Sore throat (acute pharyngitis) is globally one of the most frequent reasons for seeking healthcare. Its etiology is mostly viral. In 15-30% of cases, group A streptococci (GAS) are detected, which may cause acute rheumatic fever. We have done a worldwide systematic review to compare diagnostic and therapeutic guidelines across countries and regions. Previous reviews of sore throat guidelines were limited to specific regions and/or language; this is the first global review. Searches were performed in MEDLINE, EMBASE and COCHRANE (key words: sore throat, pharyngitis, tonsillitis or pharyngotonsillitis, and management, guidance, guideline or recommendation) and on the web sites of major health authorities and associated institutions from Africa, Asia, Europe, Middle East, North America, Oceania and South America. Thirty-six guidelines were identified from 26 countries. Most common are recommendations relying on the symptom- and age-based Centor or McIsaac scores. However, antibiotic treatment may be based on other symptomatic criteria; in the most extreme approach just sore throat in children. The recommendation of GAS-specific diagnostic tests is mainly limited to countries where such tests are readily available, although some countries choose not to use them. Penicillins are consistently recommended as first-line antibiotics. By contrast, guidance for symptomatic treatment is variable and mostly sparse or missing. African countries without sore throat guidelines and Asian countries bypassing them are afflicted by rising antibiotic resistance. The availability of sore throat guidelines varies considerably by region and country. Moreover, important divergence is found among the guidelines regarding diagnostic and treatment criteria. This may be explained by the historical background or adoption of external guidelines, rather than the local incidences of GAS infections or acute rheumatic fever. Absence of recommendations on symptomatic treatment in many guidelines is concerning, and raises issues about antimicrobial stewardship, as this is the mainstay of sore throat management, rather than antibiotics.

1. Livestock grazing and non-native plant species affect rangeland habitats globally. These factors may have important effects on ecosystem services including pollination, yet, interactions between pollinators, grazing, and invasive plants are poorly understood. To address this, we tested the hypothesis that cattle grazing and site colonization by cheatgrass (Bromus tectorum) impact bee foraging and nesting habitats and the biodiversity of wild bee communities in a shortgrass prairie system. 2. Bee nesting habitats (litter and wood cover) were marginally improved in non-grazed sites, though foraging habitat (floral cover and richness) did not differ among grazed, non-grazed, or cheatgrass colonized sites. However, floral cover was a good predictor of bee abundance and functional dispersion. 3. Mean bee abundance, richness, α-diversity and functional diversity were significantly lower in cattle-grazed habitats than in cheatgrass-colonized or non-grazed habitats. Differences in bee diversity among habitats were pronounced early in the growing season (May) but by late-season (August) these differences eroded. Fourth-corner analysis revealed that sites with high floral cover tended to support large, social, polylectic bees; sites with high grass cover tended to support oligolectic solitary bees. Both cattle-grazed and cheatgrass-colonized sites were associated with lower abundances of above-ground nesting bees but higher abundance of below-ground nesters. 4. Synthesis and applications. Cheatgrass-invaded sites do not appear to be associated with reduced bee biodiversity or abundance, but cattle grazing was negatively associated with bee abundances and altered species composition. Although floral cover is an important predictor of bee assemblages, this was not impacted by grazing and our suggests that cattle likely impact bee communities through effects other than those mediated by forbs, including soil disturbance or nest destruction. Efforts aimed at pollinator conservation in prairie habitats should focus on managing cattle impacts early in the growing season to benefit sensitive bee species.

