AIM: Immune response hyperactivation is critical in the progression of coronavirus disease (COVID-19). We studied the effect of the pre-exposure to disease-modifying antirheumatic drugs (DMARDs) that decrease immunological responses on the incidence of COVID-19 symptoms to explore therapeutic approaches in its early stages. METHODS: Multicentre retrospective cohort study including 2,494 patients with inflammatory diseases recruited from 14 primary care centres in Barcelona (Spain). The primary outcome was the presence of confirmed or highly suspected COVID-19 (hsCOVID-19) symptoms reported during March 2020 at primary care or hospital emergency department. Multivariable Poisson regression models were fitted to estimate hsCOVID-19 symptoms relative risk (RR) adjusted by comorbidities. RESULTS: Biological (RR=0.46, CI95%=0.31-0.67) and synthetic (RR=0.62, CI95%=0.43-0.91) DMARDs used in immunomediated inflammatory diseases diminished the incidence of symptomatic cases of hsCOVID-19. Striking sex differences were revealed. Protective effects of anti-TNFα pre-exposure (RR=0.50, CI95%=0.33-0.75) were higher in women (RR=0.33, CI95%=0.17-0.647), whereas anti-IL6/12/17/23 compounds pre-exposure (RR=0.47, CI95%=0.24-0.92) produced slightly higher protective effects in men (RR=0.44, CI95%=0.15-1.68). Pre-exposure to low glucocorticoid doses also revealed sex differences decreasing the incidence of hsCOVID-19 symptoms predominantly in women (RR=0.72, CI95%=0.42-1.22). A merely protective effect of pre-exposure to chloroquine/hydroxychloroquine (RR 0.76, CI95%=0.36-1.62) was observed. CONCLUSION: We identified specific DMARDs with different immune-depressor mechanisms that decrease hsCOVID-19 symptoms with striking sex differences. These results underline the potential interest of starting clinical trials with anti-TNFα compounds in women to evaluate their efficacy in minimizing disease progression in the early stages of COVID-19.

LETTER TO THE EDITOR:A 28-year-old prisoner presented with a one-year history of dysphagia and weight loss (BMI 18). Initially, he self-discharged from another trust after CT neck suggested a plastic foreign body encapsulating softer material lodged within a pharyngeal pouch at the level of T2-T3 (Figure 1). Referred as having “?Swallowed drugs”, he denied ingesting any non-food items or recreational drugs although remained unable to provide a cohesive history. Despite recently undergoing investigation for mental health concerns, he reported no other significant past medical history. Sinus bradycardia (33bpm) with a normal QTC incited suspicion of systemic absorption of intra-corporeal illicit drugs. Given the inconsistent history, bradycardia and imaging, the team maintained high suspicion and pre-emptively sought guidance on the ethics of drug testing and preservation of evidence. Unexpectedly, a plastic bottle cap was removed during rigid panendoscopy, which contained digested food substances. Pharyngoscopy revealed a significant oesophageal stricture at 24cm with no cricopharyngeal bar suspicious of chronic inflammatory stricture. 24-Hour ambulatory ECG recording confirmed only sinus bradycardia. He was discharged back to prison once eating and drinking, aiming for recurrent dilatation every two weeks until luminal diameter reached >15mm.Foreign body ingestion remains rare in adults but prevalence is greater in the elderly, drug traffickers, prison inmates and patients with psychiatric conditions[1]. Intentional ingestion of foreign bodies is more common in incarcerated populations due to perceived secondary gain, pica or psychiatric conditions[2]. Malingerers display repetitive, intentional ingestion of multiple items and may be associated with other self-harm behaviours[3]. Objects typically include sharp metals, batteries or plastic-wrapped illegal drugs. The prevalence of drug abuse within prison populations is high, with illicit substances often concealed by body packing[4]. Rupture of packaging with consequent leakage of contents may result in lethal intoxication. Imaging is notoriously difficult to interpret as scybala, fruit stones or grains may imitate packaged drugs.Clinical judgement remains pivotal in formulating diagnoses and optimising medical management. However, balancing rational associations with unconscious bias is ethically challenging. A cautious balance must be struck between implicit bias and clinical suspicion when considering the management of oesophageal foreign bodies. Overall, we propose it is clinically safer to manage such patients under the presumption that any packaging contains illicit substances. However, no patient should have their care compromised due to race, gender, age or background. As prison populations continue to rise, further work needs to be done to tackle implicit bias within a healthcare setting.WORD COUNT: 398 words

