Mini-commentary on BJOG-20-1008.R1: Cranial findings detected by second trimester ultrasound in fetuses with myelomeningocele: a systematic review

Objectives; To investigate spray technique and compliance among patients using steroid nasal spray. Design: Patient-reported survey Setting; Single centre study- a tertiary care hospital Participants: 100 participants (1 excluded) Main outcome measures 1) Nasal spray technique 2) Patient compliance Results: Out of 99 participants included in this study only one patient used steroid nose spray with a completely correct spray technique. Only 40% of patients received guidance instructions from the prescriber about the spray technique. 70% of patients reported using their spray regularly while 14% and 16% reported using mostly and sometimes respectively. 53% of patients were found using the correct dosage of the spray while 34% of patients were using incorrect dose and 13% cases dosage was unknown. Conclusions: Wrong spray technique is extremely common and can be easily corrected. Patient compliance can also be improved further. This survey emphasizes the importance of giving written and verbal instructions about the use of spray to the patients. We recommend following the written instructions for the use of steroid nasal spray from “British Society for Allergy and Clinical Immunology” or/and video tutorial from “asthma.org.uk- how to use nasal spray”

We present a case of postpartum women who collapsed immediately after delivery with probable diagnosis of amniotic fluid embolism. This is a rare but fatal condition and was managed with supportive measures. Suspicion of amniotic fluid embolism should be considered in any postpartum collapse if no obvious cause is known.

A 61-year-old woman with acute myocardial infarction (MI), cardiogenic shock and Impella CP support underwent emergency coronary artery bypass grafting. Postoperatively venous-arterial extracorporeal membrane oxygenation (va-ECMO) became necessary, followed by Impella 5.0 insertion on 7th postoperative day (POD), addition of right ventricular support by TandemHeart due to inadequate flow of Impella system, which then allowed for va-ECMO weaning. Impella und TandemHeart were removed on 14th POD, 31st POD, respectively. Biventricular decompensation following MI was successfully treated by a sequence of different mechanical circulatory support systems allowing an adaptive weaning strategy.

Background Takotsubo syndrome (TTS) often develops following various types of stressors including cardiac surgery, and may be fatal in rare cases. Case summary We report a rare case of right atrial papillary fibroelastoma that was complicated by fatal takotsubo syndrome after successful resection. The patient was evaluated for chest pain and right atrial mass that was confirmed by computed tomography and trans-esophageal echocardiography. Pathology findings were consistent with papillary fibroelastoma of the tricuspid valve. Three weeks after successful surgery, the patient was admitted due to cardiogenic shock with echocardiographic findings of apical ballooning and left ventricular outflow tract obstruction, consistent with takotsubo syndrome. Patient died one hour after her admission despite optimal medical therapy.

we report a 24 years old female patient, who presented with features of crushing syndrome. upon evaluation, she was found to have ectopic Adrenocorticotropic hormone (ACTH)–dependent Cushing’s syndrome due to a thymic tumor. histopathology confirmed ACTH secreting tumor. she was treated With Video-assisted thoracoscopic surgery and had a successful recovery.

Background:Kawasaki disease (KD) is a systemic inflammatory condition occurring predominantly in children. Coronary artery bypass grafting (CABG) is performed in the presence of inflammation and aneurysms of the coronary arteries. The objectives of our study were to assess which CABG strategy provides better graft patency and long-term outcomes. Methods:A systematic review using Medline, Cochrane and Scopus databases was performed by February 2020, incorporating a network meta-analysis, performed by random-effect model within a Bayesian framework, and pooled prevalence of adverse outcomes. Hazard ratios (HR) and corresponding 95% credible intervals (CI) were calculated by Markov chain-Monte Carlo methods. Results:Among 581 published reports, 32 studies were enrolled, including 1191 patients undergoing CABG for KD. Graft patency of internal thoracic arteries (ITA), saphenous veins (SV) and other arteries (gastroepiploic artery and radial artery) were compared. ITAs demonstrated the best patency rates at long-term follow-up (HR 0.33, 95% CI:0.17-0.66). Pooled prevalence of early mortality after CABG was 0.28% (95% CI:0.00-0.73%,I²=0%,tau²=0), with 63/1108 and 56/1108 patients, respectively, undergoing interventional procedures and surgical re-interventions during follow-up. Pooled prevalence was 3.97% (95% CI:1.91-6.02%,I²=60%,tau²=0.0008) for interventional procedures and 3.47% (95% CI:2.26-4.68%,I²=5%,tau²<0.0001) for surgical re-interventions. Patients treated with arterial, venous and mixed (arterial plus second venous graft) CABG were compared to assess long-term mortality. Mixed CABG (HR 0.03,95% CI: 0.00-0.30) and arterial CABG (HR 0.13, 95% CI: 0.00-1.78) showed reduced long-term mortality compared with venous CABG. Conclusions:CABG in KD is a safe and effective procedure. Use of arterial conduits provides better patency rates and lower mortality at long-term follow-up.

