Objectives: To determine clinical and laboratory features of pregnant woman with COVID-19 who require respiratory support. To recommend a management strategy that optimises maternal and fetal outcomes. Design: An observational cohort study of 7000 maternities between 1st March and 1st July 2020. Setting: Five maternity centres across a maternal medicine network in north-central London, UK Population: 69 pregnant women with confirmed acute SARS-COV2 Methods: Review of electronic healthcare records Main Outcome Measures: Clinical and laboratory features, maternal and fetal outcomes. Results: Respiratory support was needed by 15/69 . This cohort was more likely to present with dyspnoea (10/15 vs 10/54, p<0.001), a lower lymphocyte count (0.90.1 vs 1.40.1 x 109 cells/L; p<0.01) and hypokalaemia (3.80.1 vs 4.00.1 mmol/l, p<0.05). Radiological evidence of lung consolidation did not identify women in need of respiratory support. Women on respiratory support underwent childbirth at an earlier gestation than those who did not (36+4 vs 39+5 weeks, p<0.001), and required emergency c-section (6/15 vs 8/54, p<0.05). Childbirth did not improve respiratory function in those with severe disease, with 3 women remaining on invasive ventilation despite childbirth. Conclusions: Routine clinical data can identify pregnant women at risk of severe COVID-19. Pregnant women should be offered the same treatment as non-pregnant patients but iatrogenic childbirth should not be the default for women with severe disease. We propose a management pathway for pregnant women with severe COVID-19.

The helium burning phase represents the second stage that the star used to consume nuclear fuel in its interior. In this stage, the three elements carbon, oxygen, and neon are synthesized. The present paper has two folds, the first is to develop an analytical solution to the system of the conformable fractional differential equations of the helium burning network, where we used for this purpose the series expansion method and obtained recurrence relations for the product abundances i.e. helium, carbon, oxygen, and neon. Using four different initial abundances, we calculated 44 gas models covering the range of the fractional parameter with step . We found that the effects of the fractional parameter on the product abundances are small which coincides with the results obtained by a previous study. Second, we introduced the mathematical model of the neural network (NN) and developed a neural network algorithm to simulate the helium burning network using its feed-forward model that is trained by the back propagation (BP) gradient descent delta rule algorithm. A comparison between the NN and the analytical models revealed very good agreement for all gas models. We found that NN could be considered as a powerful tool to solve and model nuclear burning networks and could be applied to the other nuclear stellar burning networks.

In this paper, we prove the existence of solutions for the strongly nonlinear equation of the type $$Au+g(x,u)=f$$ where $A$ is an elliptic operator of infinite order from a functional Sobolev spaces of infinite order with variables exponents to its dual. $g(x, s)$ is a lower order term satisfying essentially a sign condition on s and the second term f belongs to $L^1(\Omega)$.

We outline the mathematical model of the ultrasonic response of wet cortical bone and its time harmonic formulation. We employ an energetic approach based on the Reuss-bound of the free energy of a porous material consisting of a piezo-electric solid and a conducting fluid part. Magnetic effects are taken into consideration. Corresponding boundary value problems are stated and associated theorems established. A conclusion is included concerning future developments of this formulation.} \keywords{wet bone, ultrasonic response, Maxwell equations}

This paper deals with a portfolio selection problem with uncertain returns. Here, the returns of the assets are regarded as uncertain variables which are estimated by experienced experts. First, an uncertain mean-variance-entropy model for portfolio selection problem is presented by taking into account four criteria viz., return, risk, liquidity and diversification degree of portfolio. In the proposed model, the investment return is quantified by uncertain expected value, the investment risk is characterized by uncertain variance and entropy is used to measure the diversification degree of portfolio. Moreover, different from the previous bi-objective optimization model, our model achieves both the maximum return and the minimum risk in a single objective form by introducing a risk aversion factor and the dimensional influence caused by different units is eliminated by normalization. Then, two auxiliary portfolio selection models are transformed into different equivalent deterministic models. Finally, a numerical simulation is given to verify the practicability of our model.

