Introduction: The aim of this study was to assess the impact of the COVID-19 pandemic on the activity of private medical practices in Morocco. Methods: An online survey was carried out in June 2020. The study population consisted of physicians (General practitioners and specialists) who run private practices in different regions of Morocco. The questionnaire comprised 3 sections: demographic and professional data, the impact noticed by the doctors and the strategies adopted to tackle this impact. Results: We analyzed 225 responses. Specialists represented 71.6% of the respondents. The majority (94.2%) of the private practices were located in urban areas. Almost all respondents have noticed a change in the demand for medical services, mainly a decrease (96,44%). There was an increase in urgent consultations (30.7%) and consultations for acute motives (39.1%). Respondents also reported less (69,3%) or no (23,1%) regular follow-up visits for patients with chronic diseases. Decreased incomes concerned 97,33% of the practices. Doctors reacted by working less hours (87,55%), delaying some procedures (78,22%), and applying recommended safety measures (100%). Telemedicine was used in an informal way to facilitate the communication with patients. Discussion and conclusion: During this pandemic, private practices were challenged to contribute to the continuity of healthcare services while ensuring the safety of the staff and the patients. Several strategies were adopted to cope with the new situation and to survive its many challenges.

An 88-year-old male patient with no significant medical history presented with nausea, vomiting and hypothermia. He was admitted for further testing which revealed elevated CK-MB and Troponin with no significant electrocardiogram changes.He denied cardiac symptoms or any previous cardiac history.We share this rare case of hypothermia induced elevation of CK-MB.

A novel approach towards developing a micro-bubble detection technology based on using a PZT transducer to induce an acoustic resonance state within the system under investigation is here presented. The concept, originally proof-of-concept tested in a cylindrical acoustic resonant chamber, has proven to be able to detect single microbubbles with diameters in the range of 390 to 600 µm in a swine thigh, with either saline solution or sheep blood as the medium in the bubble guide. It has shown to be extremely adaptable, capable of accommodating industrial pipes as well as biological specimens, resilient and extremely energy efficient, able to detect micro-bubbles with as little as 0.8 mW and potentially less.

Immunosuppressant drugs like Etanercept, Mycophenolate mofetil, Sirolimus, Cyclosporine and Rituximab can weaken the immune system and make patients susceptible to SARS nCoV-2 virus. These drugs make immunocompromised persons more vulnerable to complications associated with COVID-19. Moreover, it can also increase the mortality and morbidity, as a weakened immune system can lead to longer duration of infection. This study discusses the guidelines on immunosuppressant drugs and its associated risk factors with COVID-19, issued by the U.S CDC (Centers for Disease Control and Prevention), WHO (World Health Organisation), U.S FDA (Food and Drug Administration) and other accredited global health organisations. Moreover, it also includes information about pharmaceutical properties, mechanism of action, COVID-19 associated risk factors, adverse drug reactions, contraindications and drug-drug interactions. Our study will help government partners and international health organisations to better understand COVID-19 health risks associated with immunosuppressants. Increased public awareness about effective drug therapy for autoimmune diseases, cancer treatment, immunocompromised and organ transplant patients will help lower the mortality and morbidity associated with the disease amid COVID-19 pandemic.

Salicylic acid (SA) plays pivotal roles in plant defense against biotrophic and hemibiotrophic pathogens. Tremendous progress has been made in the field of the SA biosynthesis pathways and SA-mediated plant defense signaling networks in the past three decades. As one of the SA receptors, NONEXPRESSOR OF PATHOGENESIS-RELATED GENES1 (NPR1) functions as a master regulator of SA-mediated plant defense. The function of NPR1 is tightly regulated by transcriptional and post-translational regulation. This review discusses recent advances in SA and NPR1 biology, including SA perception, SA signaling, the function of SA and NPR1 in plant immunity, and the transcriptional and post-translational regulation of NPR1.

