Objectives: The aim of this study was to assess differences in echocardiographic findings between a normal adult and a post Covid-19 population. Background: Coronavirus disease (Covid-19) is known to produce a systemic inflammatory syndrome, with pulmonary and cardiac involvement. However, the cardiovascular impact in patients with mild clinical forms of the disease is uncertain. There is small evidence supporting the finding of global ventricular longitudinal strain (GLS) alterations in these patients. Methods: One hundred and five consecutive patients admitted to an ambulatory care center, underwent a conventional transthoracic echocardiographic (TTE) study with acquisition of GLS. Patients were included if they underwent a positive diagnostic reverse transcriptase polymerase chain reaction (PCR) test, having no relevant preexisting conditions, with exception of obesity. Demographic and clinical data were prospectively obtained. For this purpose, we considered a normal cut off point of -17,09%, based on previous studies. Echocardiographic findings were compared with those of 67 healthy individuals. Results: Out of 172 patients, 105 correspond to Covid-19 group, and 67 to healthy individuals. There were no significant differences in GLS regarding age, left ventricular mass index (LVMI) and E/e’ ratio. The multivariate analysis showed that the percentage of patients with pathological GLS values was significantly higher within the Covid-19 and male groups (OR 6.02 IC 1.88-22.57; p 0.004 and OR 3.17 IC 1.03-10.50; p 0.05, respectively). Conclusion: These data support that Covid-19 infection could affect ventricular GLS and encourage the use of conventional TTE with GLS measurements in patients with non-significant forms of the disease.

Mini Commentary – BJOG

Anaemia in pregnancy remains a global health problem In this issue of BJOG Hull et al …… et al report on an important study from South Africa regarding anaemia in pregnancy and the response to iron therapy. They report that in HIV-positive women the response was slower than in HIV-negative women. The underlying causes of anaemia varied and included iron deficiency (as assessed by ferritin levels) as well as concurrent infections (urinary tract infections and tuberculosis)Anaemia in pregnancy (blood haemoglobin Hb<11.0g/dl) occurs in > 40% of women living in low- and middle-income countries (LMIC) and in some settings in Asia prevalence is >60%. (McCauley et al, BMJ Global Health, 2018; 3(3):e000625) The latest WHO recommendations on antenatal care consider anaemia as the world’s second leading cause of disability and one of the most serious global public health problems (WHO Geneva 2016 ) .Although globally the focus has largely been on anaemia in pregnancy resulting from either iron deficiency or malaria, this is an incomplete approach at best. Iron deficiency is hard to measure and confirm as; i) this requires a functioning laboratory to be in place, ii) indicators for iron deficiency are influenced by the presence of concurrent infection, or, iii) repeated measures of Hb are needed to check whether the anaemia is responsive to treatment with iron. By contrast, malaria is relatively easy to diagnose via rapid diagnostic tests or microscopic examination of a stained blood smear slide. The handful of studies which have comprehensively assessed aetiology of anaemia in pregnant women demonstrate that anaemia is most commonly the result of complex multiple underlying factors including nutritional deficiencies as well as infectious diseases. Both nutritional deficiency and other infections (malaria, tuberculosis) are more likely with HIV-infection which itself can lead to anaemia probably through direct suppression of erythropoiesis.Hull et al show what was possible in a real-life clinical practice setting. This example of integration of research into clinical practice is laudable and is illustrative of how such integration could result in better services being made available for women in LMIC where burden of disease is high, but diagnostic tests are largely unavailable. It is sobering to realise that the majority of women world-wide will still only be screened for anaemia during pregnancy using ‘conjunctival inspection’ which is highly inaccurate. (van den Broek et al. Bull WHO 1999; 77(1):15-21) Rapid diagnostic tests are available for Hb, malaria, syphilis, HIV and, more recently, for tuberculosis. We are doing women a dis-service if we cannot offer at least these basic diagnostic tests as part of antenatal care.To prevent anaemia during pregnancy, the ‘fall-back’ position is to offer all women daily iron prophylaxis (30-60mg elemental iron) - with luck tablets are available that include folic acid (0.4mg) - along with presumptive treatment of malaria (various regimes) in endemic areas. Multi-micronutrients (including the required amount of iron and folic acid) might actually be better but cannot be recommended because of lack of evidence and they are still three times as expensive as iron and folic acid supplementation alone (3$ vs 1$ approximately).WHO recently recommended a better understanding of the aetiology of anaemia. A search on PubMed shows a clear lack of papers on the topic and more good research is needed. Investment in the antenatal care package offered to women is also much needed if we are aiming for a global ‘Health for All’.