Coronavirus disease (COVID-19) is an emerging infectious disease. There may be a correlation between heatstroke and severity of COVID-19. In cases where heat stress caused by COVID-19 promotes organ failure, the proactive regulation of body temperature may be considered as an effective treatment option.

Anti-vascular endothelial growth factor (VEGF) therapy is widely used to maintain visual functioning in macular diseases including diabetic macular edema (DME). We report a case of a hypertensive cerebral hemorrhage even after intravitreal injections of aflibercept for DME in which the patient’s plasma VEGF levels were below the detection limit.

We report a case of synchronous p16+ squamous cell carcinoma (SCC) involving both the nasopharynx(NPC) and base of tongue treated at our institution. PET/CT suggested a likely occult lesion in the nasopharynx and adenoidectomy was required for confirmation of p16+ NPC

In recent decades, multipartite mutualisms involving microorganisms such as fungi have been discovered in associations traditionally thought of as bipartite. Ant-plant mutualisms were long thought to be bipartite despite fungi being noticed in an epiphytic ant-plant over 100 years ago. We sequenced fungal DNA from the three distinct domatium chambers of the epiphytic ant-plant Myrmecodia beccarii Hook.f. to establish if fungal communities differ by chamber type across five locations spanning 675 km. The three chamber types serve different ant-associated functions including: ‘waste’ chambers, where ant workers deposit waste; ‘nursery’ chambers, where the brood are kept; and ‘ventilation’ chambers, that allow air into the domatium. Overall, fungi from the order Chaetothyriales dominated the chambers in terms of the proportion of OTUs (13.4%) and sequence abundances of OTUs (28% of the total), however a large portion of OTUs (28%) were unidentified at the order level. Notably, the fungal community in the waste chambers differed consistently from the nursery and ventilation chambers across all five locations. We identified 13 fungal OTUs as ‘common’ in the waste chambers that were rare or in very low sequence abundance in the other two chambers. Fungal communities in the nursery and ventilation chambers were also significantly different, but variation between these chambers was less pronounced. Differences in dominance of the common OTUs drive the observed patterns in the fungal communities for each of the chamber types. This suggests a multipartite mutualism involving fungi exists in this ant-plant and that the role of fungi differs among chamber types.

Understanding the natural diets of grazing herbivores can help fulfill their nutritional requirements and develop management strategies. Emerging metabarcoding techniques can provide more accurate estimates for dietary composition of grazing animals. Thirty-nine Tan sheep with weights of 25.10 ± 1.88 kg were randomized into three groups: the grazing group, the time-limited grazing group, and the stall-fed group. Effects of grazing on meat fatty acid composition in lambs were compared to concentrate-based systems. Simultaneously, we investigated sheep diets using DNA metabarcoding of feces to assess the prevalence of medicinal herbage plants consumed by grazing sheep. Metabarcoding data determined that Lespedeza sp., Artemisia sp., Chenopodium sp., Corispermus sp., and Phellodendron amurense were predominant with different proportions (P < 0.05). Our results demonstrated that grazing systems could transform the muscle fatty acid composition and promote n-3 PUFAs, including C18:3n3 (ALA), C20:5n3 (EPA), and C22:6n3 (DHA) deposition. To establish the association of PUFAs with the herbage taxa, we conducted multivariate and correlation analyses. Some highlighted herbage species (e.g., Bassia scoparia, Euphorbia humifusa, and Arnebia euchroma) were significantly correlated with omega-3 PUFAs. The dominant group Lespedeza sp. showed a positive correlation with C18:2n6. Overall, these results demonstrated the utility of metabarcoding diet analysis and how diversification in dietary composition was associated with muscle fatty acid deposition. This research examined the correlation between herbage taxa and omega-3 fatty acids, and the results provide an initial view of the effects of herbage on PUFAs of lambs. The study provides experimental evidence for future feeding research.

