Traditional flood simulations fail to properly consider the impact of soil infiltration in floodplain areas with high soil infiltration rates. Notably, ignoring soil infiltration will lead to considerable uncertainty in flood simulations. In this paper, a fully hydrodynamic model coupled with the Green-Ampt infiltration model is used. Taking a natural reach in northern China (HTH in this paper) as a case study, observed flood discharge data are used to analyze the influence of soil infiltration on flood propagation based on the flood propagation simulation results for various inflow conditions. The results show that soil infiltration has little effect on the inundation area during the rising stage of a flood. In the late period a flood, the inundation area considering the effect of infiltration is smaller than that without infiltration, and the smaller the peak coefficient is, the longer the flood duration is, the larger the impact of infiltration on the inundation area. The research results provide a reference for flood management and post-disaster rescue efforts.

Purpose: The aim of present study was to produce high quantity of Zn-enriched yeast biomass in the presence of zinc metal, using S. cerevisiae as an industrially important yeast strain. Methods: Yeast isolates were obtained from two alcohol factories and S. cerevisiae yeasts strains were identified using PCR method and DNA sequencing. Then, growth rate of this yeast in present of Zn2+ as well as the level of Zn2+ uptake by the yeast cells, were examined at 24-hour intervals (0, 24, 48, and 72 h), using spectrophotometry and AAS method. qRT-PCR technique was carried out to quantified expression level of Zrt1 and Fet4 in yeast cells under these conditions. Also, the effect of pH of culture medium on yeast growth rate, zinc absorbtion and Zrt1 and Fet4 expression level, was studied. After setting the optimum pH, Kjeldahl’s method was applied for assessment of total protein content of yeast cells. Results: In optimum conditions of 25 µg/ml of zinc in pH 6 and 24 h incubation, S. cerevisiae showed the maximum growth rate, zinc uptake and expression level of Zrt1 and Fet4 as Zn transporters. Also, protein content of S. cerevisiae biomass in these optimum conditions was above 50% (w/w). Discussion: we demonstrated that industrial effluents can be used to produce Zn-enriched biomass however, further researches are required.

Introduction: Children with Down syndrome (DS) often present with chronic or recurrent respiratory symptoms. This can be caused by anatomical and/or immunological predisposition. With this study, we aim to evaluate the differences in microbiota in the lower airways of patients with DS versus controls. Methods: All endoscopic procedures under general anesthesia in patients with DS were reviewed retrospectively. We compared the microbiological data from BAL samples (when available) to a cohort of children with chronic respiratory symptoms but without any other relevant medical history. Results: Endoscopic data were available for 65 DS patients, microbiological data for 47 out of 65 patients (72%). The control group consisted of 150 children without significant underlying disease, who were matched for age and sex. Microbiological data were available for 135 out of 150 patients (90%). Microorganisms were categorized and compared in both groups, with no statistical differences. Mostly present were typical bacteria such as H. influenzae, Moraxella catarrhalis, Streptococci and Staphylococci. Conclusion: There were no significant differences in presence of pathogens in the lower airways of children with DS and chronic respiratory symptoms, compared to controls with similar symptomatology.

The diagnosis and treatment of Sleep Disordered Breathing (SDB) in pediatric age differs in relation to the adult. Central sleep apnea syndrome (CSAS) is less frequent in childhood, and one of the causes of it is the alterations of the brainstem like the malformation of Chiari type I. The main diagnostic method of SDB is Polysomnography, but there are other methods like the brain magnetic resonance imaging (MRI). Here, we share our experience with an 8‐year‐old female with malformation of Chiari type I and CSAS, and the steps we follow for the diagnosis of such an infrequent pathology in childhood.