Molecular simulations from small molecules to large bio-macromolecules and polymer systems are routinely used to simulate thermodynamics properties of interests by molecular mechanics-based potentials. In a recent paper, via three different semi-empirical methods, we reported quantum singularities in dihedral energies as signature of chemical bond break-up process revealed under experimental X-ray as broken chemical moieties. In this present work, applying first principle methods of Hartree-Fock, Density Functional as well as MollerPlesset techniques we have reconfirmed the previous general predictions of singularities in in dihedral energies for the case of water dimer that connects two water monomers by weak hydrogen bond. Due to quantum nature of chemical bond breaking process leading to break-point conditions in otherwise connected molecular topology, the singularities in dihedral energies are also suggestive of large forces as onset in the bond-breaking process. We have presented the details of these novel interesting findings in this paper. These results of quantum singularities can have significant impacts to improve current force fields and can open up new areas we define as “Fracture Molecular Mechanics” or “Fracture Force Field” in overlap regions of molecular and quantum mechanics based approaches to explore and account for chemical bond-breaking mechanisms in molecular simulation techniques.

The use of deadly force to counter the threat of a knife attack is a constitutionally permissible means of ensuring police and public safety.  This paper reviews the constitutional standard for use-of-force by police, relevant case law, academic literature, statistical tables, and current police methodologies before evaluates the options available to police officers and suggesting a number of measures for minimizing the use of deadly force when encountering a person armed with a knife.

Thrombus formation inside the left ventricle (LV) is a dreaded complication following myocardial infarction. Depending on their anatomical characteristics, they pose significant risk of embolism, specifically stroke. Cardiac surgery in a patient with acute cerebral infarct is a tough predicament for the treating surgeon. Mobile clots carry higher risk than mural clots and need urgent thrombectomy. We present a case of massive LV clot in a young man leading to multiple acute embolic infarcts who was successfully treated by LV thrombectomy.

Hemolytic anaemia often challenges congenital heart surgery. Hereditary spherocytosis is a rare familial hemolytic anaemia. When associated with congenital heart disease, the safe performance of cardiopulmonary bypass becomes a priority. The increased risk of hemolysis during cardiopulmonary bypass could potentially lead to significant secondary organ damage. Till now, only very few reports of successful repair of a congenital heart defect in patients with hereditary spherocytosis have been reported. We report the only case of successful repair of a congenital heart defect in an infant with hereditary spherocytosis.

A water-soluble polymer stabilizer (VIB-co-VI-co-Py, Figure 1) assisted liquid-phase exfoliation (LPE), implemented by high-shear mixing rather than currently more often used bath/probe sonication, was developed as a new method for efficient production of few-layer graphene (FLG) in aqueous liquid. With help of VIB-co-VI-co-Py, stable aqueous dispersion of FLG forms in-situ with 90% of dispersed flakes of fewer than five layers and production rate up to 0.86 g h-1 by 5.0 L of aqueous liquid, representing the highest production rate per volume (0.17 g L-1 h-1) reported hitherto for LPE with the liquid volume no less than 5.0 L. The scale-up shear-exfoliated FLG exhibits high quality and excellent redispersibility in water, thus paving the way for a wide range of applications. As typical application demonstrations, the FLG-based flexible conductive films and polymer composite hydrogels were prepared and evaluated. The results show that the VIB-co-VI-co-Py exfoliated FLG performs well therein.

Background: Soft tissue sarcomas are a highly heterogenous group of tumors that are classified by differentiation. Their invasive or destructive growth pattern, recurrence and distant metastatic capacity are variable according to their subtype and also their localization. Aim: The aim of this study is to evaluate clinical characteristics, histopathologic subgroups, therapeutic modalities and clinical course of head and neck sarcomas. Study Design: Retrospective study and review of literature Materials and Methods: Patients with head and neck sarcomas who underwent surgery at XXXX University, Faculty of Medicine, Department of Otorhinolaryngology between 2007 to 2016 were retrospectively evaluated. Demographic features of the patients, histopathologic subtypes, immunohistochemical markers, locations of the tumor, type of surgery, margins of the specimens, type of reconstructive surgery and type of adjuvant treatment were reviewed. Results: The histopathologic subtypes were rhabdomyosarcoma, primitive neuroectodermal tumor, osteosarcoma, chondrosarcoma, leiomyosarcoma, Ewing’s sarcoma and synovyal sarcoma. The most frequent site was nasal cavity and was detected in 7 cases. Local recurrence developed in three patients. Conclusion: Sarcomas of the head and neck region are relatively rare tumors. Radical resection of the tumors is essential for these cases.