Bifurcation of the numerical solution for a system of nonlinear equations describing the industrial process of dray slag atomization is presented. In dry slag atomization, a stream of molten slag is disintegrated by impingement of a high speed jet of air, resulting in a spray of molten slag droplets. The main output of the equations is the Sauter mean diameter of the spray droplets. One-parameter bifurcation diagrams are generated for two of the operating parameters, liquid and air flowrates. In both cases, two solutions exist for the system of equations. At least one of the solutions corresponds to the stable steady state of the system. The other solution can be associated with the unstable state of the system.

In this work, the natural convection in the air gap of an inclined solar collector contains partitions attached to its glazing has been studied numerically. The temperatures of the two horizontal walls are constants and different. The two vertical walls are supposed adiabatic. The equations of the problem are solved with the finite volume method, using of the Fluent software. The necessary objective is to study the influence of the partitions (length and number) on the natural convection in the air gap of the solar collector. The obtained results indicate that the presence of the partitions has important influence on the heat transfer with the decreasing of heat losses with natural convection, so improving of the solar collector efficiency. In this study, it reached that the number of partitions must be higher than 10, and their optimal length is Lp=0.4. The presence of the partitions with the optimal values reduces the heat losses by natural convection with 46 %.

Background Methods of evaluating the ventilatory response to CO2 (VRCO2) of the respiratory center include the steady-state and the rebreathing method. Although the rebreathing method can evaluate the respiratory center more in detail, the steady-state method has been mainly performed in infants. The aim of this study was to investigate whether we could perform the VRCO2 with the rebreathing method in normal infants. Methods The subjects were 80 normal infants. The gestational age was 39.9（39.3-40.3）weeks, and the birth body weight was 3,142 (2,851-3,451) grams. We performed the VRCO2 with Read’s rebreathing method, measuring the increase in minute volume (MV) in response to the increase in EtCO2 by rebreathing a closed circuit. The value of VRCO2 was calculated as follow: VRCO2 (mL/min/mmHg/kg) = ΔMV / ΔEtCO2 / Body weight. Results We performed the examination without adverse events. The age in days at examination was 3 (2-4), and the examination time was 150±38 seconds. The maximum EtCO2 was 51.1 (50.5-51.9) mmHg. The value of VRCO2 was 34.6 (29.3-42.8). Tidal volume had a greater effect on the increase in MV than respiratory rate (5.4 to 14.3 mL/kg, 44.1 to 55.9 /min, respectively). Conclusion This study suggests that the rebreathing method can evaluate the ventilatory response to high blood CO2 in a short examination time. We conclude that the rebreathing method is useful even in infants. In the future, we plan to measure the VRCO2 of preterm infants, and evaluate the respiratory center of infants in more detail.

A document by Kam-lun Ellis Hon. Click on the document to view its contents.

ABSTRACT INTRODUCTION Tricuspid valve regurgitation (TR) and severe right ventricular (RV) systolic dysfunction may appear acutely after right atrial (RA) myxoma excision. Covid-19 infection may have a role in production of Heparin resistance. METHODS A case of post covid-19 infected RA myxoma was operated by surgical excision develop severe TR and acute right ventricular systolic dysfunction postoperatively for which Tricuspid valve ring annuloplasty was performed and RV was supported on Cardiopulmonary bypass (CPB). RESULTS RV dysfunction did not improve leading to cardiac arrest and death. Conclusion • Excision of RA myxoma can unmask the severe TR and severe RV systolic dysfunction not responsive to TV ring annuloplasty. • COVID-19 infection might have a role in production of heparin resistance. KEY WORDS: Covid-19, tricuspid annuloplasty, intraoperative heparin resistance, RV Dysfunction, cardiopulmonary bypass.

Abstract Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy affecting the airways, which is particularly common in children with primary TB. Airway compression by lymphadenopathy causes downstream parenchymal pathology, which may ultimately result in irreversible lung destruction, if not treated timeously. CT is considered the “gold standard” for detecting mediastinal lymph nodes in children with TB. CT is also the best way of imaging the airways of children with LBTB. The CT findings of the parenchymal complications and associations of LBTB on CT have been described, but no severity classification was provided to aid management decisions. Identifying the parenchymal complications of LBTB and recognising their severity has clinical relevance. Using prior publications on LBTB and post obstructive lung injury we have used an image bank of CT scans in children with pulmonary TB, presenting with airway symptoms, to create a CT severity staging of lung injury in LBTB. The staging focuses on distinguishing non-salvageable destruction [non-enhancing or cavitated lung] from salvageable lung parenchymal disease [enhancing and non-cavitated] to inform the management decisions, which range from bronchoscopic airway clearance to surgical decompression of the compressing nodes.