This study explored patterns of wildlife use by the local communities around Jorgo-Wato Protected Forest to understand its impacts on the future conservation of the forest. One hundred sixty-five respondents from five peasant associations found with a radius of 3km from the forest were interviewed about patterns of wildlife use by the local communities. Also, a direct field survey using a transect line was carried out to document destructive resource use patterns. The study revealed that agricultural products (94.72%), livestock and their products (84.48%), and poultry (51.48%) were the major sources of livelihood incomes for the local communities. A significant positive (r = 0.900) relationship was recorded between the mean number of livestock and the mean annual income, and between mean land owned per household and mean annual income per household (r = 0.930), which could be attributed to their contribution to generate income through diverse ways. The utilization of alternative energy has a positive impact on the future conservation of the forest. On the other hand, the study showed a significant negative relationship (r = -0.971) between fuel wood consumption and distance of households’ residences from the forest which reveals the impacts of distance on fuel wood collection and transportation for use. Though timber, beehive preparation, construction materials, and commercial domestic tools were reported as the main reasons for resource extraction. Fuel wood and charcoal were not used for commercial purposes in the area. Livestock grazing, debarking of trees, selective logging over the coffee plantation, girdling trees, poaching, and cutting trees for timber were identified as destructive resource use patterns in Jorgo-Wato Protected Forest. Hence, wildlife laws and conservation guidelines should be implemented to mitigate destructive resource use patterns to safeguard Jorgo-Wato Protected Forest and its wildlife resources in the future.

Study objectives: We aimed to determine if fetal sex was associated with sleep disordered breathing (SDB) in pregnancy, and if fetal sex was associated with increased risk for adverse pregnancy outcomes among women with sleep disordered breathing. Methods: We analyzed 1,312,681 maternal-infant dyads from the National Perinatal Information Center database. This database includes discharge diagnosis and procedure codes based on the International Classification of Diseases, 9th Revision (ICD-9) from hospitals across the United States. We examined associations between fetal sex and SDB, gestational diabetes, gestational hypertension, preeclampsia, preterm birth, delivery type, and stillbirth. Results: Women were on average 30 years old (SD=6) and were 46% White, 18% Black, and 7% Hispanic. Logistic regression analyses revealed that carrying a male fetus was associated with increased risk for gestational diabetes (ORadj. 1.04, 95% CI 1.02-1.05, p-value <0.001), gestational hypertension (ORadj. 1.04, 95% CI 1.02-1.05, p-value =0.001), Cesarean delivery (ORadj. 1.17, 95% CI 1.16-1.19, p-value <0.001), and preterm birth (ORadj. 1.13, 95% CI 1.11-1.15, p-value <0.001). Fetal sex was not associated with SDB (ORadj. 0.99, 95% CI 0.89-1.12, p-value=.98), nor did fetal sex increase risk for adverse pregnancy outcomes among women with SDB (p-values > .09). Conclusions: Male fetal sex was associated with an increased risk for a number of adverse pregnancy outcomes, however fetal sex was not associated with SDB. Given the low rates of SDB discharge diagnoses in this cohort, future research is needed using objective measures of SDB to evaluate the association between fetal sex and SDB.

