 cm after 4 catheter movements in the Type-1 experiment, 0.48 cm after 6 movements in the Type-2 experiment, and 0.67 cm after 7 movements in the Type-3 experiment. We demonstrated the feasibility of using the ISGA method to guide an ablation catheter to the origin of a VT focus by analyzing a few beats of body surface potentials without electro-anatomic mapping.

Network analysis is a powerful tool to describe, estimate, and predict the role of pig trade in the spread of pathogens and generate essential patterns that can be used to understand, prevent, and mitigate possible outbreaks. This study aimed to describe the network of between-farm pig movements and identify heterogeneities in the connectivity of premises in the state of Santa Catarina, Brazil, using social network analysis (SNA). We used static and temporal network approaches to describe pig trade in the state by quantifying network attributes using SNA parameters, such as causal fidelity, loyalty, the proportion of node-loyalty, resilience of outgoing contact chains, and communities. Two indexes were implemented, the first one is a normalized index based on SNA-farm level measures and other index-based SNA-farm level measures considering the swine herd population size from all premises, both indexes were summarized by municipality to target and rank surveillance activities. Within Santa Catarina, the southwest region played a key role in that 80% of trade was concentrated in this region, and thus acted as a hub in the network. In addition, nine communities were found. The results also showed that premises were highly connected in the static network, with the network exhibiting low levels of fragmentation and loyalty. Also, just 11% of the paths in the static network existed in the temporal network which accounted for the order in which edges occurred. Therefore, the use of time-respecting-paths was essential to not overestimate potential transmission pathways and outbreak sizes. Compared to static networks, the application of temporal network approaches was more suitable to capture the dynamics of pig trade and should be used to inform the design of risk-based disease surveillance.

The COVID-19 pandemic represents one of the greatest public health crises in recent history that caused unprecedented and massive disruptions of social and economic life globally. It is widely acknowledged that bats are the animal reservoir of coronavirus 2 of the severe acute respiratory syndrome (SARS-CoV-2), the causative agent of the human coronavirus disease 2019 (COVID-19). It has also long been known that coronaviruses circulate among different animal species. However, much remain to be understood of the epidemiology, the presumed existence of intermediate animal species and current and potential animal routes of SARS-Cov-2 transmission to humans. The recent observational and experimental studies also highlight the role of domestic and farmed animals in the epidemiology of COVID-19. This raises concerns of the potential spread of infection among susceptible animal species, with the risk of evolving into panzootic, and the likely occurrence of anthropozoonoses or reverse zoonosis (from humans to animals). As for other wildlife emerging pathogens, the animal-human spillover of SARS-CoV-2 is linked to a closer interface with humans, with the resulting risk of a pandemic. This knowledge has meaningful implications for the design of effective wildlife animal surveillance (epidemic intelligence) targeting CoVs in animal reservoirs, and requires the mobilization of different lines of expertise, notably veterinary epidemiologists and virologists, within a multi-disciplinary approach according to the One-Health principles.

Atrioventricular node ablation (AVNA) combined with His bundle pacing (HBP) are feasible, safe, and effective in patients with refractory atrial fibrillation (AF), however, the pacing parameters of sensing and capture threshold maybe sometimes unsatisfactory. Left bundle branch pacing (LBBP) provides obvious advantage in patients with conduction diseases at the distal His bundle for its better sensing, a lower and more stable capture threshold. Among hypertrophic cardiomyopathy (HCM) patients, AF is a common sustained arrhythmia, primarily caused by left atrial dilatation and remodeling. Few is known about the feasibility of electrophysiological performance, safety and clinical effectiveness of atrioventricular junction ablation (AVJA) combined with LBBP in patient with refractory AF and HCM. Here, we report a case of a 56-year-old woman suffering from refractory AF and HCM, however HBP was failed for its unsatisfactory sensing, a high and unstable capture threshold for her, therefore, ablation and LBBB were accepted by her to achieve better rate control. Improvement in symptoms, quality of life, and exercise capacity has been observed during the 1.5-year follow-up. To our knowledge, our case originally confirmed that the combination of AVJA and LBBP, without the defect of AVNA combined with HBP, is a better strategy with feasibility and safety for refractory AF patients with comorbidity of HCM, additionally, it may make LBBP more applicable and valuable among patients suffering from HCM meanwhile pace maker treatments are essential.