Title: Congenital Insensitivity to Pain, with Impaired Pulmonary Functions, and Diminished Cough Reflex.

Background: Depression and anxiety symptoms in patients with cystic fibrosis (CF) and their caregivers are 2-3 times higher than in the normal population. This study aims to evaluate the frequency and severity of depression and anxiety symptoms and to determine possible risk factors in CF patients and their mother and/or fathers at Marmara University CF center. Methods: The study included 132 CF patients who were followed up at our CF center. Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Questionnaire (GAD-7) were used to screen depression and anxiety. The questionnaires were completed by 50 CF patients (aged 12 - 17 years) and 132 parents of patients (aged 0-17 years). Results: While moderate to severe depression were seen in 25.5% of patients, 33.7% of mothers and 14.6% of fathers; moderate to severe anxiety were present in 17.6%, 21.8% and 8.5%, respectively. None of the demographic characteristics was identified as a predictor of depression or anxiety. GAD-7 scores have shown a higher incidence of anxiety in mothers of patients with chronic methicillin-resistant Staphylococcus Aureus (p = 0.034). Additionally, hospitalization in the last 12 months was statistically significantly higher in PHQ-9 scores of fathers (p = 0.043). Analysis of patients’ adherence to medical treatment and airway clearance showed higher depression and anxiety in mothers of the non-adherent group (p = 0.002). Conclusion: Depression and anxiety were common in CF patients and their parents. These results illustrate the importance of depression/anxiety screening and psychosocial support for the CF patient and their parents.

Article Type: News and Views: Groundbreaking Discoveries in ImmunologyTitle: Emollients for the prevention of atopic dermatitisAuthors: Akash Kothari1(https://orcid.org/0000-0003-1980-161X), Arielle Locke2,Thomas Eiwegger1,3,4(https://orcid.org/0000-0002-2914-7829)1Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada2Department of Medicine, National University of Ireland, Galway, Ireland3Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada4Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, Ontario, CanadaCorrespondence to: Thomas Eiwegger, MD, Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto, Canada, E-mail: thomas.eiwegger@sickkids.ca, Tel.: +1 416-813-7654 ext. 1862Conflicts of Interest: AK and AL have nothing to disclose. TE reports to act as local PI for company sponsored trials by DBV and sub-investigator for Regeneron, holds grants from Innovation Fund Denmark, CIHR outside the submitted work. He is Co-Investigator or scientific lead in three investigator initiated oral immunotherapy trials supported by the Food Allergy and Anaphylaxis Program SickKids and serves as associate editor for Allergy. He/his lab received unconditional/in-kind contributions from Macro Array Diagnostics and an unrestricted grant from ALK. He holds advisory board roles for ALK.Financial support: This work was supported by The Hospital for Sick Children, The Food Allergy and Anaphylaxis Program at The Hospital for Sick Children, and The Dr Lorus J And Dr Margery J Milne Scholarship from Victoria University at the University of Toronto.Statement of Author Contribution: All authors critically reviewed the original articles (references 6 and 7) and wrote the News & Views: Groundbreaking discoveries in Immunology article. All authors contributed, revised, edited, and approved the final version of the manuscript as submitted and agreed to be accountable for all aspects of the work.Keywords: emollient, atopic eczema, infancyAbbreviations : food allergy, FA; filaggrin gene, FLG; atopic dermatitis, AD; transepidermal water loss, TEWL; Barrier Enhancement for Eczema Prevention, BEEP; Preventing Atopic Dermatitis and Allergies, PreventADALL

