LS is a 39-year-old woman with systolic heart failure secondary to viral myocarditis (EF 10-15%). She was transitioned from IABP support to LVAD. Five weeks postoperatively she experienced progressive low flow alarms and underwent pericardial release via left mini-thoracotomy. Flows immediately improved postoperatively.

Protein lipoylation is essential for the function of many key enzymes, but barely studied kinetically. Here, the two-step reaction cascade of H protein lipoylation catalyzed by the multifunctional enzyme lipoate-protein ligase A (LplA) was quantitatively and differentially studied. We discovered new phenomena and unusual kinetics of the cascade: (1) the speed of the first reaction is faster than the second one by two orders of magnitude, leading to high accumulation of the intermediate Lip-AMP; (2) Lip-AMP is hydrolyzed, but only significantly at the presence of H protein and in competition with the lipoylation; (3) both the lipoylation of H protein and its hydrolysis are enhanced by the apo and lipoylated forms of H protein and a mutant without the lipoylation site. A conceptual mechanistic model is proposed to explain these experimental observations in which conformational change of LplA upon interaction with H protein and competitive nucleophilic attacks play key roles.

Key Points

Keypoints and Key wordsKeypoints :Many reports suggest that odontogenic sinusitis cause critical orbital abscess with high risk of ophthalmologic sequelae due to the pathogenic potential of anaerobic bacteria.This study aimed to compare the outcomes between odontogenic sinusitis and non-odontogenic sinusitis after management of orbital abscess in an adult population.The rates of revision surgery and visual sequelae were significantly higher in the odontogenic sinusitis group.Dental etiology of the sinusitis was overlooked in four patients (24%) of the odontogenic sinusitis group. Hence, dental cause of sinusitis has to be systematically sought and treated.Key words: Abscess, Blindness, Odontogenic infection, Orbital cellulitis, Sinusitis.Ethical considerationsThe protocol was approved by the local ethics committee. All participants gave informed consent.Main TextINTRODUCTIONOrbital cellulitis is a rare acute infection of the orbit and its contents that occurs mostly in children. The main cause is sinusitis (1). It is usually classified according to Chandler’s classification based on location and severity (2). Among orbital cellulitis, abscess formation occurs in 30% of the patients (3). Associated neurological acute complications, such as empyema or cerebral abscess, are rare but life-threatening. Long-term complications can be dramatic, notably blindness and cosmetic sequelae. The treatment includes hospitalization, intravenous antibiotics and surgery. The surgical procedure can combine endoscopic endonasal approach and external approach.According to the scientific literature, only 10% of sinusitis are odontogenic (4). Some authors suggest that odontogenic sinusitis (OS) cause critical orbital abscess (5) with higher risk of ophthalmologic sequelae (6), due to the pathogenic potential of anaerobic bacteria.This study aimed to compare the outcomes between OS and non-OS after management of orbital abscess in an adult population.MATERIALS AND METHODS

The microbiome community consists of microbes living in or on an organism and has been implicated in both host health and function. Environmental and host-related drivers of the microbiome have been studied in many fish species, but the role of the host genetic architecture across populations and among-families within a population is not well characterized. Here, Chinook salmon (Oncorhynchus tshawytscha) were used to determine inter-population differences and additive genetic variation within populations for gut microbiome diversity and composition. Specifically, hybrid stocks of Chinook salmon were created by crossing males from eight populations with eggs from an inbred line of self-fertilized hermaphrodite salmon. Based on high-throughput sequencing of the 16S rRNA gene, significant gut microbiome community diversity and composition differences were found among the hybrid stocks. These differences likely reflect divergent selection shaping the gut microbiome and its co-evolution with the host. Furthermore, additive genetic variance components varied among hybrid stocks, indicative of population-specific heritability patterns, suggesting the potential to select for specific gut microbiome composition for aquaculture purposes. Determining the role of host genetics in shaping their gut microbiome has important implications for predicting population responses to environmental changes and will thus impact conservation efforts for declining populations of Chinook salmon.