Background. Whereas dependency of left ventricular outflow tract diameter (LVOTD) from body surface area (BSA) has been established and a BSA-based LVOTD formula has been derived, the relationship between LVOTD and aortic root and LV dimensions has never been explored. This may have implications for evaluation of LV output in heart failure (HF) and aortic stenosis (AS) severity. Methods. A cohort of 540 HF patients who underwent transthoracic echocardiography was divided in a derivation and validation subgroup. In the derivation subgroup (N=340) independent determinants of LVOTD were analyzed to derive a regression equation, which was used for predicting LVOTD in the validation subgroup (N=200) and compared with the BSA-derived formula. Results. LVOTD determinants in the derivation subgroup were sinuses of Valsalva diameter (SVD, beta=0.392, P<0.001), BSA (beta=0.229, P<0.001), LV end-diastolic diameter (LVEDD, beta=0.145, P=0.001), and height (beta=0.125, P=0.037). The regression equation for predicting LVOTD with the aforementioned variables (LVOTD=6.209+[0.201xSVD]+[1.802xBSA]+[0.03xLVEDD]+[0.025xHeight]) did not differ from (P=0.937) and was highly correlated with measured LVOTD (R=0.739, P<0.001) in the validation group. Repeated analysis with LV end-diastolic volume instead of LVEDD and/or accounting for gender showed similar results, whereas BSA-derived LVOTD values were different from measured LVOTD (P<0.001). Conclusion. Aortic root and LV dimensions affect LVOTD independently from anthropometric data and are included in a new comprehensive equation for predicting LVOTD. This should improve evaluation of LV output in HF and severity of AS, avoiding use of LVOT velocity-time integral alone, which can be misleading, especially when LV cavity and aortic root dimensions are abnormal.

Primary intratracheal neurilemmoma is rare in children. Here, we reported a case of tracheal neurilemmoma in a 10-year-old girl. She had recurrent cough, dyspnea, and tachypnea. Magnetic resonance imaging revealed a soft-tissue mass was located on the right lateral posterior wall of the trachea. A multidisciplinary operation was performed. Immunohistochemical analysis demonstrated a benign neurilemmoma. Her clinical symptoms and signs improved. We reviewed the clinical features and surgical procedures of ten children with intratracheal neurilemmoma reported in literature. Radiographic techniques and bronchoscopy are helpful for diagnosis of the disease. Long-time follow-up is required.

The Great saphenous vein (GSV) has been widely used as a conduit for Coronary artery bypass grafting. The GSV can be harvested using the open or minimally invasive technique. Minimally invasive techniques are growing in popularity due to better cosmetic and wound infection outcomes. The most widely used method in minimally invasive technique is via endoscopic approach. However, the cost of endoscopes and training curve can limit its use. We describe an alternative minimally invasive technique using a mayo vein harvester with a considerably lower cost, and a smoother learning curve. Keywords: Saphenous vein harvesting, Mayo vein harvester, Minimally invasive

Background Rhinoviruses (RV) represent the most common aetiological agent of all acute respiratory tract infections across all age groups and a significant burden of disease among children. Recent studies have shown that RV-A and RV-C species are associated with varying degrees of disease severity and clinical symptoms. Methods In this study, we uncovered potential associations between RV species and subtypes, and clinical disease severity using a matched dataset of 52 RV isolates sampled from children (<18 years) in Sydney, Australia between 2006 and 2009 using epidemiological and phylogenetic methods. Results We found that RV-C was significantly more likely to be isolated from paediatric cases under two years of age compared to RV-A, although no significant differences in recorded symptoms were observed. Significant phylogenetic-trait associations between age and the VP4/VP2 capsid protein phylogeny suggests age-specific variations in infectivity among subtypes might also be possible. Conclusions This study adds to the growing body of epidemiological evidence concerning RV. Improving surveillance and testing for RV, including routine whole genome sequencing may improve our understanding of the varied diseashe outcomes of RV species and subtypes. Future studies could aim to identify specific genetic markers associated with age-specific infectivity of RV which could inform treatment practices and public health surveillance of RV.