Objective: To determine the incidence of uterine abnormalities in patients with PCOS Design: Retrospective Cohort Study Setting: Tertiary University Hospital Population: Infertile patients with PCOS vs. male factor infertility were selected from the IVF center electronic database from between the years 2011-2019. Methods: A total of 103 patients, 51 PCOS, and 52 male factor infertility were enrolled in the study. Hysterosalpingography (HSG) images of all patients were numbered. For the study, six different shapes of the intrauterine cavity were figured. All HSG images were evaluated by ten senior reproductive endocrinologists and surgeons. Seniors were blinded to the research and chose the most appropriate figure for each patient’s HSG image. Results and Demographic parameters were compared between PCOS and Male Factor Groups. Anti-Mullerian hormone correlation with Uterine abnormality was further analyzed. Main Outcome Measure: Percentage of the abnormal uterine cavity Results: The percentage of the normal uterine cavity was significantly lower in the PCOS group. (45.9 % and 73.1 %, p<0.01) The abnormal cavities were compared; Arcuate Uterus (22.18% vs 6.6% p<0.05), Partial Septate Uterus (5.1% vs 0% p<0.05), Complete Septate Uterus (5.47% vs 1.2% p<0.01) and Y-Shaped Uterus (7.47% vs 0 p<0.05) were significantly higher in PCOS patients. T-Shaped Uterus (13.8% vs. 18.9%) was statically similar. There was no correlation between serum AMH levels and the presence of uterine abnormality. Conclusion: This study provides that, compared to the healthy population, the uterine abnormality frequency is clearly higher Key Words: Polycystic Ovary Syndrome, Uterine Abnormality, Anti-Mullerian Hormone

Objective Synovial fluid (SF) accumulates extensively in joints of individuals with rheumatoid arthritis (RA), which reflects the pathological state of the synovium and disease activity. This study applied quasi-targeted liquid chromatography-mass spectrometry/mass spectrometry, an advanced metabolomics technique, to find characteristic metabolism in RA. Methods SF samples from the patients (n=20) were collected and examined using the metabolomic technique. SF samples from patients with osteoarthritis (OA) (n=20) were used as controls. Results Four hundred seventy nine variable metabolites were detected, and 250 of these metabolites were identified by searching the Human Metabolome Database (HMDB) and a self-constructed information list of possible metabolites. S-plot and volcano plot analysis detected 22 metabolites with differential levels in RA SF compared with those in OA SF. With these 22 candidate metabolites, pathway analysis using the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway database detected upregulation of pyrimidine metabolism and purine metabolism, and downregulation of fatty acid biosynthesis and unsaturated fatty acid biosynthesis in RA SF. Receiver operating characteristic (ROC) analysis and logistic regression models detected increased levels of guaiacol, naringenin, phenylpropanolamine and vanillylmandelic acid in RA SF. Furthermore, the naringenin level showed positive correlation with rheumatic factor (RF) and anti-cyclic citrillinated peptides (anti-CCP) levels. Conclusion Our study suggests disturbed pyrimidine metabolism, purine metabolism, fatty acid biosynthesis and unsaturated fatty acid biosynthesis as well as increased naringenin level are characteristic metabolism in RA.