Objective To determine the association between past hormonal contraceptive use and preeclampsia among pregnant women in public hospitals. Design A case-control study was conducted in the selected public hospitals in Northwest Ethiopia. Setting Public hospitals in Northwest Ethiopia. Sample One hundred ten cases and two hundred twenty controls were selected consecutively in the selected public hospitals. Women who had preeclampsia during diagnosis were considered as cases and women with the absence of preeclampsia were controls. Methods The data was obtained through reviewing women’s record, taking measurements and face to face interview using structured interviewer administrator questionnaire. Then the data was entered into EPI info and transferred to STATA version 14 for statistical analysis. Frequency distributions, percentages and multivariate logistic regression were done to assess the association between past hormonal contraceptive use and preeclampsia. Main outcome measures Odds ratios with 95% confidence intervals of pre-eclampsia in pregnancies among women with a history of hormonal contraceptive use, compared with women without a history of hormonal contraceptive use. Results There was no significant association between past hormonal contraceptive use prior to current pregnancy and preeclampsia except implant. Women who used before current pregnancy were less likely to develop preeclampsia (AOR=0.39, 95%CI: (0.13-0.96)). No association was observed between preeclampsia and other hormonal contraceptives (pills, injectables and intrauterine contraceptive devices). Conclusions This stud revealed that there was no significant association between past hormonal contraceptive use and preeclampsia except implant which was negatively associated with preeclampsia. Key words Hormonal contraceptive use, preeclampsia, pregnancy

Aim COVID-19 outbreak spread all over the world and created a public health catastrophe. Here, we have aimed to conduct a systematic review and meta-analysis on remdesivir use for COVID-19. Methods We searched Pubmed, Pubmed Central, Scopus, Embase, clinicaltrials.gov, and preprint sites and identified ten studies for qualitative and four studies for quantitative analysis using PRISMA guidelines. The quantitative synthesis was performed using fixed and random effect models in RevMan 5.4. Heterogeneity was assessed using the I-squared (I2) test. Results Comparing remdesivir group with placebo or standard of care (SOC) group, remdesivir reduces 14 days mortality (OR 0.61, CI 0.41- 0.91), need of mechanical ventilation (OR 0.73, CI 0.54-0.97), and overall severe adverse effects (OR 0.69, 95% CI 0.54 to 0.88). There is better clinical improvement on day 28 (OR 1.59, CI 1.06- 2.39); day 14 clinical recovery (OR 1.48, CI 1.19-1.84); day 14 discharge rate (OR 1.41, CI 1.15-1.73) among remdesivir groups. Earlier clinical improvement (MD -2.51, CI -4.16 to -0.85); and clinical recovery (MD -4.69, CI -5.11 to -4.28) seen among remdesivir group. While no difference on 28 days mortality rate; discharge rate; overall adverse effect. Longer course (10 days) of remdesivir showed higher discharge rate at day 14 (OR 2.11, CI 1.50-2.97), but there are significantly higher rates of serious adverse effects, and drug discontinuation than the shorter course. Conclusion Remdesivir showed a better 14 days mortality profile, clinical recovery, and discharge rate. Overall clinical improvement and clinical recovery were earlier among remdesivir group.

We describe a rare case of persistent atrial fibrillation originating from the prominent Eustachian ridge. A detailed mapping using the Advisor™ HD Grid catheter enabled precise identification of the non-pulmonary vein foci at the prominent Eustachian ridge. A local interatrial conduction block was observed during a single ectopy or short run. Highly localized radiofrequency ablation could completely cure persistent atrial fibrillation.

A 44-year-old lady, a follow up case of idiopathic dilated cardiomyopathy and cardiac resynchronization therapy defibrillator (CRT-D) device implantation with epicardial left ventricular (LV) lead, underwent a transvenous LV lead revision in view of epicardial lead malfunction. A chest X-ray after this, done for worsening dyspnoea, revealed pneumopericardium along with left pneumothorax. The CT revealed a communication between the left pleural and pericardial cavities, around the old epicardial lead. Drainage of the left pleural cavity resolved both the pneumothorax and pneumopericardium and the patient remained well on follow up.

