The current COVID-19 pandemic offers a unique opportunity to examine the utility of Internet search data in disease modelling across multiple countries. Google Trends data (GTD) indicating the volume of Internet searching on ‘Coronavirus’ were obtained for a range of European countries along with corresponding incident case numbers. Significant positive correlations between GTD with incident case numbers occurred across European countries, with the strongest correlations being obtained using contemporaneous data for most countries. GTD was then integrated into a lag distributed model; this improved model quality for both the increasing and decreasing epidemic phases.

Those patients with progressive QT prolongation or QT interval exceeding >500 ms may complete the COVID 19 treatment protocol containing HCQ and/or AZM without serious arrhythmias and torsades de pointes by the adding the mexiletine or lidocaine as an adjunctive drug in those patients. Counterbalancing the QT prolongation by mexiletine in association with would further decrease the labor and stress of healthcare providers during the continuing COVID 19 pandemic. Although it is a big dilemma how the therapeutic or prophylactic use of HCQ will end up, the pathophysiologic effects of HCQ on QT interval and counterbalancing by antiarryhthmic drugs mexiletine and lidocaine is out of the current discussion of COVID 19 pandemics. Counter balancing effect of mexiletine and lidocaine on QT interval in patients receiving HCQ would be helpful in patients with not only COVID 19 but also in malaria and rheumatologic disease as well.

Background Many people are used to administering their drugs with food, beverages, or herbs, which may contain chemicals that interfere with the prescribed drugs that could potentially lead to changes in their efficacy or safety and alteration in their pharmacokinetic properties. Objective To assess the extent of perception and use of food, beverages and herbs alongside with conventional drugs and their potential interactions among Jordanian society. Methods This descriptive cross-sectional survey was conducted in Jordan (20 April - 5 May 2020). The survey was developed using Google forms, validated and distributed via social media platforms. Data was analyzed using Statistical Package for Social Sciences-24. Main outcome measure Use and perception of food, beverages, herbs and their drug interactions among Jordanians. Results Of all participants (n = 789), 77.8% were females, 46.2% were 50-year-old, 69.7% were married, 70.8% were medically insured, and 51.1% had a bachelor’s degrees. Seventy percent of the study participants reported use of medicinal plants. About 66% of participants agreed that medicinal plants or herbs could treat diseases and 58.6% thought that medications could interact with drugs. In general, the participants’ knowledge about food/beverage/herb-drug interactions was considered poor. However, linear regression analysis illustrated that the level of knowledge was significantly affected (p-value <0.05) by gender, marital status, social status, the educational level, and employment sector. Conclusion Jordanians have a positive perception towards herbs and their ability to treat diseases. However, their knowledge about food/beverage-drug interactions was poor. This call needs to enhance the community awareness on food/beverage/herb-drug interactions.

While most attention in cardiovascular disease has been traditionally focused on the morphology, function and prognostic role of the left ventricle, during the last decade studies have raised awareness of the crucial role that the right ventricle plays in a variety of cardiovascular settings, including diseases primarily linked to the left ventricle. The assessment of right ventricular performance with conventional echocardiography is challenging. Novel echocardiographic techniques improve the functional assessment of the right ventricle and they showed good correlation with the gold standard represented by cardiovascular magnetic resonance. However, there is no single universally accepted parameter that accurately defines right ventricular function; hence a thorough evaluation of the right ventricle needs an integrative, multi-parametric approach. This review summarizes the traditional and innovative echocardiographic techniques used in the functional assessment of the right ventricle, focusing on the role of right ventricular dysfunction in heart failure with reduced ejection fraction and providing a perspective on recent evidence from literature.

Ischemic mitral regurgitation (IMR) is one of the common complications of coronary heart disease. The primary underlying mechanism is ventricular myopathy rather than disease of the valve itself. The decrease of myocardial blood supply will lead to myocardial damage, which will lead to the left ventricular remodeling, left ventricular enlargement, annular dilation, papillary muscle displacement and limited leaflet activity, resulting in mitral regurgitation. IMR has a certain effect on the prognosis of coronary heart disease, and the incidence rate of IMR has been increasing in recent years. IMR is a complex dynamic process, and it is a great challenge to deal with IMR. For patients with moderate or severe IMR, there are still many challenges and controversies in the choice of surgical methods. This article reviews the pathological process of left ventricular remodeling, the evaluation of IMR, the choice of mitral valve (MV) repair or replacement, and the reserve of MV function. Our review suggests that assessment of MV reserve function may be a predictor of IMR. In the future, assessment of MV reserve function may provide further useful information for evaluating MV function and determining MV repair or replacement in patients with IMR.

As the world past the few months of the deadly COVID-19 pandemic, the number of new cases continues to rise in several countries. By July 15, the confirmed COVID-19 cases reached 13,119,239, with 573,752 confirmed deaths worldwide.