Knowledge-based potentials are developed to investigate the differentiation of native structures from their decoy sets. This work presents the construction of two different distancedependent potential energy functions based on two basic assumptions using mathematical modeling. In the first case, according to Anfinsen’s dogma, we assumed that the energy of each model structure should be more positive than the corresponding native type. In the second one, we assumed that the energy difference between the native and decoy structures changes linearly with the root-mean-square deviation of structures. These knowledge-based potentials are expressed by the B-spline basis functions of the pairwise distances between Cα-Cα of inter-residues. The potential function parameters in the above two approaches were optimized using the linear programming algorithm on a large collection of Titan-HRD and tested on the remainder. We found that the potential functions produced by Anfinsen’s dogma detect native structures more accurately than those developed by the root-mean-square deviation. Both linear programming knowledge-based potentials (LPKP) successfully detect the native structures from an ensemble of decoys. However, the LPKP of the first approach is able to correctly identify 130 native structures out of 150 tested cases with an average rank of 1.67. While the second approach LPKP detects 124 native structures from their decoys. We concluded that linear programming optimization is a promising method in generating knowledge-based potential functions. All the high-resolution structures (training and testing) used for this work are available online and can be downloaded from http://titan.princeton.edu/HRDecoys.

1. Organisms may internally or behaviourally regulate their body temperatures or conform to the ambient air temperatures. Previous studies are inconclusive on whether pigmentation influences thermoregulation in various odonates. 2. We investigated the thermal response of sympatric North American Calopteryx aequabilis and Calopteryx maculata with a thermal imaging study across a 25 °C ambient temperature range. 3. We found that regressions of thorax temperature on ambient temperature had similar slopes for male and female C. maculata, but females were consistently 1.5 °C warmer than males. 4. In contrast, the sexes of C. aequabilis differed in slope, with C. aequabilis females having a slope less than 1.0 and males having a slope greater than 1.0. 5. Given that C. aequabilis is strongly sexually dimorphic in pigment, but C. maculata is not, our findings suggest that pigmentation does influence thermal response rate in sympatric populations of both species.

Abstract: Unlike most head and neck cancers, the presence of distant metastasis (DM) does not preclude curative intent treatment and surgical interventions are common in metastatic disease. DM has an adverse impact on survival and lends considerable morbidity to the patient. This research attempts to study the demographics, patterns of metastasis, and surgical interventions in this rare subgroup of patients with differentiated thyroid cancer (DTC). Materials and methods: Thirty two patients of DTC with radiologically or histopathologically or cytopathologically confirmed DM who underwent surgery at a tertiary care centre from August 2011 to December 2018 formed the study cohort of this retrospective study. Results: The study population comprised 59% females and had a median age of 55 (19- 79) years. Thorax was the most common site of metastasis, documented in 56% of patients, while 53% patients had bone metastases. Multiple DM were noted in 8 patients. All patients underwent total thyroidectomy or completion thyroidectomy with or without neck dissection. Surgery for metastatic sites was possible in 14 patients (44%) with debulking and spine fixation being the commonest surgical intervention for metastasis. Thyroidectomy, with or without neck dissection followed by radioactive iodine (RAI) ablation was used as the primary modality to treat DM in patients who did not undergo specific surgical treatment for distant metastases. The median dose of RAI received by patients was 400 (25 – 749) mCi, in one to four sessions (median- 2 sessions). Three patients received conventional chemotherapy, while four received Sorafenib. Conclusion: Metastasectomy in differentiated thyroid cancer with distant metastases is feasible in selected patients and surgical interventions are most commonly performed on the spine to prevent neurological complications. RAI ablation is universally administered in this subset of patients and in very high doses, often distributed in multiple sessions. The role of chemotherapy and tyrosine kinase inhibitor is still restricted to palliative settings and cost constraints remain a detriment to more widespread use.

Functional rehabilitation of post-laryngectomy patients is a challenging task; this includes achieving optimal speech and swallowing outcomes. Botox injections are utilised to improve pharyngoesophageal segment tonicity to improve speech and swallowing outcomes. We propose a novel and efficacious technique using a portable video-laryngoscope, GlideScope®, to directly visualise the injection of botulinum toxin in total laryngectomy patients with severe radiation-induced changes.

