The lockdown period (March-May 2020) during the COVID-19 pandemics in Europe led to a reduction in the anthropogenic emissions of primary pollutants. For ¾ of over 1100 available monitoring stations, the average NO2 concentrations decreased by at least 2.7 µg.m-3 (or 25%) compared to the average concentrations recorded during the same period of the previous seven years. The O3 response differed spatially, with positive anomalies in northern Europe and negative anomalies in southwestern Europe. Reduced cloudiness and related enhanced radiation in northern Europe played a significant role in the increase of surface ozone concentrations by shifting the photochemical partitioning between NO2 and O3 toward more ozone. The level of total oxidant (Ox = O3 + NO2) remained unchanged except in southwestern Europe where it decreased. Several episodes lasting a few days of high level of total oxidants were observed in northern Europe. Our results illustrate the complexity of the atmospheric response to the unprecedented reduction in the emission of primary pollutants.

An 84-year-old man with persistent AF (CHA2DS2-Vasc 6) was referred because of a migrated 24-mm Watchman implanted 7 months prior. Transesophageal echo (TEE) showed device malposition and protrusion outside the LAA along with a 90º tilt and peri-device leak (Figure, Movies 1-3). Under general anesthesia, an extraction was performed using TEE, intracardiac echocardiographic and fluoroscopy. Using a femoral arterial approach, a 27-mm Watchman was positioned in ascending aorta for cerebroembolic protection, never released from the connecting wire (WAASP technique, Movies 4-5) (1). A 23-Fr non-deflectable sheath (Micra, Medtronic, MN) was advanced into right atrium, through which a 12-Fr deflectable sheath (Flexcath Advance, Medtronic) was placed transeptal. A 2.4 mm x 20 cm Raptor grasping device (US Endoscopy, Mentor, Ohio; Figure) was advanced through 12 Fr sheath to grasp the Watchman device. With sustained traction, the device was dislodged from the LAA into the 23 Fr sheath (Figure, Movie 6). A new 24 mm Watchman was then placed and the temporary Watchman in the aorta was removed. A follow up TEE showed stable position without significant peri-device leak. This case demonstrates the safety and feasibility of malpositioned Watchman extraction re-implantation in the same setting (2).

This paper presents a grid connected photovoltaic (PV) system using a parallel multicellular inverter (PMI). We focus on the optimized design of an LCL filter connecting a parallel multicellular inverter by looking for the number which optimizes the losses of the inverter, as well as the energy management by controlling the power produced by the photovoltaic generator (PVG). In order to transfer the power produced by the PVG to the grid, the classical maximum power point tracking (MPPT) algorithm called perturb and observe (P & O) is used to maximize the power produced by the PVG. The active and reactive power control (PQ control) using a Phase-Locked Loop (PLL) for synchronization is applied to the inverter. We present the value of this innovative PV architecture using a PMI compared to the conventional one. We show that this PQ control, although it is classical, is well adapted to the PV architecture using a PMI. We also present and discuss the simulation results obtained by using the Matlab software (simulink and simpowersystems).

A Wenckebach periodicity at the mitral isthmus lesion has rarely been reported. We described a case presenting conduction recovery with Wenckebach periodicity at the mitral isthmus lesion after achieving the posterior mitral isthmus block. These findings demonstrate an early reconnection of mitral isthmus lesion, and an arrhythmogenic substrate that can lead to development of reentrant tachycardia, that is, peri-mitral atrial flutter.

Membrane absorption (MA) has a great prospect for CO2 capture. In MA modeling, conventional 1D- and 2D- models make simplification of membrane contactor (MC) geometry. Geometry simplification allows an easy process modeling and numerical solution, however, is only reasonable for particular MCs. Here, efforts are underway to quantify the geometry effect on the MA-CO2 performance. First, we proposed a full 3D model without geometry simplification for simulating the MA-CO2 process in real MCs and then validated it with experimental data. More importantly, we highlighted a preferable hybrid model in which a correction factor (F) was introduced to the 2D simulation results to make their combination approximately equal to the 3D simulation values. The F was correlated with dimensionless parameters obtained from computational fluid dynamics (CFD) studies for characterizing the geometry effect. Such hybrid modeling contributes to characterizing the influence of geometry on the MA-CO2 performance and improving computation accuracy-efficiency combinations.

Particle velocity measurement based on cross-correlation algorithm is explored widely in multiphase flow systems. In this study, an optical fiber probe, i.e. Labasys® 100 from MSE Meili was used to systematically investigate the big differences in the measurement quality of cross-correlation particle velocity instrument in fast and bubbling fluidized beds (FFB and BFB). Compared to an FFB, the measured particle velocity data in a BFB show poor data repeatability, higher percentage of invalid data and high sensitivity to the selection of the threshold value of maximum cross-correlation coefficient, corresponding to a much lower measurement quality throughout the bed. High measurement qualities appear in the annulus of the riser and under higher superficial gas velocity. A matchup relationship between the particle velocity measurement quality and the shape of the probability density function (PDF) curves of maximum cross-correlation coefficient is found. Narrower PDF curves correspond to higher measurement quality and vice versa.

