Background: In the context of COVID-19, cancer survivors represent a particularly vulnerable population that may be “doubly hit” both by costs of cancer treatment and financial strain imposed by the pandemic. Methods: We performed a review of the literature pertaining to cancer, financial toxicity, and economic challenges.Results: Multiple societies have put forth recommendations to modify delivery of cancer care in order to minimize patient exposure to the virus. Cancer survivors, especially patients with head and neck cancer, have been disproportionately affected by rising unemployment levels and economic recessions in the past, both of which are linked to higher cancer mortality. Patients who rely on employer-provided insurance and do not qualify for Medicaid may lose access to life-saving treatments. Conclusions: It is essential to implement interventions and policy changes in order to mitigate the effects of this pandemic but also to ensure this becomes a non-issue during the next one.

Dear Editor,The COVID-19 infection can be diagnosed from a variety of upper and lower respiratory sources including the oropharynx (OP), nasopharynx (NP), sputum, and bronchial fluid [1-3]. In general the most sensitive detection of COVID-19 is obtained by the collecting and testing of both upper and lower respiratory samples [4].However, bronchoscopy is a highly technical procedure requiring advanced diagnostic tools as well as well-trained staff which are not always available. Furthermore the collection of sputum and particularly BAL via bronchoscopy increases the biosafety risk to healthcare workers through the creation of aerosol droplets.Upper respiratory specimens such as OP and NP swabs are easy to collect especially in limited resource settings. They should be collected within the first few days from the onset of symptoms since RNA positive rates peak in upper respiratory tract specimens at 7–10 days after symptom onset and then they steadily decline [5].In China during the COVID-19 outbreak, Wang et al reported that oropharyngeal (OP) swabs (n = 398) were used much more frequently than NP swabs (n = 8). However, the COVID-19 RNA was detected only in 32% of OP swabs, compared to NP swabs (63%)[4].It appears to be extremely important to properly collect nasopharyngeal swabs reaching the posterior rhinopharyngeal tonsil region. This implies the presence of a regular nasal cavity floor. Some anatomical variants, such as nasal septum deviation, can prevent reaching of the nasopharynx and therefore to collect a proper sample. Numerous studies of nasal septal deviation have revealed a wide range of prevalence [6,7]. In 1978, Gray reported a prevalence of 48% to 60% in neonates [6].1 In adults, a recent international study found a prevalence of approximately 90% [7]. Sooknundun et al. reported a clinically relevant septal deviation prevalence of 15% to 25% [8].Current national and international guidelines do not include any special recommendations in the execution of the rhinopharyngeal swab in patients with documented nasal pathology or in patients in which a bilateral nasal fossa obstacle is encountered. We believe that in these selected cases the ENT support should be mandatory in order to obtain a representative sample. Furthermore the use of endoscopes could be very useful in the direct visualization of obstacles and to guide safely the swab toward the rhinopharynx. This would possibly also reduce the false negative rate which is reported to be more than 30% [4].

His bundle pacing (HBP) offers physiologic pacing by placing the pacing lead directly to the His bundle. We present a case in which a HBP lead, implanted at the fragile membranous septum, resulted in a persistent restrictive peri-membranous ventricular septal defect (VSD). This complication of HBP has not been reported before but brings new insights in the discussion regarding the optimal position of a pacing lead in the ventricular septum. The fragility of the membranous septum and low rate of spontaneous closure of membranous VSD, might favor lead placement in the muscular septum when aiming for physiologic pacing.

