Background: Few guidelines exist to guide pulmonary clearance therapies for children receiving invasive mechanical ventilation. In our institution, we have used sodium bicarbonate solution instilled via tracheal tube to assist with secretion clearance and improve atelectasis. Despite reports of its use, there is very little literature to characterize sodium bicarbonate via tracheal tube in clinical practice. Methods: We performed an IRB-approved, retrospective chart review in a single center of all patients who received sodium bicarbonate via tracheal tube over a 5-year period. We collected data on how sodium bicarbonate was used and analyzed for any reported improvement in respiratory status after its use. Results: Fifteen patients were reviewed. Most received 2.4% sodium bicarbonate via tracheal tube for an average of three doses of an average of 3.1 mL instilled. Most patients had documented improvement in chest radiograph appearance, and several were able to be significantly weaned from mechanical ventilator settings immediately following use of sodium bicarbonate. Most had thinner, smaller, and clearer secretions following use of sodium bicarbonate. There were no adverse events related to use of sodium bicarbonate. Conclusions: Sodium bicarbonate given via tracheal tube was safe in our group of patients. There was improvement in chest radiograph appearance, secretion tenacity, and ventilatory needs in most of our patients. This was a small, retrospective study of pediatric patients with very complex medical conditions, and most were also receiving other forms of pulmonary clearance concomitant with sodium bicarbonate. Further study is warranted in the form of prospective, randomized, blinded trials.

Application of bio-fertilizer can improve soil fertility and retard the soil degradation. Based on a field experiment, the changes of soil organic C, aggregate stability and organic C in aggregate fractions were analyzed to investigate the effects of bio-fertilizer (BF) combined with a reduced chemical fertilizer. Bio-fertilizer was applied at rates of 0 (BF0), 30 (BF30), 50 (BF50) and 70 (BF70) t ha-1 and soil samples were collected from 0-20 cm layer in 2018 and 2019. Soil cores were separated into three aggregate sizes (>0.25 mm, 0.053-0.25 mm and <0.053 mm) using the wet sieving method. The highest soil organic C and water soluble organic C were measured in BF70, while BF50 had the highest concentrations of microbial biomass carbon, extractable organic C and KMnO4-C. Significant increases of mean weight diameter (3.16 mm in 2018 and 3.39 mm in 2019) in BF50 compared with BF0 showing the improved soil structural stability after bio-fertilizer application. Increased with increasing bio-fertilizer application rates then remained relative stable, organic C in aggregate fractions was highest in BF50. More organic C was accumulated in aggregates of 0.053-0.25 mm in bio-fertilizer amended soils, suggested that C was mainly occluded in micro-aggregate and benefit for protection of C from microbial decomposition. Our results indicated that bio-fertilizer combined with chemical fertilizer was effective in increasing organic C and its labile fractions, which promoted soil structural stability in turn, thereby improving soil quality.

Tidal marsh wetlands in the Yellow River Delta provide valuable eco-services to the local population and global ecology. However, this area is suffering from serious degradation under the stresses of social development and climate change. Hydrological connectivity, a new framework in hydrology and ecology, has been proposed as the main factor affecting the ecological processes in coastal wetlands; however, its role in hydrology–soil–vegetation interactions remains unclear. In this study, the researchers parametrically quantified the hydrological connectivity in the tidal marsh wetlands and analyzed its relationship with Phragmites australis, one of the dominant species in this area. Our results showed threshold-like effects on the interaction between hydrological connectivity and P. australis on the plot scale. When biomass is lower than 2.2 kg/m2, the population density and structure size were found to increase with hydrological connectivity. When the biomass is higher than the threshold, the plots disconnected hydrologically because of high water consumption. Compared with soil chemistry, salinity, and water soil content, hydrological connectivity in the surface soil layer is more strongly linked to the plant traits and spatial structure in the tidal marsh wetlands due to the narrow ranges of other variables. Based on the authors’ analysis, the researchers do not recommend dense plantation of P. australis, especially near the freshwater sources in the tidal marsh, because of its high reproduction ability and competitive nature, which may cut the freshwater connectivity off, lowering the richness of plant species and habitat diversity.