Objective: To evaluate the thresholds of BWD for predicting early neonatal outcomes and assess the predictive accuracy of BWD. Design: Retrospective cohort study. Setting: Single Chinese University Hospital. Population: All women with liveborn twins at gestational age of ≥ 26 weeks. Methods: Multivariable logistic regression analyses of association between neonatal outcomes and BWD with different thresholds (≥15.0%, ≥20.0%, ≥25% and ≥30%). Generalized estimated equation (GEE) models to address inter-twin correlation. Restrictive cubic spline (RCS) models to draw the dose-response relationship. Clustered receiver operating characteristic (ROC) curve analysis to assess the predictive accuracy. Main outcomes: NICU admission, neonatal respiratory distress syndrome (NRDS), ventilator support and composite outcome including major morbidity and neonatal death. Results Among 2348 twin pairs, BWD were at significantly increased risks of NICU admission, irrespective of the thresholds. The risks of NRDS, ventilator support and composite outcome were significantly higher when a threshold of ≥20% or above was chosen. The dose-response relationship showed non-linear growth in risk of adverse neonatal outcomes with the increasing BWD. ROC analyses showed a low significant AUROC of 0.569 (95% CI: 0.526-0.612) for predicting NICU admission but no significant AUROC for predicting other outcomes. A BWD of ≥30% provided a moderate increase in the likelihood of NICU admission [positive likelihood ratio (LR+) =5.77]. Conclusions BWD is independently associated with adverse neonatal outcomes. Regardless of this association, BWD could not serve as a single predictor for neonatal outcomes. A cut-off of 30% is more practical for risk stratification among twin gestations.

Objective: To evaluate whether polycystic ovary syndrome (PCOS) affects pregnancy outcomes and complications in infertile women undergoing their first in vitro fertilization (IVF) treatment. Design: A retrospective cohort study. Setting: Private fertility center. Population: 7678 infertile women, including 666 women with PCOS and 7012 controls undergoing their first IVF treatment from 2010 to 2017. Methods: Maternal characteristics, pregnancy outcomes and complications were analyzed by independent t-test, Mann-Whitney U-test, or Chi-square test. A logistic regression analysis was performed to determine the impact of PCOS on pregnancy outcomes and complications. Main Outcome Measures: Risk of adverse pregnancy outcomes (miscarriage, preterm delivery, pregnancy-induced hypertension) and pregnancy outcomes (live birth rate, clinical pregnancy rate, implantation rate), adjusted for maternal characteristics. Results: After adjusting for differences in maternal age, BMI, infertility duration, total dose of gonadotropin, serum E2 and endometrial thickness on the day of hCG trigger, number of fertilized occytes, number of embryos transferred, embryo type (cleavage-stage embryo or blastocyst) and quality, women with PCOS had an increased risk of developing unfavorable pregnancy complications, including miscarriage (adjusted odds ratio [aOR] 1.629, 95% confidence interval [CI] 1.240-2.141), very preterm delivery (< 32 weeks) (aOR 2.135, 95% CI 1.170-3.895). For pregnancy outcomes, PCOS was associated with higher clinical pregnancy rate (aOR 1.248, 95% CI 1.038-1.501) and implantation rate (aOR 1.238, 95% CI 1.030-1.489) after adjusting for the above-mentioned confounders. Conclusions: Women with PCOS are at increased risk of adverse pregnancy outcomes. These women may need more frequent medical consultants and management during pregnancy and parturition.