Background: Till date people are being diagnosed through Polymerase Chain Reaction (PCR). But due to high population burden being infected, need exist to have alternate method of screening and diagnosis. Objective: To introduce alternate method of screening in the Khyber Pakhtunkwa (KPK) province of Pakistan so as to enhance the testing capacity, to overcome the burden over the PCR facility and to aware the general as well as suspected population for their immune status. Methodology: This study was conducted in Real Time PCR Laboratory and the patients were enrolled from April to 15th June 2020. A total of 200 suspected individuals with the age group of 20->60 were included. All of these patients were screened for IgM and IgG status using Immunu chromatographic Technique (ICT) (AMP, Australian). Results: Out of total 200 enrolled suspected patients, 92 (46%) subjects were positive for antibody (IgM and IgG). Among 92 positive patients, IgM and IgG positive patients were 7 (8%) and 85 (92%) respectively. Male and female subjects among total positive were 72 (51%) and 20 (3%) respectively. Age group of 20-30 was more affected, followed by age group of 30-40 and the least was age group of >60. The most noted symptoms associated with suspected subjects were temperature (85%), followed by body aches (80%), dry cough (77%) and sore throat (70%). Conclusion: Positivity ratio of antibodies IgM and IgG is quite high (46%) among the suspected patients and the most age group affected was 20-30, with most noted symptoms of temperature

Introduction Free muscle transfer for facial reanimation requires the sacrifice of motor nerves and muscles, which inevitably leads to donor site morbidity. To overcome this, the authors performed the interfascicular nerve splitting technique during neurovascular latissimus dorsi flap harvest. The aim of this study was to examine the efficacy of our interfascicular nerve splitting technique through the evaluation of donor site morbidity. Methods Records of patients in who the free latissimus dorsi flap was employed with the interfascicular nerve splitting technique between 2012 and 2016 were reviewed. Postoperative donor site morbidity was evaluated using electromyography, nerve conduction studies, and the Quick-Disabilities of Arm, Shoulder, and Hand questionnaire (QuickDASH). Results A total of 13 patients were analyzed. Grades from the electromyography and nerve conduction study were not significantly different between the donor site and contralateral side (0.42±0.51 and 0.08±0.28, respectively, P = .073). QuickDASH scores showed different results over time. Preoperative QuickDASH scores averaged 1.57±2.34. At postoperative 6 months, the average QuickDASH score was 8.74±4.62, which was significantly different from the preoperative average (P = .001). At postoperative 12 months, QuickDASH scores averaged 2.62±3.19, which was an improvement from the postoperative 6-month score. However, the improvement was not significantly different from the preoperative score (P = .059). Conclusion The present study showed that interfascicular nerve splitting could minimize donor site morbidity. Moreover, our results suggest that the split nerve can function as a donor nerve. Our novel method could be a valuable option for minimizing donor site morbidity during facial reanimation surgery.

Background. Although exposure to stings has been identified as the main risk factor for anaphylaxis due to Hymenoptera venom allergy, professional beekeepers receive hundreds of them yearly without developing systemic reactions. This study aims to analyse the immunological profile of people exposed to bee stings. Methods. A cross-sectional study was conducted. Participants were recruited and classified into three groups: allergic patients (AP) experiencing systemic reactions after bee stings, with a positive intradermal test and specific IgE (sIgE) to Apis mellifera venom (AmV); tolerant beekeepers (TBK) receiving ≥ 50 stings/year; and healthy non-exposed controls (HC). Serum levels of sIgE and specific IgG4 (sIgG4) to AmV, rApi m1, rApi m2, rApi m3, Api m4, rApi m5 and rApi m10, as well as AmV-induced basophil degranulation, percentage of T-cell subsets, Treg cells and IL-10 production were measured. Results. APs had high levels of sIgE to AmV and all allergic components (p<0.001) together with a high basophil activation rate (p<0.001) compared to TBKs. Conversely, compared to TBKs, APs showed lower levels of sIgG4 (p<0.001) and IL-10 (p<0.001) as well as a reduced CTLA-4+ Treg population (p=0.001), together with enhanced Helios+ Treg (p<0.004), Th1 (p=0.008), Th2 (p=0.004) and Th17 (p=0.007) populations. Conclusion. Two different profiles were identified: the allergic profile is well defined by parameters of IgE response, some of them also present in the tolerant beekeeper profile, which is strongly marked by Treg activity.