Objetives: The rate of eosinophilic esophagitis (EoE) diagnosis is increasing. This study aims to determine the incidence of EoE in the paediatric population residing in the southwestern Madrid and to analyse whether absolute monthly pollen counts, modified or not by the principal atmospheric pollutants, are associated with it. Methods: A prospective observational study was designed to calculate the incidence of EoE in children aged under 15 years who were diagnosed between September 2014 and August 2016 in twelve area hospitals. We collected clinical data, date of endoscopic diagnosis and the number of first-time endoscopies performed. Relative risk estimation was performed to assess the association between the incidence of diagnosis and monthly pollen counts and levels of atmospheric pollutants. Results: One hundred forty-eight patients were included. The most frequent symptoms were abdominal pain 42.57%, dysphagia 42.57% and impaction 39-86%. The average overall monthly incidence was 1.27 (0.41-2.67) cases/100,000 children and the annual average was 15.2. The overall analysis of the relationship between incidence and absolute monthly counts and air pollutants, corrected for the number of first-time endoscopies performed, revealed no statistically significant association. There was a higher frequency of diagnosis during the pollination period of Cupressaceae and during February and November (relative risk 1.67; p<0.01). Conclusions: This study confirms the high incidence of eosinophilic esophagitis and also suggest a period of higher incidence of diagnosis in the months of February and November as well as in the period of high pollination of Cupressaceae.

Objective: To conduct an umbrella review collating the existing evidence to determine whether there is an association between exposure of paracetamol in utero or in infancy, and the development of childhood asthma. Methods: In this review, systematic reviews with or without meta-analysis that reported the association between paracetamol and asthma in children were included. To identify relevant reviews, a search was performed in the electronic databases PubMed, the Cochrane Central Register of Controlled Trials Library, and Ovid. Results: The search strategy in various databases identified 1913 conceivably significant studies for inclusion. After removal of 493 duplicates ,1420 studies were screened for titles and abstracts against a standard eligibility criterion. Full text screening yielded four systematic reviews to be included in this review. Prenatal paracetamol exposure is associated with an increased risk of Asthma in the offspring. Of the four systematic reviews, 2 have an unclear risk of bias, one has a high risk and one has a low risk of bias. Association does not imply causation and we recommend further research to answer this very important question. In the absence of any other alternative, paracetamol will have to continue to be the safest and the most widely prescribed analgesic and antipyretic in pregnancy. Conclusions: We recommend further research to answer this very important question. In the absence of any other alternative, paracetamol will have to continue to be the safest and the most widely prescribed analgesic and antipyretic in pregnancy.