Objective To examine early and late pregnancy loss in women with and without polycystic ovary syndrome (PCOS) undergoing IVF/ICSI transfers. Design Retrospective cohort study. Setting Reproductive medicine center at a tertiary hospital. Population Records were reviewed for women with a positive β-hCG after IVF/ICSI treatment from May 2014 to April 2019. Methods Odds ratios (ORs) for early (13 ≤weeks) and late (13-24 weeks) pregnancy loss were calculated among women with and without PCOS for plurality of the pregnancy with adjustment for confounding factors. Main outcomes measures Early and late pregnancy loss. Results A total of 21,820 charts identified with a positive β-hCG, 2,357 (10.8%) subjects had PCOS, and 19,463 (89.2%) controls did not. Early pregnancy loss occurred in 12.4% of women with PCOS versus 12.8% in women with non-PCOS. Women with PCOS demonstrated a higher rate of late pregnancy loss (5.4% in PCOS vs 3.1% in non-PCOS, OR 1.79, 95%CI, 1.46-2.19, P<.001), regardless of the plurality of the pregnancy (one gestational sac: 4.1 vs. 2.7 percent, OR 1.56, 95%CI,1.18-2.05; ≥ two gestational sacs: 8.1 vs. 4.1 percent, OR 2.08, 95%CI,1.54-2.82, PCOS vs. Non-PCOS, respectively). Potential negative impact of PCOS was reduced to marginal level once BMI were taken into account (aOR 1.42, 95% CI, .99-2.03). BMI and maternal comorbidities were independently associated with late pregnancy loss (aOR 1.65, 95%CI, 1.26-2.17 and aOR 2.07,95%CI,1.43-3.00). Conclusions PCOS women with overweight and preexisting comorbidities would benefit from lifestyle intervention and close surveillance throughout the whole pregnancy.

Abstract A Wuhan province, of China, become a first region for the novel of coronavirus infection 2019 (COVID-19), it gradually has become a major challenge for public health in most of the countries all over the world. The World Health Organization revealed that the International concerns over the novel coronavirus outbreaks have led to the formation of a public health emergency. On February 26, 2020, the COVID-19 outbreaks appeared in more than 35 countries around the world which include many of the Gulf countries notably Iran have reported COVID-19 cases respectively, and the infectious cases with a higher laboratory-confirmed and became serious as well as more deaths were reported. In this research, we elucidated the infectious pandemic significantly in all Gulf countries, additionally to investigate the competition between various of ABO blood groups which one is more susceptible than others and high risk for others with the second disease. The effects of the disease have led to the formation of control protocol centers around the world as soon as possible. According to this research and relevant guidelines to collect the necessary information and introduces essential knowledge about COVID-19 as well as prevention and treatment are the most important task in the Gulf States.

Objectives: To study the complications of intratymapanic dexamethasone for Méniere’s disease. Study Design:a randomized controlled trial. Methods:124 patients with Méniere’s disease were randomly divided into two groups: Intratympanic dexamethasone(ITD) group (n=62) and Intratympanic lidocaine(ITL) group (n=62). According to the dose of dexamethasone used during treatment, the patients in ITD group were further divided intoITD1(2mg/ml) group (n=31) and ITD2(5mg/ml) group (n=31).The complications in each group were observed and evaluated after 10 times of intratympanic treatment with ear endoscopy. Results:3 patients suffered from the external auditory canal mycosis after ITD therapy. All the 3 patients were in the ITD2 group and the the infectious rate between patients who used 5mg/ml of dexamethasone and those who used 2mg/ml exhibited significant statistical difference. There were 5 cases of tympanic membrane atrophy thinning in ITD group , while no tympanic membrane atrophy thinning was observed in ITL group, the incidence rate between these two groups showed significant statistical difference. In addition, two patients in the ITD group had perforation accompanied by external auditory meatus mycosis, while no tympanic membrane perforation was observed in the ITL group. There was no statistical difference in the incidence of vertigo, pain, tongue numbness, tinnitus and other complications between the two groups. Conclusions: Our study suggests that the occurrence of external auditory canal mycosis and tympanic membrane atrophy thinning were significantly correlated with the use of dexamethasone and the occurrence of external auditory canal mycosis was closely related to the drug concentration, while the occurrence of tympanic membrane atrophy thinning showed not significantly correlated with the drug concentration. Further understanding of the clinical characteristics of complications after ITD will help clinicians select the appropriate concentration of dexamethasone in the therapy and better manage these complications.