ABSTRACT Background/Objective: To examine N-acetylcysteine’s renoprotective effect in adult cardiac surgery Methods: PubMed, Ovid Medline, and Embase were searched for randomised controlled trials published between January 1990 and November 2019 that investigated the effect of N-acetylcysteine in preventing acute kidney injury in patients undergoing cardiac surgery. Cochrane Library was searched to identify any prior systematic review or meta-analysis. Eligibility Criteria: Randomised controlled trials that assessed the effect of N-acetylcysteine in comparison to placebo by measuring the incidence of acute kidney injury. Two independent reviewers extracted the data and assessed the risk of publication bias of included studies. Results: Overall meta analytic estimates of all 10 included trials was controversial, showing that N-acetylcysteine did not have a significant effect (odds ratio: 0.84, 95% confidence interval 0.64 to 1.10). However further meta analytic estimates comparing the dosage and timing of NAC administered suggested that the administration of high dosages of NAC perioperatively would have significant benefit in preventing acute kidney injury. Conclusion: This study suggests that N-acetylcysteine must be administered at high dosages perioperatively to have a significant effect in reducing the incidence of acute kidney injury. However, only one out of the 10 included trials administered NAC high dosages perioperatively. Although it is worth noting that it is the only included trial to show a significant benefit in reducing the incidence of acute kidney injury (odds ratio: 0.30, 95% confidence interval 0.11 to 0.81), further studies should be conducted to confirm the renoprotective effect of administering high dosages of NAC perioperatively.

Background Medication harm has negative clinical and economic consequences, contributing to hospitalisation, morbidity and mortality. The incidence ranges from four to 14%, of which up to 50% of events may be preventable. A predictive model for identifying high-risk inpatients can guide a timely and systematic approach to prioritisation. Aim To develop and internally validate a risk prediction model, for prioritisation of hospitalised patients, at risk of medication harm. Methods A retrospective cohort study was conducted in general medical and geriatric specialties at an Australian hospital, over six months. Medication harm was identified using International Classification of Disease (ICD-10) codes and the hospital’s incident database. Sixty-eight variables, including medications and laboratory results, were extracted from the hospital’s databases. Multivariable logistic regression was used to develop the final risk model. Performance was evaluated using area under the receiver operative characteristic curve (AuROC) and clinical utility was determined using decision curve analysis. Results The study cohort included 1982 patients median age 74 years, of which 136 (7%) experienced ≥1 adverse medication event(s). The model included: length of stay, hospital re-admission within 12 months, venous or arterial thrombosis &/or embolism, ≥ 8 medications, serum sodium < 126 mmol/L, INR > 3, anti-psychotic, antiarrhythmic and immunosuppressant medications, and history of medication allergy. Validation gave an AuROC of 0.70 (95% CI: 0.65-0.74). Decision curve analysis identified that the AIME may be clinically useful to help guide decision making in practice. Conclusion We have developed a risk prediction model with reasonable performance. Future steps include external validation.

Problematic polypharmacy is a growing challenge. Medication that is intended to improve patients’ health and wellbeing is instead becoming part of the problem. The way we practice medicine has become one of the drivers for the problems. Dealing with the challenge will need us to think differently about how we do clinical care. A 2013 Kings Fund report stated that tackling problematic polypharmacy requires us to actively build a principle of ‘compromise’ in to the way we use medicines. There are implications for how we consult and make decisions with patients, in how we design health practice and systems to support that decision making, and in our understanding of the process of research – how we generate the knowledge that informs practice. This review considers the current state of play in all three areas and identifies some of the work still need to do in order to generate the practice-based evidence needed to tackle this most challenging problem. Finding a way to redesign practice to address problematic polypharmacy could offer a template for tackling other related complex issues facing medical practice such as multimorbidity, chronic pain and complex mental health.

The mechanisms of C−C activation of 1-Benzylcyclopropan-1-ol to produce 1,6-diketone have been investigated by density functional theory (DFT) calculations. The catalyst [Cp*RhCl2]2 and additive Ag2CO3 play an important role in controlling the selectivity. By employing [Cp*RhCl2]2 as catalyst and Ag2CO3 as additive, the product is 1,6-diketone, whereas the β-hydride elimination product could not be obtained. The product would become monoketone in the absence of [Cp*RhCl2]2. In addition, the combination of catalyst [Cp*RhCl2]2 and additive AgOAc would also lead to monoketone. The observed selectivity could be attributed to the electronic effect.