TitleBartholin’s Gland Cyst or Abscess: A Novel Surgical Treatment Using a Looped Packing Strip: a case reportAuthorDavid W. Hobson, MD, American Board of Obstetrics and Gynecology, Fellow American College of Obstetricians and GynecologistsDepartment of Obstetrics and Gynecology, Spring Branch Community Health Center, Houston TexasCorrespondenceSpring Branch Community Health Center 800 West Sam Houston Parkway South Suite 200 Houston Texas 77042-1914 Email: dhobson@sbchc.netCommentsThis case report is submitted to BJOG An International Journal of Obstetrics and Gynaecology in response to the paper written by Illingworth BJG, Stocking K, Showell M, Kirk E, Duffy JMN. Evaluation of treatments for Bartholin’s cyst or abscess: a systematic review. BJOG 2020;127:671-678.Illustrations(Figures)TitleBartholin’s Gland Cyst or Abscess: A Novel Surgical Treatment using a Looped Packing Strip: a case reportKeywords: Bartholin’s Cyst, Bartholin’s Abscess, Word Catheter, case report, packing stripAbstractThis is the first reported surgical treatment of a Bartholin’s cyst under local anesthesia using a looped plain packing strip passed through two incisions of the Bartholin’s cyst or abscess, loosely tied and left in place four to six weeks creating a permanent fistula. The potential advantages of this procedure include: 1) ease of use 2) low cost 3) lower risk for recurrences 4) requires minimal training 5) alternative choice in patients who would like to avoid the use of a catheter and other more invasive treatments 6) use in cysts smaller than 2 cm in size.IntroductionThe Bartholin’s gland produces mucoid secretions that provide lubrication of the distal vagina and labia minora. The Bartholin’s duct commonly becomes obstructed leading to the formation of a cyst or abscess. This affects about 2% of women mostly of reproductive age11Omole F, Simmons DJ, Hacker Y. Management of Bartholin’s duct cyst and gland abscess. Am Fam Physician 2003;68:135-40. Patients often complain of pain in the vulva when sitting, walking and during intercourse. They are seen in many clinical settings such as emergency rooms, outpatient clinics and Doctors’ offices. Treatments have included aspiration, incision and drainage, packing the abscess, insertion of catheters, rings, silver nitrate gland ablation, marsupialization, sclerotherapy, resection of the gland,and carbon dioxide laser procedures. Systematic reviews22Illingworth BJG, Stocking K, Showell M, Kirk E, Duffy JMN. Evaluation of treatments for Bartholin’s cyst or abscess: a systematic review. BJOG 2020;127:671-678 have not identified the best approach. Currently, placement of the Word catheter under local anesthesia is the favored procedure.33Krose JA, van der Velde M, Morssink LP, Zafarmand MH, Geomini P, van Kesteren P, et al. Word catheter and marsupialization in women with a cyst or abscess of the Bartholin gland (WoMan-trial): a randomized clinical trial. BJOG 2017:124:243-9. However the use of the Word catheter has several limitations such as: 1) balloon loss reported as high as 43%, 244Reif, P, Ulrich D, Bjelic-Radisic V, Hausler M, Schnedl-Lampprecht E, Tamussino K. Management of Bartholin’s cyst and abscess using the Word catheter: implemenatation, recurrence, rates and costs. Eur J Obstet Gynecol Reprod Biol 2015;190:81-84 2) technical challenges such as catheter leak, deflation, inflating the catheter with a needle larger than 24 gauge, failure to direct the needle into the lumen of the catheter, failure to maintain pressure on the syringe plunger as you remove the needle from the inflated catheter, and vulvar pain from the inflated catheter,55Mellick L. A word about Word Catheters. 2012 Aug 1. Available from: https://journals.lww.com/em_news/pages/blogs.aspx 3) recurrences of the cyst or abscess ranging from 4-17%66Wechter ME, Wu JM, Marzano D, Haefner H. Management of Bartholin duct cysts and abscesses. A systematic review.Obstet Gynecol Surv 2009;64:395-404. Figure 1. Bartholin’s cysts with open ostiaThe WoMan-trial (Word versus Marsupialization) was a randomized clinical trial that compared treatment of a Bartholin’s cyst or abscess under local or no anesthesia to marsupialization performed under spinal or general anesthesia. The recurrence of a cyst or abscess, median time for recurrence, and postoperative pain scores after 24 hours were not significantly different between the two groups. Kroese et al concluded that that treatment using a Word catheter was a faster, lower cost alternative, and relieved pain sooner after diagnosis compared to marsupialization.3Randomized clinical trials to date have not identified the best treatment of a Bartholin’s cyst or abscess. The best approach will be the development of a novel intervention with devices that are smaller in size, more comfortable, remains in place four to six weeks, and creates a permanent fistula.2Materials and MethodsA 45 year old female was seen in our clinic during the period of May 2018 through May 2020 by the author. Written informed consent was obtained for treatment and publication. There was no financial or other incentive for participation. There were no sources of support and no conflicts of interest. She complained of a six year history of swelling in the right labia minora. Physical examination confirmed a 4 cm right Bartholin’s cyst. One week later she presented with a 6 cm right and 4 cm left Bartholin’s cyst. Both cysts were incised and drained. She had recurrence of both cysts documented on visit day 15. On visit day 15, the right Bartholin’s cyst was incised, drained with placement of the looped packing strip. The left Bartholin’s cyst was 4 cm and not drained. The packing strip was removed 11 days later. The second recurrence of the right Bartholin’s cyst was 10 days after removal of the packing strip. On visit day 36 she had a 4cm right Bartholin’s and 10 cm left Bartholin’s cyst. Both Bartholin cysts were incised, drained, and treated with insertion of bilateral packing strips that remained in place for 32 days. Incision and drainage consisted of a sterile prep using povidone iodine 10% solution, local anesthesia using Lidocaine 1% 3ml, 25 gauge 5/8 inch needles, with injections into the labial skin overlying the cyst 1-2 cm outside of the introitus, and making one 5 mm stab incision with a no. 11 blade scalpel. The insertion of the packing strip consisted of making two 5 mm stab incisions with a no. 11 blade scalpel through the skin and cyst wall, under local anesthesia, one at the top and bottom edges of the cyst 1-2 cm lateral to the introitus. The tip of a curved hemostat was inserted into the lower incision passing through the upper incision. A ½ inch x 15 cm length plain packing strip was pulled through both incisions and loosely tied using a square knot. Allowance was made to avoid tension on the skin. The extra packing strip was cut close to the knot. Postoperative instructions included twice daily cleansing with a gentle wash and returning to the clinic in 4-6 weeks for removal of the packing strip.ResultsThe patient was contacted by telephone and agreed to come in for evaluation. Informed consent was obtained for publication. The patient was seen by the author in our clinic 1.72 years after placement of the looped plain strips that remained in place for 32 days. Examination confirmed that both Bartholin cysts were draining mucoid secretions through two ostia. (fig.1)DiscussionThis case report demonstrates how the treatment with incision and drainage alone and removal of the packing strip 11 days after insertion resulted in the recurrence of a right Bartholin’s cyst. Treatment using packing strip left in place for 32 days resulted in the creation of permanent fistulas. Both cysts were noted to drain through created ostia seen 1.72 years after removal of the looped plain packing strip. The primary outcome measure in the treatment of a Bartholin’s cyst or abscess is the creation of a permanent fistula. The preferred treatment of a Bartholin’s cyst or abscess should be fast, safe, performed in an outpatient setting under local anesthesia, heal rapidly without complication, and have low recurrence.2 This procedure requires minimal training, is cost effective, and well tolerated by this patient. The novel placement of the looped packing strip in this patient with bilateral recurrent Bartholin’s cysts accomplished this goal. Further research is needed to compare placement of the looped packing strip versus insertion of the Word catheter.Disclosure of interests: there were no financial, personal, political, intellectual or religious interestsContribution to authorship: there is only one author David W. Hobson, MDPatient’s consent: consent for evaluation, treatment, procedures and publication was obtained in writingFunding: none requiredReferences