Objects: To analyze the features of ultrasound images of neonates with different degrees of bronchopulmonary dysplasia (BPD), and to investigate the value in evaluating moderate and severe BPD. Methods: The neonates admitted to newborn intensive care unit (NICU) were divided into BPD group, non-pulmonary disease group and infectious pneumonia group. This study included two parts: (1)The image characteristics including pleural morphology, alveolar-interstitial syndrome (AIS), retrodiaphragmatic hyperechogenicity and diaphragmatic shape of different degrees of BPD were summarized. (2) We compared the value of lung ultrasound and chest X-ray in diagnosing moderate to severe BPD. Results: In the mild BPD group, the proportion of pleural thickening, pleural abnormalities and AIS was higher. The moderate and severe BPD group had higher prevalence of diffuse AIS, small cysts near the diaphragm and rough diaphragm. The sensitivity and specificity of ultrasound in diagnosis of moderate and severe BPD were 31.1% and 99.1%. There was no significant difference of the diagnosis values between lung ultrasound and chest X-ray. Conclusion: The ultrasound features of moderate and severe BPD were diffuse AIS, small cysts near the diaphragm and abnormal diaphragm. Compared with chest radiography, lung ultrasound showed the similar value in diagnosing moderate and severe BPD. Key words: bronchopulmonary dysplasia, lung, ultrasonography, infant

Drought has vastly impacted agriculture all over the globe. However it’s impact on crop production: degree and extent is poorly characterized. As the occurrence of more extreme droughts is likely to increase under climate change, understanding the vulnerability of crop production to droughts is a crucial to evaluate and determine the size of the losses. In this study, we used drought events in the South Asia region during the time period 2003-2018, to compare various indices developed for the study of drought phenomena. Three indices namely: the precipitation condition index (PCI), vegetation cover index (VCI) and temperature condition index (TCI) depend on remote sensing data were assimilated to produce an integrated drought severity index (IDSI) to estimate drought conditions. We also correlated the IDSI anomaly with the yield anomaly in the region. The results showed that IDSI has a good correlation with yield anomaly. The study also investigated the influence of drought on area harvested (ha) production (hg/ha) and yield (tons). Economic losses were assessed using the empirical relations between crop yields, IDSI, monthly precipitation, and annual precipitation. The results showed agriculture GDP (AGDP) has a statistically significant correlation (p-value < 0.01) with economic loss and the correlation coefficient R2 registered 0.32, 0.82, 0.84, 0.51 0.79 and 0.81 in Afghanistan, Pakistan, India, Bhutan, Nepal and Bangladesh respectively. The results of this study offer scientific support for decision-making targeted towards disaster mitigation and adaptation under climate change by identifying the regions in which drought risk control and management.

Background There is currently no consensus regarding the outcomes and outcome measures that should be reported in studies assessing planned mode of birth. Objectives To develop an inventory for reported outcomes for studies comparing planned caesarean section (CS) and planned vaginal delivery (VD) for women age 18-45. Search strategy Three online databases, Ovid SP version of MEDLINE and EMBASE and the Cochrane Pregnancy and Childbirth Group’s Trials Register, were searched from 2011 to June 2019. Selection criteria The inclusion criteria were: prospective studies evaluating planned mode of birth, age 18-45, singleton pregnancy, gestational age 37-40 weeks, >100 participants, middle or high income countries. No language restrictions were applied. Data collection and analysis Two researchers independently screened titles and abstracts, and subsequently reviewed the full text of each selected study to assess for eligibility. Discrepancies were resolved by discussion with a third author. The selected studies were evaluated using the MOMENT criteria. Outcomes and outcome measures were systematically extracted and organised into an inventory. Main results 63 prospective studies including data from 6,397,310 women were included. Based on the MOMENT score of 4 or more, 37 studies (59%) were of high quality. In total, 43 different primary outcomes and 79 different primary outcome measures were identified; 12 different secondary outcomes and 31 secondary outcome measures were identified. The primary outcome measurements and definitions of outcomes were inconsistent. Conclusions Prospective studies evaluating outcomes of planned mode of birth frequently report different primary outcomes and outcome measures. Funding: None required