Coronavirus disease 2019 (COVID-19), an acute onset pneumonia caused by a novel betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in the Wuhan City of China in December 2019 and evolved into a global pandemic. To date, there are no proven drugs or vaccines against this virus. Hence, the situation demands an urgent need to explore all potential therapeutic strategies that can be made available to prevent the disease progression and improve patient outcomes. In absence of clinically proven treatment guidelines, several repurposed drugs and investigational agents are currently being evaluated in clinical trials for their probable benefits in the treatment of COVID-19. These include antivirals (remdesivir, lopinavir/ritonavir, umifenovir, favipiravir), interferon, antimalarials (chloroquine/hydroxychloroquine), antiparasitic drugs (ivermectin, nitazoxanide), biologics (monoclonal antibodies, interleukin receptor antagonist), cellular therapies (mesenchymal stem cells, natural killer cells), convalescent plasma, and cytokine adsorber. Though several observational studies have claimed many of these agents to be effective based on their in vitro activities and extrapolated evidence from SARS and MERS-CoV epidemics, the currently available data remains inconclusive because of ill-defined patient selection criteria, small sample size, lack of concurrent controls, and use of intermediary outcomes instead of patient-relevant outcomes. Moreover, there is a need to clearly define the patient populations who warrant therapy and also, the timing of initiation of treatment. Understanding the disease pathology responsible for the clinical manifestations of COVID-19 is imperative to identify the potential targets for drug development. This review explains the pathophysiology of COVID-19 and summarizes the potential treatment candidates which can provide guidance in developing effective therapeutic strategies.

Aims Lamotrigine is one of the most widely used antiepileptic drugs, but it has a critical issue of a skin rash if the starting dose is too high or the escalation rate is too rapid. We investigated the efficacy and safety of a novel and rapid titration protocol for lamotrigine that takes only 11 days to reach a daily dose of 200 mg. Methods We prospectively enrolled 33 adult patients (age 18-85) who were diagnosed with epilepsy and started lamotrigine administration for the first time at a single tertiary hospital. Our new protocol starts with a subthreshold dose of the drug and then administer a stepwise-incremental dose until reaching the full therapeutic dose within 11 days. Results Of 29 patients analyzed, only two (6.9%) experienced idiosyncratic skin rash before the first follow-up visit at 2 weeks (±3 days). In addition, a therapeutic concentration was reached in more than 75% of studied patients after 2 weeks of lamotrigine administration Conclusion These findings demonstrate the value of the novel tolerance induction protocol for lamotrigine, which could widen the available application of lamotrigine in various situations.