Dear EditorI read with interest the paper by Xindong Qin et al. “Acupuncture for Recurrent Urinary Tract Infection in Women: A Systematic Review and Meta-Analysis.1 In this paper, under the heading “Interpretation” – they discuss possible mechanisms behind a potential effect of acupuncture. They are referring to one of my studies,2 but they are not discussing one of our study’s main finding. We found a correlation between fewer urinary tract infections and less measured volume of residual urine in the women treated with acupuncture. This change in residual urine did not occurred in the non-treated group. Residual urine or post voided volume measured by a Bladder Scan, and by a nurse, in a hospital setting, and she was blinded with regard to the participants group allocation. What is an empty Bladder? A paper by Haylen discuss this and a post-voided volume above 30 ml, in otherwise healthy women, has been regarded as one of many potential risk factors3. Interestingly all women in our study had at baseline more than 30 ml of residual urine.2 After 6 months control this was reduced to 18.2 mL in the acupuncture group while no change in the non-treated group (35.5 vs 38.8mL). Further, residual urine is recognized, and discussed as one of several potential risk factors for recurrent urinary tract infections in children 4 and healthy postmenopausal women. 5 Hence, with regard to post-voided volumes, I hope this can be included in future studies on acupuncture as a prophylactic treatment for recurrent urinary tract infections. Finally, a question to the authors,1 on page 6, you write: “None of the studies reported the secondary outcomes of urinary bacteria culture, WBCs of urine dipstick, kidney function, markers of kidney damage, health-related quality of life or healthcare costs.” However, our study 2 used a dipstick (Uricult) and we presented the number of infections with or without bacteriuria. Do I misunderstand, or do you mean the actual name of the bacteria found?Terje AlrækSchool of Health Sciences / NAFKAM, Department of Community Medicine,Kristiania University College / Faculty of Health Science, UiT The Arctic University of NorwayReferencesQin X, Coyle ME, Yang L, Liang J, Wang K, Guo X, Zhang AL, Mao W, Lu C, Xue CC, Liu X. Acupuncture for recurrent urinary tract infection in women: a systematic review and meta-analysis. BJOG 2020; https://doi-org.pva.uib.no/10.1111/1471-0528.16315Alraek T, Soedal LI, Fagerheim SU, Digranes A, Baerheim A. Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women. Am J Public Health 2002;92:1609–11Haylen BT. The empty Bladder. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Mar;18(3):237-9. doi: 10.1007/s00192-006-0111-0Hoebeke P, Van Laecke E, Van Camp C, Raes A, Van De Walle J. One thousand video-urodynamic studies in children with non-neurogenic bladder sphincter dysfunction. BJU International (2001), 87, 575–580Stamm WE, Raz R. Factors contributing to susceptibility of postmenopausal women to recurrent urinary tract infections. Clin Infect Dis. 1999 Apr;28(4):723-5. doi: 10.1086/515209.

Numb chin syndrome (NCS) is defined as reduced or absent sensation in the chin and lower lip within the distribution of the mental or inferior alveolar nerves. Although commonly associated with local trauma, NCS can indicate an underlying malignancy or can be the presenting symptom of cancer recurrence. We describe the first pediatric patient with acute myeloid leukemia (AML) who presents with NCS as a sign of AML recurrence post allogeneic hematopoietic cell transplantation. We also review the current literature on acute leukemia and NCS.

Recurrent respiratory papillomatosis (RRP) is a benign tumor of the respiratory tract associated with human papillomavirus types 6 and 11. Patients undergo multiple surgical debridements for management of rapidly growing papilloma. Adjuvant treatment options for management of RRP in children are often ineffective and do not decrease the need for repeated surgical debridement. We report on three patients initially treated with 10 mg/kg systemic bevacizumab every 4 weeks. All patients had improvement in voice and reduced need for surgical debridement. The interval between bevacizumab doses was gradually increased to every 8-12 weeks. Adverse events included mild proteinuria and self-resolving epistaxis.