Glyphozines also called SGLT2 inhibitors, are a new class of agents that inhibit reabsorption of glucose in the kidney, in proxinal tubules, and therefore lower blood sugar. They act by inhibiting sodium-glucose transport protein 2 (SGLT2). Glyphozines are used in the treatment of type II diabetes mellitus (T2DM). In studies with canagliflozin, a member of this class, the medication was found to enhance blood sugar control as well as reduce body weight and systolic and diastolic blood pressure.[1] In addition to regulate blood glucose, recent studies have shown that glyphozines have important positive cardiovascular benefits, such as weight loss, decreased volaemia and PA, reduced triglycerides, natriuresis and improved endothelial wall dysfunction. Clinical studies have shown reduction in deaths from cardiovascular events among diabetic patients treated with glyphozines. At the moment these drugs are being studied for an extension of the therapeutic indication also for cardiovascular diseases such as heart failure. In this review, we discuss the class of SGLT2 inhibitors in the treatment of diabetes, and studies focused on their possible role in the treatment of cardiac disease.

Several studies have shown a high correlation between concentration and development of low-density lipoprotein cholesterol (LDL-C)and the evolution of atherosclerosis and cardiovascular disease. Therefore, the reduction of LDL-C levels through lifestyle modification and/or pharmacological interventions has universally shown a decrease in cardiovascular events and mortality. In most cases, elevated blood lipid levels may be caused by alterations in certain genes encoding proteins involved in LDL metabolism, such as those associated with loss of function of the LDLr receptor gene , loss of function of the apoB gene or increased function of a PCSK9 protein .Family hypercholesterolemia is a hereditary disease in which a genetic alteration causes an increase in blood cholesterol. Therapy is based on dietary control and drugs such as statins, ezetimibe or PCSK9 inhibitory monoclonal antibodies. An important scientific breakthrough in recent years is the ability to identify the genetic basis of diseases and possibly correct the defective gene by interfering with small interfering RNA (siRNA) or antisense oligonucleotides (ASO). The technologies of antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs) have also been developed for the treatment of hypercholesterolemia with the aim of controlling the expression of specific genes that play key roles in lipid metabolism. Anti-sense oligonucleotides have been developed to target apolipoprotein B, the main structural protein of VLDL,LDL and chylomicrons,apolipoproteinCIII or angiopoietin 3, both of which play a role in the regulation of triglyceridesorapo(a). The siRNA approach works on the expression of PCSK9, a key modulator in LDL receptor catabolism. The purpose of this review is to present and discuss current clinical and scientific data on therapeutic evidence for new gene therapies in the treatment of hypercholesterolemia.

In recent years, new classes of drugs have entered the market for the treatment of type 2 diabetes mellitus (T2DM) with good efficacy on the normalization of blood glucoseandwithareductionin the risk of hypoglycaemia and with significant effects on weight reduction. One of the most promising classes in achieving these goals was that of the agonists(GLP)-1.However,adifficulty in using these drugs arisesfromsubcutaneousadministration,aroutethatisnotveryconvenientfor users and with the risk of infections. More recently, a GLP-1 agonist, semaglutide, has been developedwhichcanbeadministeredorally.Inthisreviewarticle,wediscussedtheeffectivenessof GLP-1 agonists, oral semaglutide and its therapeutic potential.

For some patients with SARS-CoV-2, the worst clinical damage is not caused by the virus itself, but by an overactive inflammatory state. In fact, in some people the immune system goes into overdrive and launches a large-scale assault on the tissue known as cytokine storm. This excessive immune reaction can damage tissue and eventually kill people. Evidence shows that blocking such cytokine storms can be effective, so trials are underway to test drugs that act by reducing the cytokine response, such as tocilizumab and sarilumab that bind interleukin 6 (IL-6), or anikinra that is interleukin 1 (IL-1) receptor antagonist. However, other drugs that block the cytokine cascade may also be considered. In this article we describe the scientific and molecular motivation for the use of drugs that act by modulating the inflammatory system in patients affected by SARS-CoV-2, considering in particular an old drug that has been in use for many years for other therapeutic indications such as colchicine, and that could result favorable its use, with low cost and good tolerability.