IntroductionOn 11th of March 2020 the World Health Organization declared the Coronavirus disease (COVID-19) outbreak a pandemic(1). Human-to-human transmission of COVID-19 has been established and from the 16th of March Public Health England (PHE), declared that vulnerable individuals including the pregnant population should be even more stringent about following the social distancing rules(2). This decision was most likely informed by the knowledge that pregnancy changes the immune system, which can lead to the development of more severe symptoms following a viral infection. To date 148,377 people have tested positive for SARS-CoV2, with 20,319 of those hospitalised having sadly died in the UK(3). The numbers of infected will no doubt include pregnant women and so every maternity unit should be as prepared as possible, in an ever evolving situation.The Royal Surrey NHS Foundation Trust has a maternity unit that delivers approximately 2,700 babies annually. As a smaller obstetric unit we face different challenges in regards to our physical facilities and staffing, compared to larger obstetric units. We approached the need for rapid adaptation of our services using the following concepts as highlighted by the Centers for Disease Control and Prevention (CDC)(4): 1) limiting the entry of pathogens on to the unit, 2) isolating symptomatic patients or patients living with a symptomatic individual and 3) protecting our staff. We also, implemented the recommendations by the Royal College of Obstetricians and Gynaecologists (RCOG)(5), which aligned with the aforementioned concepts.This article shares the practical steps we took , as well as the challenges and successes a small maternity unit have had so far in a dynamic climate, with constantly emerging and changing guidelines for providing evidence-informed clinical care during the COVID-19 pandemic.Limiting the entry of pathogens onto the maternity unitStructural changes that reduce patient flow throughout the maternity department were instigated early on, to minimise infection opportunities for both our women and staff, in groups thought to be negative, suspected or confirmed SARS-CoV2 positive. The hospital now only has two main entrance points. All patients arriving at the Accident and Emergency department (A&E), are screened for symptoms and have their temperature taken. At the main entrance, entry is restricted to those with an appointment and visitors are only allowed under extraordinary circumstances.Our pregnancy advice telephone service has COVID-19 symptom screening questions; aiding in the direction of pregnant women to designated ‘hot’ or ‘cold’ assessment areas in our unit. Details of these are discussed later in the commentary. Initially labelled ‘dirty’ and ‘clean’, our ‘hot’ areas are where patients suspected to have or with confirmed COVID-19 are reviewed and managed. Conversely, ‘cold’ areas are where women who are deemed low risk for having COVID-19 are seen.In line with national guidance, the unit has streamlined obstetric antenatal clinics – offering telephone consultations as a default. Any woman who requires a face-to-face consultation as per clinical need is screened on arrival by the entrance to the outpatient department with questions and her temperature is taken.Much of our community midwifery care is run from General Practice surgeries. As many reduced their face-to-face services, and we planned for lower staff numbers; we concentrated our community provision into two existing sites and one new central one – procured from a local private provider so as not to unduly increase footfall at the hospital. Informal feedback from our women via social media has been overwhelmingly positive, as they feel safer avoiding the main hospital. Where telephone consultations have replaced face to face appointments, as per the RCOG guidance(6), a temporary ‘drive-through’ service allows blood pressure and urine dip checks.Isolating patients with a contact history or symptomsOne of our main ‘hot’ areas is our designated ‘pregnancy pod’. It is a stand-alone suite of clinical rooms that are situated directly behind our A&E, that were repurposed. The suite is fully equipped with an assessment room, ultrasound machine, cardiotocograph and trolley available for emergency transfers. This area is for both emergency and routine attendances that cannot be postponed beyond the self-isolation period recommended by the Government. All pregnant women who have had contact with or are suspected of or confirmed COVID-19 enter via A&E. As an extension of the ‘hot’ A&E area, all staff working in the ‘pregnancy pod’ wear the appropriate personal protective equipment (PPE). We offer acute gynaecology, early pregnancy, antenatal and postnatal care in this environment.On delivery suite, all rooms have ensuite bathrooms. Those with a double door were prioritised for COVID-19 suspected or confirmed cases. Retrofitting additional doors has also increased our isolation capacity.Protecting our staffScreening all women at entry and adequate provision of PPE are key to staff protection. Staff who require shielding, work from home completing telephone consultations. Those who do not meet criteria but nonetheless have medical comorbidities are prioritised to work at the ‘drive-through’. The woman remains in her vehicle whilst blood pressure checks, blood tests and urine dips are carried out. Adjacent to the maternity ‘drive-through’, the pharmacy ‘drive-through’ allows collection of prescriptions from telephone consultations. All services are by appointment only to reduce congestion.

Phenotypic divergence in response to divergent natural selection between environments is a common phenomenon in species of freshwater fishes. Intraspecific differentiation is often pronounced between individual inhabiting lakes versus stream habitats. The different hydrodynamic regimes in the contrasting habitats may promote a variation of body shape, but this could be intertwined with morphological adaptions to a specific foraging mode. Herein, I studied the divergence pattern of the European minnow (Phoxinus phoxinus), a common freshwater fish that has paid little attention despite its large distribution. In many Scandinavian mountain lakes, they are considered as being invasive and were found to pose threats to the native fish populations due to dietary overlap. Minnows were recently found to show phenotypic adaptions in lake versus stream habitats, but the question remained if this divergence pattern is related to trophic niche partitioning. I therefore studied the patterns of minnow divergence in morphology (i.e. using geometric morphometrics) and trophic niches (i.e. using stomach content analyses) in the lake Ånnsjön and its tributaries to link the changes in body morphology to the feeding on specific resources. Lake minnows showed a strong reliance on zooplankton and a more streamlined body shape with an upward facing snout, whereas stream minnows fed on macroinvertebrates (larvae and adults) to a higher degree and had a deeper body with a snout that was pointed down. Correlations showed a significant positive relationship of the proportion of zooplankton in the gut and morphological features present in the lake minnows. The results of this study highlight the habitat-specific divergence pattern in morphology and resource use in this ubiquitous freshwater fish, which may promote contrasting inter-specific interactions in the respective food webs.

