Nine slope runoff plots with different soil and water conservation measures were selected in Baima small watershed of Pingshun County, Shanxi Province of China, to explore more effective soil and water conservation measures to avoid soil nutrient losses, improve soil fertility, and control non-point source pollution. Soil organic carbon (SOC), total nitrogen (TN) and available potassium (AK) were determined and compared in this paper. The results show that,1) In grass measures, sowing of both riochloa is chaemum are more suitable for nutrient protection on the upper slope, fertility and the whole nutrient content of natural grass is optimum (SOC:24.86g/kg, TN:2.09g/kg, AK:157.00mg/kg);2) Plant combined with engineering measures ,in different plant measures(fish-scale pit), shrubs are more suitable for nutrient conservation on the upper slope. SOC (25.04g/kg) and TN (2.13g/kg) contents of coniferous trees were the highest, and AK (170.89mg/kg) content of broad-leaved trees was the highest;3) Plant combined with engineering measures ,among the different engineering measures(oriental arborvitae), the overall nutrient condition of level bench was the best (SOC: 33.33 g/kg, TN: 2.21 g/kg, AK: 139.44 mg/kg), and the stone dike terrace was poor (SOC: 18.19 g/kg, TN: 1.53 g/kg, AK: 118.11 mg/kg);4) The most suitable soil and water conservation measure was level bench of coniferous tree combine 9 measures. Soil nutrient contents are determined by plant characteristics, engineering measures and soil loss. In all plots, there were significant correlations between the three nutrients (P < 0.01), showing an strong effects of conservation measures on soil nutrients.

Background: The prognosis of children with acute myeloid leukemia (AML) has improved with the efficacy of hematopoietic cell transplantation as a second-line therapy and improvements in supportive care following anthracycline- and cytarabine-based chemotherapy; however, the outcomes of children with relapsed AML still remain unsatisfactory. Procedure: In order to identify prognostic factors and improve their prognosis, we analyzed 111 patients who relapsed after treatment with the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) AML-05 protocol and who were registered in the retrospective JPLSG AML-05R study. Results: The 5-year overall survival rate was 36.1%. The major determinant of survival was duration from the diagnosis to relapse. The mean duration in the non-surviving group (10.1 ± 4.1 months) was shorter than that in the surviving group (16.3 ± 8.3 months) (p<0.01). Moreover, achieving a second complete remission (CR2) prior to hematopoietic cell transplantation was associated with a good prognosis (p<0.01). Etoposide, cytarabine and mitoxantrone (ECM)- or fludarabine, cytarabine and granulocyte colony-stimulating factor (FLAG)-based regimens were therefore recommended for reinduction therapy (p<0.01). A genetic analysis also revealed the prognostic significance of FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication as a poor prognostic marker (p=0.04) and core binding factor-AML, t(8;21) and inv(16), as good prognostic markers (p<0.01). Conclusions: Achieving a CR2 prior to HCT is important in order to improve the prognosis of relapsed pediatric AML. Recent molecular targeted therapies, such as FLT3 inhibitors, may contribute to overcome their prognoses. Larger prospective investigations are necessary to establish individualized treatment strategies for patients with relapsed childhood AML.

Objective: To establish a prediction model of clinical outcomes in women with placenta accreta spectrum (PAS) Design: Retrospective cohort study Setting: International multicenter study (PAS-ID); 11 centers from 9 countries Population: Women who were diagnosed with PAS and were managed in recruiting centers between January 1st, 2010 and December 31st, 2019. Methods: Data were collected using a standardized sheet, which included baseline information, medical and obstetric history, diagnosis, disease characteristics, management, and outcomes. Analysis of association between these variables and primary outcome was first conducted using conventional logistic regression. Data were reanalyzed using machine learning (ML) models, and 2 models were created to predict outcomes using antepartum and perioperative features. Main Outcome Measures: Massive PAS-associated perioperative blood loss (intraoperative blood loss ≥ 2500 ml, triggering massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Other outcomes include prolonged hospitalization > 7 days and admission to intensive care unit (ICU). Results: 727 women with PAS were included. Area under curve (AUC) for ML antepartum prediction model was 0.84, 0.81, and 0.82 for massive blood loss, prolonged hospitalization, and admission to ICU, respectively. Significant contributors to this model were parity, placental site, method of diagnosis and antepartum hemoglobin. Combing baseline and perioperative variables, ML model performed at 0.86, 0.90, and 0.86 for study outcomes, respectively. This model was most contributed by ethnicity, pelvic invasion, and uterine incision. Conclusions: ML models may be used to calculate individualized risk of morbidity in women with PAS, which may assist to outline management plan in priori