A very interesting formula is $$ \int_x^{x+1} B_n(u) \; du = x^n $$ for Bernoulli polynomials Bn(u). It seems that $$ \int_0^{1} B_n^2(u) \; du = {(2n)!}|B_{2n}| $$ for Bernoulli numbers Bk. Consider (formally) $$ \int_x^{x+1} ^N B_n(u) \; du = ^N x^n $$ what would be the result that gives: $$ \int_x^{x+1} ^\infty B_n(u) \; du = {1-x} $$ can we put a value to $$ f(u) = ^\infty B_n(u) $$ starting more simply $$ x \int_x^{x+1} {(1-u)^2} \; du = {1-x} $$ in general $$ \int_x^{x+1} f(u) \; du = g(x) $$ if $$ f(u) = ^\infty a_k u^k $$ then $$ g(x) = ^\infty {k+1}((x+1)^{k+1}-x^{k+1}) $$ which can also be (potentially) be written as $$ g(x) = ^\infty b_k x^k $$ then it should be true that $$ f(u) = ^\infty b_k B_k(u) $$ we have $$ g(x) = ^\infty {k+1}(^{k+1} {l}x^l -x^{k+1}) = ^\infty b_k x^k $$ or $$ g(x) = ^\infty {k+1}^{k} {l}x^l = ^\infty b_k x^k $$ for a specific power, by collecting terms, we should then have $$ ^\infty {k+1}{n} = b_n $$ $$ b_n = ^\infty a_{n+k}{n!(k+1)!} $$ FINAL RESULT If we have a double series that is hard to evaluate $$ g(x) = ^\infty ^\infty a_{n+k} {n! (k+1)!} x^n $$ we can attempt to identify the an + k term then instead evaluate the integral $$ g(x) = \int_x^{x+1} f(u) \; du $$ with $$ f(u) = ^\infty a_k u^k $$

Background: Sequencing and PCR errors are a major challenge when characterising genetic diversity using high-throughput amplicon sequencing (HTAS). Results: We have developed a multiplexed HTAS method, MAUI-seq, which uses unique molecular identifiers (UMIs) to improve error correction by exploiting variation among sequences associated with a single UMI. We show that two main advantages of this approach are efficient elimination of chimeric and other erroneous reads, outperforming DADA2 and UNOISE3, and the ability to confidently recognise genuine alleles that are present at low abundance or resemble chimeras. Conclusions: The method provides sensitive and flexible profiling of diversity and is readily adaptable to most HTAS applications, including microbial 16S rRNA profiling and metabarcoding of environmental DNA.

Along with progress in globalization of society, the spread of infectious diseases has accelerated worldwide. Although the deployment of highly sensitive genetic tests is essential for early diagnosis and early containment of potential epidemics, tedious and expensive nucleic acid extraction steps represent a major drawback. Here we developed a simple and rapid DNA extraction method, named as an EZ-Fast kit, applicable to the epidemic field setting. The kit does not require advanced laboratory equipment or expensive DNA extraction kits and achieves crude DNA extraction within 10 min at extremely low cost. When combined with real-time PCR and LAMP analyses, the performance of the method, using 183 bovine blood samples, was similar to that of the existing DNA extraction method: 92.5% (135/146) (real-time PCR) and 93.7% (133/142) (LAMP) diagnostic sensitivities, and 100% diagnostic specificities. The developed system provides a powerful tool to facilitate on-site diagnosis in an epidemic field setting.

Theories attempting to explain species coexistence in plant communities have argued in favor of species’ capacities to occupy a multidimensional niche with spatial, temporal and biotic axes. We used the concept of hydrological niche segregation to learn how ecological niches are structured both spatially and temporally and whether small scale humidity gradients between adjacent niches are the main factor explaining water partitioning among tree species in a highly water-limited semiarid forest ecosystem. By combining geophysical methods, isotopic ecology, plant ecophysiology and anatomical measurements, we show how coexisting pine and oak species share, use and temporally switch between diverse spatially distinct niches by employing a set of functionally coupled plant traits in response to changing environmental signals. We identified four geospatial niches that turned into nine, when considering the temporal dynamics of the wetting/drying cycles in the substrate and the particular plant species adaptations to garner, transfer, store and use water. Under water scarcity, pine and oak exhibited water use segregation from different niches, yet under maximum drought when oak trees crossed physiological thresholds, niche overlap occurred. The identification of niches and mechanistic understanding of when and how species use them will help unify theories of plant coexistence and competition.