Congenital pulmonary airway malformation (CPAM), previously known as congenital cystic adenomatoid malformation (CCAM), is a rare developmental lung abnormality with the potential for malignant transformation. Bronchioloalveolar carcinoma (BAC), pleuropulmonary blastoma (PPB), rhabdomyomatous dysplasia/rhabdomyosarcoma (RMS) have been associated with CPAM. We report an unusual case of a 1-day-old male newborn who underwent lobectomy for a cystic lung lesion, which was found to be a mucinous BAC with K-ras mutation in a type 1 CPAM. The case supports the relationship between type 1 CPAM and BAC/KRAS mutant, and highlights that the malignant transformation can occur in very early stage of the infancy.

We used the lung ultrasound score (LUSS) to analyze the ultrasound images and assess the lesions and aeration loss in 12 lung regions of 11 COVID-19 neonates born to mother with COVID-19 and 11 age- and gender-matched controls. In the COVID-19 group, 132 regions were reviewed and 83 regions (62.8%) detected abnormalities. Compared with controls, COVID-19 neonates showed more increased B-lines (83 regions), abnormal A-lines (83 regions), abnormal pleural line (29 regions) and subpleural consolidation (5 regions). among which 49 regions (37%) were normal, 73 regions (55%) scored 1, and 10 regions (8%) scored 2. The LUSS was significantly higher in COVID-19 group. All the lesions were bilateral, multiple regions involved, and mainly located in bilateral lower lobes and right middle lobe. The intra-observer and inter-observer reproducibility of LUSS were excellent. Lung ultrasound is a noninvasive and convenient method for the assessment of neonatal COVID-19 pneumonia and presents typical signs. LUSS provides valuable semi-quantitative information about the lesion distribution and severity.

Background: To date, no disease-specific tool is available to assess the impact of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) on Health Related Quality of Life (HRQoL). Therefore, the purpose of this study was to develop and validate a questionnaire specifically designed to this aim: the Nasal Polyposis Quality of Life questionnaire –NPQ. Methods: According to the current guidelines, the development and validation of the NPQ occurred in two separate steps involving different groups of patients. Results: In the development process of NPQ an initial list of items of 40 items was given to 60 patients with CRSwNP; the 27 most significant items were selected and converted into questions. The validation procedure involved 107 patients (mean age 52.9±12.4). NPQ revealed a five-dimensional structure and high levels of internal consistency (Cronbach’s alpha 0.95). Convergent validity (Spearman’ coefficient r=0.75; p< 0.01), discriminant validity (sensitivity to VAS score), reliability in a sample of patients with a stable health status (Interclass Coefficient 0.882) were satisfactory. Responsiveness to clinical changes was accomplished. The minimal important difference was 7. Conclusion: NPQ is the first questionnaire for the assessment of HRQoL in CRSwNP. Our results provide that the new tool is valid, reliable, and sensitive to individual changes.

ABSTRACT Background Exposed to house dust mite (HDM) is known to be associated with allergic asthma. Endoplasmic reticulum (ER) stress is involved in the regulation of mucus hyper secretion. However, the mechanism remains unclear. Our main goal was to investigate the relationship of TBK1 pathway regulates the expression of MUC5AC under the HDM induced ER stress promote allergic asthma. Methods Using HDM induced allergic mice and stimulated over expression of MUC5AC in human airway epithelial cells. We examined the mucus and the expression of ER stress markers both in vivo and in vitro. Additionally, we investigated whether TBK1, NF-κB, STAT6 play an important role in the HDM induced ER stress promote airway mucus hyper secretion. Results Mice exposed to HDM were identified ER stress, hyper secretion of mucus, and activated TBK1-NF-κB/STAT6 signaling pathway in airway epithelial cells of asthmatic mice. Similarly results had also been observed in the human airway epithelial cells after exposed to HDM. Both in vivo and in vitro study not only revealed that an anti-allergy drug, Amlexanox, reduced super response of mucus and weaken TBK1-NF-κB/STAT6 signal of induced asthma. But also indicated HDM induced ER stress result in over production of MUC5AC, which can be decreased by the inhibition of TBK1, NF-κB, STAT6, or even by using ER stress inhibitor 4-PBA, respectively. Conclusions Our results show that TBK1-NF-κB/STAT6 plays a pivotal role in the HDM induced ER stress result in over production of mucus protein MUC5AC in the asthmatic airway.