Objective: To quantify the incidence, risk and associated factors that contribute to the development of Surgical Site Infection (SSI) in emergency Caesarean Section (CS). Design: A retrospective case-control study. Setting: An acute District General Hospital in England. Sample: 206 patients (101 SSI patients and 105 non-SSI patients) who had emergency CS between January-December 2017. Methods: Grade of surgeon, smoking status, pre-operative vaginal swab, diabetes status, age, body mass index (BMI), membrane rupture to delivery interval and length of surgery were recorded. Risk factors significantly associated with SSI were identified using simple and multiple logistic regression procedures. Results: BMI (kg/m2) was significantly associated with SSI occurrence and age (odds ratio (OR) 1.17; 95% confidence interval (CI) 1.11 to 1.24; p<0.001). Substantive non-significant associations were recorded between SSI, patient age and vaginal swab. Conclusion: This study identified BMI as the only significant risk factor from a range of patient-level factors for the development of an SSI in emergency CS, possibly due to the impact of excessive adipose tissue on the body’s immune system and reduced effectiveness of antibiotics. The importance of appropriate wound management including frequent wound cleaning, appropriate dressings and dressing change and education is highlighted. Improved guidelines and strategies for managing at-risk patients would enable clinicians to manage emergency CS patients better and reduce the risk of SSI development. Diabetes status, patient age and pre-op vaginal swab were not significantly associated with SSI in emergency CS. Future research on larger samples should be conducted to validate these findings.