Aim Kelp forests worldwide are important marine ecosystems that foster high primary to secondary productivity and multiple ecosystem services. These ecosystems are increasingly under threat from extreme storms, changing ocean temperatures, harvesting, and greater herbivore pressure at regional and global scales, necessitating urgent documentation of their historical to present day distributions. Species range shifts to higher latitudes have already been documented in some species that dominate subtidal habitats within Europe. Very little is known about kelp forest ecosystems in Ireland, where rocky coastlines are dominated by Laminaria hyperborea. In order to rectify this substantial knowledge gap, we compiled historical records from an array of sources to present historical distribution, kelp and kelp forest recording effort over time, and present rational for the monitoring of kelp habitats to better understand ecosystem resilience. Location Ireland (Northern Ireland and Éire). Methods Herbaria, literature from the Linnaean society dating back to late 1700s, journal articles, government reports, and online databases were scoured for information on L. hyperborea. Information about kelp ecosystems was solicited from dive clubs and citizen science groups that are active along Ireland’s coastlines. Results Data were used to create distribution maps, analyse methodology and technology used to record L. hyperborea presence and kelp ecosystems within Ireland. We discuss the recent surge in studies on Irish kelp ecosystems and fauna associated with kelp ecosystems that may be used as indicators of ecosystem health and suggest methodologies for continued monitoring. Main Conclusions While there has been a steady increase in recording effort of the dominant subtidal kelp forest species, L. hyperborea, only recently have studies begun to address other important eco-evolutionary processes at work in kelp forests including connectivity among kelp populations in Ireland. Further monitoring, using suggested methodologies, is required to better understand the resilience of kelp ecosystems in Ireland.

Tetralogy of Fallot (TOF) is the most common etiology of congenital cyanotic heart disease, and Blalock-Taussig shunt (BTS) operation is considered the first-step management to maintain pulmonary blood flow in TOF patients. Complete repair of TOF is the standard surgical treatment that should be performed in infancy or early childhood for improved long-term survival. However, the prognosis of TOF patients treated by only palliative operation remains uncertain. We report a man with TOF underwent classic BTS operation at 2 years of age. Despite no medication, he had a long asymptomatic life. At 53 years of age, he started to complain of dizziness and recurrent attacks of syncope due to complete heart block (CHB) and inserted a permanent pacemaker. 2D and 3D Echocardiography showed uncorrected TOF with an overriding aorta, two ventricular septal defects (VSDs) were seen; a large inlet type VSD and another small muscular one with marked right ventricular hypertrophy with marked infundibular stenosis. Cardiac Computed Tomography (Cardiac CT) showed TOF with noted severely stenotic right ventricular outflow tract and pulmonary flow was maintained through a patent classical BTS between left subclavian artery (SCA) and the left pulmonary artery (LPA). Due to his stable condition, he was discharged on close up follow-up visits.