This paper studied the potential mechanism of form drag from emergent vegetation by the effective combination of experimental verification and numerical simulation. The rigid cylindrical sticks arranged in the open channel were used to simulate vegetation and experiments on flow velocity distribution characteristics in open channel with different vegetation density and vegetation arrangement forms were carried out. Based on the new expression of hydraulic radius from the recent paper, it indicates the form drag from vegetation is closely related with the wake volume near the vegetation. The relationship between the wake volume and form drag is proposed and verified by different experimental conditions. Based on this relationship, the experimental results show that the resistance form of vegetation in vegetated open channels can be divided into: K-type and D-type based on different sticks arrangement within one vegetation patch. The calculated values and measured values achieve a good agreement under different experimental conditions. Meanwhile, numerical simulation based on SAS turbulence model was conducted and the simulation results also fit well with the experimental values so more complex experimental conditions are simulated by numerical simulation method. The results of this study will provide a theoretical basis for the layout of vegetation in the ecological open channel.

Aim: Infantile haemangioma (IH) is the most common benign tumour in children. Since 2014, propranolol has become the first-choice therapy and currently Hemangiol® is the only approved drug for complicated haemangioma. This post-marketing study reported the use of Hemangiol® for IH in paediatric practice. Method and Results: From January 2014 to November 2018, 94 children (median age 4 [0;21] months; 75% female) treated with Hemangiol® for proliferative IH were enrolled in the study. The systematic paediatric cardiology consultation never contraindicated beta-blockers. Two Hemangiol® initiation protocols were used: a conventional ambulatory 3-week titration phase protocol (N=76, 80.9%), and a rapid initiation protocol with a 48-hour dose escalation in conventional hospitalization for severe proliferative IH (N=18, 19.1%). In both protocols, the haemodynamic tolerance was good. The mean maintenance dose of Hemangiol® was 2.7±0.8 mg/kg/day, with a median treatment duration of 7 [1.5;19] months. Adverse events (AEs) have been found in 25 (26,6%) patients including 8 (8.5%) patients with serious AEs (uncontrolled bronchial hyperreactivity, N=5; serious hypoglycaemia, N=3). Some patients had one or more AEs, a total of 24 non-serious AEs was reported in 19 patients (sleep disturbances, N=9; respiratory disorders, N=5; digestive disorders, N=6). No cardiac adverse event was reported. Conclusion: This post-marketing surveillance drug study supports the good tolerance of Hemangiol® in children with IH. A rapid initiation protocol is of interest when treatment is urgent. The pre-therapeutic paediatric cardiology consultation should not be systematic but only indicated on specific patients. ClinicalTrials.gov: NCT 04105517.

Shared phylogenetic breaks across taxa, syntopic clusters of endemics, and paleogeographic reconstruction of isostatic and vegetation change over time suggest the existence of one or more ice-free glacial refugia off of North America’s North Pacific Coast. However, both an incomplete fossil record and cosmogenic 10Be exposure dating create uncertainty over whether hypothesized coastal refugia even existed. If refugia existed, then identifying the persistent species is critical to interpretation of the timing, duration, and paleoenvironment-reconstructions. We use whole-genome resequencing to assess the historical biogeography of these complex northern landscapes that span multiple archipelagos and mountain ranges. Unanticipated discovery of genomically-distinct insular and continental clades within forest-associated Pacific martens (M. caurina) is consistent with morphometric and parasitological investigations, and also with the Coastal Refugium Hypothesis. Our results support the persistence of forested refugial communities along the western edges of the Alexander Archipelago. We found no evidence of admixture on islands that received historical translocations of American pine martens (M. americana), but detected introgression in two zones of secondary contact: one insular, one continental. Evidence of early-generational hybrids across multiple hybrid zones, each backcrossed with M. americana, is consistent with a history of genetic dilution of M. caurina through outbreeding. Into the future, these hybrid zones will serve as instructive natural experiments for forecasting outcomes of genetic management initiatives, such as genetic rescue or restoration. Evidence of refugial divergence in a forest-associated, medium-sized carnivore along the North Pacific Coast suggests that genomic reevaluations may identify new perspectives on a suite of forest-associated species and provide new insight into refugial community composition.