A commentary on: Personalised dosing of vancomycin: a prospective and retrospective comparative quasi-experimental study by Luqman Vali et al.Vancomycin is frequently used to treat Staphylococcal infections resistant to beta-lactam antibiotics. Overexposure to vancomycin increases risk of nephrotoxicity while underexposure can lead to therapeutic failure. This narrow therapeutic window makes it necessary to measure vancomycin serum concentrations aiming for an effective and justifiable dose. Often mathematical software is used to calculate a pharmacokinetic (PK) / pharmacodynamic (PD) target and predict the right vancomycin dosage.In this journal, Vali et al. compared the prospective results of a bedside Bayesian-guided software package (DoseMeRx) to guide vancomycin dosing with retrospective results of vancomycin-dosing with a standard algorithmic approach. Bedside Bayesian-guided dosing resulted in significantly more area under the curves (AUC) measured within the target range (350 – 450 mg/L*h) and in a significantly higher percentage of time in the acceptable range in comparison with the standard algorithmic approach.Unfortunately, the authors were not able to relate their findings to clinical outcomes such as clinical cure or mortality, possibly due to insufficient power. Still, PK/PD modelling is the cornerstone in calculating vancomycin dosages and user friendly bedside software can increase the availability and integration of these models in clinical practice. However, the precision of the dose calculations based on pharmacokinetic and pharmacodynamic modelling can be misleading and should not be used to determine the optimal dose without further considerations.Several factors impact the interpretation of individual dose calculations of antibiotics based on PK/PD modelling: the PK/PD-index of the antibiotic that is used to predict the efficacy; clinical and pharmacological factors that influence PK and the accuracy of minimal inhibitory concentration (MIC) of the causative pathogen. We will discuss these three factors and elaborate on their influence on dose calculations.Several studies aimed to establish the dose-response relation of vancomycin. Generally accepted vancomycin PK/PD targets are an AUC/MIC > 400 or a trough serum or plasma level (Ctrough)/MIC > 10-15. Using the AUC/MIC as predicting parameter requires the use of specialized software to calculate the AUC on intermittent dosing regimens, but is generally accepted as the most appropriate PK/PD-index of vancomycin. A recent meta-analysis of several cohort studies showed that AUC/MIC guided dosing resulted in a lower incidence acute kidney injury (AKI) in comparison to trough level dosing with an odds ratio of 0.68 (95% CI: 0.46 – 0.99). However, included studies were small, mostly retrospective and the effect of PK/PD-based dosing on AKI and other clinical outcomes therefore need to be confirmed in larger studies.Experiments with novel in-vitro models, such as two-compartment hollow fiber models, could add valuable information to the currently available evidence on the optimal PK/PD index of vancomycin. However, as far as we are aware, studies with these novel in-vitro models with vancomycin have not yet been reported.Tissue penetration is another major determinant in applying PK/PD calculations in clinical practice. The extent of tissue penetration depends on the solubility of the compound in fat (or octanol - thelog P ), the acid dissociation constant (pKa), the extent of protein binding, the molecular mass and the affinity to certain transmembrane transporters, such as P-glycoprotein. It could be questionable if serum or plasma concentrations are a representative factor in the treatment outcome when the tissue penetration of an antibiotic is low, while the infection is mainly situated in tissue. A good example is the high molecular mass of vancomycin and therefore low penetration characteristics.Microdialysis, has delivered promising results to quantify the tissue penetration of antibiotics. With microdialysis, a small dialysis tube is placed in the tissue of interest. Due to diffusion of the antibiotic from the extracellular fluid into the dialysis fluid, the antibiotic concentration can be measured in the dialysate. Microdialysis can help to extrapolate the PK/PD index to infections in tissue either by computing serum-tissue ratios or by building multiple-compartment PK models. However, a complicating aspect is the large interindividual variation in tissue concentrations. Studies on microdialysis with vancomycin have shown large variation in interstitial fluid concentrations which could not be explained by patient characteristics. In addition, the penetration of vancomycin in the central nervous system (CNS) is also highly variable. For CNS infections, one should consider to administer vancomycin intrathecally or switch to a different antibiotic with proven acceptable penetration in the CNS, such as linezolid. Overall, vancomycin tissue penetration is relatively low but some high unexplained variability is observed. Overall, microdialysis and hollow fiber models are potentially useful techniques in gaining more insight in the relation between serum concentrations, tissue concentrations and efficacy. Yet, clinical evidence for their use is still limited.Beside the optimal PK/PD target and extent of tissue penetration, the way of dosing is also of importance. Continuous vancomycin administration is increasing in clinical practice, making sampling easy as the concentration measured does not depend on the time of sampling. Furthermore calculation of the AUC0-24h (mg/L*h) of vancomycin on continuous infusion is simple: multiply the measured concentration (in mg/L) by 24. In a meta-analysis the incidence of nephrotoxicity was found lower in patients treated with continuous vancomycin vs. patients treated with intermittent vancomycin, with no difference in treatment failure or mortality. A limiting practical factor in applying continuous vancomycin is the availability of one dedicated intravenous (IV) catheter or lumen, since vancomycin is incompatible with many other medicines and IV fluids. In the paper by Vali et al. we missed vancomycin continuous infusion simulations to collect evidence for this upcoming method of administration.A final major determinant of PK/PD modelling is the MIC. The MIC is defined as the lowest concentration that inhibits growth of the isolated micro-organism. The golden standard for MIC testing is broth microdilution. However, many clinical microbiological laboratories use automated systems or antimicrobial gradient strips for their first-line antimicrobial susceptibility testing (AST). These methods are rarely precise enough to be used to calculate the AUC/MIC or Ctrough/MIC. Therefore, Mouton et al. suggested to include the epidemiological cut-off value (ECOFF) when interpreting MIC results for target attainment calculations. The ECOFF is determined as the highest MIC of the bacterial species of interest without acquired resistance, i.e. the wildtype population. Using the ECOFF instead of the MIC, however could add potential risks of overdosing of an antibiotic for the wildtype population of a micro-organism with broad MIC ranges. For example, the suggested ECOFF of S. aureus for vancomycin is 2 mg/L, which would indicate that the target AUC0-24hshould be above 800 mg/L*h (AUC/MIC > 400). Such high AUCs increase the risk of nephrotoxicity and should not be applied in regular care. PK/PD-based modelling with accurate MIC testing therefore seems of importance to decrease risk of overdosing.In conclusion, the use of software programs can facilitate the measurement of these targets and the prediction of the right dose of vancomycin. The prescriber and pharmacist should, however, always be aware of the ’pseudo- precision’ of those calculations: many other factors influence the efficacy and toxicity of vancomycin besides the trough concentration or the AUC.

Objective: To evaluate the incidence of adverse pregnancy outcomes (APOs) in women with uterine myomas and clarify the effect of uterine myomas on pregnancy outcomes. Design: Prospective cohort study Setting: The Japan Environment and Children’s Study (between 2011–2014) Population: Women (86,370) with singleton births after 22 weeks of gestation. Methods: Using logistic regression, the adjusted odds ratios (aORs) for APOs were calculated considering women without uterine myomas as the reference. Additionally, we used logistic regression to evaluate the effect of intrauterine infection (II) on the incidence of preterm births (PTB) and preterm premature rupture of membranes (pPROM). Main Outcome Measures: PTB (before 37 and 34 weeks), pPROM, II, and gestational hypertension (GH). Results: In women with uterine myomas, the aORs for PTB before 37 and 34 weeks, pPROM, II, and GH were 1.37 (95% confidence interval [CI], 1.22–1.54), 1.61 (95% CI, 1.27–2.05), 1.65 (95% CI, 1.33–2.04), 1.05 (95% CI, 0.75–1.46), and 1.20 (95% CI, 1.05–1.38), respectively. In women with both uterine myomas and intrauterine infection, the aORs for PTB before 37 weeks and pPROM were not significantly increased. Conclusions: Intra-pregnancy uterine myomas were associated with an increased risk of APOs. II in women with uterine myomas was not associated with PTB or pPROM. These data suggest a potential mechanical disadvantage in pregnant women with uterine myomas. Funding: Ministry of the Environment, Japan Key words: uterine myoma, preterm birth, preterm premature rupture of membrane, intrauterine infection