Quality education is a great concern in many societies across the world. In a highly competitive education sector, the success of academic institutions depends on the quality of education. Educationalists, policy makers, scholars, and researchers are showing their sincere interest towards the total quality management (TQM) as it is recognized as an effective management philosophy for continuous improvement, customer satisfaction, and organizational excellence. The purpose of the paper is to analyzing thoughts of the modern management paradigm "Total Quality Management" (TQM), and its application in the field of education. The basic theme of TQM is participatory approach to address the question(s) of quality in business as well as in the field of education, Enterprise Resource Planning systems are the new solution to business systems. These systems provide comprehensive business functionality in an integrated fashion using a state-of-the-art IT architecture. This trend towards enterprise systems in large and mid-sized organizations has a significant impact on IS careers paths. Enterprise systems essentially change fundamental business work processes thus implying that the system that supports these processes, and the design and development of these systems, also changed. The educational ERP of business activities in higher education go through a different modules. ERP in higher education should respond the real requirements of education system. Enhancements or mere adaptations of legacy solutions, which stemmed from the experience in business practice, are not always successful. The current paper shows the contents of the ERP that serve the education system successfully also shows the needs and future expectations of higher education institutions and the current business oriented ERP system.

Early prediction of disease severity is important for effective treatment of COVID-19. We determined that age is a key indicator for severity predicting of COVID-19, with an accuracy of 0.77 and an AUC of 0.92. In order to improve the accuracy of prediction, we proposed a Multi Criteria Decision Making (MCDM) algorithm, which combines the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) and Naïve Bayes (NB) classifier, to further select effective indicators from patients’ initial blood test results. The MCDM algorithm selected 3 dominant feature subsets {Age, WBC, LYMC, NEUT}, {Age, WBC, LMYC} and {Age, NEUT, LYMC}. Using these feature subsets, the optimized prediction model could achieve an accuracy of 0.82 and an AUC of 0.93. This result indicated that using age and the indicators selected by the MCDM algorithm from blood routine test results can effectively predict the severity of COVID-19 at an early stage.

Abstract Background: Nasal CPAP introduces positive pressure of air into both trachea and stomach, which may affect gastric emptying. The rate of gastric emptying can be estimated by US by two validated techniques: “antral cross-sectional area” (2-dimensional estimate of the surface area at the gastric antrum), and “spheroid gastric volume” (3-dimensional estimate of the stomach content volume). No study examined gastric emptying rate in infants on bubble CPAP (bCPAP). Objective: To compare gastric emptying rates in neonates on machine-derived nasal CPAP (MD-nCPAP) with those on bCPAP. Methods: Ultrasound measurements of the amount of milk in the stomach were performed before feeding and at 1, 2, and 3 hours after the start of feeding, using both the ACSA and spheroid methods. Rates of gastric emptying were calculated during the “early” (1-2 hours) and “late” (2-3 hours) phases after feeding. Results: We recruited 32 infants (25-34 weeks gestational age). Seventeen infants were treated with MD-nCPAP [median birth weight 1015 g (IQR: 870 to 1300), gestational age 28 weeks (IQR: 27 to 29), postnatal age 20 days (IQR: 14 to 28)], while 15 infants were treated with bCPAP [median birth weight 960 g (IQR: 855 to 1070), gestational age 27 weeks (IQR: 26 to 28), postnatal age 17 days (IQR: 15 to 25)]. Gastric emptying rates (% emptied/min) were significantly faster in the “early” compared to the “late” phase for all infants. There were no significant differences in the rates of gastric emptying (either “early” or “late”) or volumes of gastric residuals between infants receiving MD-nCPAP or bCPAP, measured by either method. Conclusions: Gastric emptying is faster during the “early” compared to the “late” phase. Gastric emptying rates are not different in infants receiving MD-nCPAP vs bCPAP.

The aim of this analysis was to model the pantograph - catenary system at static equilibrium and provide analytical solutions by computing the natural frequencies of the system, mode functions, equivalent stiffness of the catenary system and the deflections of the catenary wire as a function of position, time and tensioning force. Furthermore, dynamic analysis was conducted analytically and the results of the dynamic performance were obtained. It was shown that the dynamic response of the catenary system is dependent on the design parameters in which tensioning force is included. It was also shown that low tensioning forces result in high risk of contact loss and increased wave propagation in the catenary wire while high tensioning forces result in increased static stresses in the catenary system. The results in this article can be used to select optimum tensioning forces and design parameters for desired pantograph-catenary dynamic performance.

Objective Post-menopausal nocturia is poorly understood. This study aimed to identify hormonal and lifestyle factors associated with nocturia and to understand the relative contribution of altered urine production and bladder storage dysfunction in women. Design, setting, population and methods Women ≥40 years presenting to public continence services were enrolled in a cross-sectional study. 153 participants completed a hormone status questionnaire, a validated nocturia causality screening tool and a 3-day bladder diary. Descriptive statistics and logistic regression models for nocturia severity and bladder diary parameters were computed. Results Overall, 91.5 % reported nocturia, 55% ≥2 /night. There was a difference of 167.5 mL (p<0.001) in nocturnal urine volume between women with nocturia ≥2 (median 736mL) vs less often (517mL). Significant predictors of self-reported disruptive nocturia were age (OR 1.04, 95%CI 1.002-1.073) and vitamin D supplementation (OR 2.33, 95%CI 1.11-4.91). Nocturnal polyuria was significantly more common with nocturia ≥2 compared to less often (p<0.002). 150 minutes of exercise per week was protective for nocturnal polyuria (OR 0.22, p=0.001). Nocturia index >1.3 was significantly predicted by age (OR 1.07, p<0.001), regular exercise (OR 0.41, p=0.036), day flushes (OR 4.00, p=0.013) and use of Vitamin D (OR 2.34, p=0.043). Maximum voided volumes were significantly lower with nocturia≥2 vs less often (night: 268ml vs 350mL; day: 200mL vs 290mL). Conclusions Bothersome nocturia in post-menopausal women is associated with changes to both nocturnal diuresis and bladder storage. Regular physical activity, prolapse reduction and oestrogen replacement may be adjunctive in managing bothersome nocturia in women.