Objective Venous thromboembolism (VTE) is a common health problem. This study aimed to identify genetic variants associated with pregnancies with VTE. Design A case-control experimental study. Setting Ten hospitals in Shanghai. Sample Blood samples from 25 pregnant patients with VTE and 17 pregnant controls without VTE. Methods All samples were sequenced by whole exome sequencing (WES). Functional and enrichment analyses and PPI network were performed using DAVID and STRING database. Primary outcome P-value and OR were obtained by Pearson’s chi-squared test and logistic regression. Results 5810 significant variants annotated in 3417 genes, were associated with pregnancies with VTE (P < 0.05). Fifty-six variants annotated in 46 genes (P < 0.001) were identified. Logistic analysis revealed that rs7099478 in GRK5, rs8041208 in WDR72, rs17215792, rs13035688, rs6725221 and rs3214417 in KLF7 were associated with an increased risk of developing VTE (P < 0.05, OR > 1). In addition, Pathway and PPI analyses revealed that CDC7 and MCM6 involved with DNA replication were associated with VTE in pregnancies. Conclusions Several variants in KLF7, GRK5, and WDR72 may be genetic risk factors for VTE in pregnancies. CDC7 and MCM6 may be related to the pathogenic process of VTE in pregnancies. Notably, the KLF7 gene with 4 genetic variants was found to be associated with lipid metabolism and cardiovascular diseases. Funding The National Natural Science Foundation of China (No.81472990) and Clinical Research Project of Shanghai Municipal Commission of Health and Family Planning (No.201840095) Keywords Pregnant, Venous thromboembolism, whole exome sequencing, KLF7

Objective Investigate the antihemorrhagic effect of intravenous perioperative tranexamic acid in hysterectomy for benign gynecological diseases. Study Design A prospective randomized case-control study was carried out in the Department of Obstetrics and Gynaecology, PGIMS, Rohtak, on 150 patients planned for hysterectomy for benign conditions. The women were randomized into two groups- Group I and Group II, with 75 subjects in each group. Group I was not be given any drug, while Group II was given TXA as intravenous bolus injection of 10mg/kg (maximum 1g) for 10 min about 30 min before incision. Unpaired ‘t’ test and ANOVA test were used to calculate the difference of means of quantitative variables. An association was significant if the p-value < 0.05. Results Intraoperative blood loss was reduced in the group given tranexamic acid preoperatively (mean loss 489.07± 279.248 ml) v/s the control group (mean loss 539.93 ± 211.08ml) (p<0.05). This result was particularly significant in the subjects who underwent vaginal hysterectomy (mean loss 364.58 ± 108.53ml in Group II v/s 278.91 ± 118.34ml in Group I; p<0.05). The incidence of transfusion of blood or blood products intraoperative to postoperative day seven was significantly reduced in the tranexamic acid group (0.47 vs. 0.23, P = .02). Conclusion The results show that preoperative intravenous tranexamic acid reduces the total blood loss irrespective of the route of hysterectomy and the number of perioperative transfusions. No incidences of serious adverse events occurred. Thus, tranexamic acid should be considered as a prophylactic treatment before benign hysterectomy.

Objectives: The Medicines and Healthcare Products Regulatory Agency in the United Kingdom (UK) formally reclassified sildenafil citrate 50 mg tablets as a pharmacy medicine (sildenafil-P) in 2017 for adult men with erectile dysfunction (ED). A one-year prospective real-world observational study was conducted to track men’s health behavior, particularly their healthcare resource utilization (HCRU) and quality-of-life (QoL) before and after the availability of sildenafil-P. Methods: Adult men with ED aged ≥18 years provided data at baseline (prior to launch of sildenafil-P) and every three months after the launch. Demographics, health characteristics, treatments at baseline and HCRU, including number of pharmacist and physician/nurse practitioner visits over time are reported. QoL-related outcomes were assessed via Self-Esteem and Relationship Questionnaire (SEAR), 2-Item Patient Health Questionnaire, and ratings of sexual satisfaction. Generalized linear models were used to assess the association of sildenafil-P use with total physician/nurse practitioner and pharmacist visits and QoL-related outcomes at 12 months. Results: Overall, 1162 men completed the survey at all 5 time-points. The mean ± SD age was 59.02 ± 12.06 years; 55.42% reported having a moderate-to-severe ED. Hypertension (37.52%) and hypercholesterolemia (31.50%) were the most common risk factors for ED. At baseline, 62.99% were not using any ED treatment. After adjusting for baseline visits/other covariates, mean physician/nurse practitioner (3.68 vs 2.87; P = .003) and pharmacist visits for any reason (2.10 vs 1.34; P < .001) at 12 months were significantly higher among sildenafil-P users than those who never used sildenafil-P. Sildenafil-P users had significantly higher SEAR total and domain (sexual relationship and self-esteem) scores at 12 months. Conclusion: Following the reclassification to pharmacy medicine in the UK, sildenafil-P was associated with a higher number of physician/nurse practitioner and pharmacist visits for any reason. Sildenafil-P use was also associated with better QoL, although group differences were small in magnitude.