Editorial: Respiratory outcomes post Nusinersen in Spinal Muscular Atrophy Type 11 Kate Gonski1,2 Dominic A. FitzgeraldDepartment of Respiratory Medicine, The Children’s Hospital at Westmead, Sydney, NSW, Australia 2145Discipline of Child & Adolescent Health, Sydney Medical School, Faculty of Health Sciences, University of Sydney, NSW, Australia 2145Corresponding author:Dominic A. Fitzgerald MBBS PhD FRACPClinical Professor Child & Adolescent HealthDepartment of Respiratory MedicineThe Children’s Hospital at WestmeadLocked Bag 4001Westmead, NSWAustralia, 2145.1458 words15 referencesTime to wake up and smell the roses as the real world respiratory experiences have arrived for Spinal Muscular Atrophy type 1 (SMA1)! Nusinersen, the first drug to be approved for treatment of SMA1, has changed the natural history of the disease and has now been commercially available in many countries for up to four years(1). SMA 1, the most common cause of infant death attributed to respiratory insufficiency, results from a degeneration of alpha motor neurons in the spinal cord and brainstem resulting in progressive skeletal muscle weakness of the limbs, respiratory and bulbar muscles (2). Most patients with SMA1 will have respiratory complications in the first year of life requiring therapy to support airway clearance and ventilation (2). The pan-ethnic incidence is 1 in 11,000 births (3). Milder phenotypes occur as SMA types 2 and 3 in childhood with a much better prognosis (4) and countries may offer nusinersen for these patients also.In this issue, Lavie and colleagues (5) offer insights into clinicalrespiratory outcomes from 3 years of prospective data collection in their cohort of 20 SMA1 patients treated before and after 2 years of nusinersen in Israel. Their work builds on the scientific evidence of efficacy of nusinersen primarily for motor outcomes over the last decade. A phase 3 randomised, double-blinded, sham controlled clinical trial in patients with SMA 1 showed that those treated with nusinersen had a significant motor milestone response with a higher likelihood of event-free survival(6). This group did not show a difference in the frequency of serious respiratory adverse events between the groups, thereby leaving unanswered questions about the effect of the medication on respiratory morbidity. Over the past few years, the translatability of outcomes from randomized controlled studies to current real-world outcomes has been questioned (7-9).A letter to the editor by LoMauro et al. involving children with SMA1 described a milder subset of children with SMA 1 [Described as type SMA 1c: onset between 3 and 6 months] treated with nusinersen who had an improvement in accessory muscle use and reduced daily hours of ventilation when compared to a natural history cohort (7). This was not reported in the more severe SMA 1a and 1b groups. Sansone et al. (8) published an observational, longitudinal cohort study looking at respiratory support requirements at baseline, 6 months and 10 months after nusinersen treatments in 118 children with SMA1. Semi-structured qualitative interviews from caregivers were collected at each interval. They showed that 77% of the cohort’s respiratory requirements remained stable and more than 80% of children treated before 2 years survived in contrast to the lower survival reported in natural history studies. The limitation of this study is that they used modality and number of hours of ventilation as the surrogate for respiratory function which can be influenced significantly by respiratory care, management and patient compliance. Chen et al. (9) also published follow-up data (single-centre) in SMA 1 children treated with nusinersen in order to further understand the comprehensive real-world outcomes of this new treatment. While this study was limited by its small sample size of 9, it highlighted that children with SMA1 treated with nusinersen continued to develop considerable respiratory comorbidities. Although a large amount of data has been collected over the past 5 years, there remain gaps in the understanding of many aspects of the use of nusinersen in SMA beyond modest increases in peripheral muscle strength and in particular whether these improvements will translate into reduced respiratory morbidity and less respiratory failure with dependence upon non-invasive ventilation (NIV) (10).The paper by Lavie et al. (5) contributes to our understanding with its focus on ‘real-world’ variables including starting or ongoing need for assisted ventilation, the use of mechanical insufflation-exsufflation, respiratory complications, and treatment cessation due to respiratory reasons, or death in around 15% of cases attributed to pulmonary aspiration. In essence, it is a source of modest encouragement for clinicians as the majority of children demonstrated stability of respiratory support over the first two years of treatment with nusinersen which is in itself much better than the natural history of the condition with progressive decline and death in 90% by the age of 2 years. However, there are some gaps in knowledge in this paper which will require further studies. It is unclear exactly why children started ventilation specifically, who went to tracheostomy and why others went to NIV and what their initial ventilator pressures were. Management algorithms have been available to outline this in neuromuscular diseases [11]. Further, it is unclear how many children had polysomnograms and what the results were in terms of apnoea indices, measures of hypoventilation, alterations in oxygenation and extent of transcutaneous CO2 abnormalities, other than that they were consistent with the standards of care for the treatment of children with SMA published in 2007 [12]. Further guidelines have since emerged in the nusinersen era [13]. Certainly, the positive impact of the use of NIV on respiratory outcomes, including hospitalisations, albeit in the broader neuromuscular population, has been established [14]. As would be hoped, a reduction in admissions was seen in the present study in SMA1. Nonetheless, as all clinicians appreciate, what is prescribed and what is used for the treatment of anything in “the real world” varies widely. Think of asthma preventers or any therapies in cystic fibrosis including expensive correctors. In a prospective study on real world respiratory outcomes, the absence of information on adherence with average daily hours of support from memory cards inside the NIV devices is a short-coming of the study of Lavie et al. (5). This is something which, with serial assessment of polysomnography parameters, should be addressed in future studies in SMA1 treated patients to ascertain the true rather than potentially perceived benefit of NIV.Lavie et al. (5) provide insight into the everyday clinical respiratory burden of patients with SMA1 treated with nusinersen while highlighting further areas of research. Specifically, they rightly suggest a beneficial effect with the earliest initiation of nusinersen due to the possibility that nusinersen may have an effect on preserving respiratory function if started at a younger age. This mirrors data in the larger RCT where earlier treatment was associated with better motor outcomes. Logically, this could be readily achieved with emerging increase in new born screening programs including SMA genes in countries such as Australia and Belgium [15]. This would also enable quantification of the number of copies of SMN2 genes present, missing in 30% of cases in the series of Lavie et al. (5). This stratification of genotype may be more important than ever in the nusinersen era as we improve our ability to predict outcomes beyond age of presentation [Types 1a, 1b and 1c] [13]. The argument for newborn screening for SMA, with earlier diagnosis and improved outcomes for such an expensive therapy seems persuasive.This article explores patient outcomes in a real-world setting and found that the need for assisted ventilation did not worsen as would be with the natural progression of SMA1. However, they showed no improvement either. Therefore, nusinersen is a small step forward with the promise of much more to come from gene therapy and potentially combinations of therapies. Longer term studies with international prospective data registries are warranted and should be funded by international neuromuscular societies at arm’s length from pharmaceutical companies. It is as important to document respiratory outcomes rather than just predominantly modest motor outcomes not only for SMA1 but also SMA2 and SMA3, because at the end of the day in the real world, your respiratory wellbeing determines morbidity and mortality.References1. LoMauro A, Mastella C, Alberti K, Masson R, Aliverti A, Baranello G. Effect of nusinersen on respiratory muscle function in different subtypes of type 1 spinal muscular atrophy. American Journal of Respiratory and Critical Care Medicine. 2019;200(12):1547-1550.2. Kolb SJ, Coffey CS, Yankey JW, Krosschell K, Arnold WD, Rutkove SB, et al. Natural history of infantile-onset spinal muscular atrophy. Ann Neurol. 2017; 82(6):883-8913. Sugarman EA, Nagan N, Zhu H, Akmaev VR, Zhou Z, Rohlfs EM, et al. Pan-ethnic carrier screening and prenatal diagnosis for spinal muscular atrophy: Clinical laboratory analysis of >72 400 specimens. Eur J Hum Genet. 2012; 20 (1):27-324. Farrar MA, Park SB, Vucic S, Carey KA, Turner BJ, Gillingwater TH, et al. Emerging therapies and challenges in spinal muscular atrophy. Annals of Neurology. 2017; 81(3):355-3685. Lavie M, Diamant N, Cahal M, Sadot E, Be’er M, Fatal A, Sagi L, Domany KA, Amirav I. Nusinersen for Spinal muscular Atrophy Type 1: real World Respiratory Experience. Pediatr Pulmonol 2020; XXXX; doi xxxx6. Finkel RS, Mercuri E, Darras BT, Connolly AM, Kuntz NL, Kirschner J, et al. Nusinersen versus sham control in infantile-onset spinal muscular atrophy. N Engl J Med. 2017; 377:1723-17327. LoMauro A, Mastella C, Alberti K, Masson R, Aliverti A, Baranello G. Effect of nusinersen on respiratory muscle function in different subtypes of type 1 spinal muscular atrophy. American Journal of Respiratory and Critical Care Medicine. 2019 Dec 15;200(12):1547-508. Sansone VA, Pirola A, Albamonte E, Pane M, Lizio A, et al Respiratory Needs in Patients with Type 1 Spinal Muscular Atrophy Treated with Nusinersen. The Journal of Pediatrics. 2020; 219 P223-228. E49. K-A. Chen, J. Widger, A. Teng, D.A. Fitzgerald, A. D’Silva, M. Farrar, Real-world respiratory and bulbar comorbidities of SMA type 1 children treated with nusinersen: 2-year single centre Australian experience, Paediatric Respiratory Reviews (2020), doi: httpds://doi.org/10.1016/j.prrv.2020.09.00210. Fitzgerald DA, Doumit M, Abel F. Changing respiratory expectations with the new disease trajectory of nusinersen treated spinal muscular atrophy [SMA] type 1. Paediatric Respiratory Reviews. 2018 Sep 1;2 8:11-7.11. Hull J, Aniapravan R, Chan E, Chatwin M, Forton J, Gallagher J, Gibson N, Gordon J, Hughes I, McCulloch R, Russell RR. British Thoracic Society guideline for respiratory management of children with neuromuscular weakness. Thorax. 2012 Jul 1;67(Suppl 1):i1-40.12. Wang CH, Finkel RS, Bertini ES, Schroth M, Simonds A, Wong B, Aloysius A, Morrison L, Main M, Crawford TO, Trela A. Consensus statement for standard of care in spinal muscular atrophy. Journal of child neurology. 2007 Aug;22(8):1027-49.13. Finkel RS, Mercuri E, Meyer OH, Simonds AK, Schroth MK, Graham RJ, Kirschner J, Iannaccone ST, Crawford TO, Woods S, Muntoni F. Diagnosis and management of spinal muscular atrophy: Part 2: Pulmonary and acute care; medications, supplements and immunizations; other organ systems; and ethics. Neuromuscular Disorders. 2018 Mar 1;28(3):197-207.14. Young HK, Lowe A, Fitzgerald DA, Seton C, Waters KA, Kenny E, Hynan LS, Iannaccone ST, North KN, Ryan MM. Outcome of noninvasive ventilation in children with neuromuscular disease. Neurology. 2007 Jan 16;68(3):198-201.15. Boemer F, Caberg JH, Dideberg V, Dardenne D, Bours V, Hiligsmann M, Dangouloff T, Servais L. Newborn screening for SMA in Southern Belgium. Neuromuscular Disorders. 2019 May 1;29(5):343-9.