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder presented with social and communication deficits, restricted, repetitive behaviours and interest. Several recurrently mutated genetic risk-factors have been implicated in ASD manifestation. Chromodomain helicase remodeller (CHD8) is one such gene that is a master regulator mediating the expression of genes controlling neuron functions. We collected 8,124 exonic SNPs in CHD8 from 4 databases representing the general and ASD populations; subjected them to multi-layered analyses on >20 computational tools. We observed that nsSNPs were common in the general population. Distinct hotspots for truncating and nsSNPs were identified within exons encoding the N and C terminals, respectively. Evolutionarily conserved regions involving CHD8 core domains: Helicase-C-terminal, Helicase-ATP-binding and SNF2_N domains, recorded the lowest density but severely pathogenic SNPs. Conversely, evolutionarily variable regions- CHD7-binding and BRK domains- hosted the highest SNPs, but were benign. Post-Translational-Modifications (PTMS) occurred on residues outside domains (P<0.01) i.e., non-conserved regions of CHD8 including the N and C terminals that were determined to be Intrinsically-Disordered-Protein-Regions (IDPRs) with 9 Molecular-Recognition-Features sites. Contrastingly, ASD population recorded significantly higher incidences of truncating SNPs than general population (P<0.0001). ASD-SNPs frequently occurring within core domains were severely damaging and accounted for >30% of all ASD variations. The CHD7-DNA-binding motif, with most PTMs, recorded the highest recurring truncating ASD-SNPs. The CHD8 PPIs effortlessly recapitulated the phenotypes presented by children with CHD8 mutations. 11/13 (84.6%) interacting molecules were IDPs. We identified 9 CHD8 nsSNPs that produced the strongest long-range disturbances, altering the modelled protein’s global conformational dynamics.

Molecular dynamics (MD) simulations are a popular method of studying protein structure and function, but are unable to reliably sample all relevant conformational space in reasonable computational timescales. A range of enhanced sampling methods are available that can improve conformational sampling, but these do not offer a complete solution. We present here a proof-of-principle method of combining MD simulation with machine learning to explore protein conformational space. An autoencoder is used to map snapshots from MD simulations onto the conformational landscape defined by a 2D-RMSD matrix, and we show that we can predict, with useful accuracy, conformations that are not present in the training data. This method offers a new approach to the prediction of new low energy/physically realistic structures of conformationally dynamic proteins and allows an alternative approach to enhanced sampling of MD simulations.

To the editor, Coronavirus Disease 2019 (COVID-19) has emerged as a major new public health threat, with high rates of morbidity and mortality among patients with chronic medical conditions. The Disease was classified as pandemic by March 2020 after its widespread over the world.(1)Globally, up to 28th July 2020, there has been more than 16 millions of confirmed cases of COVID-19, causing more than 650,000 deaths with the fatality rate of almost 4%.(2)As of 28th July 2020, a total of 77,904 laboratory confirmed COVID-19 cases reported in Oman with mortality rate of 0.52%. Up to this date, 6315 children <14 years of age were diagnosed with COVID-19 which account for 8.1% of total confirmed cases with no recorded deaths.(3) In Oman, children with mild COVID-19 are managed at home and those with moderate and severe disease are managed as inpatients. Ludvigssonet al in their systematic review found that COVID-19 in children tend to have a milder course and better prognosis compared to adults. (4)There is a limited literature describing SARS-CoV-2 infection in children with cancers and post haematopiotic stem cell transplantations . (5)Despite extensive testing of any fever or URTI symptoms in these vulnerable children, there were only 3 children with cancersand post-haematopiotic stem cell transplantations (HSCT) tested positive and required admission for COVID-19 in Oman for the last 5 months; 2 with acute leukemia and one is post-HSCT for primary immune deficiency. Patients were tested for SARS-CoV-2 infection by sending nasopharyngeal specimens either for clinical suspicion of COVID-19 or as a screening following exposure to SARS-CoV-2. The first one has relapsed acute lymphoid leukemia (ALL) and was admitted for non-COVID-19 related issues. He has mild course of COVID-19 and chemotherapy was stopped with no additional management. Another child with ALL who has just completed his chemotherapy courses was admitted for pneumonia and started on oral azithromycin for 3 days and IV ceftriaxone for 1 week. His CBC remained normal with normal coagulation profile, D-dimers andCRP of 7 mg/l. He was discharged in excellent good general condition. The 3rd patient is post-HSCT for primary immunodeficiency tested positive for SARS-CoV-2 following surveillance done following exposure and was admitted for short period for non-COVID-19 related issues.Although there is a theoretical concern that children with cancers are at risk of severe COVID-19 because they are immunocompromized, the limited available data does suggest that COVID-19 in this population is generally mild with self-limited course similar to the presentationof SARS-CoV-2 infection in healthy children. (5)Our series of children with cancers and post-HSCT showed similar results to what have been described in Italy, France and United States. Boulad et al. reported a low overall morbidity of COVID-19 in children with cancer with only 5% (1/20) required hospitalization for management of COVID-19. (6)Rossoff et al described their experience from Chicago where they reported 6 children with cancers and post HSCT who got SARS-COV-2 infection. All of them had mild SARS-CoV-2-related symptoms and none were admitted for COVID-19 related issues. (5)Nazon et al described 6 children managed by their haematology/oncology unit at Strasbourg, France over 3 months period and all were either asymptomatic or have mild disease and none require admission for management of COVID-19.(7)Flash survey on children with cancer from 25 countries which follow up about 10,000 children at risk by March 2020, revealed that 9 out of >200 children tested for COVID-19 had the infection and 8/9 were either asymptomatic or have mild course.(8)Severe COVID-19 has been described among five children (5/33, 15%) by a prospective nationalsurvey conducted by the French society of pediatriconcology among 30 French centers by Mid-April. These children required intensive care for respiratory support following mild initial course of COVID-19. At the time of writing the report, 4 of them were still managed in ICU and none have died.(9)The Spanish Group of Transplantreported their experience of 8 children post HSCT with COVID-19; 5 required management as inpatients and 3 managed at home. Two children required intensive care admission for mechanical ventilation; one was still on extracorporeal membrane oxygenation (ECMO) and one died secondary to alveolar haemorrhage. Lymphopenia and low ratio CD4/CD8 was associated with severe COVID-19 in this small cohort. (10)Our case series and the available experience reported from different countries showed that most of the children with cancer and post-HSCT have either asymptomatic or mild COVID-19 and these children have similar vulnerability and risk morbidity resulting from COVID-19 to healthy children.(11). Decisions on whether or not to postpone chemotherapy/HSCT need to made on a case-by-case basis and according to the risk of cancer progression which can results in a poor outcome.(5, 6)

