Critical care provision is fundamental in all developed health systems in which severe disease and injury is managed. This is especially true in major trauma centres and high-acuity establishments, where acutely unstable patients can be admitted at any time, requiring clinical monitoring and interventions appropriate for their burden of illness. This single-centre, prospective service evaluation applied validated scoring systems to a surgical population, sampling and following those considered “high-risk” through to discharge or death, alongside all intensive care unit (ICU) admissions during 2019. Primarily we aimed to quantify the number of patients objectively suitable for Level 2 critical care, conventionally provided in a high-dependency unit (HDU) setting. Secondary outcome measures included ICU readmission rate, in-hospital mortality, and delays to ICU admission and discharge. Of the “high-risk” surgical patients, more than eight per week were found to have peri-operative Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) scores that would advocate critical care admission. Only one individual received scheduled peri-operative critical care. Post-operative mortality in this group was 6.1%, though none of these patients was admitted to ICU prior to death. There were 605 ICU admissions in 2019, with 32.1% of admitted days spent at the equivalent of Level 2 critical care, which could have been administered in a HDU if one was available. The ICU readmission rate was 6.45%. This data demonstrates substantial unmet critical care needs, with patients not uncommonly managed in clinically inappropriate areas for extended periods due to delays accessing ICU. A designated HDU may mitigate clinical risk from this subgroup, reducing morbidity and in-hospital mortality, and this methodology for assessing requirements could be used in other similar institutions.

Plants in suburban forests of eastern North America face the dual stressors of high white-tailed deer density and invasion by nonindigenous plants. The combination of chronic deer herbivory and strong competition from invasive plants could alter a plant’s stress- and defense-related secondary chemistry, especially for long-lived juvenile trees in the understory, but this has not been studied. We measured foliar total antioxidants, phenolics, and flavonoids in juveniles of two native trees, Fraxinus pennsylvanica (green ash) and Fagus grandifolia (American beech), growing in six forests in the suburban landscape of central New Jersey, USA. The trees grew in experimental plots that had been subject for 2.5 years to factorial treatments of deer access/exclosure X addition/no addition of the nonindigenous invasive grass Microstegium vimineum (Japanese stiltgrass). As other hypothesized drivers of plant secondary chemistry, we also measured non-stiltgrass herb layer cover, light levels, and water availability. Univariate mixed model analysis of the deer and stiltgrass effects and multivariate structural equation modeling (SEM) of all variables showed that both greater stiltgrass cover and greater deer pressure induced antioxidants, phenolics, and flavonoids, with some variation between species. Deer were generally the stronger factor, and stiltgrass effects were most apparent at high stiltgrass density. SEM also revealed that soil dryness directly increased the chemicals; deer had additional positive, but indirect, effects via influence on the soil; in beech PAR positively affected flavonoids; and herb layer cover had no effect. Juvenile trees’ chemical defense/stress responses to deer and invasive plants can be protective, but also could have a physiological cost, with negative consequences for recruitment to the canopy. Ecological implications for species and their communities will depend on costs and benefits of stress/defense chemistry in the specific environmental context, particularly with respect to invasive plant competitiveness, extent of invasion, local deer density, and deer browse preferences.

Objective: To develop and validate a predictive model assessing the risk of cesarean delivery in primiparous women based on the findings of magnetic resonance imaging (MRI) studies. Design: Observational study Setting: University teaching hospital. Population: 168 primiparous women with clinical findings suggestive of cephalopelvic disproportion. Methods: All women underwent MRI measurements prior to the onset of labor. A nomogram model to predict the risk of cesarean delivery was proposed based on the MRI data. The discrimination of the model was calculated by the area under the receiver operating characteristic curve (AUC) and calibration was assessed by calibration plots. The decision curve analysis was applied to evaluate the net clinical benefit. Main Outcome Measures: Cesarean delivery. Results: A total of 88 (58.7%) women achieved vaginal delivery, and 62 (41.3%) required cesarean section caused by obstructed labor. In multivariable modeling, the maternal body mass index before delivery, induction of labor, bilateral femoral head distance, obstetric conjugate, fetal head circumference and fetal abdominal circumference were significantly associated with the likelihood of cesarean delivery. The discrimination calculated as the AUC was 0.845 (95% CI: 0.783-0.908; P < 0.001). The sensitivity and specificity of the nomogram model were 0.918 and 0.629, respectively. The model demonstrated satisfactory calibration. Moreover, the decision curve analysis proved the superior net benefit of the model compared with each factor included. Conclusion: Our study provides a nomogram model that can accurately identify primiparous women at risk of cesarean delivery caused by cephalopelvic disproportion based on the MRI measurements.