Background: As pregnancy is a physiological prothrombotic state, pregnant women may be at increased risk of developing coagulopathic and/or thromboembolic complications associated with COVID-19. Objectives: To investigate the occurrence of haemostatic and thrombo-embolic complications in pregnant women with COVID-19. Search Strategy: Two biomedical databases were searched between September 2019 and June 2020 for case reports and series of pregnant women with COVID-19. Additional registry cases known to the authors were included. Steps were taken to minimise duplicate patients. Selection criteria: Pregnant women with COVID-19 based either on a positive swab or high clinical suspicion e.g. symptoms and radiographic evidence. Data Collection and Analysis: Information on coagulopathy based on abnormal coagulation test results or clinical evidence of disseminated intravascular coagulation (DIC), and on arterial or venous thrombosis, were extracted using a standard form. If available, detailed laboratory results and information on maternal outcomes were analysed. Main Results: 1063 women met the inclusion criteria, of which three (0.28%) had arterial and/or venous thrombosis, seven (0.66%) had DIC, and a further three (0.28%) had coagulopathy without meeting the definition of DIC. Five hundred and thirty-seven women (56%) had been reported as having given birth and 426 (40%) as having an ongoing pregnancy. There were 17 (1.6%) maternal deaths in which DIC was reported as a factor in two. Conclusions: Our data suggests that coagulopathy and thromboembolism are both increased in pregnancies affected by COVID-19. Detection of the former may be useful in the identification of women at risk of deterioration.

By doping two potassium atoms among three C20F20 cages, peanut-shaped single molecular solvated dielectron C20F20@K@C20F20@K@C20F20 as new type of spin molecular switches was theoretically presented. The triplet structure with two single-excess-electrons individually inside left and middle cages is thermodynamically more stable than the singlet one with lone pair of excess electrons inside middle cage. It is found that applying an oriented external electric field (OEEF) of 111 × 10-4 au (0.5705 V/Å) or -120 × 10-4 au (-0.6168 V/Å) in the x-axis direction firstly and then releasing it, the field-free triplet C20F20@K@C20F20@K@C20F20 with two single-excess-electrons can change into singlet one with lone pair of excess electrons through a singlet one with lone pair of excess electrons inside the end cage. Different spin states can bring significantly different dipole moment component values and considerable different intensities of maxumum wavelengths in intense absorption band. Therefore, C20F20@K@C20F20@K@C20F20 is a good candidate for spin molecular switching materials.

Objective To investigate the prevalence of vaginal flatus (VF) in women with pelvic floor disorders and its impact on quality of life. Design A cross-sectional study. Setting A tertiary medical center. Population Women visited a urogynecologic clinic in 2019. Methods Patients were asked about their experience of VF. Other evaluations included urodynamics, genital prolapse stage, and valid questionnaires, including the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). Clinical characteristics, urodynamic parameters, stage of prolapse, and quality of life scores were compared between women with and without VF. Main Outcome Measures: The impact of VF on quality of life. Results: Among 341 women, 118 (35%) reported VF, which was more common in those who were younger (49.3±9.2 vs. 59.9±13.4 yr, p<0.001) and more sexually active (98% vs. 55%, p<0.001) women. Women with VF had significantly worse sexual function (PISQ-12, 16.3±15.9 vs. 30.9±8.0, p<0.001), and incontinence-related quality of life (UDI-6, 23.4±10.5 vs. 17.8±8.9, p=0.039; IIQ-7, 25.5±14.5 vs. 17.2±12.5, p=0.012). For frequency and bother, 46% (48/116) of the women reported often or always having symptoms during sexual activity, 15% (5/34) when performing daily activities, and 12% (4/31) when exercising; and 60% (70/116) felt least moderate bothersome during sexual activity compared to 5% (2/34) when performing daily activities and 18% (6/31) when exercising. Conclusions: VF is prevalent in younger and sexually active urogynecologic patients. It has a significantly negative impact on sexual function. Routine counseling should be considered for these patients.

Paragangliomas (PGLs) are rare neuroendocrine tumors that arise from the autonomic ganglia. A 34-year-old woman was admitted to our department with palpitation, fatigue and chest pain under stress. Past medical history included a para-carotid PGL surgically removed 5 years earlier. Her family history was notable for familiar PGL with SDH mutation. At stress-echocardiography, was recorded a marked ST-elevation on precordial-leads, concomitant to new onset anterior septum hypo-kinesis, and therefore the patient was proposed for coronary angiography. Although angiographic evidence of atherosclerosis were not recorded, was found that Left Anterior Descending Coronary Artery gave off some branches towards a vascular structure (3×2 cm) in contiguity with the left coronary sinus of the aortic root. Subsequent Compute-Tomography and Magnetic-Resonance clarified the anatomical relationships of the mass with adjacent cardiac structures, in particular the mass was located behind the pulmonary artery trunk and lateral to aortic root, lying above the first portion of the anterior descending coronary artery. Subsequently a careful discussion about the risks and benefits of all therapeutic opportunity, the open surgical resection was deemed the best option for the patient despite the complex clinical anatomy. After standard cannulation for CPB and cardioplegic arrest, transection of the pulmonary artery and the aorta was performed granting adequate exposure of the mass and identification of afferent and efferent vascularization for complete resection though a cleavage plane. To ensure adequate hemostasis on a such critical area, the continuity of the pulmonary trunk was ensured only after removing aortic cross-clamp. The post-operative course was uneventful