As science and student populations continue to diversify, it is important for ecologists, evolutionary scientists, and educators to foster inclusive environments in their research and teaching. Academics are often poorly trained in diversity, equity, and inclusion best practices and may not know where to start to make scientific environments more welcoming and inclusive. We propose that by approaching research and teaching with empathy, flexibility, and a growth mindset, scientists can be more supportive and inclusive of their colleagues and students. This paper provides guidance, explores strategies, and directs scientists to resources to better cultivate an inclusive environment in three common settings: the classroom, the research lab, and the field. As ecologists and evolutionary scientists, we have an opportunity to adapt our teaching and research practices in order to foster an inclusive educational ecosystem for students and colleagues alike.

Background: The novel coronavirus disease, COVID 19, is a highly contagious infectious disease declared by the World Health Organization pandemic and a global public health emergency. During outbreaks, health care workers are submitted to enormous emotional burden as they must balance the fundamental “duty to treat” with the parallel duty to family and loved ones. The aims of our study is to evaluate disease perceptions, levels of stress, emotional distress, and coping strategies among medical staff (COVID 19 versus non-COVID 19 department) in tertiary pulmonology teaching hospital in the first month after the outbreak of COVID 19. Methods: One hundred fifteen health care workers completed four validated questionnaires (the brief illness perception questionnaire, perceived stress scale, the profile of emotional distress emotional, cognitive coping evaluation questionnaire) that were afterward interpreted by one psychologist. Results: There was a high level of stress and psychological distress among health care workers in the first month after the pandemic outbreak. Interestingly, there was no difference between persons that work on COVID 19 department versus those working in non-COVID 19 department. Disease perceptions and coping mechanism were similar in the two groups. As coping mechanism, refocusing on planning and positive reappraisal were used more than in general population. Conclusions: there is no difference in disease perceptions, levels of stress, emotional distress, and coping strategies in medical staff handling COVID 19 patients versus personal that does not handle COVID patients the first month after the pandemic outbreak

Our work depicts a familial Duchenne muscular dystrophy case with a complex structural variant (cxSV) and a manifesting pregnant woman. Were our aims to provide molecular diagnosis and hypothesize mechanisms underlying the origin of the cxSV. We implemented a multi-technique approach including MLPA, STRs-segregation, AR-assay, SNP-array, WGS and a bioinformatic algorithm for identification of double strand breaks (DSB) stimulator motifs. We established the carrier status of the prenatal sample and explained its mother´s symptomatology by skewed X-chromosome inactivation. Furthermore, an ancestral familial ex38-43 duplication plus a de novo ex45-54 deletion was revealed in the proband, who carried the cxSV in a recombinant maternal X-chromosome. Characterization of cxSV´s breakpoints junction and its surrounding sequences allowed us to identify DSB stimulator motifs. The replication-dependent “Fork Stalling and Template Switching” mechanism was predicted to be the most likely scenario for the duplication´s origin. Whilst, the de novo deletion could arise from a germline event of inter-chromosome non-allelic recombination involving the “Non-Homologous End Joining” mechanism. The multi-technique strategy enabled precise diagnosis, accurate genetic assessment and widen the understanding of the molecular mechanisms involved in SVs’ generation. Finally, the further comprehension of the occurrence of DMD variants, favors the development of new gene therapy strategies.

A document by Chirag Patel. Click on the document to view its contents.