Those patients with hypopharyngoesophageal cancer often sacrificed larynx before reconstruction using jejunum to restore the continuity of the digestive tract and allow oral alimentation. We retrospectively collected and analyzed three patients who underwent hypopharyngoesophageal reconstruction by free partial patch and partial tube jejunal graft transfer with reservation of laryngeal function caused by hypopharyngeal cancer invading the cervical esophagus. The partial patch and partial tube jejunal graft transfer survival rate was 100%(3/3). The larynx was reserved in the three patients. The partial patch and partial tube jejunal graft transfer is a safe and reliable choice for reconstruction of large and complex defects after pharyngectomy and cervical esophagectomy with larynx preserved.

Key Points: 1. We have identified ambiguity in the current guidance on thyroid MDT’s, and have also found nationwide variation in compliance with this. 2. We recommend: a. All surgeons undertaking thyroid surgery should complete a minimum of 20 thyroid procedures per year, and this should also form part of surgeons’ annual appraisal. b. All surgeons should contribute data to UKRETS (unless prevented by local legal frameworks) and this should form part of surgeons’ annual appraisal and be audited by individual MDT’s and regional cancer networks. c. Thyroid MDT’s should be held weekly where possible, with a minimum frequency of fortnightly. d. The core membership of a thyroid MDT (stand alone and joint) should include thyroid surgeons, specialist radiology, endocrinology, nuclear medicine, nurse specialists, histopathology +/- cytology and clinical oncology.

A document by Mark Wilkie, written on Authorea.

A 46- year old male, during intense physical activity, sustained malperfusion of the lower extremities from Type A thoracic aortic dissection. We took him to the operating room. emergently and perfusing both lower extremities using a modified straight graft with side to side anastomosis to one limb and end to side anastomoses to the inflow perfusion and contralateral limb. The patient was successfully discharged and remained to be doing well. for four years.

Background: There is limited information available on the use of PIP medication in older adults having psychiatric illness. Objective: To determine the prevalence of PIP medications, and assess its predictors in older adults with psychiatric illness. Methods: A cross-sectional study was carried out at a tertiary care hospital on 456 patients of either sex, with a median age of 65 years attending the psychiatry outpatient department. Evaluation of PIP medication was done using Beers criteria 2019 and STOPP criteria 2015. Bivariate logistic regression was used to find out the predictors of PIP prescribing. Results: Results of the study reflect that a staggering number of older adults, (more than 91% and 73%) out of total of 456 patients were prescribed with at least one PIP medication identified by Beers criteria and STOPP criteria, respectively. Long-acting benzodiazepine (LABZD) like clonazepam was identified as one of the most commonly prescribed PIP medications by both set of criteria. Further analysis revealed that older adults from rural background (Odds Ratio (OR) 2.60, 95% Confidence Interval (CI) 1.20-5.65; P=0.015), TCA (OR 0.30, 95% CI 0.12- 0.75; P= 0.010), LABZD (OR 33.72, 95% CI 11.27-100.85; P=<0.001), atypical antipsychotics (OR 22.35, 95% CI 5.31- 93.99; P= <0.001) use were most common predictors for PIP medication prescribing. Conclusion: The use of PIP medication is highly prevalent among older adults according to Beers criteria and STOPP criteria. The study reflects a more comprehensive and sturdy nature of Beer criteria as it significantly detects more PIP medication than STOPP criteria.