Background and Aim of the Study: Barlow’s disease is characterized by excess myxomatous degenerative tissue, leaflets prolapse and/or billowing, chordal-elongation, and annular-dilation. We reviewed our experience in Minimally Invasive Mitral Valve Repair (MIMVR) techniques to treat this complex mitral pathology. Methods: Between 1999 and 2017 a group of 125 patients was identified as Barlow’s disease undergoing MIMVR. The diagnosis of Barlow disease was based upon preoperative transesophageal-echocardiography (TEE) and confirmed by the surgeon’s assessment during open-heart procedure. Operative technique and data were retrospectively collected along with intra-hospital and long-term follow-up. Results: Successful Mitral Repair was possible in 100% of cases (125 patents) within the first cross clamp. Most patients (118 – 94.4%) were treated by the Edge to Edge (Alfieri-Stich), while 2 (1.6%) where corrected by neochordae implant and 2 (1.6%) by quadrangular resection. 58 patients (47.1%) received complete semi-rigid ring, while 65 (52.9%) incomplete flexible partial ring excluding the LAM. Concomitant procedures were additional cleft occlusion in 10 cases (8%), tricuspid valve repair (ring implant or remodeling) in 29 cases (23.2%), left atrial ablation for atrial fibrillation in 4 cases (3.2%) and atrial septal repair in 4 (3.2%). Operative mortality was 0%. Average long-term follow-up was 85 ± 62 months, with a survival rate of 97.6%, freedom from redo mitral surgery of 98.4% and freedom from >2+ recurrent mitral regurgitation of 94.5%. No difference in outcome could be related to annuloplasty ring type. Conclusions: Mitral repair can be safely and successfully achieved though minimal-invasive approach, with optimal long-term results.

Linden and Yarnold1 recently proposed classification tree analysis (CTA), a machine‐learning procedure, as an alternative to conventional methods for analyzing mediation effects in treatment-outcome research. They note that CTA may have a number of advantages in this regard. It requires no assumptions about the distribution of variables or the functional form of the best-fitting model, for example, thus affording greater potential flexibility in identifying complex forms of association among variables with varying scales of measurement (e.g., binary and continuous). The authors further argue that CTA, unlike conventional approaches to testing mediation, “will not generate a model if a treatment-mediator-outcome relationship does not exist” (p. 359) and, conversely, that CTA “will systematically identify a treatment-by-mediator interaction if it exists, as well as any other interaction between variables.” (p. 359). Using data from the Job Search Intervention Study (JOBS II), they find that structural equation modeling, a conventional approach to testing mediation, failed to indicate support for job-search self-efficacy as a mediator of the effects of the intervention on whether the study participant was reemployed at follow-up. In contrast, the authors conclude that CTA applied to the same set of variables revealed that job-search self-efficacy was a mediator of intervention effects on employment among those in the treatment group.There are, however, two problematic aspects of the authors’ approach. First, as they point out, causal inference of a mediational pathway depends on the assumption that the associations involved exist net of potential confounding variables. In a randomized control trial such as JOBS II, confounding of the association between the mediator and outcome is of particular concern.2 The authors seek to address this concern by conducting a CTA that includes a set of 9 potential confounders (e.g., income, age, initial level of depressive symptoms) as candidate predictors. This approach does not ensure statistical control for these variables, however, for at least two reasons. First, there is no guarantee that the variables involved will actually be included in the resulting classification tree; failing to meet the criterion for inclusion does not rule out the possibility that a given potential confounder or combination of such confounders nonetheless share an association with the mediator and outcome to an extent that renders their association non-significant. This concern proves pertinent to the authors’ analysis as only 3 of the potential confounders earn entry into the resulting classification tree for reemployment status. A second concern with the approach taken by the authors is that whatever covariates are included in the classification tree may be included in positions that are inadequate for the purpose of controlling for confounding of the mediator-outcome association. Gender, for example, in their analysis is included in the control group branch of the tree, whereas job-search self-efficacy, the potential mediator, is included only in the treatment group arm. As a further example, education is included on the treatment group arm, but only after job-search self-efficacy’s role in the model already has already been established through its inclusion on a higher tier of the model. An alternative approach for addressing confounding in the context of CTA would be to residualize the candidate mediator on possible confounders and then fit a classification tree with this adjusted variable. If the residualized mediator continues to discriminate across levels of the outcome, conditional on treatment status, it could be concluded that the mediate-outcome portion of the potential mediational pathway of interest is evident independent of the measured confounders. Applying this approach, I find that the job-search self-efficacy continues to emerge as a discriminating variable for reemployment in the treatment arm branch of the classification tree that I fit with the same JOBS-II data. However, it cannot be assumed that this more rigorous approach to taking into account confounders will always yield the same result as one in which they are merely included as candidate predictors within a CTA.A more fundamental concern with the CTA approach to identifying mediation employed by the authors is that the mediator in the predictor-mediator and mediator-outcome segments of the mediational pathway are not assured of having a consistent definition. This is a result of the optimal cut-point on the mediator being determined separately for the two segments, through an optimal discriminant analysis for the treatment-mediator segment and CTA for the mediator-outcome segment. Thus, in the case of the mediational pathway for reemployment, treatment status predicts a dichotomous measure of job-search self-efficacy determined by a cut-score of 3.92 (i.e., high job-search self-efficacy corresponds to values above 3.92 and low to values equal to and below 3.92), whereas the dichotomous measure of job-search self-efficacy predicting reemployment is determined by a different cut-score of 4.92. Yet, it is essential by definition that the mediator in a mediational pathway that is influenced by the initial variable in the pathway (in this case, treatment) be the same variable that then influences the outcome (in this case, reemployment). In this case, nearly one half of the sample (47.3%; n = 426) has a different high-low classification on the job-search self-efficacy, suggesting considering divergence between the versions of this variable determined by the respective cut-scores. One approach to addressing this concern would be to define a new mediator that reflects the overlapping portion of the differing definitions. In the present example, this could be a dichotomous measure of job-search self-efficacy defined by a cut-score of greater 3.92, which would ensure that all those with scores classified as relatively high on the measure continue to be classified as such; alternatively, a cut-score of 4.92 could be used if priority is given to ensuring that all those classified as low remain in this category. Still another option would be to use the mid-point between the two cut-scores of 4.42. One could then evaluate the mediational pathway of interest using one or more of these options. Applying this approach using PROC CAUSALMED in SAS3, allowing for the suggested treatment-mediator interaction and including all covariates, I find evidence of an indirect mediated pathway when using the lower bound cut-off score of 3.92 for job-search self-efficacy (Odds Ratio for natural indirect effect of .959, 95% CI limits of .893, .998), but not when using the other two cut-off scores, although the differences in estimates are admittedly small in this case (complete results are available upon request).To summarize, Linden and Yarnold (2018) make a significant contribution by introducing CTA as a promising strategy for identifying mediated effects in intervention research. Further refinements to their approach, however, are recommended to more fully incorporate fundamental assumptions that accompany all tests for mediation as well as to evaluate and confirm potential mediational pathways using conventional procedures.References1Linden A, Yarnold PR. Identifying causal mechanisms in health care interventions using classification tree analysis. J Eval Clin Pract. 2018;24:353–361. https://doi.org/10.1111/jep.128482Imai K, Keele L, Tingley D. A general approach to causal mediation analysis. Psychol Methods . 2010;15:309‐334.3Yung, Y, Lamm, M, Zhang, W. Causal Mediation Analysis with the CAUSALMED Procedure . Paper SAS1991-2018. Cary, NC: SAS Institute Inc.; 2018.