Comparing life history traits among populations that have been separated genetically for several hundred thousand years, but live in similar habitats on different continents, may help us understand how ecological and anthropomorphic factors shape life histories. We compared patterns of growth in body length and mass, and the influence of population density, habitat quality (NDVI), and reproduction on age-specific length and mass of male and female brown bears between Alberta, Canada, and Sweden. We found that Swedish females were significantly smaller in both length and mass than Alberta females. Swedish females also reached primiparity earlier and at a smaller mass and length. However, there were no continental differences in the patterns of growth in males. We found strong positive effects of NDVI, but only weak negative effects of population density on female mass and length in both areas. Generally, especially mass of Alberta females was more strongly affected by NDVI and density than for Swedish females. Reproduction had stronger negative effects on female mass in Alberta than in Sweden. We found no effects of NDVI and population density on male mass and body length in both areas. The larger variation in female growth and size between the areas, in contrast to males, may be related to differences in female reproductive investment due to differences in population trends, i.e., earlier reproduction in increasing populations or populations below carrying capacity, or to different selection pressures in the past, potentially due to human persecution. Swedish females exhibited characteristics typical of increasing populations, whereas Alberta females exhibited characteristics typical of stable or decreasing populations. The difference in reproduction investment means that Swedish bears can be harvested at higher rates, whereas Alberta bears must be managed more conservatively.

Half heusler compounds have gained attention due to their excellent properties and good thermal stability. In this paper, using first principle calculation and Boltzmann transport equation, we have investigated structural, electronic, mechanical and thermoelectric properties of PdXSn (X=Zr,Hf) half Heusler materials. These materials are indirect band gap semiconductors with band gap of 0.52 (0.44) for PdZrSn (PdHfSn). Calculations of elastic and phonon characteristics show that both materials are mechanically and dynamically stable. At 300K the magnitude of lattice thermal conductivity observed for PdZrSn is 15.16 W/mK and 9.53 W/mK for PdHfSn. The highest ZT value for PdZrSn and PdHfSn is 0.32 and 0.4 respectively.

Objective: The objective of this study is to establish maternal reference values of AMH in a fertile multi-ethnic urban pregnant population and to evaluate the effect of gestational age. Design: The Generation R Study is an ongoing population-based prospective cohort study from early pregnancy onwards. Setting: Rotterdam, the Netherlands, out of hospital setting. Population: In 5806 women serum AMH levels were determined in early pregnancy (median 13.5 weeks; 95% range 10.5-17.2). Methods: The model-based AMH reference ranges for maternal age and gestational age were created using GAMLSS. Associations between AMH and several first trimester biomarkers were analyzed using multivariate linear regression analyses. Main outcome measures: AMH levels in early pregnancy and the association with placental biomarkers, hCG, sFLT, and PLGF. Results: A nomogram of AMH in early pregnancy was developed. Serum AMH levels showed a decline with advancing gestational age. Higher AMH levels were associated with a higher level of hCG and sFLT. This last association was predominantly mediated by hCG. AMH levels were negatively associated with PLGF levels. Conclusion: In this large study we show that AMH levels in the first trimester decrease with advancing gestational age. The association between AMH and the placental biomarkers hCG, sFLT and PLGF suggests a better placental development with a lower vascular resistance in mothers with higher AMH levels. AMH might be useful in predicting adverse pregnancy outcome due to impaired placental development. Keywords: Ovarian reserve, placental biomarker, nomogram, first trimester, human Choriogonadotrophin (hCG), soluble FMS-Like Tyrosine kinase-1 (sFLT), Placental Growth Factor (PLGF).

OBJECTIVE(S): to evaluate the severity of HDFN in subsequent pregnancies with RhD immunization and to identify predictive factors for severe disease. DESIGN: prospective cohort. SETTING: the Netherlands. POPULATION: nationwide selection of all pregnant women with RhD antibodies. METHODS: women with two subsequent RhD immunized pregnancies with RhD-positive children after antibodies were detected were included. MAIN OUTCOME MEASURE: the severity of HDFN in the first and subsequent pregnancy at risk. RESULTS: 62 RhD immunized women with a total of 150 RhD-positive children were included. The severity of HDFN increased significantly in the subsequent pregnancy (P<.001), although it remained equal or even decreased in 44% of women. When antibodies were already detected at first trimester screening in the first immunized pregnancy, severe HDFN in the next pregnancy was uncommon (22%), especially when no therapy or only non-intensive phototherapy was indicated during the first pregnancy (6%), or if the ADCC result remained <10%. Contrarily, women with antibodies detected during the first pregnancy of a RhD positive child (>= 27th week), most often before they had ever received RhIg prophylaxis, were most prone for severe disease in a subsequent pregnancy (48%). CONCLUSION(S): RhD-mediated HDFN in a subsequent pregnancy is generally more severe than in the first pregnancy at risk and can be estimated using moment of antibody detection and severity in the first immunized pregnancy. Women developing antibodies in their first pregnancy of a RhD-positive child are at highest risk of severe disease in the next pregnancy.