The Qilian Mountain Grassland is an important animal husbandry production base in northwestern China. Horses, cattle and sheep are the main livestock, which are widely distributed in the desert grassland and alpine meadow around the Qilian Mountains. Grazing livestock produce large amounts of feces, and the germinated seeds in the feces constitute the dung seed bank of the grassland. Research on the size, composition and distribution of livestock manure seed bank in the Qilian Mountain grassland may provide a deeper understanding of the interaction between grass and livestock and help inform comprehensive management practices for grazing livestock. In mid-October 2018, we collected the dung of horses, cattle and sheep in the alpine meadows and desert grasslands of the Qilian Mountains and measured the composition and size of the dung seed bank by the greenhouse germination method. The dominant species of seeds in the dung collection site were also collected to determine the relationship between the size and composition of the dung seed bank and the seed traits (mass and shape). A total of 30 different species of seedlings germinated from the dung of the three livestock. Of these, 22 species (73% of total) were perennial. The seedling densities (g-1 dung) of horse, cattle and sheep were 5.23, 3.27 and 0.72, respectively. The species richness, species diversity, and the Jaccard coefficients of similarity between dung seedling and aboveground vegetation of horse dung were significantly greater than those of cattle and sheep (P < 0.05). Regression analyses indicated that medium-sized (10–30 mg) and spherical (0.04–0.10 shape index) seeds had the greatest germination potential. Our study suggests that, of the three livestock species tested, the horse dung seed bank contributes most to grassland recovery and restoration of the Qilian Mountains.

Objective: We aimed to investigate the venous thromboembolism (VTE) status in China, and identify the hospital organizational factors that affect VTE incidence. Design: Retrospective study. Setting: Online survey to evaluate hospital-related factors associated with VTE. Population or sample: Hospital-related general data, and those on system and strategy, diagnosis and treatment, and patient education were collected. Methods: T-tests and analyses of variance were performed to determine whether hospital-related factors were associated with VTE incidence. Main outcome measures: VTE incidence. Results: Totally, 113 hospitals were included. Of 770,828 deliveries, VTE was observed in 526: 423 cases with deep vein thrombosis (DVT), 103 with pulmonary embolism (PE), and three with maternal death due to VTE. Higher prevalence rates of DVT and PE were observed in tertiary hospitals (P<0.001), general hospitals (P=0.006), hospitals with a Cesarean section performance rate >50% or <30% (P<0.001). Women in hospitals with a higher Cesarean section performance rate (relative risk [RR]=1.6), and that did not have emergency transfer facilities (RR=10.6) or early mobilization implementation (RR=1.6) showed a significantly higher risk of DVT. Those in hospitals that did not use B ultrasound of the lower extremity vein (RR=1.4) and anticoagulants (RR=1.2), and did not implement early mobilization after vaginal (RR=1.3) and Cesarean section delivery (RR=1.1) had an increased PE risk. Conclusions: Large hospital-related variations were shown in the incidence of thromboembolism in pregnancy, significantly influenced by hospital-related characteristics and diagnostic competency. Improved patient education levels and VTE treatment availability are vital to reducing the VTE-related maternal mortality and morbidity risk.

Objective: To evaluate the associations between maternal hemoglobin concentration during pregnancy and placental weight, birthweight, and placental weight to birthweight ratio (PW/BW ratio). Design: A cohort study. Setting: Data from the Japan Environment and Children’s Study (JECS). Population: 83 354 singletons born at 28 to 41 weeks of gestational age and their mothers. Methods: The associations between maternal hemoglobin concentration and placental weight, birthweight, and PW/BW ratio were assessed by applying regression analyses with restricted cubic splines. Main outcome measures: Placental weight, birthweight, and PW/BW ratio. Results: Adjusted placental weight and birthweight decreased as hemoglobin concentration increased. The decrease in placental weight was more marked when the hemoglobin concentration was below12 g/dl; however, the decrease in birthweight was steeper when the hemoglobin concentration was above 12 g/dl. Analysis showed that the PW/BW ratio followed decreasing trend as the hemoglobin concentration increased to 12 g/dl, at which point the ratio changed into increasing trend. Conclusions: We found that placental weight was higher in women with low hemoglobin level during pregnancy than women with normal or elevated hemoglobin level while birthweight of women with elevated hemoglobin level is lower than that of women with normal hemoglobin level. As a result, a U-shaped relationship was found between maternal hemoglobin concentration and PW/BW ratio. Funding: The Japan Environment and Children’s Study was funded by the Ministry of the Environment, Japan. Key words: anemia during pregnancy, hemoglobin, Japan Environment and Children’s Study, JECS, placental weight

A document by Katarzyna Mech. Click on the document to view its contents.