Background In patients with chronic heart failure, QRS duration is a consistent predictor of poor outcomes. It has been suggested that for indicated patients, cardiac resynchronisation therapy (CRT) could come sooner in the treatment algorithm, perhaps in parallel with the attainment of optimal guideline-directed medical therapy (GDMT). We investigated differences in left ventricular (LV) remodelling in those with narrow QRS (NQRS) compared to wide QRS (WQRS) in the absence of CRT, whether an early CRT strategy resulted in unnecessary implants and the effect of early CRT on outcomes. Methods and results Our cohort consisted of 214 consecutive patients with LV ejection fraction (LVEF) ≤35% who underwent repeat echocardiography 1-year after enrolment. Of these, 116 patients had NQRS, and 98 had WQRS of whom 40 received CRT within 1-year and 58 did not. In the absence of CRT patients with WQRS had less LV reverse remodelling compared to those with NQRS, with differences in ΔLVEF (+9% vs 2 %, p<0.001), ΔLV end-diastolic diameter (-2mm vs -1mm, p=0.095) and ΔLV end-systolic diameter (-4.5mm vs -2mm, p=0.038). LVEF was more likely to improve by ≥10% if patients had NQRS or received CRT (p=0.08). Thirteen (24%) patients with WQRS achieved an LVEF >35% in the absence of CRT, however none achieved >50%. Conclusions A strictly linear approach to HF therapy might lead to delays to optimal treatment in those patients with the most to gain from CRT and the least to gain from GDMT.

Background: Feather duvet lung (FDL) is an underestimated form of acute and chronic hypersensitivity pneumonitis. Serological tests for FDL need to be validated. We investigated the ability of recombinant pigeon Proproteinase E (r-PROE) and Immunoglobulin-lambda-like-polypeptide-1 (r-IGLL1) proteins to support the serological diagnosis of FDL, and propose them as a serological tool for clinicians to differentiate cases from FDL and Bird fancier’s lung (BFL). Methods: Specific IgG antibodies against r-PROE and r-IGLL1, analyzed with ELISA, were measured in patients diagnosed with FDL (n=31), BFL (n=15) controls exposed (n=15) and unexposed to feathers (n=15). Results: The sensitivity and specificity of the r-PROE ELISA for the serological diagnosis of FDL cases versus exposed and unexposed controls were 74.2% and 86.7% respectively, with an index threshold of 0.5. (AUC: 0.9). In addition, this serological test was effective to support the serological diagnosis of FDL and BFL cases with significantly different thresholds. The r-IGLL1 ELISA was only effective for the serological diagnosis of BFL. Also, these two serological tests were useful for the diagnosis of both chronic and acute forms. Conclusions: The new diagnostic test for FDL using r-PROE protein should help to detect overt and hidden cases of FDL. The combination of both test will help the clinician in distinguish between the etiology of birds or feathers duvet.

A document by Nasrin Amini Tehrani. Click on the document to view its contents.