Introduction: The anatomy of the paranasal sinuses is important for many surgeon groups. The precise knowledge of such structures with variable anatomy will be important for the preservation of these structures and the management of complications in surgeries such as endoscopic sinus surgery and osteotomies involving the maxilla. Objective: The purpose of the present study is to investigate volumetric differences between ethmoid, sphenoid and maxillary sinus volumes in patients with maxillary deficiency requiring Le Fort osteotomy and healthy patients, by employing computed tomography imaging. Methods: Computed tomography scans of 120 patients (59 maxillary deficiency patients and 61 control patients) were included in the study. Images were processed, the paranasal sinuses were sculpted out from 3D images and measured. All measurements were taken twice by the same observers. The observers performed the study twice with an interval of 2 weeks to detect intra-observer variability. Results: Ethmoid and left and right maxillary sinus volumes were smaller in the Le Fort group, although no differences were observed for sphenoid sinus volumes. Conclusion: Paranasal sinus volumes varied between maxillary deficiency patients and control patients. This condition may be crucial for the surgeon operating in these areas and should be taken into consideration during surgeries.

Understanding the spatiotemporal changes in soil organic carbon (SOC) and their driving factors is an important prerequisite for decision-making in maintaining sustainable agricultural development and addressing climate change. A total of 1219 cropland topsoil SOC data (0-20 cm) collected from southern Jiangsu Province of China in 1980, 2000, and 2015, and geostatistical sequential Gaussian simulation were used to identify the changes in the spatiotemporal patterns of SOC during the period of 1980-2015. Results showed that the changes in SOC within the different time periods were significantly different, with a net increment of 3.65 g kg-1 during the period of 1980-2000 and a net decrement of 2.32 g kg-1 during the period of 2000-2015. Significant SOC accumulation occurred throughout the study area during 1980-2000, while SOC decline became predominant in the southeast during 2000-2015. Overall, the SOC contents for 60% of the study area increased significantly over the entire 35-year period. The SOC increase during the first two decades (1980-2000) was largely attributed to the increasing soil C input that resulted from the enhanced crop productivity by chemical fertilizers, while the stagnant soil carbon inputs associated with the rapid urban expansion were the primary reason for constraining cropland SOC accumulation in the subsequent 15 years (2000-2015). These findings highlight the importance of balancing agricultural development and urbanization processes to maintain SOC levels, and may also provide some guidance for planning cropland soil C management strategies in many areas that are undergoing similar urbanization processes.

The drum is the core part of a supercharged boiler that is prone to fatigue damage due to the dual action of thermal and mechanical stress. However, owing to its complex structure, complete modeling calculation of the drum requires considerable computational resources. Therefore, based on the basic theory of beam elements, we propose a simplified method using beam elements in place of solid tubes and evaluate the feasibility of this method. The results demonstrate that the simplified method reduced the overall mesh number of the model by 67.19% and the calculation time by 68.08%. Moreover, compared to the solid model, the maximum relative errors of stress and displacement were only 3.44% and 5.16%. Considering the dispersion of low-cycle fatigue life, we applied a statistical approach to the fatigue life assessment of the drum, and obtained the probability of failure corresponding to the fatigue life of the drum under the given operating conditions. This method provides an important basis for the systematic evaluation of fatigue life under various operating conditions and the prediction of failure occurrence.