Interactions between the land surface and the atmosphere play essential roles in hydrological variations at local scales. Variations of regional climate patterns over preceding years have key effects on the seasonal water and moisture conditions in the following year. The linkage between regional climate and local hydrology is challenging due to scale differences, both spatially and temporally. In this study, multiple hydroclimatic phases were identified to relate climatic teleconnection patterns to hydrological processes in a small headwater basin within Reynolds Creek Experiment Watershed, Idaho, USA. A singular spectrum analysis and a combination of hydrological observations and outputs from a physically based hydrological model were used for this purpose. Results showed that a positive phase of North Atlantic Oscillation (NAO) is more influential than a positive phase of the Pacific North American (PNA) pattern on the observed annual runoff and the modeled rain on snow runoff in the study area. Specifically, we found a 43% and 26% shift below normal in annual runoff and rain on snow runoff from NAO and a 29% and 9% below normal from PNA. More frequent rain on snow events were observed under a positive phase of Antarctic Oscillation, leading to a 45% increase in the rain on snow runoff, which accounts for one-third of the mean annual runoff. A high runoff-to-precipitation ratio was observed in the study area under negative phases of Arctic Oscillation and Sea Surface Temperature in the Niño 3.4 region of the Equatorial Pacific Ocean. A switch in the phase of the teleconnection patterns of NAO and PNA in 2012 was concomitant with a transition from wet to dry conditions in the basin, suggesting the importance of the regional teleconnections in affecting snow and runoff regimes at local scales. The identified hydroclimatic phases can be implemented in operational models to improve uncertainties in hydrological forecasts, climate projections, and water resources planning.

The Mongolian Plateau (MP) plays an important role in the global carbon cycle and has significant impacts on the ecological security of northeastern Asia. Affected by land degradation and desertification, the vegetation cover on the MP experiences major changes under the influence of human activity and climate change. In contrast to previous holistic studies on the MP, this research focusses on the features of vegetation cover and divides the MP into three subregions (desert, grassland, and forest) to analyze vegetation dynamics and identify the driving factors behind vegetation change in this region. The residual analysis method is used and its “errors” are discussed. The results show the following. 1) The area of vegetation restoration is larger than the area experiencing vegetation degradation, and, overall, vegetation is greening and vegetation degradation is tending to reverse on the MP. 2) The ranking of vegetation change intensity is forest > grassland > desert subregions. 3) Climate change is the principal control on vegetation restoration across the whole MP, including the grassland and forest regions. Human activity similarly affects both vegetation restoration and degradation, but the effect of human activity is greater than that of climate change in the desert region. This research confirms that vegetation restoration activity is effective in the desert subregion of the MP.

Identifying priority areas and vegetation restoration modes is important for alleviating the conflicting demands for water between the ecosystem and humans based on the ecological effectiveness of payment for ecosystem services (PES) in arid or semi-arid areas. This study uses the treatment effect model to estimate the marginal contribution of Sloping Land Conversion Programme (SLCP) in the Northern Shaanxi Loess Plateau towards greater vegetation cover in the Northern Shaanxi Loess Plateau, including conversion of farmland to forestland (CFF) and conversion of farmland to grassland (CFG). In addition, we build a relative advantage index (RAI) to identify priority areas and vegetation restoration modes based on an assessment of the PES‘ ecological effectiveness. The RAI can identify priority areas and vegetation restoration modes. Furthermore, the areas with a RAI of more than 1 qualify for afforestation reach 11460 km2, accounting for 14.101% of the Northern Shaanxi Loess Plateau, mainly distributed in the south of the Northern Shaanxi Plateau while others are more suitable for grass-planting. The government should improve PES schemes to guide farmers to choose the appropriate vegetation restoration modes in different areas from a cost-effectiveness perspective.

There are no robust data from clinical trials to guide the clinician in the choice of therapeutic agents for the child with intravenous immunoglobulin (IVIG) resistance. Moreover, the treatment regimen for IVIG-resistant patients varies between institutions, and the best option has not yet been established. Therefore, in this trial, 955 patients with Kawasaki disease (KD) were selected and were initially treated with IVIG (2 g/kg), of these patients, 80 (8.38%) assessed as IVIG resistant were randomly divided into two groups: Group A (n = 40) received a second IVIG treatment, and Group B (n = 40) received methylprednisolone pulse therapy (MPT). Duration of fever, duration of fever after retreatment, hospital days, medical costs, readmission rate, and laboratory examination difference (△) were calculated. Coronary artery lesions (CALs) outcomes were followed up over two years. Patients in MPT group had a shorter fever after retreatment and lower medical costs; more rapid decline in C-reactive protein (CRP), Neutrophils% (N%), platelets (PLT) levels; and a more rapid rise in sodium. However, they also had a higher incidence of treatment failure and CALs than the additional IVIG treatment group in the long-term follow-up. Caution is still required in the use of MPT to treat IVIG-resistant KD.