Background: Ventilated neonates with respiratory distress may show a ventilation-perfusion (V/Q) mismatch. Objective: To evaluate the difference between the Bohr (Vd,Bohr) and Enghoff (Vd,Enghoff) dead spaces in infants by using volumetric capnography (Vcap) based on ventilator graphics and capnograms. Methods: This study enrolled 46 ventilated infants (mean birth weight, 2239 ± 640 g; mean gestational age, 35.5 ± 3.3 weeks). We performed Vcap and calculated Vd,Bohr and Vd,Enghoff when arterial blood sampling was necessary for treatment. Each measurement was classified according to the severity of acute respiratory distress syndrome (ARDS) by using the Berlin definition: severe or moderate ARDS, ratio of partial pressure of oxygen to fraction of inspired oxygen (P/F ratio) ≤ 200; mild ARDS, 200 < P/F ratio ≤ 300; and non-ARDS, 300 < P/F ratio. Next, regression analysis was performed to evaluate the correlation between the P/F ratio and the difference between Vd,Enghoff and Vd,Bohr. Results: Median Vd,Enghoff/tidal volume (VT) was significantly higher in the ARDS groups (severe or moderate: 0.60 [IQR, 0.49–0.68]; mild: 0.50 [0.43-0.59]) than in the non-ARDS group (0.45 [0.36-0.56]). The ARDS groups showed a large difference between Vd,Enghoff and Vd,Bohr (severe or moderate: median, 0.23 [0.15-0.30]; mild: median, 0.14 [0.09-0.21] vs. control: median, 0.09 [0.06-0.13]). The regression analysis for the relationship between P/F ratio and Vd,Enghoff - Vd,Bohr showed a negative correlation (r = -0.55, p < 0.001). Conclusion: Ventilated neonates with respiratory distress showed a large difference between Vd,Enghoff and Vd,Bohr, possibly reflecting a low V/Q mismatch and right-to-left shunting.