Introduction: On March 11, 2020, the World Health Organization (WHO) declared the coronavirus outbreak (COVID-19) to be pandemic. By March 16, 2020, 139 countries were affected. In this situation, the Scientific Societies decided to prepare this Contingency Plan to guide the response of health services. 4,088,848 COVID-19 cases and 283,153 deaths were confirmed worldwide. Recent data presented by the Ministry of Health in Brazil show that 177,589 cases of coronavirus and 72,597 recovered people have already been registered. However, nursing homes usually are not counted in these statistical data, as people usually die in the Istitution. Thus, developing a monitoring program in medical services, such as in nursing homes for eldery people (NHE) with ideal care for possible patients infected with COVID-19, is essential to increase the protection of the most vulnerable, as well as professionals of health. Objective:  To present the monitoring program of the Nursing homes in the city of São José do Rio Preto/SP, by Faceres Medica School, as an important strategy to identify, control and allocate patients infected by COVID-19. Methods:. All the NHE registered in the city council were raised , with data such as head nurse name, number of beds available and number of inpatients . According to the program's action plan, telephone calls was made daily by trained medical students with a professor tuition to all institutions and information was provided by the head nurse. Thus, when a resident or employee has symptoms, he was removed and tested for SARS-CoV-2. Subsequently, epidemiological surveillance was communicated and the case was monitored. Final Considerations: According to the world literature, elderly patients with COVID- 19 are more likely to progress to severe disease. Therefore, extensive measures to reduce the transmission of COVID-19 from person to person are being implemented to control the current outbreak. The monitoring program at the NHE proposed in the present study aims to collaborate in this regard, especially to the most vulnerable.