Background: We previously reported that the specific IgE levels to αs1-casein (CN) and β-CN in patients with cow’s milk allergy decreased with similar dynamics during oral immunotherapy. Therefore, we hypothesized that αs1- and β-CN have strong cross-reactivity among CN components, despite the low similarity in the full-length amino acid sequences. Methods: The αs1-, β-, and κ-CN were purified from commercial cow’s milk. We recruited 39 patients with cow’s milk allergy and the serum IgE levels for each CN component were measured by enzyme-linked immunosorbent assay (ELISA). Cross-reactivity between CN components was investigated by competitive ELISA against αs1-CN. Sequence homology between CN components at the peptide level was calculated using in silico analysis and quantified by the Property Distance (PD) value. Results: The αs1-CN-specific IgE levels exhibited a strong positive correlation with the β-CN-specific IgE (r = 0.945, P < 0.001). Complete competition was observed by β-CN against αs1-CN, suggesting the presence of common epitopes between them. In silico analysis detected 24 peptide sets with PD values lower than 10 between αs1- and β-CN, and 14 sets between αs1- and κ-CN. The amino acid sequences of αs1- (E61-E70) and β-CN (I12-E21) that showed the lowest PD value (5.30) were present in the characteristic sequence known as casein phosphopeptide (CPP). Conclusion: We detected strong cross-reactivity between CN components. Furthermore, we found highly homologous sequences in the CPP region, which contains a core sequence of “SSSEE” with phosphorylated serine residues.

Using a model developed previously by the authors, a risk assessment was conducted to predict the change in the risk of ASF entering Japan as a result of the coronavirus pandemic in humans. The annual probability of ASF entering Japan was calculated to be 23% (90% prediction interval: 0-91%), 4.7% (0-24%) in February, 0.4% (0-2.1%) in March and 0.004% (0-0.01%) in April 2020 indicating a significant decline in the risk of ASF entry into Japan from China. The decline was attributed to a decline in the number of air travelers from China and amount of restaurant food.

Background The association of post-implant tricuspid regurgitation (TR) and heart failure (HF) hospitalization in patients without HF and preexisting abnormal TR and TR pressure gradient (PG) remain unclear. This study aimed to explore the clinical outcomes about progressive post-implant TR after permanent pacemaker (PPM) implantation. Methods A total of 1,670 patients who underwent a single ventricular or dual-chamber transvenous PPM implantation at our hospital between January 2003 and December 2017 were included in the study. Patients with prior valvular surgery, heart failure (HF), and baseline abnormal TR and TRPG were excluded. Finally, a total of 1,075 patients were enrolled in this study. Progressive TR was defined as increased TR grade of ≥2 degrees and/or TRPG of >30 mmHg after implant. Results 198 (18.4%) patients (group 1) experienced progressive post-implant TR and/or elevated TRPG. Group 1 had l larger changes in post-implant TRPG (group 1 vs. group 2; 12.8 ± 9.6 mmHg vs. 1.1 ± 7.6 mmHg; p < 0.001) than group 2 without progressive post-implant TR. Group 1 had a higher incidence of HF hospitalization compared to group 2 (13.6% vs. 4.7%; p < 0.001). Pre-implant TRPG (HR: 1.075; 95% confidence interval (CI): 1.032-1.121; p = 0.001) and post-implant left atrial dimension (HR: 1.076; 95% CI: 1.038-1.114; p < 0.001) were independent predictors of progressive post-implant TR. Conclusion After a transvenous ventricular-based PPM implantation, 18.4% of patients experienced progressive post-implant TR and/or elevated TRPG. Higher pre-implant TRPG and larger post-implant LA dimension were independent predictors of progressive post-implant TR.

Backgrounds: The role of non-pulmonary vein (PV) triggers ablation in persistent atrial fibrillation (PEAF) was suggested but it is still under debate. Objectives: We aimed to assess the effectiveness of non-PV trigger targeted ablation for patients with PEAF. Methods: Consecutive patients with PEAF undergoing catheter ablation (CA) between January 2015 and April 2017 were enrolled. Isoproterenol plus adenosine challenge was performed to provoke non-PV triggers. Non-PV triggers were defined as the non-PV foci inducing AF and/or frequent premature contraction (non-PV PAC) from other than PVs. Three groups were defined: group 1 (n=186) without non-PV triggers; group 2 (n=65) with non-PV triggers that could be completely eliminated with CA; group 3 (n=49) with non-PV triggers still inducible after CA. Primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence. Results: A total of 300 patients (230 males, age 64±10) were enrolled. Mean follow-up period was 27±10 months. Freedom from ATa recurrence at 1- and 2 years were significantly lower in group 3 compared to the other 2 groups (group 1; 74.7%, 67.2% vs. group 2; 75.8%, 68.3% vs. group 3: 52.1%, 38.6%, P=0.0005), irrespective of the type of non-PV triggers (non-PV PAC vs. non-PV foci initiating AF). On multivariate analysis, unsuccessful elimination of non-PV trigger was an independent predictor for ATa recurrence (HR 1.80 [95%CI:1.07-2.93], P=0.026). Conclusions: Successful non-PV trigger elimination can improve the ATa recurrence rate in PEAF ablation. ATa recurrence rate is higher, if non-PV foci or even non-PV PAC remains in patients with PEAF.