Background: Several studies have explored the predictive value of impulse oscillometry (IOS) for asthma exacerbations in childhood, but its specific parameters are still unclear. Therefore, we designed this meta-analysis to determine the related indicators of acute asthma attacks. Methods: A comprehensive literature search was performed in July 2020 based on Pubmed, Embase, and Web of science database. Weighted mean differences (WMD) were calculated using Fixed-or random-effects models. Results: A total of 615 patients from 6 trials were included in this analysis. IOS may be a useful tool to predict asthma exacerbations. And the results showed that R5 (WMD = − 1.21, 95%CI: −1.55 to −0.87, P＜0.001), Fres (WMD = − 1.34, 95%CI: −2.03 to −0.65,P=0.018) and AX (WMD = − 7.35, 95%CI: −9.94 to −4.76,P＜0.001) had significant correlation with asthma exacerbations. In addition, X5 may also predict the acute attack of asthma (WMD =0.81, 95%CI: 0.56 to 1.01, P＜0.001). Conclusion: R5, AX, Fres, and X5 may be able to identify the risk of an acute attack of asthma. Besides, our research further demonstrated that peripheral airway injury may play an important role in the acute attack of asthma.

Sphagnum mosses account for most accumulated dead organic matter in peatlands. Therefore, understanding their responses to increasing atmospheric CO2 is needed for estimating peatland C balances under climate change. A key process is photorespiration: a major determinant of net photosynthetic C assimilation that depends on the CO2 to O2 ratio. We used climate chambers to investigate photorespiratory responses of Sphagnum fuscum hummocks to recent increases in atmospheric CO2 (from 280 to 400 ppm) under different water table, temperature, and light intensity levels. We tested the photorespiratory variability using a novel method based on deuterium isotopomers (D6S/D6R ratio) of photosynthetic glucose. The effect of elevated CO2 on photorespiration was highly dependent on water table. At low water table (-20 cm), elevated CO2 suppressed photorespiration relative to C assimilation, thus substantially increasing the net primary production potential. In contrast, a high water table (~0 cm) favored photorespiration and abolished this CO2 effect. The response was further tested for Sphagnum majus lawns at typical water table levels (~0 and -7 cm), revealing no effect of CO2 under those conditions. Our results indicate that only hummocks, which typically experience low water table levels, benefit from the 20th century’s increase in atmospheric CO2.

Understanding the evolutionary processes that have molded the genetic structure to adapt to environmental changes is an important component of successful and sustainable long-term management for the fisheries resources. In this study, we analyzed mitochondrial control region (D-loop) sequence data to reveal population genetic variation, phylogeography and demographic history of T. ilisha collected from six locations of the Indian Ocean regions (Bay of Bengal, Arabian Sea and Persian Gulf). High haplotype diversity was found for all of the populations of T. ilisha. The Analysis of Molecular Variance (AMOVA) and conventional population FST comparisons detected both high population-level genetic variation and high degrees of divergence between groups within the Bay of Bengal (Irrawaddy river, MP; the coast of Cox’s Bazar, XP; the delta of Meghna, MP and Hooghly river, IP) and Arabian Sea (the delta of Indus river, PP and the coast of Kuwait, KP). Four cryptic genetic barriers were found for the studied populations of T. ilisha, and the highest degree of population divergence was found between the Eastern Indian Ocean (Arabian Sea and Persian Gulf) and Western Indian Ocean (the Bay of Bengal region) regions based on the Voronoï tessellation of BARRIER analysis. The gene flow analysis detected almost no migration between Eastern and Western part of the Indian Ocean regions. Besides, one-way migration was found from IP to MP population in the Bay of Bengal and from PP of Arabian Sea to KP population of Persian Gulf. Mismatch distribution showed that T. ilisha underwent long-time stable population size. Distinct cryptic genetic barriers, limited gene flows and complex evolutionary process resulted a significant population genetic and phylogeographic structure, and intricate demographic histories of T. ilisha populations. Further, the study provided additional insights for conserving and managing of this fishery resource in its broad geographical distribution coverage.