Manuscript title: Do gender and puberty influence allergic diseases?To the Editor:The differences between biological sex, gender identity and its impact on health can have significant implications for the prevention, screening, diagnosis and treatment of various diseases, including allergic diseases. Gender and sex are multidimensional, interactive, intertwined and are sometimes difficult to separate, so the use of the two words (gender and sex) can help to understand the social, cultural and biological context.1During childhood (0-10 years) prevalence of allergic rhinitis (AR) is higher among boys than girls. On the contrary, during adolescence (11-17 years) females display higher prevalence of AR compared to their male counterparts. However, when they reach adulthood (18-79 years), there is no difference in prevalence between genders. The same pattern occurs, even more pronounced, for prevalence of coexisting AR and asthma.2,3In the first year of life, rates of allergic sensitization (specific IgE production) are significantly higher in males, as are serum levels of total IgE. In this age group, serum levels of total IgE appear to suffer a strong genetic influence and may not predict levels of total IgE in the same individual later in life. Increased levels of IgE and higher prevalence of sensitization in boys remains until adolescence. After puberty, total serum and allergen-specific IgE levels in men are thought to remain higher or comparable to those in women. In adulthood, IgE levels decrease in both genders. In addition to changes during life, IgE levels are also influenced by menstrual periods and pregnancy, suggesting the participation of sex hormones in their regulation.4A recent analysis performed in 4,500 brazilian children aged 13-14 years has shown that females not only have a higher prevalence of AR compared to males, but also of allergic rhinoconjunctivitis (ARC), asthma, allergic conjunctivitis (AC) and atopic dermatitis (AD) (Figure 1, A). Interestingly, there is an opposite allergic sensitization pattern with respect to gender, with more allergic sensitization in boys than in girls (Figure 1, B). Moreover, it has also been observed that monosensitization is more frequent in females, while polysensitization is more common in males.5A global meta-analysis showed sex-related differences in rhinitis prevalence with a switch at around puberty from a male predominance to a female predominance. For the prevalence of rhinitis in adulthood, this evaluation found no predominance in either males or females, although the number of studies was low. In the future, it will be mandatory to perform longitudinal studies in which the follow-up is continued into adulthood.6A meta-analysis of longitudinal birth cohorts showed a sex shift from higher incidence in boys before puberty towards a rather sex-balanced incidence after puberty onset. The elevated risk of asthma and rhinitis incidences in teenage girls should lead to more consideration of a sex-specific and age-specific focus on diagnosis and treatment of respiratory diseases.7The complexity of most allergic diseases is based on a dynamic heterogeneous combination of hyperresponsiveness, dysregulated immune response, chronic inflammation, and tissue remodeling in affected organs. It is vital to systematically investigate sex disparities, possibly in different age groups, allergic diseases incidence, and their outcomes. When they are identified, it is necessary to elucidate their biological basis and understand if better outcomes could be obtained with sex-specific treatment modifications.8There are different risk factors for developing allergic diseases in boys and girls. A longitudinal study found that obesity, together with rhinitis and current smoking were risk factors for developing asthma in girls, while the main risk factors for boys were reduced FEV1, seasonal allergic symptoms and a family history of asthma.9To optimize clinical practice, it is necessary to understand, in addition to the molecular mechanisms and biomarkers, the phenotypes of allergic diseases, as well as the difference in their distribution between genders. This is recognized as an innovative element, as there is scientific evidence that men and women not only have distinct clinical manifestations for the same disease, but have different therapeutic responses. These can be influenced by biological (hormonal, organic) and socio-cultural factors (adherence to treatment, work, purchasing power).8Men and women have different lifestyles, in terms of choosing specific professions, sports, intake of hormonal medications and quality of diet. Immune cells (lymphocytes, monocytes, eosinophils and mast cells) express hormone receptors and, therefore, may be highly influenced by endogenous and exogenous hormones, which fluctuate in women.1Longitudinal studies would be interesting to evaluate possible mechanisms underlying these differences in prevalence. Sex- and gender-specific evaluations beyond 14 years of age are scarce and further allergic multimorbidity studies in different populations, especially in adults, are necessary.3 References:Franconi F, Campesi I, Colombo D, Antonini P. Sex-Gender variable: methodological recommendations for increasing scientific value of clinical studies. Cells. 2019;8(5):476. doi: 10.3390/cells8050476Keller T, Hohmann C, Standi M, Wijga AH, Gehring U, Melén E, et al. The sex-shift in single disease and multimorbid asthma and rhinitis during puberty – a study by MeDALL. Allergy. 2018;73(3):602-614. doi: 10.1111/all.13312Frohlich M, Pinart Gilberga M, Keller T, Reich A, Cabieses B, Hohmann C, et al. Is there a sex-shift in prevalence of allergic rhinitis and comorbid asthma from childhood to adulthood? A meta-analysis. Clin Transl Allergy. 2017;7:44. doi: 10.1186/s13601-017-0176-5Leffler J, Stumbles PA, Strickland DH. Immunological Processes Driving IgE Sensitisation and Disease Development in Males and Females. Int J Mol Sci. 2018;19:1554. doi: 10.3390/ijms19061554Rosario CS. Fatores associados à conjuntivite alérgica em adolescents de Curitiba, Paraná. [Dissertação] 2018. Curitiba (PR): Universidade Federal do Paraná. https://hdl.handle.net/1884/65989 (2018). Accessed 14 Apr 2020.Pinart M, Keller T, Reich A, Fröhlich M, Cabieses B, Hohmann C, et al. Sex-related allergic rhinitis prevalence switch from childhood to adulthood: a systematic review and meta-analysis. Int Arch Allergy Immunol. 2017;172(4):224-235. doi: 10.1159/000464324Hohmann C, Keller T, Gehring U, Wijga A, Standi M, Kull I, et al. Sex-specific incidence of asthma, rhinitis and respiratory multimorbidity before and after puberty onset: individual participant meta-analysis of five birth cohorts collaborating in MeDALL. BMJ Open Respir Res. 2019 doi:10.1136/ bmjresp-2019-000460De Martinis M, Sirufo MM, Suppa M, Di Silvestre D, Ginaldi L. Sex and gender aspects for patient stratification in allergy prevention and treatment. Int J Mol Sci. 2020;21(4):1535. https://doi.org/10.1016/j.jaip.2018.08.008Kalm-Stephens P, Nordvall L, Janson C, Neuman A, Malinovschi A, Alving K. Different baseline characteristics are associated with incident wheeze in female and male adolescents. Acta Paediatr. 2020 Mar 18. doi: 10.1111/apa.15263 [epub ahead of print].Rosario CS1, Cardozo CA2, Chong Neto HJ1, Rosario NA1,1-Pediatric Allergy and Immunology, Federal University of Parana.2- Department of Pediatrics, Universidade Positivo.Cristine Secco Rosário: ORCID ID https://orcid.org/0000-0003-4457-3540 cristinerosario@hotmail.comCristina Alves Cardozo: ORCID ID criscardozo.cwb@gmail.com 0000-0001-6091-7142Herberto José Chong Neto: ORCID ID h.chong@uol.com.br https://orcid.org/0000-0002-7960-3925Nelson Augusto Rosário: ORCID ID https://orcid.org/0000-0002-8550-8051 nelson.rosario@ufpr.brCorresponding author: Cristine Secco Rosário. Address: Rua Padre Camargo, 453. Alto da Gloria. Curitiba – PR – Brazil. Tel: +55 (41) 3208-6500. e-mail: cristinerosario@hotmail.com