The quadripolar catheters used for the transesophageal electrophysiological study is an alternative in such cases due to limitations of vascular access and size of the pediatric patients, additional catheter for intracardiac electrograms cannot be placed in atria stable position.To aim of this article is to report the effectiveness of transesophageal electrode as a reference catheter in patients with limited vascular access and complex congenital heart disease during ablation procedures. Transesophageal catheters can be used as an alternative to the reference catheter in the electrophysiology laboratory for provoking or terminating arrhythmias, understanding mechanism of arrhythmias or as an aid in mapping

The present study analyzed the characteristics in leaf of Terrestrial Orchidaceae member i.e different species of Habenaria Wild ( H. plantaginea Lind1., H. ovalifolia. Wight., H. multicaudata Sedgw. , H. crinifera Lind1., H. heyneana. Lindl., H. elwesii Hook.f., H. longicorniculata J.Graham. , H. pelorioides Par. & Rchb.f. (Odisha cleistantha S.Mishra).). Anatomical characters are important in identification and ecological adaptations. The anatomical characters have serving as a tool for the genus’s systematic. The plants was collected at different forest types from Shivamogga district. Materials was fixed in FAA solution. Transverse sections were obtained by freehand sections, stained with 1% safranin. Leaf anatomical organization of Habenaria species ( Stomata ,epidermis, mesophyll, vascular bundles, hypodermis.) was observed. There was a distinct variation in the anatomical characters of the leaf. Detailed leaf anatomical characters can be used to distinguish species from others. Leaf anatomical characters with structural adaptation helps plants to survive in different vegetation. The implication of this study is the importance of leaf anatomical features to support species identification and to increase understanding of orchid biology which are important in orchid conservation.

We are all likely to need a blood test, a biopsy or wind up on the wrong end of an endoscope. We know that the experience is not going to be pleasant. Many of us will revert to techniques to divert attention away from painful stimuli, such as counting forwards or backwards in our heads, deep breathing, imagining tranquil places or listening to music. But the paper published in this issue of BJOG by (Neo D et al, BJOG 2020; xxxx) shows us how we can distract patients in a more sophisticated way, using virtual reality (VR) technology. The procedure the research groups chose to investigate was outpatient hysteroscopy.Outpatient hysteroscopy is a key part of contemporary gynaecological practice. The procedure is acceptable to the vast majority of women, but most will experience some pain and, in a small proportion of women, this can be severe (Smith P, et al, BJOG 2019;126:891-899). Thus, outpatient hysteroscopy, being common and potentially painful, is a good health technology to evaluate the impact of VR technology on patient experienceDeo N et al, conducted a randomised trial of 40 women undergoing outpatient hysteroscopy for a variety of indications and simple therapeutic procedures were allowed such as biopsy, polypectomy and insertion of a Mirena® device. Women were allocated to standard care or “immersive and interactive video content using a portable, standalone VR headset”. The latter delivered a “guided relaxation experience” which included viewing an 8-minute, narrated video depicting “a calming rainforest and lake setting with animated wildlife, which could be explored by using the “head-tracker”.The preliminary results are impressive. Reduction in peri-procedural pain was statistically significant but more importantly the effect size of a 2cm (20%) difference on a 10cm visual analogue scale must be clinically significant. Reduction in anxiety scores were of a similar magnitude. However, the average hysteroscopy procedure duration was less than 4 minutes, which begs the question, is the cost, time and hassle of setting up and using VR technology worth it? Moreover, 16% of eligible women did not want to use the VR technology because of prior adverse experiences, anxiety or state a preference to see the procedure or use their own distraction media.No-one is going to change clinical practice on a sample of 40, but many practitioners will be energised to conduct larger scale trials to confirm these provisional results and to analyse more deeply the impact of immersive VR technology on reducing pain and anxiety associated with outpatient hysteroscopy. Future work should look at the type of VR technology, the context where it is deployed for what kind of procedure. The optimal VR programme may vary according to patient characteristics, the type of surgery and its duration. VR technology should be tested in more painful gynaecological interventions such as endometrial ablation, cervical biopsy and transvaginal egg collection. Moreover, the prospective benefit of VR need not be restricted to gynaecological practice but should be evaluated in a whole host of ambulatory procedures involving conscious patients.No disclosures: A completed disclosure of interest form is available to view online as supporting information.