On March 30, 2020, the COVID-19 health service utilization forecasting team at the University of Washington's Institute for Health Metrics and Evaluation (IHME) published national and state-level projections of the number of COVID-19 deaths in the United States anticipated in the next four months (i.e. by July 30, 2020). At the time of writing (May 5, 2020), less than half of the time between that paper's publication and the date to which its predictions apply has passed, but comparing these predictions to the actual number of deaths reported so far is still useful in determining whether the models have significantly underestimated the number of deaths. Data regarding the cumulative number of predicted COVID-19 deaths per state was obtained from the IHME's published paper on medRxiv, as were the corresponding lower and upper bounds accompanying each state-level prediction. These predictions covered all 50 states and the District of Columbia. They were then compared to the reported total number of deaths based on data from the COVID Tracker (as of May 5, 2020). The findings indicate that most of the included regions still have not surpassed the number of COVID-19 deaths predicted that they would experience cumulatively, though seven states (Connecticut, New Jersey, New York, Massachusetts, Maryland, Rhode Island, and Illinois) and the District of Columbia have already done so. Nationally, the total number of deaths reported in the United States as of May 5, 2020 is 62,698, which represents about 77% of the 81,111 deaths predicted in the United States by July 30, 2020. The total national number of deaths has increased at a rate of about 1,726 deaths per day since the IHME report was published. If this trend continues at the same rate until July 30, the number of Americans who would have died from COVID-19 at that point would be 213,689, more than twice the IHME prediction. 

Little information is available about the effects of different species of shrubs on the composition of the soil seed bank (SSB) and how the SSB could contribute to the restoration of degraded area in semiarid regions. We determined the role of three dominant shrub species on SSB characteristics and evaluated their potential for their possible use in rangeland restoration projects. Fifteen sites, each containing three shrub species (Amygdalus scoparia, Daphne mezereum and Ebenus stellata) and a herbaceous patch (control) in close proximity, were sampled and their SSB density, species richness and diversity at 0-10 cm depth were determined. The results showed that density of the SSB was highest under A. scoparia (1133 seeds per m2) and lowest in herbaceous vegetation (110 seeds per m2). Species richness and diversity of the SSB was significantly greater under E. stellata than under the other shrubs and control. This study revealed that the extent to which vegetation affected SSB characteristics did not only depend on the presence of shrubs, but also on the species of shrub. These different roles of different species of shrubs on SSB are advised to be considered in restoration of degraded areas through conservation of shrubs in semiarid regions.

Introduction: Hypertension is a global public health issue. Data on the effect of Anti- hypertensive drugs on dementia, Alzheimer’s disease, cognitive impairment is limited and inconclusive. Material and Methods: It was a Prospective, randomized, open label, comparative study. Total 60 hypertensive Patients were randomized to receive either Telmisartan or Cilnidipine. Memory functions were evaluated with PGI Memory Scale, while psychomotor functions were evaluated with Six Letter Cancellation test (SLCT) and Digit Letter Substitution test (DLST) and card sorting test (CST). Student t-test was used to compare the means of test scores between and within the groups. Statistical significance was considered at P<0.05. Results: An improvement was observed in scores of memory in both the groups which was not significant. A significant improvement (p < 0.05) was shown in 3 of 10 subtests of memory in Telmisartan group compared to Cilnidipine. Both the drugs showed significant improvement in psychomotor function tests (P<0.05). SLCT score was 40.33 ± 1.58 (CI 38.8 - 42) in Cilnidipine group and 38.80 ± 1.56 (CI 37.2 - 40.4) in Telmisartan group. Cilnidipine showed significant improvement in SLCT and DLST scores compared to Telmisartan. Both the study drugs decreased BP significantly (P < 0.01). Conclusion: Both Telmisartan and Cilnidipine showed no change in memory and significant improvement in psychomotor functions in newly diagnosed Stage - I essential hypertension patients. But Telmisartan showed more improving trends in memory than Cilnidipine. Cilnidipine significantly improved psychomotor functions compared to Telmisartan. Further randomized controlled studies are needed to establish these effects.