Importance: Tumor encasement of the common carotid artery (CCA) and/or the internal carotid artery (ICA) in patients with advanced head and neck tumors represents a significant surgical challenge. At present, there are few reports on the treatment approach that can achieve the maximal oncological resection and reduce the difficulty of operation without affecting the carotid artery blood flow. Objective: To examine whether the combination of oncologic complete tumor resection and intravascular covered stent placement is more advantageous in the management of advanced head and neck cancer. Design, Setting, and Participants: Five patients with advanced head and neck squamous cell carcinoma (AHNSCC) invading one side of the carotid artery were retrospectively enrolled. The contrast-enhanced computed Tomography (CT) and angiography were performed to assess the severity of extrinsic tumor compression to the carotid artery. Covered stent was placed intra-arterially at least 1 cm proximal and distal beyond the area of tumor involvement. The tumor and the involved carotid artery were resected, and pectoralis major flap transfer was utilized for coverage of the great vessels supported with intra-arterial covered stent. Main Outcomes and Measures: Efficacy of oncologic complete tumor resection combined with endovascular stent placement. Results: The post-stenting demonstrated an improvement in the appearance and caliber of the affected carotid artery. Four patients experienced transient bradycardia and hypotension. All five patients underwent R0 resection. Postoperatively, the flap all had rich vascularity and healing. Three patients underwent adjuvant radiotherapy or chemoradiation. With median follow-up 6.5 months, one patient died of multiple organ failures at 6.5 months after surgery; one patient developed tracheal stoma recurrence and treated with salvaged surgery; the three other patients had no disease recurrence in their last follow-ups. Conclusions and Relevance: Surgical resection with intravascular covered stent placement could potentially achieve the maximal oncological resection without compromise carotid artery blood flow in patients with carotid artery encased head and neck cancer.

Introduction: The population is aging and older adults comprise the majority of patients in intensive care units. Colistin (COL) has been reintroduced to treat increasingly common resistant Gram-negative bacterial infections. Our study aims to investigate the factors affecting colistin nephrotoxicity in the general population and geriatric age group. Materials and Method: This retrospective study included 170 patients, 116 (68.2%) of which were in the geriatric group (age ≥65). Acute renal failure was evaluated using the RIFLE score. Firstly, factors associated with COL nephrotoxicity in the general population were investigated. Then, risk factors for COL nephrotoxicity were evaluated in the geriatric patient group. Results: Advanced age (odds ratio [OR]=1.043; 95% confidence interval [CI]: 1.018-1.068; p=0.001) and initial serum creatinine level (OR=23.122; 95% CI: 3.123-171.217; p=0.002) were found to be independent risk factors associated with nephrotoxicity. In the evaluation of the geriatric population-based on nephrotoxicity, the initial serum urea and creatinine levels, immunosuppression, and overall mortality rates were found to be statistically significant in the group with nephrotoxicity (p<0.05). Initial serum creatinine level (OR=22.48; 95% CI: 2.835-178.426; p=0.003) and concomitant nephrotoxic agent use (OR=2.516; 95% CI: 1.275-4.963; p=0.008) were independent risk factors associated with nephrotoxicity in geriatric patients. Conclusion: Advanced age was found to be a risk factor for COL nephrotoxicity. Caution should be exercised especially in geriatric patients who have initial serum creatinine levels close to the upper limit, concomitant use of nephrotoxic drugs should be avoided and if possible, evaluation should be made in terms of non-COL treatment options in these patients.

Objectives: To evaluate clinical characteristics and prognosis of patients presented with ventricular tachyarrhythmia (VTA) during the course of acute coronary syndrome (ACS) and to analyze it according to period of presentation. Background: VTA is an infrequent yet serious complication of ACS. There is limited data regarding the incidence and prognostic implications of VTA in the last decade as compared with the previous decade. Methods: We evaluated clinical characteristics, major adverse cardiovascular events, short and long- term mortality of patients hospitalized with ACS who were enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) during the years 2000-2016. Patients were classified into three groups: no VTA, early VTA (≤48h of onset) and late VTA (>48h of onset). Data were analyzed according to decades of presentation (current decade vs. previous decade). Results: The study population comprised 15,200 patients. VTA occurred in 487 (3.2%) of patients. Early VTA presented in 373/487 (77%) patients and late VTA in 114/487 (23%) patients. VTA’s, occurring in ACS patients were associated with increased risk of in-hospital, 30-days, 1-year and 5-year mortality rates during both early and late periods in compared with no VTA. Moreover, late VTA was associated with the highest mortality rate with up to 65% in 5-year follow up (p<0.001). Nevertheless, late VTA was associated with lower mortality rate in the current decade (2008-2016) compared with last decade (2000-2006). Conclusions: Any VTA following ACS was associated with high short and long-term mortality rate. However, over the past decade there has been a significant improvement in survival rates, especially in patients with late VTA. This may be attributed to early and invasive reperfusion therapy, implantable cardioverter defibrillator implantation and better medical treatment.