An Unusual Case of Necrotizing Pneumonia Presenting with Acute Kidney InjuryUgur Berkay Balkanci, MDSchool of Public Health, University of Minnesota, Minneapolis, MNDavid J. Sas, DODivision of Pediatric Nephrology and Hypertension, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MinnesotaNadir Demirel, MDDivision of Pediatric Pulmonology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MinnesotaCorresponding Author:Nadir Demirel, MDDivision of Pediatric Pulmonology200 First Street SWRochester, MN 55906Tel. No.: 5075380754Fax No.: 5072840727Demirel.nadir@mayo.eduKey words: postinfectious glomerulonephritis, pneumothorax, complications, complicated pneumoniaFinancial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.Funding: No external funding.Short title: “An unusual case of necrotizing pneumonia”To the Editor:Lower respiratory tract infections are the most common reason for hospitalization in the pediatric age group in the United States. Although pneumonia is prevalent, complicated pneumonia such as empyema, lung abscess and necrotizing pneumonia (NP) is uncommon in children1. The prevalence of complicated pneumococcal pneumonia decreased significantly after the introduction of the thirteen-valent pneumococcal vaccine in 20101. NP in the pediatric population is a severe disease characterized by extensive destruction and liquefaction of the lung tissue resulting in loss of the pulmonary parenchymal architecture, cavitation of the lung, and pleural involvement. Renal complications of complicated pneumonia are rare and mostly reported as atypical hemolytic uremic syndrome (HUS)2. Post-infectious glomerulonephritis (PIGN) is an unexpected complication of bacterial pneumonia3.We report a six-year-old otherwise healthy fully vaccinated girl with a 4-day history of fever, abdominal pain, vomiting, non-bloody diarrhea, and poor oral intake. Parents reported decreased urine output and dark-colored urine on the day of admission. Initial evaluation revealed serum creatinine of 5.01 mg/dL and blood urea nitrogen of 86 mg/dL, elevated acute phase reactants suggesting acute kidney injury (AKI) in the setting of an undiagnosed acute infectious process. The patient was admitted with decreased effective circulatory volume. Urinalysis revealed hematuria with <25% dysmorphic red blood cells (RBCs), proteinuria, pyuria, and RBC casts and granular casts, suggestive of acute glomerulonephritis.She was started on intermittent hemodialysis at day 2 of admission to address uremia, fluid overload, and hyperphosphatemia. A renal biopsy revealed diffuse exudative glomerulonephritis, consistent with infection-related glomerulonephritis. ASO, Anti-DNase B were negative; C3, C4 levels were low. She was treated with pulse IV methylprednisolone 10mg/kg/day for three days. The first 5 days in the hospital, the patient remained afebrile and her lung exam was normal without respiratory symptoms.On day six of admission, she developed acute right-sided chest pain and shortness of breath during hemodialysis. Chest x-ray (CXR) revealed a large right-sided tension pneumothorax, prompting therapeutic chest tube placement. Repeat CXR revealed reexpansion of the right lung and a significant right upper lobe consolidation with an ovoid hyperlucency and an air-fluid level. A chest CT scan confirmed the diagnosis of NP with multiple cavities (Image).Flexible bronchoscopy was performed with bronchoalveolar lavage revealing 42% neutrophils and negative cultures. She was treated with broad spectrum intravenous antibiotics.During admission, she developed hypertension, well-controlled with scheduled enalapril and amlodipine, as well as isradipine as needed. On day 14 of admission, hemodialysis was discontinued as kidney function improved, and chest tube was removed. She was discharged at day 26 of admission on intravenous ceftriaxone and oral metronidazole to complete 30 days of treatment. A repeat chest CT at end of treatment showed complete resolution of NP. Renal functions and blood pressure normalized on follow up.NP is characterized by persistent high fevers and prolonged hospitalizations even with appropriate antibiotic treatment1. Most often, NP affects immunocompetent children with no underlying risk factors4. The pathophysiology of this complication is acute liquefactive necrosis of the lung parenchyma which results in the development of pneumatoceles4. The most common pathogen causing NP is Streptococcus pneumoniae followed by Staphylococcus aureus and Streptococcus pyogenes. Other rarer bacterial and viral pathogens are Mycoplasma pneumonia, Influenza, and Adenovirus1. Identifying the microbiologic pathogen can be challenging and is only made in 50% of cases1. In our case, we did not isolate the causative microorganism. NP typically resolves without residual morbidity, even after a protracted course1,4.Pleural involvement is almost universal in NP, and the course of pleural disease often determines duration and outcome, particularly as it relates to the complication of bronchopleural fistula (BPF)1. BPF is most likely due to the necrotic development of a connection between bronchial space and pleural space4. BPF formation is associated with a significantly longer hospital stay in children with NP4. Yet, most cases heal without surgical intervention4. Tension pneumothorax has been observed as a rare complication of NP1.Renal involvement in complicated pneumonia is rare. Atypical HUS has been reported as a complication of pneumonia, particularly associated with empyema. (most commonly due to invasive Streptococcus pneumoniae)2. In a case series of 37 cases of atypical HUS, 34 patients (92%) had pneumonia with 10 patients (29%) with NP5. Less commonly, pneumonia can be associated with PIGN. PIGN is the most common glomerulonephritis in children worldwide. Pneumonia-associated PIGN is rare. In a case series from the US, PIGN accounted for 0.15% of admissions for pneumonia and 0.39% of admissions for glomerulonephritis6. Pneumonia-associated PIGN is known to be caused by various bacterial pathogens including Streptococcus pneumoniae, Staphylococcus aureus, Mycoplasma pneumoniae, Chlamydia pneumoniae, Nocardia, and Coxiella burnetii3. Different from the usual presentation of the PIGN (in which the time interval between a pharyngeal group A Streptococcal infection and PIGN is 6 to 10 days), pneumonia-associated PIGN is usually concomitant with the pulmonary disease3,6.Our case is unusual in several ways: pneumonia-associated PIGN typically presents with respiratory symptoms first, and acute kidney injury developing during the course of pneumonia3. More surprisingly, the patient developed NP which is characterized by even more severe respiratory symptoms1. Yet, our patient presented without respiratory complaints and pneumonia became apparent only after the development of pneumothorax. We could only identify 2 cases of pneumonia-associated PIGN who presented with renal involvement before pulmonary complaints6,7. Also, previous cases in the literature of pneumonia-associated PIGN report mostly a non-complicated course of pulmonary disease3,6. In a case series of 11 children with pneumonia-associated PIGN, only one case developed a small empyema6. Similarly, the majority of the reported cases of pneumonia-associated PIGN describe a benign course of renal disease3,6. Our patient’s kidney failure progressed rapidly, and she required 2 weeks of intermittent hemodialysis and a three-day course of pulse steroid therapy. At present, systemic corticosteroids are not recommended for patients with complicated pneumonia. A Cochrane review including 17 randomized controlled trials, of which four were conducted on children, found that corticosteroid therapy reduced mortality and morbidity in adults with severe CAP, and morbidity, but not mortality, in adults and children with non-severe CAP1. We speculate that pulse steroid treatment may have modified the course of NP in our patient.This case suggests an atypical presentation of NP with predominant renal complications is possible. Pediatricians should be aware of renal complications of respiratory diseases. Systemic steroids should be considered in the treatment of NP.References:1. de Benedictis FM, Kerem E, Chang AB, Colin AA, Zar HJ, Bush A. Complicated pneumonia in children. Lancet 2020;396:786-798.2. Spinale JM, Ruebner RL, Kaplan BS, Copelovitch L. Update on Streptococcus pneumoniae associated hemolytic uremic syndrome. Curr Opin Pediatr 2013;25:203-208.3. Carceller Lechón F, de la Torre Espí M, Porto Abal R, Écija Peiró JL. Acute glomerulonephritis associated with pneumonia: a review of three cases. Pediatr Nephrol 2010;25:161-164.4. Sawicki GS, Lu FL, Valim C, Cleveland RH, Colin AA. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. Eur Respir J 2008;31:1285-1291.5. Banerjee R, Hersh AL, Newland J, Beekmann SE, Polgreen PM, Bender J, Shaw J, Copelovitch L, Kaplan BS, Shah SS. Streptococcus pneumoniae-associated Hemolytic Uremic Syndrome Among Children in North America. Pediatr Infect Dis J 2011;30:736-739.6. Srivastava T, Warady BA, Alon US. Pneumonia-associated acute glomerulonephritis. Clin Nephrol 2002;57:175-182.7. Schachter J, Pomeranz A, Berger I, Wolach B. Acute glomerulonephritis secondary to lobar pneumonia. Int J Pediatr Nephrol 1987;8:211-214.