Leaf stomatal density is known to covary with leaf vein density. However, the functional underpinning of this relation, and how it scales to whole-plant water transport anatomy, is still unresolved. We hypothesized that the balance of water exchange between the vapour phase (in stomata) and liquid phase (in vessels) depends on the consistent scaling between the summed stomatal areas and xylem cross-sectional areas, both at the whole-plant and single-leaf level. This predicted size-covariation should be driven by the covariation of numbers of stomata and terminal vessels. We examined the relationships of stomatal traits and xylem anatomical traits from the entire plant to individual leaves across seedlings of 53 European woody angiosperm species. There was strong and convergent scaling between total stomatal area and stem xylem area per plant and between leaf total stomatal area and midvein xylem area per leaf across all the species, irrespective of variation in leaf habit, growth-form or relative growth rate (RGR). Moreover, strong scaling was found between stomatal number and terminal vessel number while not in their respective average areas. Our findings have broad implications for integrating xylem architecture and stomatal distribution, and deepen our understanding of the design rules of plants’ water transport network.

Today’s available therapies to treat patients infected with human immunodeficiency virus (HIV) aim at preventing viral replication and transmission but fail to eliminate the virus. Although transplantation of an allogeneic CCR5Δ32 homozygous stem cell grafts provided a cure for three patients, this approach is not considered a general therapeutic strategy because of potential severe side effects. Conversely, genome editing to disrupt the CCR5 locus that encodes the major HIV coreceptor was shown to confer resistance to R5-tropic HIV strains on the cellular level. Here, we present a clinically relevant and highly efficient approach to produce HIV-1 resistant CD4+ T cells. After transferring mRNA coding for CCR5-targeting TALEN into CD4+ T cells by electroporation, up to 89% of CCR5 alleles were disrupted. Genotyping confirmed genetic stability of the edited cell product and off-target analyses established absence of relevant mutagenic events. When challenging these edited T cells with R5-tropic HIV, we observed protection in a dose-dependent manner. Functional assessments revealed no significant differences between edited and control CD4+ T cells in terms of proliferation capacity and their ability to secrete cytokines upon exogenous stimuli. Overall, we successfully engineered HIV-resistant CD4+ T cells under clinically relevant conditions, paving the way for clinical translation.

Severe recurrent mitral regurgitation (MR) within 1 year of mitral valve repair is usually attributed to a technical issue with the original repair procedure. However, when artificial chordae are employed to correct mitral valve prolapse, ventricular remodeling (i.e. decreased ventricular size) can lead to recurrent prolapse and valve dysfunction. To highlight this phenomena, we present 2 patients who experienced early failure after undergoing mitral valve repair with artificial chordae.

Chennai aquifer system covering an area of 6629 km2 is one of the most stressed aquifer systems in southern India as groundwater is relentlessly used for irrigation, domestic, industrial purposes and for drinking water supply to ever expanding Chennai city. This heavy extraction necessitated a paradigm shift towards groundwater management. Multidisplinary-integrated approach was taken up to map the aquifers, delineate its geometry, hydrodynamic characterization and to formulate an aquifer management plan through groundwater model. Weathered & fractures gneiss/charnockites along with alluvium form the aquifer units. Alluvium is the potential aquifer system of the region with potable quality except for the eastern/northeastern region affected by to seawater intrusion. Two-layered hydrogeological model was developed with one km2 grid pattern to simulate groundwater flow for nine years. The model calibrated under steady and transient conditions, allows quantifying the components of recharge, groundwater draft, and fluxes on the regional scale. Simulated results indicate that this aquifer system is under tremendous stress with the present groundwater withdrawal of 899 mcm and becomes unstable with 25 % increase in groundwater withdrawal by 2025. 54 mcm increase in resources due to recharge measures has groundwater head build up and easterly movement of the potential lines. Scenario of maintaining 120 days flow in rivers shows increase in groundwater head and development of the groundwater mounds, which are positive signatures for arresting the decline and pushing the saline water. Regulation of groundwater abstraction and rejuvenation flow in the rivers would sustainably manage the available groundwater resources of the region.