Introduction This study is to compare the efficacy of two different methods of nerve hydrodissection (HD), called short- and long-axis injection, for patients with mild-to-moderate carpal tunnel syndrome (CTS). Methods Forty-seven patients with mild-to-moderate CTS were enrolled in a prospective, randomized, single-blinded, controlled trial (6 months follow-up). With ultrasound guidance, patients in both groups (short-axis or long-axis groups) were injected with normal saline (5 mL per session). Assessments were performed before and 2 weeks after the injection, as well as at 1, 3, and 6 months post-intervention. The primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score and secondary outcomes included the cross-sectional area of the median nerve and electrophysiological studies. Results Forty-four patients (21 wrists in the short-axis group and 23 wrists in the long-axis group) completed the study. Compared with the baseline, both groups showed improved BCTQ and cross-sectional area at all follow-up assessments (p<0.05). Moreover, the short-axis group had significant improvements in BCTQ-severity and BCTQ-function 1 month post-injection compared to the long-axis group (p = 0.031 and p = 0.023, respectively). Conclusion Both short- and long-axis HD were effective for patients with mild-to-moderate CTS; however, the short-axis HD conferred relatively better efficacy 1 month after the injection.

Here we describe a case involving an elderly man with Citrobacter freundii-associated infectious rupture of a dissecting thoracoabdominal aortic aneurysm. We performed emergency thoracoabdominal aortic replacement using a rifampicin-soaked prosthetic graft and omental flap wrapping. The patient was discharged on postoperative day 255, although he experienced pseudomembranous enteritis and paraplegia.

Cervical lymphadenopathy following COVID-19 vaccine: Clinical characteristics and implications for head and neck cancer servicesRunning title: COVID-19 vaccine-associated lymphadenopathyAhmad K. Abou-Foul1*, Elizabeth Ross1, Mahmoud Abou-Foul2, Ajith P. George1,3

Background: While the number of patients with aortic regurgitation (AR) has been increasing in the aging society, its etiologies remain to be fully elucidated. Methods: We studied consecutive 126 patients with chronic moderate or severe AR who underwent TEE. After the study subjects were divided into 2 groups by the age of 65 years, AR etiology was examined in each group. Results: In the older group (n = 85), cusp bending was the most frequent cause of AR (48.2%), and right coronary cusp (RCC) was the most common (90.2%). In the younger group (n=41), bicuspid valve was the most frequent cause (36.5%), and cusp bending was less frequent (16.5%). Multivariate analysis revealed that age was the only factor associated with cusp bending. Conclusion: Cusp bending of RCC was the most frequent etiology of AR in the elderly. Because AR caused by cusp bending has a possibility to be mended by aortic plasty, it is important to detect it by TEE especially in the older patients.

Exploring the driving factors of ecosystem services (ESs) trade-offs/synergies is crucial for ecosystem management, especially in ecological conservation red line (ECRL) areas that maintain regional and national ecological security. Soil conservation (SC), water yield (WY) and carbon sequestration (CS) were simulated in the Beijing ECRL areas. Geographical weighted regression was used to explore the trade-offs/synergies, and the geographical detector was applied to quantitatively identify their driving factors. Results show that (1) the SC and CS show marked synergy which characterized more than 80% of each ECRL area; the proportion of the space area of trade-off and synergy between SC and WY, and WY and CS was roughly 3 to 7 and 4 to 6 in each ECRL area, respectively. (2) The synergy of the three pairs of ESs was most sensitive to terrain factors. The precipitation erodibility of soil and its necessity for vegetation make it a determinant of the trade-off between SC and CS; temperature was the determinant in the trade-off between WY and CS, with an explanatory power of 32.8%; potential evapotranspiration was best able to explain the spatial distribution of the trade-off between SC and WY. (3) The interaction between precipitation and other factors had the greatest explanatory power on the spatial relationship between SC and WY. Precipitation and relief amplitude are the main interactive factors respectively affecting the spatial trade-off and synergy between SC and CS. The trade-off and synergy between WY and CS were most sensitive to the interaction between climate factors and terrain factors.