Li-Fraumeni syndrome (LFS) is a cancer predisposition syndrome caused by germline TP53 mutation. Malignancies associated with LFS include osteosarcomas, leukemias, CNS, and adrenocortical tumors. While CNS tumors are common primary malignancies, we report the case of a pediatric patient with LFS who developed a never reported secondary anaplastic medulloblastoma.

Abstract Background: Primary pediatric brain tumors are the most prevalent type of childhood tumors and the most common cause of cancer death among children. However, there is insufficient literature regarding the use of novel chemotherapy agents to treat such tumors. Therefore, the purpose of this study is to evaluate the effectiveness of Irinotecan-based chemotherapy regimen for the treatment of primary brain tumors as well as minimizing morbidity and mortality rates. Procedure: In this cross-sectional study, 88 children aged 0 to 18 years old with primary brain tumors were investigated. Data was extracted from patients’ medical records. 38 patients received Irinotecan treatment from the beginning (B) or after relapse (AB). At study termination, the response rate to the treatment as well as the Overall Survival (OS) and 6 months Progression Free Survival (6-mo-PFS) were estimated using Kaplan-Meier survival analysis and PFS estimation. Results: According to the findings of this study, pediatric brain tumors in males are more common than in females (60% in comparison to 40%). The highest incidence of brain tumors was reported in the age range of 6 to 12 years old. The findings of this study suggest that there is no statistically significant correlation between OS/6-mo-PFS and age, sex, tumor type, type of treatment and relapse. Conclusions: The administration of combination Irinotecan-based regimen leads to a high response rate and low toxicity in some types of primary pediatric brain tumors especially embryonal tumors, while it has little effect on others such as astrocytoma and ependymoma.

In this paper, random coupled Ginzburg-Landau equation driven by colored noise on unbounded domains is considered, in which nonlinear term satisfies local Lipschitz condition. It is shown that random attractor of such coupled Ginzburg-Landau equation is singleton set, and the components of solutions are very close when the coupling parameter becomes large enough.

Background: There is need for a fast, efficient, and safe way to induce tolerance in patients with allergic rhinitis. Methods: Patients with birch and timothy allergy were randomized and received three doses of 0.1 ml of birch and 5-grass allergen extracts (10,000 SQ units/ml, ALK-Abelló), or birch and placebo or 5-grass and placebo by ultrasound-guided injections into inguinal lymph nodes at monthly intervals. Rhinoconjunctivitis Total Symptom Score, Medication Score and Rhinoconjunctivitis Quality of Life Questionnaire were evaluated before treatment and after each birch and grass pollen season during three subsequent years. Circulating proportions of T helper subsets and allergen-induced cytokine and chemokine production were analyzed by flow cytometry and Luminex. Results: The three groups reported fewer symptoms, lower use of medication and improved quality of life during the birch and grass pollen seasons each year after treatment at an almost similar rate independently of treatment. Nine patients had severe adverse events which were judged to be unrelated to the therapy. Mild local pain was the most common adverse event. IgE levels to birch decreased, whereas birch-induced IL-10 secretion increased independently of treatment. IgG4 levels to birch and timothy and skin prick test reactivity remained mainly unchanged. Conjunctival challenge tests with timothy extract showed a higher threshold for allergen. In all three groups, regulatory T cell frequencies were increased three years after treatment. Conclusion: Intralymphatic immunotherapy against grass and birch pollen allergy was effective, safe and associated with bystander immune modulatory responses.

Background: Peanut allergy has a rising prevalence in high-income countries, affecting 0.5–1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents. Methods: Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food induced anaphylaxis cases in a tertiary paediatric allergy centre. Results: 3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs 38%; p=0.001), asthma comorbidity (47% vs 35%; p<0.001), relevant co-factors (29% vs 22%; p=0.004) and biphasic reactions (10% vs 4%; p=0.001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs 56% and grade IV 1.1% vs 0.9%; p=0.001). Self-administration of intramuscular adrenaline was low (17% vs 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs 26%; p=0.003). Hospitalisation was higher for peanut anaphylaxis (67% vs 54%; p=0.004). Conclusions: The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g. presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