Adaptive relationships between traits and the environment are often inferred from observational data by regressing community-weighted mean (CWM) traits on environmental gradients. However, trait‒environment relationships are better understood as the outcome of trait‒abundance and environment‒abundance relationships, and the interaction between traits and the environment. Accounting for this functional structure and for interrelationships among traits should improve our ability to accurately describe general trait‒environment relationships. Using forest understory communities in Wisconsin, we applied a generalized mixed model (GLMM) incorporating this structure. We identified a simple hierarchy of trait‒environment relationships dominated by a strong positive effect of mean temperature on plant height. Compared to the traditional CWM approach, the GLMM was more conservative in identifying significant trait‒environment relationships, and also detected important relationships that CWM regressions overlooked. This work highlights the need to consider the complexity underlying trait‒environment relationships in future analyses

There is growing evidence that the clinical manifestations of COVID-19 are not just respiratory, but also gastrointestinal symptoms. The difference of organ infection should be considered. In addition, as a key molecule mediating viral infection of cells, angiotensin-converting enzyme 2 (ACE2) provides an important intervention means for the exploration of antivirus. This is particularly important as the pandemic intensifies.

Placenta accreta spectrum and placenta praevia are a significant cause of obstetric haemorrhage, maternal morbidity and mortality worldwide. We report a novel surgical technique, which pre-emptively and prophylactically reduces intrapartum bleeding during caesarean sections for these conditions and hence reducing the risk for a caesarean hysterectomy. This technique is particularly useful in low resource healthcare settings where interventional radiology is not readily available and where the woman is keen on uterine preservation. In this report we present the surgical and clinical outcomes of a case series of 16 patients on whom this technique was piloted demonstrating its feasibility and safety.

Nitric oxide (NO) along with Carbon monoxide (CO) and Hydrogen Sulphide (H2S) are biologically significant gaseous molecules generally called as “gasotransmitters”. At a concentration higher or lower than optimum value may result in toxicity or malfunctioning of mammalian tissues. Soon after the acknowledgment of NO as multifunctional bio-signalling molecule in 1987, many interesting implications of this field emerged out. Meanwhile, several studies have proven the NO-biosynthetic pathway responsible for normal functioning of eye. High intraocular pressure (IOP) has been suggested as the main risk factor in this context and collaborative approach with nitric oxide releasers is said to control IOP and hence the relation with glaucoma. Similar miracles were reflected from several other naturally produced gaseous molecules,viz., CO and H2S after year 1990. The biological roles of both these molecules are now widely accepted and in the current era investigations focused mainly with development of efficient CO and H2S releasing compounds. CO and H2S donors are also said to help in normalising IOP like NO. Therefore the trio-gasotransmitters have collective relation with the ophthalmic homeostasis in association with nervous control. On one hand, the antimicrobial efficiency of these three molecules is widely known and on the other hand, their collaborative key-role in ocular nerve functioning makes it remarkable to state here that their donors are supposed to act as a shield for both the infectious as well as the non-infectious eye defects.

Equine chorionic gonadotropin (eCG) is a heterodimeric glycoprotein hormone produced by pregnant mares that has been used to improve reproduction activity in different types of livestock. Several strategies to produce the hormone in a recombinant way have been reported; nevertheless, none approach has been able to produce a recombinant eCG (reCG) with significant in vivo bioactivity or in sufficient quantities for commercial purposes. For this reason, the only current product available on the market consists of partially purified preparations from serum of pregnant mares (PMSG). Herein, we describe a highly efficient process based on third-generation lentiviral vectors as delivery method for the production of reCG in suspension CHO-K1 cells, with productivities above 20 IU.106 cell-1.d-1 and 70% purification yields after one purification step. Importantly, reCG not only demonstrated biological activity in bovine cattle but also this bioactivity appeared to be higher than PMSG, since 140 IU of reCG were needed to exert the same biologic effect in an ovulation synchronization protocol compared to 400 IU of PMSG. The results obtained show that the developed strategy represents an attractive option to produce reCG and constitutes an auspicious alternative for the replacement of animals as a source of PMSG.