Purpose: This retrospective study aimed to evaluate the prognostic value of metabolic parameters in baseline fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) for pediatric lymphoblastic lymphoma (LBL). Method: Thirty patients with LBL who underwent baseline 18F-FDG PET/CT from April 2013 to November 2018 were enrolled. Their metabolic parameters including maximum standardized uptake value (SUVmax), total metabolic tumor volume (TMTV), and total lesion glycolysis (TLG) were measured and compared with those from different clinical characteristic groups. Event-free survival (EFS) and overall survival (OS) curves were constructed using the Kaplan–Meier method and compared with the log-rank test. Results: The patients with stage Ⅳ had higher TMTV than stage Ⅲ (mean 580.66cm³ vs. 176.52cm³; p=0.031). No statistical significance in SUVmax and TLG was observed between patients with stages Ⅲ and Ⅳ (p=0.061; p=0.291). After a median follow-up of 41.5 months (range of 1–86 months), the patients with a low TMTV (<242.91cm³) had better 3-year EFS rate compared with those with a high TMTV (88.9% vs. 56.3%; p=0.036). However, SUVmax and TLG were not predictive of EFS(p=0.874; p=0.152). Conclusions: TMTV may be a potential PET/CT metabolic parameter for predicting the prognosis of pediatric lymphoblastic lymphoma. A high TMTV indicates a poor outcome. However, SUVmax and TLG are not related to the prognosis of pediatric lymphoblastic lymphoma.

We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days post-discharge (i.e. 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.

Objectives To study the CT diagnosis of COVID-19 that was based on the imaging features of secondary pulmonary lobular structure. Materials and methods After institutional review board approval and informed consent, 139 cases with suspected COVID-19 who undergone CT were retrospectively analyzed. Based on the anatomical structure of pulmonary lobule, the imaging features of secondary pulmonary lobular structure on CT images was defined and built simulation diagrams serve as a unified standard. The imaging performance of confirmed 103 cases was evaluated for diagnosis of COVID-19. Results Of these 139 cases, 103 cases were confirmed for COVID-19, 36 cases were confirmed for other diseases.The sensitivity, specificity and accuracy of CT are 83.33%, 20.39%, 80.58%,Of the 103 COVID-19 cases, 82(79.61%) cases were typical cases and 21(20.39%）cases were atypical cases. 65(63.11% ) cases were in the early or advanced stage, 26(25.24%) cases were in the severe or recovery stage, and 12(11.65%)were in multiple stages. The scores of pulmonary lobular structure in typical COVID-19 (3.42±1.25) were significant different compared with atypical COVID-19 (1.51±1.34, P<0.001). The inter-observer agreement for the score of secondary pulmonary lobular structure was excellent (kappa = 0.863, P<0.05). Conclusion To recognize the CT common imaging signs of secondary pulmonary lobular structure in COVID-19 can deepen the understanding of COVID-19 from the basis of image anatomy, and screen suspected cases and provide imaging basis for diagnosis and differential diagnosis.