To the Editor: Asthma is a complex and heterogeneous chronic airway inflammatory disease with the involvement of environmental factors through epigenetic mechanisms.1 Accordingly, repeated injury, repair and regeneration of the airway epithelium following exposure to environmental factors and inflammation results in histological changes and functional abnormalities in the airway mucosal epithelium, which are associated with the pathophysiology of asthma.2Epigenetics is defined by heritable changes in gene expression without changes in the DNA sequence.3 Regulation of gene expression is mediated by different mechanisms such as DNA methylation, histone modifications and RNA-associated silencing by small non-coding RNAs. CpG sites are dinucleotides consisting of guanine and cytosine concentrated in clusters referred to CpG islands found at important regulatory sites, such as promoter and enhancer regions.4 Their de novo methylation occurs in response to various cellular stressors and signals by DNA methyltransferases (DNMT3a and 3b), which add a methyl group to position 5 of cytosine residues at the CpG site. During DNA replication both of the separated strands of DNA carry one methylated cytosine to be used as a template for duplication. Daughter DNA duplex strands will thus be hemi-methylated, which is recognized by a different DNA methyltransferase isoform (DNMT1).5 Because DNA methylation is a reversible process, the DNMTs are considered as a therapeutic target. Several DNMT inhibitors have been identified recently, among the non-nucleoside inhibitors, 4-aminoquoline-based inhibitors, such as SGI-1027 showed potent inhibitory activity. SGI-1027 occupies the binding site of DNMTs resulting in the prevention of access of target DNA to the substrate binding pocket.6We have demonstrated in previous studies from our laboratory that human primary bronchial epithelial cells (HBEC) isolated from patients with asthma showed lower barrier integrity compared to controls.7 To investigate the level of global methylation in HBEC, we investigated control and asthma samples for the long interspersed nuclear element-1 (LINE-1) methylation levels (Figure 1A). HBEC from asthma patients showed a tendency for higher global methylation levels, together with higher expression of 5-methylcytosine (5-mc) in immunofluorescence staining (Figure 1B). Next, we performed methylation profiling (Illumina Infinium EPIC array) to investigate genes methylated in ALI cultures of HBEC. Interestingly, in a highly methylated group of top 100 genes, we found many genes associated with cell growth, ion transport, and cytoskeletal remodeling (Figure S1). We kept our attention on the methylated epigenetic and tight junction (TJ) genes and further focused on TJs, especially zonula occludens and claudins which showed higher methylation in contrast to occludin, which was not methylated (Figure S2). As higher methylation levels were observed in HBEC of asthmatic origin, we inhibited the DNA methyltransferase enzyme with a specific inhibitor, SGI-1027, to demonstrate the role of CpG methylation on epithelial barrier integrity. ALI cultures were treated with the DNA methyltransferase inhibitor for 72 hours. Significantly decreased expression of 5-mc was observed after 48 hours of DNA-methyltransferase inhibition, demonstrating that the methylation of 5-methylcytosine (5-mc) in bronchial epithelium was reversed (Figure 2A). This prompted us to investigate the changes triggered by the inhibitor in epithelial cells. Further experiments showed increased transepithelial electric resistance (TER) in bronchial epithelial cells, in ALI from asthmatic donors after 48 hours of DNMT inhibition (Figure 2B). The link between barrier integrity and TER results were confirmed by the significantly decreased paracellular passage of FITC-labelled 4kD dextran after inhibition of DNMTs (Figure 2C). The reconstitution of TER in asthmatic ALI was associated with decreased protein DNMT1 expression and increased ZO-1 and claudin-18 proteins (Figure 2D). We also observed increased claudin-4, but not occludin expression upon DNMT inhibition (Figure S3). Increased expression of ZO-1 with an intact and honeycomb-like structure in the immunofluorescence staining of bronchial epithelial cells confirmed the effect on protein expression of bronchial epithelial barrier in asthma donors (Figure S4).Defective epithelial barrier has been established in asthma in addition to several chronic inflammatory diseases.8 Direct targeting of the epithelial barrier leakiness for the treatments represents an important target, however so far there is no treatment possibility targeting epigenetic mechanisms. The present study demonstrates an increased global methylation level in HBEC from asthmatic individuals. CpG methylation of specific genes is essential for the defect of epithelial barrier integrity, which is reversed upon DNMT inhibition. The inversion of CpG methylation, restores leakiness in the epithelium in asthma by increasing TER, decreasing paracellular flux and improves the structure of bronchial epithelial cells by increasing the expression of TJ proteins. The better understanding of the importance of epigenetic memory in chronic tissue inflammatory diseases together with the availability of treatment modalities targeting epigenetic mechanisms and transition of these molecules into the clinical studies may lead to curative treatment of allergic and autoimmune inflammatory diseases.9Paulina Wawrzyniak1, PhD,Krzysztof Krawczyk1,3, MSc,Swati Acharya5, PhD,Ge Tan1,7, PhD,Marcin Wawrzyniak1, PhD,Emmanuel Karouzakis4, PhD,Anita Dreher, Sci. Tech.,Bogdan Jakiela2, MD, PhD,Can Altunbulakli1, PhD,Marek Sanak2, MD, PhD,Liam O‘Mahony1,6, PD, PhD,Kari Nadeau5, MD, PhD,Cezmi A. Akdis1, MD1Swiss Institute of Allergy and Asthma Research (SIAF), University of Zürich, Davos, Switzerland, Christine Kühne-Center for Allergy Research and Education (CK-CARE)2Department of Medicine, Jagiellonian University Medical College, Krakow, Poland3Faculty of Biology and Environmental Protection, Department of Cellular Immunology, Lodz, Poland4Department of Rheumatology, University Hospital of Zurich5Departament of Medicine, Stanford University, United States6 Department of Medicine and School of Microbiology, APC Microbiome Ireland, University College Cork, Cork, Ireland.7 Functional Genomics Center Zurich, ETH Zurich/University of ZurichCorresponding author:Paulina WawrzyniakSwiss Institute of Allergy and Asthma Research (SIAF), University of Zürich, Davos, SwitzerlandObere Strasse 22,7270 Davos, SwitzerlandTel: +41 81 410 08 48Fax: +41 81 410 08 40paulina.wawrzyniak@uzh.chConflict of interest:The authors declare that they have no conflicts of interest.Founding sources:Supported by Swiss National Science Foundation grants 310030_156823, and 320030_176190.Word count: 765Keywords: asthma, tight junction, CpG methylation, DNA methyltransferases,