BJOG-20-0640.R1 The evolving definition of pre-eclampsia

Background and Purpose: There is an increasing number of evidence-based indications for pharmacogenetic (PGx) tests and a growing demand for PGx screening. We aimed to evaluate clinical relevance of a 16-gene panel test for PGx-guided pharmacotherapy. Experimental Approach: Observational cohort study of subjects tested with a PGx panel for variants of ABCB1, COMT, CYP1A2, CYP2B6, CYP3A4, CYP3A5, CYP2C9, CYP2C19, CYP2D6, CYP4F2, DPYD, OPRM1, POR, SLCO1B1, TPMT and VKORC1. Specialized clinical pharmacology consultations with PGx-guided pharmacotherapy management were supported by the PGx expert system SONOGEN XP. Study outcomes were PGx-based changes and recommendations regarding current and potential future medication. Key Results: PGx-testing was triggered by specific drug-gene pairs in 102 subjects, whereas screening was performed in 33. Based on PHARMGKB expert guidelines the 16-gene panel identified at least one “actionable” variant relevant for current or potential future medication in all 135 (100%) tested patients. Drugs that triggered PGx-testing were clopidogrel in 60, tamoxifen in 15, polypsychopharmacotherapy in 9, opioids in 7, and other in 11 patients. Among those, PGx variants resulted in clinical recommendations to change PGx-triggering drugs in 33 (32.4 %), and other current pharmacotherapy in 23 (22.5%). Conclusion and Implications: The 16-gene PGx panel detected clinically relevant variants in a high proportion of tested patients, and SONOGEN XP supported their interpretation based on latest evidence. Additional costs of panel vs. single gene tests are moderate, and the efficiency of PGx panel testing challenges traditional cost-benefit calculations for single drug-gene pairs. However, PGx-guided pharmacotherapy requires specialized consultations with interdisciplinary collaborations.

Aim：Chronic subdural hematoma (CSDH) is common in aged people, and minimally invasive surgical interventions such as burr-hole-drainage and twist-drill craniostomy are the first-line therapeutic options for this condition. However, the mortality rate among super-aged patients (over 90 years of age) with CSDH is as high as 38.4% after these surgical procedures. Atorvastatin alone or in combination with dexamethasone has been proven to be effective in eliminating CSDH. In the current study, the researchers evaluated the therapeutic efficacy of atorvastatin with or without dexamethasone on the CSDH patients over 90 years. Methods：The study attempted to treat 12 super-aged patients with primary or post-operative relapsed CSDH by using atorvastatin alone or in combination with dexamethasone. The changes in hematoma volume measured with computed tomography (CT) or magnetic resonance imaging (MRI) and the patients’ neurological improvement were monitored by activities of daily living (ADL) and modified Rankin scale (MRS) scores. Results：Treatment with atorvastatin or atorvastatin combined with low-dose dexamethasone had beneficial effects on hematoma elimination and/or symptom remission within 6 to 24 weeks in 12 super-aged patients. All of them showed complete recovery after 1~4 years of follow-up. Conclusion：The findings in this study indicate that atorvastatin with or without dexamethasone is safe and effective for the treatment for CSDH in super-aged patients.

Afforestation is among the most effective means of preventing and controlling desertification. Silver poplar (Populus alba) is commonly planted tree species for afforestation of the Horqin Sandy Land of China. However, this species has exhibited some drawbacks such as top shoot dieback, premature senescence and mortality, and soil and ecosystems degradation. In contrast, Siberian elm (Ulmus pumila) rarely experiences these problems in the same regions. Ecological stoichiometry plays a vital role in exploring ecological processes and nutrient cycle relationships in plant–litter–soil systems. We measured C, N, and P concentrations in leaves, branches, roots, litter, and soils and analyzed N and P resorption efficiencies, and stoichiometric homeostasis in elm and poplar plantations in the Horqin Sandy Land. The results showed that soil C and N concentrations, C:P, and N:P were greater in the elm plantation than in the poplar plantation. The plant N concentrations, C:P, and N:P and litter N and P concentrations were greater, whereas N and P resorption efficiencies were lower, in the elm plantation than in the poplar plantation. Generally, elm exhibited greater homeostasis than poplar. These findings indicate that poplar exhibited more developed internal nutrient conservation and allocation strategies but poor nutrient accumulation in soil, which may contribute to degradation of poplar plantation. In contrast, elm tended to return more nutrients to the soil. Therefore, compared with poplar, elm may be a more suitable afforestation tree species for the Horqin Sandy Land, where it may promote the accumulation of soil nutrients and enhance ecosystem stability.