Introduction: Early recurrence of atrial tachyarrhythmias (ERAT) cause various symptoms and predict worse outcomes after pulmonary vein isolation (PVI). This study aimed to clarify whether ablation index (AI) guided PVI, which is a novel technology of radiofrequency ablation, could reduce ERAT as compared to conventional contact force (CF) guided PVI. Methods: Consecutive AF patients who underwent initial PVI from September 2014 to August 2019 were enrolled. We divided the patients into two groups: patients who underwent AI-guided PVI (AI group) and those who underwent CF-guided PVI (CF group). Using propensity score matching (PSM), we adjusted for the patient backgrounds. We compared the incidence of ERAT and late reconnection rate of isolated PVs during second session between the two groups. ERAT was defined as any atrial tachyarrhythmias ≥30 seconds during a 90-day blanking period. Results: A total of 697 patients (paroxysmal 51%) were enrolled. After the PSM, both groups included 229 patients. The incidence of ERAT was significantly lower in AI group than CF group (21.5% vs. 36.1%, P<0.001). The rate of PV reconnection was lower in AI group than CF group (45.8% vs. 71.4%, P=0.028). Multivariate analysis demonstrated that AI-guided PVI was independently correlated with the incidence of ERAT (OR=0.415, 95%CI=0.269-0.639, P<0.001). Conclusion: AI-guided PVI can reduce ERAT as compared to conventional CF-guided PVI.

Information on atrial arrhythmias in patients with COVID-19 pneumonia is limited, and we aimed to explore the possible association of left atrial (LA) involvement and of atrial fibrillation (AF) occurrence with mortality in patients with COVID-19 pneumonia. A total of 140 hospitalized patients with COVID-19 pneumonia were included in the analysis; mean age was 66.6 years (range, 20-89 years), and 56 (40%) were female. A total of 35 patients had cardiac injury (increased troponin levels), and these patients were older, had more frequently systemic hypertension, had higher levels of C-reactive protein and of D-Dimer, and a higher proportion of multiple ground-glass opacities in computed tomography findings. By echocardiography, LA diameters and volume index (LAVI) injury (33.9± 27.2±8.7 ml/m2; P<0.001) were significantly increased in patients with cardiac. Greater proportion of patients with cardiac injury showed AF occurrence (14 of 35 [40.0%] vs 11 of 105 [10.4%]; P < 0.0001). Patients with cardiac injury had higher mortality than those without cardiac injury (17 of 35 [48.5 %] vs 9 of 105 [8.5%]; P < 0.0001). In a Cox regression model, in the overall population of COVID pneumonia patients, troponin levels (Hazard Ratio, 4.29 [95% CI, 1.85-8.43] P< 0.001), LA volume index (HR 3.6 [95% CI, 1.15‒7.48; p<0.001], PASP (HR: 3.9; [95% CI, 1.72-6.39] P< 0.001) and AF occurrence (HR: 2.5; [95% CI, 1.22-5.4] P< 0.001) emerged as independent predictors of in-hospital death. Assessment of both LA morphology and function during the recovery of COVID patients with cardiac injury may represent key points in the prognostic stratification

LSD is a notifiable disease caused by lumpy skin disease virus belonging to Poxviridae family leading to high economic losses. LSD is transmitted by an insect vector, contaminated vehicles, and equipment. It causes generalized lymphadenitis, circumscribed skin nodules, and subcutaneous edema of limbs and ventral parts of the body. The first case of LSD was seen in Nepal on 24th June 2020 in Morang. Jersey cross-bred showed higher susceptibility to LSD over Holstein-Friesian and buffalo. Morbidity and mortality were obtained to be around (3-7) % and (0.5-1) % in cattle and (2-3) % and 0% in buffaloes respectively to date. The vaccine isn’t available in Nepal and is being focused on the isolation and symptomatic treatment of infected animals.