Neuromuscular respiratory medicine has traditionally focused on mechanically assisted lung ventilation and mucus clearance. These therapies have prolonged survival for patients with Duchenne muscular dystrophy (DMD). However, the field is rapidly evolving in a new direction: it is being revolutionized by molecular and genetic therapies. A good correlation between a patient’s dystrophin mutation and his cardiopulmonary phenotype would allow accurate prediction of patient prognosis and would facilitate the design of studies that assess new DMD therapies. Instead, patient prognosis and the design of valid therapeutic studies are complicated by cardiopulmonary phenotypic discordance and variability, by which a notable proportion of DMD patients have unexpectedly good or poor cardiopulmonary function. The likely cause of phenotypic variability and discordance is genetic modifiers. Once the modifiers that affect cardiopulmonary function are better understood, it should be possible to create a personalized genetic profile that accurately predicts the prognosis of each individual DMD patient. This would allow investigators to assess the effect of new therapies in the context of each patient’s particular cardiopulmonary natural history. Amplification of beneficial cardiopulmonary genetic modifiers and blocking of detrimental modifiers is a promising strategy for creating new DMD therapies. When patients with chronic respiratory failure are treated with assisted ventilation, cardiac function determines their survival. Therefore, prioritizing new cardiac therapies is most likely to prolong patient survival. By focusing on these topics we aim to move neuromuscular respiratory medicine beyond assisted ventilation and coughing and into the age of translational medicine.