Background, aims and objectives: With ageing global populations, hospitals need to adapt to ensure high quality hospital care for older inpatients. Older person friendly hospital (OPFH) principles and practices to improve care for older people are recognised, but many remain poorly implemented in practice. The aim of this study was to understand barriers and enablers to achieving OPFH from the perspective of key informants within an academic health system. Methods: Interpretive phenonomenological study, using open-ended interviews conducted by a single researcher with experienced clinicians, managers, academics and consumers who had peer-recognised interest in care of older people. Initial coding was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Coding and charting was cross checked by three researchers, and themes validated by an expert reference group. Reporting was guided by COREQ guidelines. Results: Twenty interviews were completed (8 clinicians, 7 academics, 4 clinical managers, 1 consumer). Key elements of OPFH were: older people and their families are recognized and respected; skilled compassionate staff work in effective teams; and care models and environments support older people across the system. Valuing care of older people underpinned three other key enablers: empowering local leadership, investing in implementation and monitoring, and training and supporting a skilled workforce. Conclusions: Progress towards OPFH will require genuine partnerships between clinicians, consumers, health system managers, policy makers and academic organisations, and reframing the value of caring for older people in hospital.

Study of the soil water dynamic and water balance in coral islands is important to utilize and manage the limited freshwater resources of islands. In this study, we studied the soil water dynamic in Zhaoshu Island, Xisha archipelago using the observed data and the Richards equation, and analyzed the water balance of this island in the dry and wet seasons, respectively. The soil water movement showed that there was a dry soil layer at the depths between 40cm and 160cm of the soil profile in the dry season. The evaporation (Es) flux was low, but the transpiration (Er) could still absorb water from the capillary zone to maintain growth. In the wet season, the infiltration dominated the main process of soil water movement. The result of water balance showed the precipitation, the change values of water in the entire flow domain (△Volume), bottom boundary flux (vBot), Er, Es were 913mm, 10mm, 349mm, 203mm, 351mm, respectively from October 2018 to September 2019. Precipitation is the only source of the freshwater, about 38% of the precipitation infiltrated into the groundwater, 22% of the precipitation was uptaken by the vegetation, and 39% of the precipitation was evaporated from the land surface. In the dry season, the evapotranspiration (ETa) was just 44mm/month which was 94% larger than the precipitation, and about 14mm/month of water was uptaken from groundwater by the plants. But in the wet season, 56% of the precipitation infiltrated into the groundwater, 37% of the precipitation was consumed by ETa. This study can help us well understand the process of water movement in coral islands, and provide references for further management in protecting coral island ecologies.

Minimally Invasive Aortic Valve Replacement is not just a metric of the incision, but rather a holistic approach to minimize the surgical trauma: the technique should reproduce the gold-standard conventional procedure in terms of safety, effectiveness and operative times through a small and different incision. Moreover, the procedure should be simple and reproducible in every Center all over the world. In our experience, we rely more on surgical skills and technique optimization, rather than CT-scan planning: definitely, the pre-operative imaging is helpful in the beginning of the experience to rule out difficult cases.