Background: Acute myeloid leukemia (AML) and hyperleukocytosis are related to an unfavorable prognosis. The impact of hyperleukocytosis on the prognosis of pediatric AML has not been fully explained so far. We aimed to assess the clinical characteristics and prognosis of pediatric AML with hyperleukocytosis, referred to as white blood cell (WBC) count ≥50×109/L. Methods: A total of 307 newly diagnosed non-acute promyelocytic leukemia patients were continuously enrolled at our center from October 2005 to September 2015. 81 patients with initial leukocyte counts ≥50×109/L. The baseline demographic and clinical characteristics of AML patients were compared. Progression-free survival (PFS) and overall survival (OS) were documented. Results: Hyperleukocytosis occurred in 26.38% of AML patients, and FAB M5 subtype (n=41, 50.62%) and FLT3-ITD mutations (n=16, 19.75%) had a high proportion in AML and hyperleukocytosis. Overall mortality was significantly higher in patients with hyperleukocytosis than patients without hyperleukocytosis (50.62% vs. 35.84%, P=.020). Patients with hyperleukocytosis had a lower 10-year PFS and OS rates than those without hyperleukocytosis (44.4%±9.4% vs. 59.7%±5.5%, P=.041; 49.4%±9.4% vs. 64.2%±5.4%, P=.051, respectively). There were similar PFS and OS rates between the subgroups of patients with WBC count 50-100×109/L and WBC count ≥100×109/L (43.8%±13.3% vs. 44.9%±12.3%, P=.507; 46.9%±13.3% vs. 51.0%±12.3%, P=.907, respectively). In all patients with hyperleukocytosis, male and FAB M5 subtype patients had a significantly inferior survival, while CBF-AML had a better survival. Conclusions: A WBC count greater than 50×109/L at onset was a critical predictive adverse factor in pediatric AML.