Pulmonary arterial sling is a relatively rare congenital anomaly in which left pulmonary artery (LPA) branch originates abnormally from the RPA, eventually resulting with respiratory symptoms, due to airway obstruction. In this report, we present a PAS in a neonate who showed progressive respiratory distress in the second week following delivery. At 25 days of age, the patient underwent total surgical correction of the anomaly, during which left pulmonary artery reimplantation to main PA without the use of cardiopulmonary bypass was employed. Following an uneventful recovery, the patient was discharged eight days after surgery.

Which positive predictive value for Diffusion-Weighted Magnetic Resonance Imaging for children’s cholesteatomas? A retrospective study of 126 MRI exams

Aims Non-sustained ventricular tachycardia (NSVT) occurs frequently in patients with dilated cardiomyopathy (DCM), especially in high-risk patients. The role of rapid-rate NSVT (RR-NSVT) documented by an implantable cardioverter defibrillator (ICD) in DCM patients has not been fully explored. This study aimed to determine the relationship between RR-NSVT and the occurrence of ventricular tachyarrhythmias (VTAs) in DCM patients with ICD. Methods From December 2000 to December 2017, 136 DCM patients received ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation for primary or secondary prevention of VTAs. Based on the occurrence of documented RR-NSVT, patients were classified into RR-NSVT (-) or RR-NSVT (+) groups. Result During the median follow-up of 4.5 years, 50.0% (68/136) of patients experienced ≥ 1 episode, and 25.0% (34/136) of patients experienced ≥ 3 episodes of RR-NSVT. Event-free survival for VTAs was significantly higher in the RR-NSVT (+) group whereas those for heart failure admission and cardiovascular mortality were comparable between groups. In the multivariate cox regression analysis, any RR-NSVT showed a positive association with the occurrence of VTAs (HR: 5.087; 95% CI: 2.374-10.900; p<0.001). In RR-NSVT (+) patients, a cluster (≥ 3 times/6 months) and frequent pattern (≥ 3 runs/day) of RR-NSVT were observed in 42.6% (29/68) and 30.9% (21/68) of patients, respectively, who showed further increased incidence of VTAs. Conclusion In DCM patients with ICD/CRT-D, 50.0% experienced at least 1 episode of RR-NSVT. RR-NSVT documentation showed a positive association with subsequent occurrence of VTAs, suggesting the importance of constructive arrhythmia management for patients with RR-NSVT.