To the Editor, Sweat conductivity (SC) is a well-established screening test for Cystic Fibrosis (CF).1,2 It is semi-automated, fast, doesn’t require skilled technicians or specialized personnel, and needs a small amount of sweat. Moreover, one response to the demanding and labour-intensive requirement for robust quality sweat testing has been the testing of sweat samples by electrical conductivity.3As every laboratory method, SC is subject to error. Then, it should be assessed and tested to ensure that it produces results which make it reliable and suitable for the intended purpose, i.e., its role as screening method. Repeatability is one of these vital requirements.The International Organization for Standardization defines repeatability as the nearest agreement between independent test results performed in identical conditions in a short period of time, i.e., same test items and steps, same equipment, same technician, same laboratory.4Although SC is adopted worldwide there is no study evaluating specifically that requirement in any age group, including newborns and young infants. Therefore, the present study aimed to assess the correlation between two concomitant SC assays.We prospectively and consecutively recruited clinically stable infants younger than 3 months. They had two previous positive immunoreactive trypsin results (IRT), and then, two concomitant SC assays, performed by the same technician in the same facility. IRT and SC were carried out in the single accredited Reference Center for Newborn Screening and Genetic Diagnosis, located in the city of Belo Horizonte, State of Minas Gerais, Brazil.Sweat samples were obtaining from each forearm through the Wescor Macroduct system and then analyzed through a SC analyzer (Sweat-Chek analyzer, model 3120, Wescor Inc., USA). All steps were performed according to the manufacturer’s recommendations, and described elsewhere.1,2Apart from descriptive statistics, to assess the relationship between the two SC assays we used Spearman’s rank correlation coefficient. SPSS software, version 18.0 (SPSS Inc., Chicago, Illinois) was used for statistical analyses. The research protocol was approved by the Research Ethics Committee of Federal University of Minas Gerais, under number CAAE 21958014.1.0000.5149.A total of 322 young infants were recruited. Most of them (89%) were from smaller towns within the same State, and 11% lived in Belo Horizonte, the State capital. There was a slightly predominance of males (54%), and the majority (59%) were younger than 60 days, being 15.2% of them aged up to 30 days of life. Mean and median age was 52 and 46 days (range, 19-89 days), respectively.A sufficient amount of sweat was obtained from all participants. Means and medians for the first and second SC values were 37.0 mmol/L, and 34.3 mmol/L (range, 29.0-39.6 mmol/L), and 38.0 mmol/L and 35.3 mmol/L (range 30.0-40.7), respectively.Figure 1 displays the Spearman’s correlation scatter plot for the two SC results.

Introduction: There is growing evidence that COVID-19 can cause cardiovascular complications. However, there are limited data on the characteristics and importance of atrial arrhythmia (AA) in patients hospitalized with COVID-19. Methods: Data from 1029 patients diagnosed with of COVID-19 and admitted to Columbia University Medical Center between March 1st and April 15th 2020 were analyzed. The diagnosis of AA was confirmed by 12 lead electrocardiographic recordings, 24-hour telemetry recordings and implantable device interrogations. Patients’ history, biomarkers and hospital course were reviewed. Outcomes of death, intubation and discharge were assessed. Results: Of 1029 patients, 82 (8%) were diagnosed with AA. Out of the 82 patients with AA. Of the AA patients, new-onset AA was seen in 46 (56%) patients, recurrent paroxysmal and chronic persistent were diagnosed in 16 (20%) and 20 (24%) individuals, respectively. Sixty-five percent of the patients diagnosed with AA (n=53) died. Patients diagnosed with AA had significantly higher mortality compared to those without AA (65% vs. 21%; p < 0.001). Predictors of mortality were older age (Odds Ratio (OR) =1.12, [95% Confidence Interval (CI), 1.04 to 1.22]); male gender (OR=6.4 [95% CI, 1.3 to 32]); azithromycin use (OR=13.4 [95% CI, 2.14 to 84]); and higher D-dimer levels (OR=2.8 [95% CI, 1.1 to7.3]). Conclusions: Patients diagnosed with AA had 3.1 times significant increase in mortality rate versus patients without diagnosis of AA in COVID-19 patients. Older age, male gender, azithromycin use and higher baseline D-dimer levels were predictors of mortality.