Background Pediatric patients with oncologic and hematologic diagnoses who experience functional decline during a hospitalization may benefit from intensive therapies. However, acute medical issues or disease treatment plans may prevent a safe transfer to the inpatient rehabilitation unit. Accordingly, an alternative inpatient rehabilitation program was developed. Procedure Short-term Pediatric Rehabilitation Intensive Therapy (“SPRINT”) is a 2-week inpatient intensive therapy program developed for pediatric patients on hematology-oncology and bone marrow transplant units at a pediatric tertiary care hospital. This pilot study evaluates functional outcomes of SPRINT participants measured by the Caregiver Assistance section of the Pediatric Evaluation of Disability Inventory (PEDI) and differences in participants’ symptoms with a questionnaire. Results Eighteen pediatric patients (50% female, age 1.9-17.8 years) participated in SPRINT, and 11 parents and 4 children completed questionnaires. Common diagnoses included leukemia and lymphoma (N=9, 50%) and central nervous system tumor (N=6, 33%). Deconditioning (N=18, 100%) and peripheral neuropathy (N=8, 44.4%) were common rehabilitation diagnoses. Significant gains were found in tasks in self-care and mobility domains of PEDI (all p<0.05), as well as functional expression in social function domain (p=0.03). No adverse events related to SPRINT participation were identified. There was no significant difference between pre- and post-SPRINT questionnaire responses. Conclusion SPRINT is an alternative model for intensive rehabilitation care delivery. Data suggest that SPRINT participation can result in significant functional gains in mobility, self-care, and functional expression for pediatric patients with hematologic and oncologic diagnoses during hospitalizations. No difference was found in questionnaire responses after SPRINT participation.

Background: Patient-reported outcomes (PROs) that assess health-related quality of life (HRQoL) are increasingly important components of cancer care and research that have been infrequently used in sub-Saharan Africa (SSA). We aimed to longitudinally measure HRQoL among pediatric lymphoma patients in Malawi. Methods: We administered the Chichewa Pediatric Patient-Reported Outcome Measurement Information System Pediatric (PROMIS)-25 at diagnosis, active treatment, and follow-up among pediatric lymphoma patients in Lilongwe, Malawi. Mean scores were calculated for the six PROMIS-25 HRQoL domains (Mobility, Anxiety, Depressive Symptoms, Fatigue, Peer Relationships, and Pain Interference) using the PROMIS scoring manual. Results: Seventy-five children completed PROMIS-25 surveys at diagnosis, 35 (47%) during active treatment, and 24 (32%) at follow-up. The majority of patients died (n= 37, 49%) or were lost-to-follow-up (n=8, 11%). Most (n=51, 68%) were male, median age was 10 (IQR 8-12), 48 (66%) presented with advanced Stage III/IV, 61 (81%) were diagnosed with Burkitt lymphoma and 14 (19%) had Hodgkin lymphoma. At diagnosis, HRQoL was poor across all domains, except for Peer Relationships. Improvements in HRQoL during active treatment and follow-up exceeded the minimally important difference. Poor Lanksy performance status ≤ 70 and Pain Intensity = 10 at diagnosis were associated with increased mortality risk and worse survival. Conclusions: Our experience suggests incorporating assessments of HRQoL via PROs in oncology care is feasible in SSA, can provide prognostic information, and generates clinically meaningful data to inform supportive care interventions. Further, PROs offer an opportunity to include patient voices and prioritize holistic patient-centered care even in low-resource settings.

We present a case of a 40-year-old male admitted with a non-ST segment elevation myocardial infarction and found to have an anomalous origination of the left main coronary artery from the opposite sinus, a congenital disorder associated with a significant risk of sudden cardiac death.

COVID-19 has created challenges for society and the medical community. While the pandemic continues to unfold, the transplant community has had to pivot to keep recipients, donors, and transplant teams safe given these unprecedented times. This has resulted in a decrease in the number of transplants performed in the United States and an increased number of inactive patients on the UNOS waiting list.1 Waitlist and transplant recipients have an increased risk for acquiring COVID-19. It is speculated that this patient population is particularly vulnerable given their immunocompromised status and the high prevalence of comorbidities.2 Given the uncertainty surrounding the risk of transplant patients contracting COVID-19, there is interest in describing these cases in the literature.

The novel severe acute respiratory syndrome coronavirus (SARS-COV-2) affects different people in different ways. Most infected people will develop mild to moderate respiratory flu-like illness and recover without the need for hospitalization. However, one of the not uncommonly observed extrapulmonary associations with SARS-COV-2 is developing large-vessel acute ischemic stroke.

In reconstructive rhinoplasty, the nasal framework must be securely fixated to the facial bony skull. We present a surgical technique to fixate the nasal L-strut to the facial skull by using exclusively titanium L-shaped micro-plates in cases where the anterior nasal spine and the nasal bones cannot be used

A 2-month-old male harboring a duplication of DMD exons 1-7 classified as pathogenic by an outside institution presented with mildly elevated CK levels; molecular breakpoint analysis by our laboratory reclassified the duplication as likely benign. To date, proband continues to develop normally with decreased CK levels, further supporting our reclassification.