Sheka people dependency on the Sheka forest has made the people of Sheka create various techniques and strategies that are used to manage the Sheka forest. In the indigenous culture of Sheka people, there is a great deal of forest allocation, benefit sharing, and management practice. Locally, these forests are known as KOBO. This is clearly reflected in the KOBO forest allocation, benefit sharing, and management culture. A framework based on ethnographic information is proposed in this paper; accordingly, qualitative indicators are suggested for different variables relating to indigenous forest allocation, benefit sharing, and management practice among the Sheka people. In Sheka culture, the clan leader (Gebi tato) allocates forests to each member of the clan in the village. The management of the KOBO forest is the responsibility of the individual KOBO holders. All members of the clan who have the KOBO forest are entitled to get a share of the benefits that are derived from the use of the KOBO forests. The KOBO forest is the principal source of honey for the Sheka people. The production of quality honey from the KOBO forest creates a huge market demand within and outside the Sheka zone. In addition to the production of honey, the KOBO forest is used for the extraction of trees for house building and another household consumption. The paper concludes that the current KOBO forest allocation, benefit sharing, and management practices could substantially enhance sustainable forest management and social and economic development of the Sheka people.ΟΕΖΠΠ

Increased blood group 2 innate lymphoid cells contribute to blood eosinophilia, elevated IgE, and itching in Kimura diseaseIchiro Tojima, MD, PhD, Shiori Hara, MD, Takuya Murao, MD, Keigo Nakamura, MD, Sayuri Yamamoto, MD, Hiroyuki Arai, MD, Hideaki Kouzaki, MD, PhD, Shino Shimizu, MD, PhD, Takeshi Shimizu, MD, PhDDepartment of Otorhinolaryngology, Shiga University of Medical Science, Otsu, Japan

Objective: This study aimed to clarify the effectiveness of cervical cerclage in preventing recurrent preterm births. Design: A retrospective study. Setting: The perinatal registration database of the Japan Society of Obstetrics and Gynecology Perinatal Center from 2014 to 2016. Population or Sample: For this study, 6,060 multiparous women with a history of preterm birth were reviewed. After excluding 17 subjects who had unknown indications for cervical cerclage, 6,043 subjects were included in this study. Methods and main outcome measures: The efficacies of elective, ultrasound-indicated, and emergency cerclage as preventive treatments for women with a history of preterm birth were evaluated by comparing the cerclage and non-cerclage cases. Prior to evaluation, a propensity score matching was performed for elective and ultrasound-indicated cerclage patients. Results: Elective cerclage did not reduce the risk of preterm birth in subsequent pregnancies for any of the pregnancy periods (p = 0.413). Similarly, ultrasound-indicated cerclage was ineffective (p = 1.000). In addition, for ultrasound-indicated cerclage, Kaplan-Meier survival curves showed that the risk of a subsequent preterm birth might increase at < 33 weeks of gestation. However, the hazard ratio could not be determined to be statistically significant using the log-rank test at < 28 weeks of gestation. In contrast, emergency cerclage significantly reduced the risk of subsequent preterm birth for all pregnancy periods (p < 0.001). Conclusions: Subsequent preterm births were effectively prevented only in emergency cerclage cases. For elective and ultrasound-indicated cerclage, statistically significant differences in subsequent preterm births were not evident.

Objective: To compare the cost-effectiveness of laparoscopic assisted supracervical hysterectomy (LASH) with NICE’s gold-standard treatment of Levonorgestrel-releasing intrauterine system (LNG-IUS) for menorrhagia treatment. Design: Economic evaluation. Setting: European studies. Population: Women under 50 referred for surgical menorrhagia treatment and eligible for endometrial ablation. Methods: A cost-utility analysis was conducted from an NHS perspective using data from existing literature to compare the treatments. Individual costs and benefits were assessed within one year of having interventions. An Incremental Cost-Effectiveness Ratio (ICER) was calculated, followed by sensitivity analysis. Main Outcome Measures: Expected Quality Adjusted Life Years (QALYS) and costs to the NHS were calculated alongside health net benefits (HNB) and monetary net benefits (MNB). Results: An ICER of 0.7 was used to calculate a MNB between -£14.99 and -£714.99, coupled with a HNB between –0.0357 QALYs and –0.0005 QALYS. LNG-IUS was more cost-effective than LASH, with LASH exceeding the upper bound of the £30,000/QALY limit used by NICE. Sensitivity analysis lowered the ICER below the given threshold. Conclusions: The ICER demonstrates it would not be cost-effective to replace the current gold-standard LNG-IUS with LASH, when treating menorrhagia in the UK. The ICER’s proximity to the threshold and its high sensitivity alludes to the necessity for further research to generate a more reliable cost-effectiveness estimate. Funding: None. Keywords: Economic evaluation, Cost-utility analysis, Incremental cost-effectiveness ratio (ICER), Levonorgestrel-releasing intrauterine system (LNG-IUS), Laparoscopic assisted supracervical hysterectomy (LASH), Menorrhagia. Tweetable abstract: LNG-IUS is marginally more cost-effective than LASH as a gold standard treatment for menorrhagia.