Background: The incidence of prosthetic tricuspid valve (TV) thrombosis is the highest among heart valves. It can lead to high morbidity and mortality without proper treatment. In this study we sought to report the management and clinical outcomes of patients with mechanical TV thrombosis. Methods: In in a retrospective single-center study, all patients with mechanical TV thrombosis were evaluated from 2006 to 2017. The data on baseline characteristics, management of mechanical TV thrombosis, and the rates of adverse events during follow-up period were assessed. Results: A total of 67 episodes of mechanical TV thrombosis in 42 patients were observed. The mean age of patients was 45.5±14.3 years (19 to 77), and overall two-thirds were female. Thrombolytic therapy (TT) was used in 41 (61.1%), anticoagulant intensification in 15 (22.3%), and surgery as first approach in 11 (16.4%) episodes; subsequently, surgery as the final approach was implemented in 20 (29.8%) episodes. There were a total of 2 (2.98%) in-hospital deaths. Moreover, 2 (4.87%) episodes of retroperitoneal hematoma and 1(2.43%) episode of non-hemorrhagic thalamic infarct in TT group, and 1 (5%) episode of non-hemorrhagic stroke following surgery were developed. The rates of freedom from recurrent thrombosis were 84%, 61%, and 21% at the end of 2, 4, and 10 years, respectively. Survival rates and freedom from chronic valve dysfunction was 93%, 82%, and 75% after 1, 4, and 10 years. Conclusions: The recurrent thrombosis requiring intervention is a major complication of mechanical TV, which underscores individual-approached therapy and close follow-up to improve outcome.

Correlation between AHI and right ventricular diastolic function in patients with obstructive sleep apnea syndromeJunfang Li 1, MD, PhD, Changhong Lu2, MD, Zhibin Wang 1, MD, PhD1, Department of Echocardiography, Qingdao University Affiliated Hospital, Qingdao, 266001,China2, Department of Heart Center, Qingdao Fuwai Cardiovascular Hospital, Qingdao, 266034,ChinaCorresponding author: Zhibin Wang, Department of Echocardiography, Qingdao UniversityAffiliated Hospital, No. 16, Jiangsu Road, Qingdao 266001, China

Background: Reproductive complications for cancer survivors are identified as one of the top unmet needs. Current models of care do not routinely incorporate reproductive follow-up for cancer patients. The Kids Cancer Centre have had a one stop survivorship clinic which includes a gynecologist and fertility specialist. Methodology: To inform the future development of our reproductive survivorship care we audited this service over a twelve-year period reviewing who used the service and their gonadotoxic risk, their reproductive needs and concerns. Main results: 278 patients were seen (397 consultations), including 189 female patients (68.0%). Median age at follow up was 25.0 years (range=6-50) and they were 19.2 years from their primary diagnosis (range=3-46). We identified 10 themes of reproductive need. Patients had on average 2.5 reproductive concerns documented per consultation (range 1-5). The three most commonly documented concerns at initial consultation related to fertility status (43.9%), endocrine dysfunction (35.3%), and contraception advice (32.4%). In patients younger than 25 years discussions were predominately about endocrine dysfunction, fertility status and contraception, while dominant themes for 26-35 years olds were fertility status, reproductive-related health prevention strategies, contraception and endocrine dysfunction. Survivors aged 36-45 prioritised fertility status, pregnancy, and contraception. Fertility preservation (p=0.05), preventative health strategies (p=0.001), and contraception advice (p<0.001) were more commonly discussed by females than males. Conclusion: Longitudinal reproductive follow up care is important, as patients have a number of ongoing reproductive concerns which change over time. Our data can assist in informing the model of care.

Point-of-care tests (POCTs) offer considerable potential for improving clinical and public health management of COVID-19 by providing timely information to guide decision-making, but data on real-world performance are in short supply. Besides SARS-CoV2-specific tests, there is growing interest in the role of surrogate (non-specific) tests such as FebriDx, a biochemical POCT which can be used to distinguish viral from bacterial infection in patients with influenza-like illnesses. This short communication assesses what is currently known about FebriDx performance across settings and populations by comparison with some of the more intensively evaluated SARS-CoV2-specific POCTs. While FebriDx shows some potential in supporting triage for early-stage infection in acute care settings, this is dependent on SARS-CoV2 being the most likely cause for influenza-like illnesses, with reduction in discriminatory power when COVID-19 case numbers are low, and when co-circulating viral respiratory infections become more prevalent during the autumn and winter. Too little is currently known about its performance in primary care and the community to support use in these contexts and further evaluation is needed. Reliable SARS CoV2-specific POCTs – when they become available – are likely to rapidly overtake surrogates as the preferred option given the greater specificity they provide.