Bacillus Calmette-Guérin (BCG) is commonly used in treating superficial urothelial carcinoma. Though rare, local and systemic disseminated BCG infections are important to recognize as they require prolonged antimicrobial therapy and surveillance. We present an unusual case of a parapharyngeal space mass as manifestation of disseminated BCG following urothelial carcinoma treatment.

Objective Although acute appendicitis is the most common emergency surgical pathology it is not easy to diagnose in pediatric patients. This study aims to compare the accuracy of Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado scores in the diagnosis of acute appendicitis in children. Methodology Demographic data, examination findings, leukocyte count, neutrophil percentage, urine analysis and radiology reports of 163 consecutive patients who were underwent surgery for acute appendicitis were recorded. RIPASA and Alvarado scores of patients were calculated prospectively. Cutoff value was >7.5 for RIPASA score , ≥7 for Alvarado score. The accuracy of the diagnosis was confirmed by the histopathology result. The accuracy, sensitivity, specificity, positive predictive value, negative predictive value, area under the ROC curve of the RIPASA vs. Alvarado scores were evaluated. Results Negative appendectomy rate was 11.1%. The accuracy rate was 76.1% in the RIPASA score vs. 68.7% in the Alvarado score. The sensitivity and specificity values were 77.9%, 61.1% for RIPASA score vs. 68.2%, 72.2% for Alvarado score, respectively. Positive predictive value was 94.1% and negative predictive value was 25.5% for RIPASA score vs. 95.1%, 22.1%, respectively for Alvarado score. The area under the ROC curve was 0.74 for RIPASA score vs. 0.68 for Alvarado score, with no statistically significant difference between the two scores (p> 0.05). Conclusions RIPASA and Alvarado scores are not superior to each other in the diagnosis of acute appendicitis in children. Clinical examination, laboratory and radiology were more valuable in the diagnosis of acute appendicitis in children.

PRV1 was first detected in deceased pigs from Hong Kong in 2013. It has since been detected in the USA, Chile and most recently in Hungary. Information on the pathogenicity and global spread is sparse, however it has been speculated to play a role in the porcine respiratory disease complex. In an effort to investigate the porcine virome, we screened 53 pig samples from 29 farms using SMg within the Dutch/German border region. In five farms we detected PRV1. qPCR confirmed the presence of the virus in 2 of these farms and found an additional 6 positive farms. Phylogenetic analysis found the closest match to the first detected PRV1 strain in Hong Kong. The Dutch/German region represents a major area of pig farming within Europe and could provide important information on the characterization and circulation of porcine viruses, such as PRV1. Together with the recent detection of PRV1 in Hungary, these findings suggest widespread of PRV1 in Central Europe, highlighting the need for further research on persistence, pathogenicity and transmission in Europe.

Advanced and accurate forecasting of COVID-19 cases plays a crucial role in planning and supplying resources effectively. Artificial Intelligence (AI) techniques have proved its capability in time series forecasting of the non-linear problems. In the present study, the relationship between weather factor and COVID-19 cases was assessed and also developed a forecasting model using long short term memory (LSTM), a deep learning model. The study found that the specific humidity has a strong positive correlation, whereas there is a negative correlation with maximum temperature and positive correlation with minimum temperature was observed in various geographic locations of India. The weather data and COVID-19 confirmed cases data (1st April-30th June 2020) was used to optimize univariate and multivariate LSTM time series forecast models. The optimized models were utilized to forecast the COVID-19 cases for the period 1st July 2020 to 31st July 2020 with 1 to 14 days of lead time. The results showed that the univariate LSTM model was reasonably good for the short term (1day lead) forecast of COVID-19 cases (relative error < 20%). Moreover, the multivariate LSTM model improved the medium-range forecast skill (1-7days) after including the weather factors. The study observed that the specific humidity played a crucial role in improving the forecast skill majorly in the West and northwest region of India. Similarly, the temperature played a significant role in model enhancement in the Southern and Eastern regions of India.

Soil salinization and sodification are types of degradation due to salt accumulation in the soil. They develop in all climatic zones but are prevalent in arid and semi-arid areas. Assessment of their true occurrence is challenging owing to inadequate consideration of their evolution, lack of harmonization steps, and omission of diagnostic soil properties in the assessment. This paper developed a new assessment protocol using combined application of time-series diagnostic soil indicators, remote sensing, and environmental variables related to the occurrence of soil salts. The protocol focuses on standardization of the soil indicators, digital soil mapping, and application of classification schemes to identify levels of salt accumulation in the soil. It was tested in Lesotho, Afghanistan, and Sudan using measured soil electrical conductivity, pH, and exchangeable sodium percent, and covariates such as relief, remote sensing indicators of soil salinity, climate, hydrogeology, and land cover between 2001 and 2018. It was able to identify different types of salt-affected soils and levels of salt accumulation with over 80% accuracy on holdout samples. It identified emerging subsoil (30-100 cm) salt problems in agricultural areas in Lesotho, advancing topsoil (0-30 cm) salinization and subsoil sodification in agricultural areas in Sudan, and salinization of saline topsoils in Afghanistan. It also established important environmental covariates which can be used in periodic monitoring of salt accumulation in the soil. We recommend its wide application in different temporal and spatial scales to improve its performance in identifying salt accumulation in agricultural areas