Aims In the absence of a commonly agreed dosing protocol based on pharmacokinetic considerations, the dose and treatment duration for hydroxychloroquine (HCQ) COVID-19 disease currently vary across national guidelines and clinical study protocols. We have used a model-based approach to explore the relative impact of alternative dosing regimens proposed in different dosing protocols for hydroxychloroquine in COVID-19. Methods We compared different PK exposures using Monte Carlo simulations based on a previously published population pharmacokinetic model in patients with rheumatoid arthritis, externally validated using both independent data in lupus erythematous patients and recent data in French COVID-19 patients. Clinical efficacy and safety information from COVID-19 patients treated with HCQ were used to contextualize and assess the actual clinical value of the model predictions. Results Literature and observed clinical data confirm the variability in clinical responses in COVID-19 when treated with the same fixed doses. Confounding factors were identified that should be taken into account for dose recommendation. For 80% of patients, doses higher than 800mg day on D1 followed by 600mg daily on following days might not be needed for being cured. Limited adverse drug reactions have been reported so far for this dosing regimen, most often confounded by co-medications, comorbidities or underlying COVID-19 disease effects. Conclusion Our results were clear indicating the unmet need for characterization of target PK exposures to inform HCQ dosing optimization in COVID-19. Dosing optimization for HCQ in COVID-19 is still an unmet need. Efforts in this sense are a prerequisite for best the benefit/risk balance.

BackgroundAt the end of 2019, an outbreak of a respiratory disease called “novel coronavirus disease 2019” (COVID-19) started in Wuhan (China) and has spread worldwide, reaching a pandemic proportion since 11th March. To date (24th April 2020), the responsible pathogen, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has infected 2’626’321 people all over the world, causing 181 938 confirmed deaths. The most affected countries are U.S.A., Italy and Spain, with 42’311, 25’549, and 22’157deaths, respectively, according to W.H.O. data. The unpredictable speed of diffusion, notwithstanding a low direct mortality rate, brought to a severe intensive care units overcrowding and seriously jeopardize health-services, particularly in Italy.Indeed, the risk of contagion is higher in the hospital environment than in the community. A supposed hospital-related transmission has been estimated to occur in more than 40% of cases.1 Among healthcare workers, anesthesiologists, otorhinolaryngologists and head and neck surgeons seem to be the most prone to direct exposure.2 In fact, being the SARS-CoV-2 primarily transmitted by respiratory droplets or infected secretions, the abovementioned specialists daily incur high-risk clinical maneuvers and surgical procedures, such as intubation, nasal endoscopy, flexible fiber endoscopy of the upper aerodigestive tract, and oral or oropharyngeal examination.2 While patients’ face masks obviously need to be removed during these procedures, clinicians are strongly encouraged to follow personal protection guidelines, wearing all the proper personal protective equipment (PPE) such as N95, FFP3 or FFP2 masks, gown, cap, eye protections (goggles and face shields), and gloves.2 In addition to this, all non-urgent elective intervention and follow-up visits should be conceivably procrastinated and the treatment of time-sensitive cases, as cancer patients, should be discussed on a case-by-case basis minimizing the risks of contamination.2In the field of Otorhinolaryngology there are urgent microsurgical procedures, such as mastoidectomy for otologic meningitis, or not deferrable oncologic surgeries on the upper aerodigestive tract, that should reasonably be performed even if dealing with suspicious or confirmed COVID-19 patients. Nevertheless, the unmodifiable necessity of the operating microscope, or the robotic da Vinci robotic surgical system, impede a proper use of the overcited PPE, since the protective glasses or face mask hinder the surgeon’s eyes to lean directly against the microscope ocular or the da Vinci console.2 In order to find a feasible alternative to the traditional microsurgery setup, it is herein proposed a possible solution with an innovative exoscopic setting based upon a 4K 3D system of vision.