After its first description in Wuhan (China), SARS-CoV-2 the agent of coronavirus disease 2019 (COVID-19) rapidly spread worldwide. Previous studies suggested that pets could be susceptible to SARS-CoV-2. Here, we investigated the putative infection of SARS-CoV-2 in 22 cats and 11 dogs from owners previously infected or suspected of being infected by SARS-CoV-2. For each animal, rectal, nasopharyngeal swabs and serum were taken. Swabs were submitted to RT-qPCR assays targeting 2 genes of SARS-CoV-2. All dogs were tested SARS-CoV-2 negative. One cat was tested positive by RT-qPCR on rectal swab. Nasopharyngeal swabs from this animal were tested negative. This cat showed mild respiratory and digestive signs. Serological analysis confirm the presence of antibodies against the SARS-CoV-2 in the two serum samples taken 10 days apart. Genome sequence analysis revealed that the cat SARS-CoV-2 belongs to the phylogenetic clade A2a like most of the French human SARS-CoV-2. This study reports for the first time the natural infection of a cat in France (near Paris) probably through their owners. There is currently no evidence that cats can spread COVID-19 and owners should not abandon their pets or compromise their welfare.

In the present study one hundred and sixteen partial G gene sequences of Avian metapneumovirus (aMPV) subtype B, obtained during routine diagnostics in different European Countries in the last few years (2014-2019), were analysed by sequence and phylogenetic analyses in order to draw an updated picture of the molecular characteristics of circulating strains. Nucleotide sequences were compared with other sequences of European and extra-European aMPV-Bs collected prior to that period or retrieved from GenBank. Phylogenetic relationships among the aMPV-B strains, reconstructed using the Maximum Likelihood method implemented in MEGA X, demonstrated that aMPV-B has evolved in Europe from its first appearance, frequently displaying a clear relation with the geographic area of detection. The 40% of aMPV-B viruses analysed were classified as vaccine-derived strains, being phylogenetically related, and showing high nucleotide identity with live commercial vaccine strains licensed in Europe. The remaining 60% were classified as field strains since they clustered separately and showed a low nucleotide identity with vaccines and vaccine-derived strains. The phylogenetic tree showed that the virus has continued to evolve from its first appearance in the ’80s since more recently detected strains belonged to clades phylogenetically distant from the older strains. Unlike vaccine-derived strains, field strains tended to cluster according to their geographic origin and irrespective of the host species where the viruses had been detected. In conclusion, the molecular characterization of aMPV-B and the differentiation between vaccines and field strains through G gene sequence analysis can be a useful tool towards correct diagnosis and should be routinely applied in order to better address the control strategies.

OBJECTIVE We reported the clinical characteristics, laboratory findings, and radiologic features of a COVID-19 registry in Iran and compared disease manifestations between the deceased patients and those who recovered. DESIGN This was a retrospective cross-sectional study with census sampling. SETTING Three hundred forty-five patients were enrolled from February 25th, 2020, to April 21st, 2020, in a tertiary referral hospital. PARTICIPANTS Patients with suggestive lung computed tomography scans (CT scans) who had respiratory symptoms and one of the followings: 1) loss of consciousness, 2) Respiratory rate more than 24, 3) pulse rate more than 90, 4) Systolic blood pressure less than 90 mmHg, 5) abnormal respiratory sounds, or 6) O2 saturation less than 93% or high-risk patients with respiratory symptoms or fever were enrolled to the study. MAIN OUTCOME MEASURES The primary outcome measures were days of hospital stay, any event of intubation, ICU admission, and in-hospital death. Logistic regression was done to assess the association between survival status and patients’ characteristics. RESULTS Nearly 45% of patients were older than 65 years, and 57.6% were male. Twenty hundred and sixty-five patients (74.8%) survived. Univariate analysis showed a significant association between mortality and older age, higher body mass index, aspartate transaminase, consciousness, cancer, organ transplant, oxygen saturation (SO2), systolic and diastolic blood pressure, body temperature, respiratory rate, pulse rate, anemia, leukocytosis, neutrophil to lymphocyte ratio (NLR), thrombocytopenia, creatinine, CRP, PH, PCO2, and bicarbonate. The relationship between mortality and consciousness, cancer, low SO2, tachycardia, platelet count less than 150,000 per microliter of blood, creatinine over 1.2 mg/dL remained statistically significant in multivariate analysis. The average total length of hospital stay was 5.98 days (SD: 5.87). CONCLUSION We observed that increased tachycardia, high-grade fever, tachypnea, and NLR strongly correlated with in-hospital death. In contrast, higher levels of systolic blood pressure had a protective role.