Hypokalemia can be multifactorial. When the primary driver of hypokalemia is obvious it is easy to miss other contributing causes that could be vital to optimal patient management and outcomes. Our case report highlights the importance of recognizing recurrent, refractory hypokalemia as a diagnostic clue to thyrotoxic periodic paralysis.

Background Despite significant advancements in operative techniques and myocardial protection, triple valve surgery (TVS) remains a formidable operation with a relatively high in-hospital mortality. We evaluated the prognostic value of Model for End-stage Liver Disease score including sodium (MELD-Na) for mortality after TVS and its predictive value when incorporated in the EuroSCORE risk model. Methods We performed a retrospective cohort study of 61 consecutive patients who underwent TVS from November 2005 to June 2016. Demographics, clinical, biochemical, and operative data were collected and analysed. Results Median follow-up duration was 8.0 years. 70.5% of patients suffered from rheumatic heart disease. 86.9% underwent mechanical double valve replacement with tricuspid valve repair. There were six operative deaths (9.84%), with the most common cause of death being multiorgan failure (83.3%). 26.2% had a moderately elevated MELD-Na score of 9 to 15, and 4.9% had a severely elevated score of >15. Patients with a MELD-Na >9 had a higher unadjusted rate of operative mortality, prolonged ventilation, need for dialysis and acute liver failure after TVS. Hierarchical logistic regression was performed using logistic EuroSCORE as the base model. After risk adjustment, each point of MELD-Na score increase was associated with 1.405 times increase in odds of operative mortality. The regression analysis was repeated by incorporating individual components of the MELD-Na score, including bilirubin, sodium, and albumin. All three biochemical parameters were significantly associated with operative mortality Conclusion MELD-Na score as a quantifier of hepatorenal dysfunction is sensitive and specific for mortality after triple valve surgery.

Knowledge of genetic diversity and structure is essential for developing conservation strategies for endangered species. The advances in museum genomics can assist in better understanding the effects of over-hunting on the genome by comparing historical to present-day samples. Blue whales were hunted to the point of near extinction in the mid-twentieth century. Herein, we use whole genome sequencing to elucidate the poorly understood population structure of North Atlantic (NA) blue whales (Balaenoptera musculus musculus). We generated a de novo genome assembly of 2.49 Mbp for a NA blue whale (N50 of 1.46 Mb) to analyze 19 whole genomic sequences and 28 complete mitochondrial genomes. We included present-day and historical samples (earliest from 1900) from the Atlantic and Antarctica to understand the impact of whaling on the genetic diversity. We found low population structuring, but high genetic diversity, suggesting a single, panmictic population in the NA. We identified gene flow from fin whale to blue whales, accounting for ~3.5% of the genome. Introgression between blue and fin whales was observed in all the present-day samples but were lacking in some whales sampled early in the 20th century, which suggests increasing disruption in mate choice concomitant with decline in blue whale population. We also assembled and analyzed the transcriptome and revealed positive selection of oncogenes, which may be involved in reduced cancer rates in this largest of mammals ever known. Our sequencing and population structuring studies provide a genomic framework to guide ongoing conservation strategies for this iconic species.

Type A aortic dissection after percutaneous coronary intervention is a rare and life-threatening situation. The reported incidence ranges from 0,02% to 0,6% of all diagnostic and interventional percutaneous procedures. We describe a case of aortic dissection after percutaneous coronary intervention in a patient with acute myocardial infarction from spontaneous coronary artery dissection. The patient was initially treated with primary percutaneous coronary intervention of the affected left coronary artery branches and left main coronary artery. Conservative management for the aortic dissection proved inadequate due to increasing diameter of the false lumen and the patient was referred to our cardiovascular unit for definite surgical management.

Necrotizing soft tissue infections (NSTIs) are life-threatening conditions burdened with high mortality. They’re often associated to a poor prognosis if early diagnosis and prompt treatment is not warranted. Treatment is always medical, often surgical and sometimes with hyperbaric oxygen.