Background: The total number of thyroidectomies performed worldwide both for benign and malignant disease has increased dramatically during the past few decades. Gestational hypothyroidism has deleterious effects on the fetus. Objective: The aim of this study was to assess the extent of thyroid function control among pregnant women who had previously undergone a therapeutic thyroidectomy. Methods: This retrospective cohort study included all female patients insured in the largest health maintenance organization in Israel who were pregnant between May, 2001 and September, 2012 and had a medical history of thyroid surgery. The thyroid-stimulating hormone (TSH) levels throughout the pregnancy were compared to recommended trimestral values. A multivariate analysis was performed to determine risk factors for not attaining TSH recommended range. Results: A total of 477 females with a history of thyroid surgery had given 701 births during the study period. Forty-three percent (n= 203), had thyroidal malignancy. Nearly half of the women underwent total thyroidectomy (43.4% n=207). The women’s TSH values were within the recommended range in only 60% (n= 350) of the pregnancies during the first trimester (0.1-2.5 mIU/L), in 61% (n=335) during the second trimester (0.2–3 mIU/L), and in 70% (n=338) during the third trimester (0.3–3 mIU/L). In multivariate analysis, women that underwent a total thyroidectomy due to a benign thyroid disease, were at the highest risk for not attaining target TSH levels. Conclusions: This very large cohort of pregnant women with a past history of thyroid surgery demonstrated a significant percentage of pregnancies with TSH values above the recommended range. Women that underwent a total thyroidectomy due to benign thyroid disease were at the highest risk for gestational hypothyroidism.

The occurrence of two types of headaches in one patient is rare. In this study, we want to draw attention to the therapeutic problem that can be encountered in the presence of trigeminal and occipital neuralgia and how the PRF can help.

Resistance of antibiotic to organisms is the matter of global concern. Methicillin resistant Staphylococcus aureus (MRSA) infection is rapidly increasing in both human and animals. A 2.5-year-old indigenous calf brought with myiasis wound and bacteria associated with myiasis wound was studied and further molecular detection confirms the presence MRSA.

Otic lichen planus (LP) is rare and associated with stenosis of external auditory canal, conductive hearing loss (HL) and otorrhea. We report the case of a 78 years old woman affected by otic LP complaining mixed HL. We successfully treated the patients with local therapy and with bone-anchored hearing device.

In this case study, we reported a case of 8-year-old Saudi patient diagnosed with polysplenia, situs inversus totalis and double outlet right ventricle. We identified five novel missense mutation in three genes GATA4, NIPBL and APC as causative mutations and could be used for early detecting of polysplenia syndrome.

Background: Psychosocial factors are significant drivers of inappropriate antibiotic prescription leading to antibiotic resistance (ABR). Objective: To ascertain the psychosocial predictors of outpatient antibiotic prescribing behavior among early-career clinicians in India. Methods: We enrolled 200 early-career clinicians, including 100 medical interns and 100 junior residents (postgraduate student doctors) in six clinical departments, and collected data using a self-administered questionnaire. Response options were coded on five-item Likert scales. Results: Antimicrobial resistance (AMR) was viewed as a significant public health problem by most (95%) participants. Presumptive antibiotic prescribing was reported by 84% of participants, although the participant attitude indicated a slight disinclination against the presumptive use of antibiotics (Mean = 2.8, SD = 0.72). The majority (52.5%) of the participants’ perceived social pressure frequently influenced their decision to prescribe antibiotics to their outpatients, which was most commonly attributed to patient expectation for antibiotics and from observing the antibiotic prescribing behavior of their peers and colleagues. The perception of increased social pressure stipulating antibiotic prescribing negatively correlated with the participant’s intention to reduce antibiotic use in outpatients (r=-0.124, p < 0.001). Social pressure was reported to be higher when treating adult patients reporting diarrheal symptoms, and children having cough. Conclusions: Outpatient antibiotic prescribing practices among early-career clinicians working in the government health sector in India are mediated by considerable social pressure despite their perceived intention for reducing antibiotic use.