Background: Day‐case tonsillectomy (DCT) compared with inpatient tonsillectomy has increasingly become a norm for many patients undergoing elective surgeries. Unjustified stays of tonsillectomy can be avoided by day case surgery which consequently reduces treatment costs. The aim of this study was to determine the cost and effectiveness of DCT or outpatient operation in comparison with inpatient tonsillectomy. Methods: This study was a cost-effectiveness study which was performed on 300 patients. Patients were randomly divided into two groups: day case (n = 150) and inpatient (n = 150). Consequences used in model included incidence of bleeding, blood transfusion and re-operation frequency within two weeks after surgery and also the patients’ pain during 24 hours after surgery. This study was conducted from the social perspective; therefore, direct and indirect costs are included in the study. One-way sensitivity analysis was conducted to measure the uncertainty effects of the parameters. The collected data was analyzed using software Tree-Age and Excel 2016. Results: The results showed that DCT was less costly and more cost effective than the inpatient one. Mean total costs in day case and inpatient were $ 915.1 and $ 1227.9, respectively. Besides, the mean effectiveness was 0.921 and 0.914 percent, respectively. Also, one-way sensitivity analysis proved the robustness of the results of the study. Conclusion: The results showed that DCT is a cost-effective strategy and can be suggested as a good alternative for a wide range of patients after tonsillectomy. According to the result of our study, supporting day case surgery for tonsillectomy cases can significantly reduce the financial burden. Keywords: Day Case Tonsillectomy, outpatient tonsillectomy, Inpatient tonsillectomy, Cost-effectiveness analysis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has resulted in the current COVID-19 pandemic. Worldwide this disease has infected around 1.5 million individuals with a mortality rate ranging from 5 to 10%. There are several efforts are going on in the drug discovery to control the SARS-CoV-2 viral infection. The main protease (MPro) plays a critical role in viral replication and maturation, thus can serve as the primary drug target. To understand the structural evolution of MPro, we have performed phylogenetic and SSN analysis, that depicted divergence of Coronaviridae MPro in five clusters specific to viral hosts. This clustering was also corroborated with the comparison of MPro structures. Furthermore, it has been observed that backbone and binding site conformations are conserved despite variation in some of the residues. This conservation can be exploited to repurpose available viral protease inhibitors against SARS-CoV-2 MPro. In agreement with this, we performed screening of ~7100 molecules including active ingredients present in the Ayurvedic anti-tussive medicines, anti-viral phytochemicals and synthetic anti-virals against SARS-CoV-2 MPro as the primary target. We identified several natural molecules like -Viniferin, Myricitrin, Taiwanhomoflavone A, Lactucopicrin 15-oxalate, Nympholide A, Biorobin and Phyllaemblicin B that strongly binds to SARS-CoV-2 MPro among. Most of the predicted lead molecules are from Vitis vinifera, also reported for anti-tussive and/or antiviral activities. These molecules also showed strong binding with other main targets RdRp and hACE-2. We anticipate that our approach for identification of multi-target-directed ligand will provide new avenues for drug discovery against SARS-CoV-2 infection.

Introduction: We aimed to analyze the rate of visualization of real-time (RT) recordings and dual fascicle electrograms in our first series of patients treated with the fourth generation cryoballoon (CB) device. Methods: All consecutive patients who underwent CB ablation using the fourth generation technology were included in the analysis. In all procedures we used a 28 mm CB placed via a single transseptal puncture guided by intracardiac ultrasound. A 20 mm octapolar intraluminal circular catheter was used for intracranial recordings. A single 180 seconds freeze strategy was employed. Results: A total of 123 patients (72.9% male, mean age 60.1±10.9 years) were enrolled in the study. RT recordings were detected in 445 (86.2%) pulmonary veins (PVs). Specifically, RT recordings were visualized in 115 left superior PVs (89.2%), 107 left inferior PVs (82.9%), 118 right superior PVs (91.4%) and 105 right inferior PVs (81.3%). Furthermore, in 23 of 516 PVs (4.4%), two fascicle electrograms were detected. Dual fascicles were most commonly observed in left superior PV (6.2%). In both inferior PVs dual fascicles were observed in 4.6% while this phenomenon was least frequent in right superior PV (2.3%). Conclusion: By using the fourth-generation CB we report a specific pattern of isolation represented by a sequential isolation of two apparently distinct PV fascicles during a single CB freeze delivery. This phenomenon occurred in 4.4% of PV ablations. Of note, the rate of visualization of RT isolation with this novel CB was very high and could be documented in 86.2% of PVs.

The COVID-19 outbreak is a global pandemic with rapid community spread. Patients with multi-morbidities are particularly vulnerable during this time. The number of cases soared in early February 2020, and Singapore declared escalation of the Disease Outbreak Response System Condition (DORSCON) level to Orange. Multiple measures have been taken to combat the spread of this highly contagious infection. Despite our medical manpower being diverted to the wards, our hospital aims to maintain nearly full operations at the clinic, balancing against concern about the spread of the virus and exposing healthcare workers to potential risks. We describe the measures taken in a tertiary hospital in Singapore to mitigate the risk of infection in the outpatient setting while ensuring that continuing clinical care of patients with chronic diseases is not compromised.