Rationale, aims and objectives New therapies are increasingly approved by regulatory agencies such as the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) based on testing in non-randomized clinical trials. These treatments have typically displayed “dramatic effects” (i.e., effects that are considered large enough to obviate the combined effects of bias and random error). The agencies, however, have not identified how large these effects should be to avoid the need for further testing in randomized controlled trials (RCTs). We investigated the effect size that would circumvent the need for further RCTs testing by the regulatory agencies. We hypothesized that the approval of therapeutic interventions by regulators is based on heuristic decision-making whose accuracy can be best characterized by the application of signal detection theory (SDT). Methods We merged the EMA and FDA database of approvals based on non-RCT comparisons. We excluded duplicate entries between the two databases. We included a total of 134 approvals of drugs and devices based on non-RCTs. We integrated Weber-Fechner law of psychophysics and recognition heuristics within SDT to provide descriptive explanations of the decisions made by the FDA and EMA to approve new treatments based on non-randomized studies without requiring further testing in RCTs. Results Our findings suggest that when the difference between novel treatments and the historical control is at least one logarithm (base 10) of magnitude, the veracity of testing in non-RCTs seems to be established. Conclusion Drug developers and practitioners alike can use the change in one logarithm of effect size as a benchmark to decide if further testing in RCTs should be pursued, or as a guide to interpreting the results reported in non-randomized studies. However, further research would be useful to better characterize the threshold of effect size above which testing in RCTs is not needed.

Background & Objectives:  Testing rates, Case fatality rate (CFR), and Recovery rates (RR) are important parameters for assessing the measures taken in fighting during epidemics and pandemics. The present study was carried out to estimate average tests/day the, % of confirmed cases and compare the CFR and RR during the pandemic of COVID-19 in the states of India after completion of the 1st& 2nd phases of lockdown.Methods:  The data were retrieved from accurate databases including the Ministry of Health and family welfare, Centre for Evidence-Based Medicine, COVID19 India, and the World Health Organization. States with total cases ≥ 100 were included in the study and 1st phase of lockdown were commenced from 22nd March to 14th April 2020 & 2nd phase of lockdown was from 15th April to 03rd May 2020Results:  32 states have reported COVID 19 as of 3rd May 2020. Average tests/day, RR have improved, and % of confirmed cases, CFR have decreased among Indian states when compared after 1st& 2nd phases of lockdown.Conclusion:  Indian states have shown improvement with testing and mitigation measures to fight against COVID 19 as evidenced by a decrease in % of confirmed cases, CFR, and improvement in RR. Apart from that, employing mass testing and epidemiological studies will expand the screening of asymptomatic cases. Also, case studies with a detailed medical history and scoring CFR alongside RR should be adopted in hospitals, which may be helpful in exactly pointing the hotspots of infection.

Abstract: Patients with liver disease are more prone to thrombosis and bleeding events than healthy people. The decision to use anticoagulation in patients with pulmonary embolism and liver disease requires a cautious evaluation of the risks of bleeding and the benefits of anticoagulation. In this paper, we reported a case of a patient with fatty liver that developed pulmonary embolism. Although the low molecular weight heparin sodium injection was only administered at a regular dose, the patient still developed epistaxis and hematuria. After evaluating the efficacy and safety of different anticoagulants in patients with pulmonary embolism and liver dysfunction, rivaroxaban is more suitable for this patient to be treated by sequential therapy. After three weeks of treatment with rivaroxaban, the patient’s blood routine test results were normal, and no side effect was found. As far as we know, this is the first reported anticoagulant therapy case for patients with pulmonary embolism and fatty liver.