Rationale, Aims, and Objectives Quick diagnosis units, a paradigmatic innovative model of hospital ambulatory medicine in Spain, are suggested to be cost-effective. While former studies have been conducted as cost analyses of single units or comparative analyses between these patients and inpatients hospitalized for the same condition, how cost outcomes compare between units of different hospitals and different levels of complexity is unknown. Using micro-costing, the costs of patients managed at quick diagnosis units from a tertiary and a secondary hospital were compared. Methods The study population included 407 patients from each unit who were evaluated over 8 years. Through a bottom-up approach, we analyzed all single cost components that contributed to the mean total cost per patient in both units. Results Patients from the tertiary hospital unit were more likely than those from the secondary hospital to be referred for cancer suggestive symptoms, to have a diagnosis of cancer, and to be referred from the emergency department. Although the ratio of successive/first visits was 3.098 ± 0.6584 in the tertiary vs. 2.123 ± 0.2171 in the secondary hospital unit (P=0.0064), the time to diagnosis was significantly longer in the latter. With a similar mean cost per visit, the cost per patient was \euro577.5 ± \euro219.6 in the tertiary vs. \euro394.7 ± \euro92.58 in the secondary hospital unit (P=0.0559). Personnel and indirect costs including both the monetary estimate and their percent contribution to the mean cost per patient accounted for the main differences between units. Conclusion The ratio of successive/first visits was the main driver of cost differences. A greater complexity of patients from the unit of the tertiary hospital and the inherent characteristics of this type of hospital including volume of patients and staff and staff time justified the differences in the ratio of visits and the cost outcomes.

Introduction: Presence of preferential pathway conduction is mostly detected as fractionated presystolic potentials preceding the QRS onset during premature ventricular contractions (PVCs) and late potentials during sinus rhythm (SR), but the electrophysiologic mechanisms and significance of these potentials have not been fully clarified. We describe a PVC case series in which the preferential pathway conduction was 3-dimensionaly visualized by coherent mapping with the conduction velocity vector. Methods: Five PVCs (2 from the left coronary cusp, 2 from the commissure of the left and right coronary cusps, and 1 from the pulmonary artery) in 4 patients for which a fractionated presystolic potential during the PVCs and late potential during SR were recorded at the successful ablation site were reviewed, and 3-dimensional coherent activation maps with the conduction velocity vector during the PVCs and SR were reconstructed. Results: At the successful ablation site, an “M”-shaped discrete presystolic-potential and “W”-shaped discrete late-potential were recorded in all patients. The configuration of the flipped electrogram of the presystolic-potential nearly matched that of the electrogram exhibiting the late-potential. We created coherent activation maps annotating the onset of the presystolic potentials during the PVCs, and the offset of the late potentials during SR, which suggested bidirectional conduction of the preferential pathway connecting the PVC origin to the myocardium. Conclusion: In this case series, the M-shaped presystolic potential and W-shaped late potential were reversely matched. These reverse potentials, and the coherent activation vector maps during PVCs and SR suggested bidirectional conduction of the preferential pathway in opposite directions.

Background : Early repolarization pattern (ERP) is associated with long-term cardiovascular death. However, the incidence of early repolarization syndrome ( ERS) has never been studied in a general population-based cohort study. Purpose : To determine the prevalence and long-term outcome of ERP as well as the incidence of ERS in a general population-based cohort study. Methods : Participants from the electricity generating authority of Thailand (EGAT) study during 1997 to 2015 were included. The outcomes included cardiovascular death,deaths due to acute myocardial infarction, SCD, and all-cause mortality. A Cox- proportional hazard model was used to determine the association between ERP and the outcomes. Results: 2,689 participants with completed ECGs and risk factor profiles were included for the analysis. Mean follow up duration was 11.2±6.7 years. There were 444 participants with baseline ERP. There were 566 deaths during the follow-ups; of these, 21 were SCD including 6 ERS. The prevalence and incidence of ERS in our study was 0.22% and 0.20 per 1000 person-year. Overall, ERP was not associated with an increased risk of all-cause mortality (hazard ratio [HR]=1.04; 95% confidence interval [CI]:0.81 to 1.34; p =0.75). However, ERP was associated with an increased risk of all-cause mortality in the population ≤55 years old (HR=2.36; 95% CI:1.47-3.77; p <0.01). Conclusion : The prevalence of ERP in the Thai population was higher than the prevalence in other countries in Asia. Our study supports previous studies that ERP is associated with a long-term increased risk of all-cause mortality in the young-middle age population.