To the Editor: The spread of the coronavirus disease-2019 (COVID-19) remains a worsening global health crisis. Although many studies have reported risk factors for severe COVID-19, asthma characterization in COVID-19 is still controversial, with different early reports from China and recent reports from the Europe and United States.1 Prolonged viral shedding is not only a risk factor for poor outcome of COVID-19, but also clues to host immune response against the virus. However, there is limited data on this except for results from relative small group studies.2 In this study, 2 200 adult patients hospitalized for COVID-19 in Daegu were evaluated for prevalence of asthma and clinical outcomes with COVID-19 according to asthma. In addition, the risk factors for delayed viral clearance were evaluated.The prevalence of asthma in patients with COVID-19 was 3.2% which was not different from its prevalence in the Korea National Health and Nutrition Examination Survey (KNHANES) (Figure 1A and Table S1). By age group, the prevalence of asthma showed a similar U-shaped pattern as the general prevalence pattern in Korea. However, the prevalence of asthma in the 19–29-year age group (2.1%) was lower than that of KNHANES (Figure 1B).Table S2 compares the characteristics between the asthma group and the non-asthma group. Older age, overweight, and comorbidity of chronic obstructive pulmonary disease, and initial symptoms of dyspnea and nausea/vomiting were more common in the asthma group. Compared with the non-asthma group, the asthma group had a greater risk of death (13.6%vs. 6.4%, P = 0.02) and a greater need for high-flow oxygen therapy (18.2% vs . 10.5%, P = 0.048) (Figure 1C and Table S3). The higher mortality rate in asthma patients compared with non-asthmatic patients was particularly noticeable in female and overweight patients. Older patients (> 65 years) with asthma tended to have a higher mortality rate than those without asthma (Figure 1D). After adjusting for potential confounders, asthma had no significant association with clinical outcomes of COVID-19 (Figure 1E and Table S4). Meanwhile, older age, male gender, and comorbid diseases including overweight, diabetes, chronic kidney disease, cancer, autoimmune disease, dementia, and other psychological disorder were significant risk factors for mortality (Tables S5 and S6).Asthma is considered to have a lower risk of death than other well-known risk factors.3, 4 However, asthma is a heterogeneous disease and is often associated with atopic and eosinophilic asthma in younger patients. Meanwhile, obese asthma and elderly asthma are known to have common neutrophilic phenotypes.5, 6 The recent results of higher expression of COVID-19 receptors in respiratory specimens with neutrophilic asthma phenotype compared with the eosinophilic asthma phenotype.7 Considering prevalence and clinical outcome results, it is possible that neutrophilic asthma is a risk factor for infection and poor prognosis of COVID-19 rather than eosinophilic asthma.When delayed viral clearance was divided into two groups based on 30 days, 906 patients were included in the non-delayed viral clearance group and 415 patients in the delayed viral clearance group. After adjusting for potential confounders, delayed viral clearance was not significantly associated with asthma (Figure 1E and Table S4). However, older age >65 years (Odds ratio (OR) 2.002, 95% Confidence interval (CI) 1.292–3.101; P = 0.002), comorbid diseases including dementia (OR 3.123, 95% CI 1.833–5.321; P<0.001), and other psychological disorder (OR 2.084, 95% CI 1.178–3.687; P = 0.012), initial symptom of skin rash (OR 15.943, 95% CI 1.613–157.535; P = 0.018), and initial laboratory abnormalities including hemoglobin <10 g/dL (OR 2.156, 95% CI 1.161–4.003; P = 0.015) and C-reactive protein (CRP) ≥1.0 mg/dL (OR 1.588, 95% CI 1.061–2.377; P = 0.025) were significant risk factors for delayed viral clearance. On the other hand, male sex (OR 0.752, 95% CI 0.567–0.997; P = 0.047), hypertension (OR 0.704, 95% CI 0.519–0.953; P = 0.023), and initial symptom of headache (OR 0.673, 95% CI 0.485–0.932; P = 0.017) were significant protective factors for delayed viral clearance (Figure 2A and Table S7). In particular, when limited to the mild COVID-19 group classified as no activity limitations in the outcome parameters, older age, dementia, initial symptoms of skin rash and headache, and initial hemoglobin <10 g/dL showed significant differences (Figure 2B, Table S8).Several factors related to the nervous system were identified as important risk factors for delayed viral clearance. Previous studies have shown that the coronavirus can initially invade the peripheral nerves and enter the central nervous system through a synapse path.8 It is hypothesized that the ability of the immune system to find and remove viruses that have penetrated the nervous system is important for virus clearance. Male sex, hypertension and elevated CRP did not show a significant difference when analyzed only mild patients, and these may be indicators associated with severity rather than a direct effect on viral clearance.Anti-inflammatory drugs such as hydroxychloroquine and systemic steroid were shown to be risk factors for mortality and delayed viral clearance (Table S6 and S8). These medications were used more often when the hospitalization period was extended or when showing poor prognosis factors. Notwithstanding these, our results suggest that anti-inflammatory drugs need to be used with proper consideration of appropriate indications.On May 9, 2020, there were 6,859 patients with PCR-confirmed COVID-19 in Daegu. This data excluded asymptomatic or minimal symptomatic patients who did not require hospitalization. However, our study covered almost all hospitalized patients diagnosed with COVID-19 in Daegu from February to May ,therefore, selection bias is minimized.9 In Korea, most hospitals decided to terminate the quarantine by repeating PCR every week. In addition, the Korea Centers for Disease Control & Prevention (KCDC) thoroughly managed the criteria for quarantine termination and PCR results. Through this, in our study, we were able to perform a large-scale study to confirm the risk factors for delayed viral clearance.In summary, despite the positivity of differences depending on phenotypes, the prevalence of asthma was not significantly different in patients with COVID-19, and asthma did not affect the outcomes of COVID-19. Age, dementia, and initial presentations of headache, skin rash, and anemia were independently associated with viral clearance.

Atrial fibrillation (AFib) is the most common arrythmia characterized by rapid and irregular beating of the atrial chambers of the heart. Besides medication, thermal ablation of myocardial tissue is currently the “gold standard” of clinical treatment of AFib, which works by destroying local myocardial tissue to isolate faulty electrical signals causing the arrhythmia within the local area. It is usually performed by heating local tissue with radiofrequency (RF) electrical current, creating conduction-blocking lesions that stop AFib. However, problems associated with RF ablation are related to thermal side effect, such as PVI, thrombus formation, cardiac tamponade, phrenic nerve injury, esophageal fistula, and even stroke. The recent developed ablation modality of using IRE, appears to solve all these problems with less procedure time. This paper highlights the significant event of the IRE ablation in the timeline, and also compare IRE and RF ablation in safety and efficacy.