During geographical expansion of a species individual colonizers have to confront different ecological challenges, and the capacity of the species to broaden its range may depend on the total amount of adaptive genetic variation supplied by evolution. We set out to test whether the distribution of loci under selection along a contrasting environmental gradient can be turned into a model that accurately predicts a species' range. If positive, this may shed light on the genetic source of adaptive limits that shape range boundaries. We sampled five populations of the western Mediterranean lizard Psammodromus algirus that inhabit a noticeable environmental gradient of temperature and precipitation. We used 21 SNPs putatively under selection to correlate the genotypes of 95 individuals with environmental variation among their populations, using 1x1 km2 grid cells as sampling units. By extrapolating the resulting model to all possible combinations of alleles, we inferred the locations that were theoretically suitable for the species. The inferred distribution range overlapped to a large extent with the realized range of the species, including an accurate prediction of internal gaps and range borders. Our results suggest an adaptability threshold determined by the amount of genetic variation available that would be required to warrant adaptation beyond a certain limit of environmental variation. These results support the idea that the expansion of a species' range may be ultimately linked to the arising of new variants under selection.

Over time, populations of species can expand, contract, and become isolated, creating subpopulations that can adapt to local conditions. Understanding how species adapt following these changes is of great interest, especially as the current climate crisis has caused range shifts for many species. Here, we characterize how Drosophila innubila came to inhabit and adapt to its current range: mountain forests in southwestern USA separated by large expanses of desert. Using population genomic data from more than 300 wild-caught individuals, we examine four distinct populations to determine their population history in these mountain-forests, looking for signatures of local adaptation to establish a genomic model for this spatially-distributed system with a well understood ecology. We find D. innubila spread northwards during the previous glaciation period (30-100 KYA), and has recently expanded even further (0.2-2 KYA). Surprisingly, D. innubila shows little evidence of population structure, though consistent with a recent migration, we find signatures of a population contraction following this migration, and signatures of recent local adaptation and selective sweeps in cuticle development and antifungal immunity. However, we find little support for recurrent selection in these genes suggesting recent local adaptation. In contrast, we find evidence of recurrent positive selection in the Toll-signaling system and the Toll-regulated antimicrobial peptides.

Legumes in the tribe Fabeae form nitrogen-fixing root nodules resulting from symbiotic interaction with the soil bacteria Rhizobium leguminosarum symbiovar viciae (Rlv). These bacteria are all potential symbionts of the Fabeae hosts but display variable competitiveness to form root nodules (CFN) when co-inoculated in mixture. Because CFN and nitrogen-fixation capacity behave generally as genetically independent traits, the efficiency of symbiosis is often suboptimal when Fabeae legumes are exposed to natural bacterial populations present in soil. A core collection of 32 bacteria was constituted based on the genomic comparison of a collection of 121 genome sequences representative of known worldwide diversity of the rhizobium symbiovar. A variable part of the nodD gene sequence was used as a DNA barcode to discriminate and quantify each of the 32 bacteria in a mixture. This core collection was co-inoculated on a panel of 9 genetically diverse Pisum sativum, Vicia faba and Lens culinaris cultivars. We estimated the relative CFN of the bacteria with the diverse hosts by DNA metabarcoding on the nodulated root systems. Comparative genomic analyses within the bacterial core collection allowed us to identify genes associated with host-dependent CFN. These results highlight the emergent properties of rhizobial populations and present a new strategy to identify genetic markers related to important symbiotic traits operating at this level.