Soil water stable isotopes are widely used across disciplines (e.g. hydrology, ecology, soil science, and biogeochemistry). However, the full potential of stables isotopes as a tool for characterizing the origin, flow path, transport processes and residence times of water in different eco-, hydro-, and geological compartments has not yet been exploited. This is mainly due to the large variety of different methods for pore water extraction. While recent work has shown that matric potential affects the equilibrium fractionation, little work has examined how different water retention characteristics might affect the sampled water isotopic composition. Here, we present a simple laboratory experiment with two well-studied standard soils differing in their physico-chemical properties (e.g., clayey loam and silty sand). Samples were sieved, oven-dried and spiked with water of known isotopic composition to full saturation. For investigating the effect of water retention characteristics on the extracted water isotopic composition, we used pressure extractors to sample isotopically labelled soil water along the pF curve. After pressure extraction, we further extracted the soil samples via cryogenic vacuum extraction. The null hypothesis guiding our work was that water held at different tensions shows the same isotopic composition. Our results showed that the sampled soil water differed isotopically from the introduced isotopic label over time and sequentially along the pF curve. Our and previous studies suggest caution in interpreting isotope results of extracted soil water and a need to better characterize processes that govern isotope fractionation with respect to soil water retention characteristics. In the future, knowledge about soil water retention characteristics could be applied to predict soil water fractionation effects under natural and non-stationary conditions.

Aims: Opioid misuse and overuse has contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids, and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids. Results: In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a CBD-predominant oral extract in the daytime and consider adding THC. When adding THC, start with 0.5–3 mg, and increase by 1–2 mg once or twice weekly up to 30–40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain, and/or the cannabis dose has been optimized. The opioid tapering schedule may be 5%–10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥ 30% reduction in pain intensity, a ≥ 25% reduction in opioid dose, a reduction in opioid dose to < 90 mg MED, and/or reduction in opioid-related adverse events. Conclusions: This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.

Introduction: Hydroxychloroquine (HCQ) alone or in combination with azithromycin (AZ) is one of the many therapies being explored for the treatment of Coronavirus 2019 (COVID-19). We performed a systematic review regarding the effects of HCQ versus HCQ+AZ on corrected QT interval (QTc) and cardiovascular outcomes. Methods: We performed a systematic search, using PubMed, EMBASE, SCOPUS, and Google Scholar from inception to May 3rd, 2020, with studies fulfilling the following inclusion criteria: (1) compared HCQ versus HCQ+AZ in COVID-19; (2) reported change in QTc interval and/or cardiovascular outcomes. The primary outcome was change in QTc (maximum QTc–baseline QTc) and incidence of TdP in COVID-19 patients on HCQ vs. HCQ+AZ. Results: A statistically significant change in QTc interval was observed with HCQ+AZ compared to HCQ alone (WMD 9.13 ms, 95%CI 3.74-14.01, p=0.01, I2=29.04%). However, no significant difference in the risk of development of QTc>500 ms was observed between two groups (10.6% in HCQ vs. 14.7% in HCQ+AZ, RR 0.71, 95% CI 0.32-1.59, p =0.40, I2 = 35.8%). Also, no significant difference in risk of TdP was observed between the two groups (0% vs. 0.5%, risk difference -0.002,95% CI-0.02 to 0.02, p=0.83, I2 =0%, respectively). However, one patient experienced TdP, three days after discontinuation of HCQ+AZ for prolonged QTc (499 ms). Conclusion: The risk/benefit of HCQ and AZ should be carefully contemplated, given the risk of QTc prolongation. Until further safety data is available, we recommend close monitoring of QTc interval and electrolytes, avoiding drug-drug interactions in these high-risk patient populations.

Introduction: Pulmonary vein (PV) isolation using cryoballoon ablation (CBA) is a common therapy for patients with drug refractory paroxysmal atrial fibrillation (PAF). However, initial CBA is successful in only 70-80% of patients. The role of an atypical left common PV (LCPV) and PV anatomical indices on CBA outcomes remains unclear. Methods and Results: We followed 80 patients (age 60.7 ± 9.7, 31 % women) with PAF undergoing CBA for one-year post-procedure for the development of recurrent atrial arrhythmias (AA). Recurrence was assessed by documented AA on EKG or any form of long-term cardiac rhythm monitoring. The presence of an LCPV and individual PV diameters were evaluated using cardiac CT. Based on the maximum and minimum PV ostial diameters, the eccentricity index (EI), ovality index (OI), and PV ostial area (PVA) were calculated for all the veins. A multivariable cox-proportional hazard model assessed whether the presence of an LCPV or PV anatomic indices (EI, OI and PVA) predicted recurrence of AA following CBA. After one year follow up, 19 (23.7%) participants developed recurrence of AA. On multivariable regression, the presence of an LCPV did not predict the recurrence of AA (p = 0.38). Among the PV anatomical indices, on univariate analysis, only the area of the left inferior PV showed a trend towards predicting recurrence, though this result was not significant on multivariate analysis (p = 0.09). Conclusion: In patients with PAF, neither the presence of an LCPV nor individual PV anatomical indices predicted recurrence of AA following CBA.