Instruction Cessation of oral anticoagulation (OAC) is common after the first 3 months of catheter ablation of atrial fibrillation (AF); however, thromboembolic risk has not been defined in patients with and without AF recurrence (RAF vs. NRAF) post ablationMethods and Results We identified 796 patients who discontinued OAC at 3 months post AF ablation from January 2015 to May 2018 in our center. Regular follow-up was performed to detect RAF, collect medication management and thromboembolic and major bleeding events. CHA2DS2-VASc score was 1.79±1.50; 547 (68.7%) patients were at intermediate and high risk (i.e. CHA2DS2-VASc score ³1 in male patients, or ³2 in female patients); 169 (21.2%) were RAF. During 29.2±12.2 months follow-up, the incidence rate of thromboembolism was 1.62 per 100 patient-year (7 in 431 years) in RAF, 0.33 per 100 patient-year (5 in 1503 years) in NRAF. After adjusting for potential confounding factors, RAF was associated with more 3.5-fold higher rate of thromboembolism compared with NRAF (adjusting HR, 4.488; 95%CI, 1.381-14.586). Rate of thromboembolism was even higher in patients with intermediate and high risk (2.16 per 100 patient-year [7 in 323 years] versus 0.38 per 100 patient-year [4 in 1043 years], aHR, 5.807; 95%CI, 1.631-20.671). In multivariate logistic regression analysis, RAF was the only independent predictor of thromboembolism (4.837 [1.498-15.621], P=0.008).

Background and Aim: Attempting to place an aortic cross-clamp may complicate surgery and post operative outcomes in patients who have mediastinal adhesions or in those with extensive aortic calcification. Although right sided cardiac surgery via thoracotomy is not a new technique in these patients, robotic-assisted intracardiac repair without cross-clamping was not reported in a large group of patients previously. In this study, the safety of robotic-assisted cardiac surgery without aortic cross-clamping was examined. Methods: From January 2010 to March 2020, 304 patients underwent robotic-assisted cardiac surgery in our center and in 25 of these patients (8.2%) with a mean age of 65.5±20 years myocardial protection was succeeded with moderate hypothermic ventricular fibrillatory arrest. Severe pericardial adhesions or existence of highly calcified ascending aorta were the indications for fibrillatory arrest during robotic assistant surgery. Results: Most patients were in NYHA class ≥II (88.0%) and mean logistic Euroscore value was 18.5±22.3. The type of the operations were mitral/tricuspid valve repair/replacement, Cryoablation, ASD closure and pericardiectomy. CPB times were 141.5±47 (min 77- max 252) minutes. There was no case of conversion to open thoracotomy or sternotomy. Hemiparesis was observed in one patient. Two patients with 78.2 and 81.9 Euroscore values had mesenteric ischemia and multi-organ failure, respectively, and died at postoperative period. Conclusions: Robotic-assisted cardiac surgery without cross-clamping may provide reasonable outcomes in patients with severe aortic calcification or mediastinal adhesions undergoing intracardiac repair. These acceptable outcomes may encourage surgeons to perform this approach in appropriate group of patients.

The preoperative differentiation of left ventricular aneurysm from pseudoaneurysm is a diagnostic challenge. This distinction is critical as the timing of surgical correction varies; elective for true aneurysm versus urgent for pseudoaneurysm. Our aim is to present a case report demonstrating these difficulties and to review imaging characteristics and the approach to distinguish the two entities.

Bronchial asthma is a heterogeneous disease with complex pathological mechanisms representing different phenotypes, including severe asthma. The airway epithelium is a major site of complex pathological changes in severe asthma due, in part, to activation of inflammatory and immune mechanisms in response to noxious agents. Current imaging procedures are unable to accurately measure epithelial and airway remodeling. Damage of airway epithelial cells occurs is linked to specific phenotypes and endotypes which provides an opportunity for the identification of biomarkers reflecting epithelial, and airway, remodeling. Identification of patients with more severe epithelial disruption using biomarkers may also provide personalized therapeutic opportunities and/or markers of successful therapeutic intervention. Here, we review the evidence for ongoing epithelial cell dysregulation in the pathogenesis of asthma, the sentinel role of the airway epithelium and how understanding these molecular mechanisms provides the basis for the identification of candidate biomarkers for asthma prediction, prevention, diagnosis, treatment and monitoring.

Objective: It was hypothesized that heated humidified high flow nasal cannula (HFNC) is non-inferior to non- invasive ventilation (NIV) for preventing reintubation in high risk children. Design: Prospective randomized clinical non-inferiority trial Setting: Single centre study in a 12-bed multidisciplinary paediatric intensive care unit (PICU) in Delhi. Patients: All children (1month -18years) receiving invasive mechanical ventilation longer than 48 hours and ready for scheduled extubation. Intervention: Heated humidified high flow nasal cannula(HFNC) or Non-invasive ventilation (NIV) Measurements and Main Results: Of total 230 patients enrolled, 139 were analysed (3 left against medical advice), out of which 70 (50.4%) received NIV and 69 (49.6%) HFNC. Mean duration of intubation was 150.8 ±74.3 hours in NIV group vs 138.5 ±81.9 hours in HFNC group (p= 0.16). Out of 139 children, 15(10.8%) were re-intubated; 6 (8.6%) in the NIV group vs 9 (13%) in the HFNC group (absolute difference 4.4%; p= 0.42). Median time to re-intubation did not differ between the group; NIV group 4 hours (IQR 1.7-12.5hours) vs HFNC group 3.7 hours (IQR 2-4hours) (absolute difference, 0.3 hours; p= 0.50). Mean post extubation PICU length of stay was significantly lower in HFNC group (3.5 ±2.5 days) vs NIV group (4.1± 2.3days; p= 0.01). There were multiple reasons for failure of assigned intervention which were comparable in both groups. These included : stridor, impaired consciousness (fall in GCS>2), haemodynamic instability, inability to clear airway, increased work of breathing, hypoxemia, respiratory acidosis. There was no mortality in either group within 48 hours of extubation. Conclusion: Among high-risk children who had undergone extubation, HFNC therapy was found to be non-inferior to NIV with respect to the re-intubation rate.