Aim: SARS-COV-2 infections are causing substantial morbidity and mortality, especially due to “exuberant cytokine storm”. In this study we review effectiveness of anti-inflammatory and immunomodulatory drugs in this situation. Methods: Ovid MEDLINE, PUBMED, Google Scholar and Cochrane library searched for anti-inflammatory and immunomodulatory drugs against COVID-19 including: Anti malaria agents, non-steroidal anti-inflammatory drugs, steroids, cyclosporine, thalidomide, IVIG, interlukin-6 blockade, IL-1 blockade, tumor necrosis factor-α blockade, and Janus kinase inhibitors. Results: We included 95 studies. Unlike preliminary positive results, the effect of Chloroquine is questionable. Thalidomide has been shown to be effective in some studies but not be proved yet. Low dose Corticosteroids may be effective in the early phases of SARS-CoV-2 as a bridge. There is neither evidence of benefits or adverse outcomes for the use of NSAIDs, nor is there evidence indicating that target therapies (IL-1, TNFα and JAK inhibitors) and also cyclosporine are effective. In some cases and clinical trials, interlukin-6 blockade is useful in critically ill patients. Finally, the high dose IVIG reversed the deterioration of patients in most clinical trials. Conclusion: Unlike preliminary positive results, Hydroxychloroquine seems ineffective. Thalidomide is effective in some cases. Although, low dose CS may be effective in the early phases of illness, administration of NSAIDs and steroids is controversial. The effectiveness of more target therapies including IL-1, TNF-α, and JAK inhibitors, also cyclosporine is less clear. Tocilizumab can be used in severe situations, where other drugs are ineffective. IVIG can be used at least as a bridge therapy in deteriorating patients.

Freshwater habitats are under stress from agricultural land use, most notably the influx of neonicotinoid pesticides and increased nutrient pressure from fertilizer. Traditional studies investigating the effects of stressors on freshwater systems are often limited to a narrow range of taxa, depending heavily on morphological expertise. Additionally, disentanglement of multiple simultaneous stressors can be difficult in field studies, whereas controlled laboratory conditions do not accurately reflect natural conditions and food webs. To overcome these drawbacks, we investigated the impacts of two agricultural stressors (the neonicotinoid insecticide thiacloprid and fertilizer) in full-factorial design in a semi-natural research site, using environmental DNA sampling to study three different taxonomic groups representing three trophic levels: bacteria (decomposers), phytoplankton (primary producers), and chironomids (consumers). The results show considerably impact of both stressors across trophic levels, with an additive effect of fertilizer and thiacloprid on community composition at all levels. These findings suggest that agricultural stressors affect the entire food web, either directly or through cascade reactions. They are also consistent with morphological assessments that were performed in the same study site, even at a lower number of replicates. The study presented shows that the use of multi-marker environmental DNA provides a more comprehensive assessment of stressor impacts across multiple trophic levels, at a higher taxonomic resolution than traditional surveys. Additionally, over a thousand putative novel bio-indicators for both agricultural stressors were discovered. We encourage further investigations into stressors impacts at different trophic levels, which will lead to more effective monitoring and management of freshwater systems.

Prolonged bisphosphonate therapy associated with atypical femoral fracture continues to occur. Protocols to avoid excessive duration of therapy should be utilised routinely. The importance of reviewing risk factors for fractures such as vitamin D status, interacting medications and management of comorbidities such as hemiplegic stroke with spasticity is highlighted.

Seizure-like movements after general anesthesia is not common. Abnormal movements following general anesthesia may be difficult to differentiate because it is difficult to find out the exact cause of these seizure-like movements. These cases can occur at any stage This is a rare case of seizure-like movement after tonsillectomy.

Binswanger's disease is a type of vascular leukoencephalopathy that can lead to cognitive impairment and neurological deficits and is sometimes difficult to diagnose. We present a case of Binswanger's disease with an interesting differential diagnosis based on clinical aspects, laboratory findings and imaging studies.