Global estimates for 2017 indicated that there were 295,000 maternal deaths, 35 per cent lower than in 2000 with a decline in global maternal mortality ratio from 342 to 211 deaths per 100,000 live births (World Health Organization (WHO) 2019). Maternal hemorrhage is the leading direct cause of maternal death worldwide, representing 27% (20-36) of maternal deaths ( Say L, et al. Lancet 2014).Multiple large retrospective population cohorts have identified risk factors invariably associated with maternal hemorrhage including mode of delivery, prolonged labor, chorioamnionitis, and twins among others (Briley A, et al. BJOG 2014). Factors such as maternal BMI, race or ethnicity, pregnancy induced hypertension, and maternal age have not been consistently associated with increased PPH and require more research, especially given the relationship between maternal obesity, gestational diabetes, pregnancy induced hypertension and PPH.Over 80% of cases of primary PPH are preventable and are due to uterine atony. Active management of the third stage is the gold standard for prevention of PPH. Among women at low risk it is not clear whether active management provides benefit, as with women at mixed risk or at high risk for PPH (RR 0.34, 0.14-0.87) (Begley CM, et.al. Cochrane 2019). The WHO has published evidence-based recommendations for management of PPH and have included use of an effective uterotonic with oxytocin being the preferred agent with alternatives used in specific circumstances when oxytocin is not available (Who, 2018). Most recently, use of tranexamic acid has been introduced for prevention and treatment of PPH with a potential to reduce risk of severe PPH by 50% and maternal death by 20%. (Shakir H, et. al. Lancet 2017). These evidence based interventions have been endorsed by professional organizations and the WHO, and have contributed to a progressive decrease in maternal mortality secondary to hemorrhage.Assessment of risk for hemorrhage incorporates risk factors and appropriate protocols according to risk, implementing preventive measures on an individualized basis. It has been demonstrated that successful implementation requires more than identifying risk factors and their interdependence. Attention to organizational context, involvement of entire health care team, and increased recognition of the role of organizational leadership have been identified as basic components (Main EK, et al. AJOG 2017).In this issue of BJOG, Neary et. al. (BJOG 2020 xxxx) address the important aspect of quality and clinical applicability of risk assessment tools using a structured review that included systematic assessment for bias, sample size and both internal and external validation following a standardized methodology established by PRISMA and CHARMS. The authors concluded that current risk assessment protocols have deficiencies related to general obstetrical applicability and lack of external validation. They recommend development of more broadly applicable and appropriately validated risk assessment protocols that would applicable to the general obstetrical population.Evidenced based risk assessment and corresponding protocols during the antepartum, intrapartum and most importantly immediately after delivery, has the potential of contributing to the prevention of over 80% of maternal deaths attributable to maternal hemorrhage.No disclosures: A completed disclosure of interest form is available to view online as supporting information.

As you would be aware, COVID-19 has rapidly spread to a number of countries around the world. In our letter, we have reviewed chest imaging from a 36-year male with severe COVID-19. We found that his lung lesions started to gradually diminish after about a month. Besides, we found that invasive mechanical positive pressure ventilation had both positive and negative effects. Lung-protective ventilation strategies should be adopted and full attention given to iatrogenic injuries in the diagnosis and treatment of patients with COVID-19. This case report may have a significant impact on the clinical management of patients with COVID-19.

This paper proposed the comparative study on Incoloy 825 Ni-based alloy and AISI 316L austenitic stainless steel dissimilar joints. Welding is accomplished by Nd: YAG pulsed laser beam welding process. This paper is about to investigate the process parameters like laser focal diameter, Power, and pulse frequency in LBW welding of above dissimilar plates. Characterization was conducted by optical microscopy, electron microscopy to understand the microstructural changes during welding. Micro-hardness and tensile tests are carried out to study the evolution of mechanical properties of solder joints. Based on the research work, laser beam welding has certain advantages over other welding techniques due to its less heat affected zone, high power intensity, high repetition rate. Among various analytical and experimental optimization methods, the Taguchi method is more efficient. So this experimentation is about to prove the weld efficiency of dissimilar metal can meet the requirements in oil and gas industries and other industries.

Background: By interrupting all human-to-human transmission, SARS and MERS were effectively eradicated few years ago, but, due to the numerous asymptomatic cases of COVID-19, spreading of disease is facilitated and it will be difficult to overcome it in this way. Methodology: The aim of our study was to compare the efficacy and consequences of proposed epidemiological measures between countries. We analyzed the available databases to compare states with strict whit those with relatively liberal approach to COVID-19 prevention. Results: We showed a statistically significant difference in the number of patients and deaths caused by SARS-CoV-2 depending on the degree and timing of the epidemiological measures introduced in studied countries. Conclusion: Apart from the characteristics of the virus itself, the epidemiological measures that have been introduced, as well as their timing, are essential for preventing the spread of COVID 19 infection. In the absence of an effective drug or vaccine traditional epidemiological measures are the only weapon in the battle against COVID-19.

Although early postoperative outcomes after Fontan improved in the modern era, the convincing evidence in the resource-scare setting was sparse. Our study aimed to determine the incidence of early Fontan failure (EFF) in a contemporary series of palliated patients and to identify its potential risk factors. A single-center retrospective study was conducted between 2012 and 2019 on 145 patients undergoing the Fontan procedure. The primary outcome of interest was EFF, defined as death, Fontan takedown, or listing for heart transplantation prior to hospital discharge or within 30 postoperative days. Our study reported the incidence of EFF of 9.66% (n = 14: thirteen deaths, and one Fontan takedown). In the univariate analysis for pre-operative data, the anatomical diagnosis of unbalanced atrioventricular (AV) septal defect, situs inversus form, AV valve regurgitation, large aorta-pulmonary circulation in Doppler echocardiography, elevated pulmonary artery pressure (PAP), and elevated pulmonary vascular resistance were significantly associated with EFF. At the Fontan, four risk factors influencing EFF included pulmonary artery reconstruction, AV valve repair, bleeding, and elevated PAP. Post-operative edema was also significantly associated with EFF. A final reduced model with multivariate logistic regression analysis indicated preoperative elevated PAP, AV valve repair at Fontan, and postoperative elevated PAP were independent predictors for EFF. In conclusion, EFF is relatively high in our series, and is associated with significant mortality. Patients with a single ventricle physiology undergoing preoperative elevated PAP, AV valve repair at Fontan, and postoperative elevated PAP were identified as independent risk factors to predict EFF.