Background: There is a concern about worsening of anemia after atrial fibrillation (AF) ablation in anemic patients. We aimed to clarify whether or not patients with anemia who are on an oral anticoagulant therapy are more likely to lose blood after AF ablation. Methods: We studied AF patients in 3 cardiovascular centers who skipped a single dose of direct oral anticoagulants prior to the ablation, and compared the drop in the hemoglobin level 24 hours after the procedure and bleeding complications between the patients with and without preexisting anemia. Results: We identified 183 (15.7%) patients with anemia at baseline out of 1163 patients. The reduction in the hemoglobin level (-0.39±0.71 vs. -0.93±0.9 g/dL; P<0.001) was smaller in the anemic than non-anemic patients. A fall in the hemoglobin level of ≥2 g/dL was less common in anemic patients (1.6% vs. 11.3%; P<0.001). A female gender (odds ratio [OR] 1.62, confidence interval [CI] 1.07-2.45; P=0.02), persistent or longstanding persistent versus paroxysmal AF (OR 1.67, CI 1.13-2.49; P=0.01), ORBIT score ≥3 (OR 3.5, CI 1.34-8.94; P=0.01), and preexisting anemia (OR 0.02, CI 0.004-0.14; P<0.001) were independently associated with the fall in the hemoglobin level of ≥2 g/dL. No difference was noted in the rate of major bleeding complications (1.6% vs. 1.2%; P=0.72). Conclusions: Paradoxically, patients with preexisting anemia may be less likely to lose blood following AF ablation.

A 2-year-old boy with severe combined immunodeficiency developed gut graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT), associated with massive intestinal pneumatosis (IP), pneumoretroperitoneum (PRP) and pneumomediastinum. His fair clinical conditions allowed conservative management, with progressive normalization of imaging findings. The patient did not require surgery and is alive and in good clinical conditions at follow-up. In children with GVHD-related IP but good clinical conditions and no signs of peritonitis, IP, is not a mandatory indication for surgery, despite its potentially striking imaging features. Conservative management, with intestinal rest, decompression and antibiotics, often allows regression of the clinical picture.

Objective: To investigate the prognostic factors to developing parotid and neck metastasis in locally advanced and relapsed cutaneous squamous cell carcinoma (CSCC) of the head and neck region. Study Design: Retrospective cohort study. Setting: Single-center study enrolling consecutive patients with advanced CSCC from 2009 to 2019. Subjects and Methods: Seventy-four cases were identified. Study variables demographic data, clinical skin tumor stage, neck stage, parotid stage (P stage), surgical treatment features, and parotid, regional, and distant metastases. Survival measures: overall survival (OS) and disease-specific survival (DSS). Results: The study group included 72.9% men (median age, 67 years); 67.5% showed T2/T3 tumors, 90.5% comorbidities, 20.2% immunosuppressed, with median follow-up: 35.8 months. The most frequent skin primary were auricular and eyelid regions, 75% underwent primary resection with flap reconstruction. Parotid metastasis was present in 50%, 32.4% showing parotid extracapsular spread, multivariate analysis found OR=37.6 of positive parotid metastasis evolve into positive neck metastasis, p=0.001. Occult neck metastasis, neck metastasis, and neck extracapsular spread were observed in 13.5%, 51.3%, and 37.8%, respectively. Kaplan-Meier survival: Clinical T4 and T1, p=0.028, P1 stage: 30% and 5% survival at 5 and 10 years, P3 stage: 0%, p=0.016; OS and DSS showed negative survival for the parotid metastasis group, p=0.0283. Conclusion: Our outcomes support a surgically aggressive approach for locally advanced and relapsed CSCC, with partial parotidectomy for P0, total parotidectomy for P1-3, selective I-III neck dissection for all patients and adjuvant radiochemotherapy to appropriately treat patients with advanced CSCC of the head and neck region.

Objective Chronic otitis media with anterior perforation is a challenging condition to treat with a microscope especially if the canal is narrow or has overhang. The endoscope provides the advantage of wide-angle view and transcanal access avoiding postaural approach and canaloplasty. The aim of this study was to compare the anatomical, functional outcomes, and surgical duration between endoscopic and microscopic type I tympanoplasty performed for anterior perforation Design Prospective comparative study Setting Tertiary Referral Hospital Participants A total of 100 cases with anterior perforations were enrolled which was divide into two groups, the microscopic (MT) and the endoscopic (ET) with 50 cases in each group. Main outcome measures Graft uptake rate, hearing outcomes and surgical durations were compared between the two groups. Results The graft uptake in MT and ET was 81.8% and 91.3% respectively, statistically not significant. The mean operative time for MT and ET was 68.68±18.79 minutes and 61.24 ± 11.18 minutes respectively with statistically significant difference (p-0.003). Hearing outcomes were improved after the surgery within the groups. However, there was no significant difference in the hearing between the groups. Conclusions The endoscopic tympanoplasty for anterior perforation provides superior visualization avoiding postaural incision and canaloplasty, with good graft closure rate, improved hearing. It also offers significantly faster completion of surgery than a microscope. Thus, with the endoscope, minimally invasive surgery can be performed. Key points • Anterior perforations are challenging condition and difficult to treat, carrying poor prognosis than central or posterior perforations. • Microscope provide straight line of vision, making it difficult to access anterior perforations. • Endoscope provides wide angle view, high magnification and high definition image which avoids postaural incision or canaloplasty for anterior perforation repair. • Transcanal Endoscopic ear surgery provides advantage of performing minimally invasive surgery. • It indirectly lessens the financial burden to the patient which is significant in the developing countries.