Grade Level: 4th Suggested Time: 50 minutes OverviewStudents will work in small groups, and each group will be assigned a continent. Each group will use online resources to research their assigned continent’s climate zone, geography, and animals. Then the groups will use different project materials to create posters to present what they found out about the continent. At the end of this lesson, the class will combine all the continents to form a map of the Earth, and students will discuss the map.VocabularyAfrica, Antarctica, Asia, Australia, Climate, Climate Zone, Continents, Europe, Fahrenheit, Geography, North America, Polar Zone, South America, Temperate Zone, Tropical ZoneObjectivesStudents will work in small groups to use online resources to search for information about the assigned continent.Each group will use project materials, such as colored markers, sticky notes, and animal stickers, to design a poster that presents information about the continent, including climate, geography, and animals.Students will combine all the continent posters to form a map of the Earth and discuss the map.Required Project MaterialsLaptops and iPads with Internet accessGoodNotes app on iPadsPoster paper with the outline of a specific continentSticky notesColored markersAnimal stickersTapeMultimedia ResourcesElla Cane. Continents in My World. https://www.amazon.com/Continents-My-World-Ella-Cane/dp/1476531234/ref=sr_1_1?dchild=1&keywords=continents+in+my+world&qid=1587670112&sr=8-1Dr. Binocs from Peekaboo Kidz. The Dr. Binocs Show - Climate Zones of the Earth. https://www.youtube.com/watch?v=5tC8OOxOFEkOnline books related to different continents on myon.comOnline books and educational videos about different continents on getepic.comOptional Multimedia ResourcesCleverBooks augmented reality world mapBefore the Lesson/Background InformationDivide the students into seven groups of fourPrepare poster papers with an outline of a continent on each oneThe LessonPart 1: The Seven Continents and the Three Climate Zones (10 minutes) The whole class reads Ella Cane’s read-to-me online book, Continents in My World, to develop a basic understanding of the seven continents. Discuss: How are the seven continents different?  The whole class watches The Dr. Binocs Show – Climate Zones of the Earth on YouTube.com to develop a basic understanding of the three climate zones.Discuss: How do we use different temperatures to represent each climate zone? How do the three climate zones affect the animals that live on the seven continents?  Part 2: Researching a Continent (15 minutes) Students are divided into groups of four. Each group is assigned a specific continent. Students use laptops to access different online resources, such as myon.com and getepic.com, to search for information on their assigned continent. They take notes using the GoodNotes app on their iPads. Discuss: How can you help other groups understand your continent, including climate, geography, and animals? The climate information should include the temperature on the continent in Fahrenheit. The geography information should include the continent’s area in square miles. The animal information should include the animals’ appearances and behaviors. Students brainstorm their notes and select useful information for their continent assignment.Part 3: Creating a Poster about a Continent (15 minutes)Each group is given colored markers, sticky notes, animal stickers, and a poster paper with an outline of their assigned continent. Each group uses the project materials to create a meaningful and informative poster that shows their understanding of their assigned continent, including climate, geography, and animals. After the students spend eight minutes designing their posters, each group sends two students to look at other groups’ posters. Students exchange their design ideas among groups. After exchanging poster design ideas, students improve their poster designs. Part 4: Forming a Map of the World (10 minutes) All the groups put their posters on the classroom whiteboard to form a map of the Earth. The whole class takes ten minutes to discuss the relationship among the seven continents, three climate zones, and many kinds of animals.When students compare and contrast the geographies of the different continents, students should use different temperatures and areas in square miles to support their opinions.Discuss: Why do animals have appearances and behave in specific ways on each continent? How do the seven continents and the three climate zones affect the animals’ lifestyles?The teacher keeps all the continent posters for future teaching and learning. The teacher takes photos of the posters and posts the photos on the school’s STEM web page and Twitter.HomeworkThe teacher assigns students to read Diyan Leake’s Oceans and Sea. Each student should create a diagram that shows a map of the Earth and the five oceans.StandardsNext Generation Science Standards. 4-LS1-1: Construct an argument that plants and animals have internal and external structures that function to support survival, growth, behavior, and reproduction. International Society for Technology Standard. ISTE Students 4a: Students know and use a deliberate design process for generating ideas, testing theories, creating innovative artifacts or solving authentic problems. NYS CTE – Standard 5 – Engineering Design: Generate ideas for possible solutions, individually and through group activity; apply age-appropriate mathematics and science skills; evaluate the ideas and determine the best solution; and explain reasons for the choices. NYS Common Core Math Standard. CCSS.MATH.CONTENT.4.MD.A.1: Know relative sizes of measurement units within one system of units including km, m, cm; kg, g; lb, oz.; l, ml; hr, min, sec. Within a single system of measurement, express measurements in a larger unit in terms of a smaller unit.