Objective: Τo investigate the association of serum vitamin D and nasal secretion antimicrobial peptides (AMPs) levels with the severity of acute bronchiolitis. Study design: We conducted a prospective single pediatric tertiary care center cohort study of inpatients aged 0-18 months with a first episode of acute bronchiolitis from November 1st 2014 to April 30th 2017. Disease severity was determined by the length of hospitalization and supplemental hospital data. Qualitative measurements included serum 25(OH)D and nasal secretion LL-37 and β-defensin-2 levels. Correlations were examined with the Mann-Whitney and Kruskal-Wallis criteria for qualitative and the correlation coefficient Spearman’s rho for quantitative factors. Multiple linear and logarithmic regression were performed in order to adjust for confounding factors. Results: The study population consisted of 153 infants and toddlers with mean age 3.6 months (SD: +2.8). The median level of serum 25(OH)D was 51.4 nmol/L (IQR: 29.7-72.2). No association was found between serum 25(OH)D and AMPs nasal secretions levels. Serum 25(OH)D and nasal secretion β-defensin-2 levels were not associated with the severity of bronchiolitis. In contrast, LL-37 levels were inversely associated with the length of hospitalization (rho = -0.340, p = 0.001) and the need for medication use (p = 0.001) and this association remained significant after adjustment for potential confounders. Conclusion: A significant association between LL-37 nasal secretions levels with the severity of acute bronchiolitis was found in hospitalized infants and toddlers. The role of LL-37 in the pathogenesis of bronchiolitis merits further investigation.

The immunopathology of respiratory syncytial virus (RSV) infection, the most common cause of lower respiratory tract infections (LRTI) in the pediatric population, with severe disease being the exception. The variability of the clinical presentation is incompletely explained by host, viral and environmental factors but, in infants and young children, disease severity is certainly linked to the physiological immune immaturity. There is evidence that the maturation of the host immune response is, at least in part, promoted by the composition of the nasopharyngeal microbiome that, modulating excessive inflammation, can counteract the predisposition to develop viral respiratory infections and lower the risk of disease severity. However, interaction between the nasopharyngeal microbiota and respiratory viruses can be bidirectional. Microbial dysbiosis can drive disease pathogenesis but may also represents a reflection of the disease-induced alterations of the local milieu. Moreover, viruses like RSV, can also increase the virulence of potential pathogens in nasopharynx, which is a main reservoir of bacteria, and therefore promote their spread to the lower airways causing superinfection. Negative changes in microbial community composition in early life may constitute a heightened risk towards severe RSV respiratory infection and bacterial superinfection, whilst specific groups of microorganisms can be associated with protection. A better understanding into the potential negative and positive role of the different nasopharyngeal bacterial species in disease prevention as well as into the possible benefits of microbiome therapeutic manipulation, may improve patient outcomes.

Intravenous Magnesium SulfateIV was cost-saving in emergency settings for treating children with asthma exacerbations. This shift in treatment approach proved to be economically favorable, reducing the cost of hospitalization and mechanical ventilation

Background: Medical care has shifted from a paternalistic model towards one centered around patient autonomy and shared decision-making (SDM), yet the role of the pediatric patient in decision-making is unclear. Studies suggest that many children with chronic disease are capable of participating in and even making medical decisions at a young age, and yet we do not standardly involve them. Methods: This is a single center survey study investigating physician attitudes towards involvement of children in decisions regarding lung transplantation, utilizing a hypothetical case scenario with systematic manipulation of age and maturity level. We evaluated physician belief regarding ultimate decision-making authority, attempts at reconciliation of parent-child discordance, and views towards utilizing ethics and psychiatry consultation services. Results: The majority of pediatric pulmonologists believe decision-making authority rests with the parents. The effects of age and maturity are unclear. In instances of parent-child disagreement, physician are more likely to try to convince parents to defer to the child if the child is both older and more mature. Physicians are divided on the utility of ethics and psychiatry consultations. Conclusion: Involvement of children in shared decision-making is broadly supported but poorly implemented. Despite evidence that children with chronic disease may have decisional capacity starting at a young age, the majority of physicians still grant decisional authority to parents. There are numerous barriers to involving children in decisions, including legal considerations. The role of age and maturity level in influencing these decisions appears small and warrants further investigation.