Cytotoxic agents are the major part of current therapeutic arsenal in pediatric oncology. Recently, small molecules have been combined in the standard regimen for targeted cancer therapy. Both drugs provoke adverse effects on the living cells via the specific and non-specific actions to neoplastic cells. Considering genetic and epigenetic events, the late effect rather than acute toxicity is a matter of concern for healthy subjects at risk of exposure to anticancer drugs. To reduce the risk, a list of hazardous drugs (HDs) has been updated by the National Institute for Occupational Safety and Health (NIOSH) including commonly used cytotoxic agents. HDs are defined by their association with genotoxicity, carcinogenicity, teratogenicity, impaired fertility, reproductive toxicity, and/or serious organ toxicity even at a lower dose.1 The American Society of Clinical Oncology (ASCO) standard promotes the safety of professional staff of pharmacists, physicians, nurses, and other collaborators in oncology care.2 It recommends the preventive measures to avoid the toxic products, incorporating the latest evidence of the deleterious late effects after exposure, and the benefits of control measures, along with expert consensus. United States Pharmacopeia Chapter <800> requires an appropriate list of HDs in healthcare settings, providing concrete information regarding the articles of personal protective equipment, as well as where and how they should be donned, used, and removed is prescribed.3Several guidelines for the occupational exposure to HDs have been established for the health of hospital workers,1-5 but not the family members of childhood cancer. We thus investigated the exposure of caregiver and medical staff to anticancer drugs and the environmental contamination. Fifteen inpatients with pediatric cancer were recruited who received high-dose cyclophosphamide (CPM) from 2017 to 2018. Seven infants and 8 adolescents had 4 leukemias and 11 solid tumors. The median age at the time of this study was 78 months ranging from 13 to 200 months. The infants and adolescents received CPM of 1g /m2 or more; median 640 (range 620~1300) mg, and 1230 (range 780~1230) mg, respectively. Six hours after the first administration, the concentration of CPM was measured in the urine and saliva from attending mothers, nurses, doctors, nursery teachers, child-life specialists, and housekeeping staff members in the ward, using the liquid chromatography/mass spectrometry method (Shionogi Analysis Centre Co., Ltd., Osaka, Japan)6. Safe handling and closed-system-drug-transfer devices (JMS Co. Ltd., Hiroshima, Japan) are the standard of our center to minimize the technical exposure.7 This study was approved by the institutional review board of Kyushu University. Five of 7 (71%) infant’s and 2 of 8 (25%) adolescent’s mothers showed increased urine levels of CPM. The median value of infant’s mothers (192 ng/10 mL, range 0~1,510) was significantly higher than that of adolescent’s mothers (0 ng/10 mL, 0~58.4) (p =0.005). CPM was detected in the saliva samples of two mothers caring infants, but not in the urine or saliva of any medical staff (Figure ). The environmental contamination in a room of the infant whose mother showed the highest concentrations was assessed by the modified method.6 High levels of CPM were determined in the monitoring samples from a 17-year-old boy; toilet floor (1020 times of the detection limit), toilet seat (167 times), wash basin (45.6 times), a 13-year-boy; underwear (735 times) bed sheets (224 times), bed fence (34.8 times), bedside floor (20.9 times), exhaust vent (13.1 times), bedside table (7.4 times), door knob (4.9 times), curtain (4.7 times), and a 2-year-boy; bathing hot water (205 times) at 24 hours after the first administration, respectively. No staff having detectable CPM levels represented the control of HDs exposure in our hospital. In contrast, the exposure was frequently found in attending mothers caring infants. The higher levels of CPM in infants’ mothers than in adolescents’ mothers are explained by the closer contact for care. The environmental contamination has occurred from the body fluid of patients but not the drug delivery.The latest systems and guidelines have effectively controlled the accidental exposures of drugs to medical staff, as shown in the present results, throughout the process from the formulation in the pharmacy department, transportation, and administration to bed-side patients. The mother’s exposure is categorized as an intermediate risk. It may occur in case of high-dose therapy with limited duration. However, the metabolites of CPM including 4-hydroxycyclophosphamide show cytotoxicity.9 The mixture of selected cytostatic drugs has an augmented cytotoxicity leading to the late effects on genome even at low concentrations.10 During the long-term intense chemotherapy for pediatric cancer, the preliminary results may raise the need for preventive measures for caregivers according to the equivalent levels to medical staffs.