34 years old man with frequent palpitations referred to our center. Three standard diagnostic catheters were introduced through left and right femoral veins and placed in right atrium, right ventricle and coronary sinus positions. A narrow complex tachycardia with long RP-short PR could be initiated after extarstimulation from HRA following an AV nodal jump. The earliest retrograde atrial activation was recorded from His bundle position. RV apical pacing showed decremental with earliest atrial activation in His area, although no fused V-A potential was recorded in either CS or His position. His synchronous pacing from RV apex failed to advance or reset the arrhythmia. Morady maneuver by RV overdrive pacing repeatedly terminated the tachycardia. Mapping was initiated from His region and extended to all anticipated areas from parahisian region to tricuspid annulus, posteroseptal TV ring and CS. The construction of RA activation map failed to reveal earliest activation site. Mapping catheter was introduced through femoral artery and advanced to the left ventricle. At anteroseptal mitral annulus corresponding to Aorto-Mitral continuity, we recorded the earliest retrograde atrial activation (A-distal CS =50 ms). RF energy (30 W) was delivered using an irrigate tip catheter during tachycardia and resulted in termination of tachycardia immediately.

EP ROUNDS

Less invasive techniques for cardiothoracic surgical procedures are designed to limit surgical trauma, but technical requirements and preoperative planning are more demanding than those for conventional sternotomy. Patient selection, interdisciplinary collaboration, and surgical skills are key factors for procedural success. Aortic valve replacement is frequently performed through an upper hemisternotomy, but the right anterior minithoracotomy represents an even less traumatic, technical advancement. Preoperative assessment of the ascending aorta in relation to the sternum is mandatory to select patients and the intercostal access site. This description of the surgical technique focuses on the specific procedural details including the obligatory planning with computed tomography, and our cannulation strategy. We also sought to define the anatomical ascending aorto-sternal relationship, as it is of utmost importance in preoperative computed tomographic planning.

i. Rationale, aims and objectives Antimicrobial Stewardship programs are critical for promoting and monitoring judicious use of antimicrobials, however, there are many well-established barriers to their effective implementation the rural setting. Pharmacist involvement in such programs is recommended as part of a multidisciplinary approach to improve appropriate antimicrobial prescribing. The aim of this study was to describe the impact of implementing a clinical pharmacy service on antimicrobial prescribing in a rural GP led hospital; explore areas of suboptimal antimicrobial prescribing; and review the change in total antimicrobial cost per patient day. ii. Methods: A retrospective case series audit of pre- and post-implementation of a new clinical pharmacy service was undertaken. All adult patients who had presented with sepsis, cellulitis, urinary tract infections and pneumonia between May and August 2015 and repeated for months in 2018 were included. Appropriateness of therapy was assessed using the National Antimicrobial Prescribing Survey guidelines. iii. Results: A total of 115 antibiotic orders from 2015 and 158 orders from 2018 were included. During admission, 86% of patients (55/64) in the post-intervention group were reviewed by a clinical pharmacist. Appropriate prescribing increased from 57% (66/115) in 2015 to 82% (129/158) in 2018 (P=0.001). Ceftriaxone was the most inappropriately prescribed antimicrobial. The cost of antimicrobial therapy was halved from $10.00 to $5.33 per patient day, pre- and post-implementation of a clinical pharmacy service respectively. iv. Conclusions: The implementation of a clinical pharmacy service in a small rural GP led hospital can significantly improve antimicrobial prescribing practices and provide considerable cost savings. Keywords Antimicrobial stewardship; antibiotics; pharmacists; hospitals, Rural; Inappropriate Prescribing

Ultra sound wire guided markers are safe and effective for unpalpable suspicious nodes Particularly useful on the setting of the previously operated neck Placement by an experienced radiologist in the presence of the operating surgeon is advocated