Background: Concerns about virus spread during surgery contributed to changes in the clinical management of ectopic pregnancies (EP) during the COVID19 pandemic. Objective: To compare published data on EP management prior versus during the COVID-19 pandemic and evaluate any difference in the management, rupture rate and complications where Early Pregnancy Unit (EPU) structures exist. Search strategy: We performed a systematic review of the literature using a keyword strategy based on our PICO criteria. Selection criteria: We included studies which recruited women diagnosed with ectopic pregnancy and compared the management during and prior the COVID-19 pandemic peak. Data collection and Analysis: Three independent reviewers screened the literature and extracted the data. Meta-analysis of the data was performed on Revman. Main Results: Our search yielded 34 studies; 12 were included in our meta-analysis (3122 women). We found no difference in the type of management of EP between the pre-Covid and Covid cohorts [2714 women, OR 0.99(0.63-1.55), p=0.96, I2=77%]. We observed a non-statistically significant reduction of surgical management within the EPU branch ([OR 0.47(0.19-1.13), p=0.09, I2=81%]). There was no difference in the ectopic rupture rate in units with EPU [OR= 0.66 (0.33-1.31), p=0.24, I2=37%]. In contrast, in non-EPU (NPEU) the risk of ruptured EP [OR=2.86(1.84-4.46), p<0.01 I2=13%] and complications [OR=1.69(1.23-2.31), p=0.001, I2=45%] were increased. Conclusions: The worldwide trend was not reflected in the UK suggesting that EPU may have contributed to prompt diagnosis and safe management of EP. Funding: No funding was received. Keywords: ectopic pregnancy, COVID 19, meta-analysis, early pregnancy unit

Conventional approach of establishing soil conservation strategies in degraded drylands has had negligible success. This has been contributed by many constraints, including; lagging of farmers in technology adoption, inadequate resources, and lack of motivation. Thus, a study was conducted among three agro-pastoral community farmer groups in Korellach Parak, Kapkitony, and Kaporowo villages domiciled in Chepareria ward, West Pokot, Kenya, to assess contributory factors and consequences of adopting terracing as a soil conservation measure. Mixed methods comprising; one-on-one interviews, cross-sectional field measurements, and focus group discussions (FGDs), were used for data collection. Results indicate that the agro-pastoral communities are fully aware of soil degradation and its impacts. Besides terracing, farmers practice stone bands, enclosures, agroforestry, and ridges. Terracing is a recently adopted farm-level soil conservation practice achieved through organized farmer groups dubbed “Kemorokorenyo” (meaning let us reclaim our land) merry-go-round. Within the three villages, 60% of the households have their farms terraced with an average terrace volume of 103.8±21.45m3, 105.89±33.126m3, and 129.6±15.966m3 in Parak Kapkitony and Kaporowo, respectively. Rapid sedimentation of terraces dykes, which contributes to the reduced effectiveness of the terrace system was identified as the major challenge. The sediment volume significantly differs along the slope, with the highest sediment build-up experienced on high slopes as shown by the Kruskal Wallis test; H (2) =6.699, p=0.035. Terrace embankments reinforcement practice to counter sedimentation challenge has faced slow adoption. The poor reinforcement is attributable to the lack of knowledge on suitable local context multipurpose materials to meet the community’s needs.

Background The interconception period is considered a time when parents are likely to engage with health messages and are in frequent contact with healthcare professionals. Objectives Through this literature review and policy analysis, we synthesised articles and guidelines on interconception care to provide recommendations to improve health outcomes for parents, infants and future generations. Search Strategy Four databases were searched systematically, using MeSH and free-text terms based on ‘interconception’ and ‘postpartum’. Selection Criteria Selected articles included reviews, pilot studies and guidelines on interconception and postpartum interventions published in English by UK public health organisations and government agencies between 1st January 2010-12th January 2021. Data Collection and Analysis 30% of titles, abstracts and full-text papers were double-screened. The description table of identified guidelines were qualitatively analysed to generate categories, later developed into a framework of six domains. Findings are described using a narrative synthesis approach. Main Results We found 47 documents with guidelines, 29 reviews and six pilot studies on interconception and postpartum care. Interconception care opportunities include the postpartum period, family planning, routine practice, and risk assessments. Health and non-healthcare professionals have a role to play in the interconception period including GPs, health visitors, dieticians, nutritionists, health psychologists, community groups, local authorities and charities such as Tommy’s and First Step Nutrition. Conclusions The interconception and postpartum periods offer crucial opportunities to intervene to reduce possible long-term effects of suboptimal nutrition. Though the policy analysis for this review focused on the UK, the recommendations can have wider implications for other countries.

Primitive neuroectodermal tumor (PNET) is a highly aggressive tumor and mostly develops in children and young adults. PNETs of peripheral nerves are uncommon. Ulnar nerve, in particular, is an extremely peculiar origin for PNET and to the best of our knowledge only few well-documented cases have been yet reported.

Hydrogen reduction of tungsten oxide is currently the most widely applied ultrafine tungsten powder production process. The process has the advantage of short, pollution free and simple production equipment. But it is difficult to effectively control the morphology and particle size of the tungsten powder because of lacking in-depth understanding of the dynamic mechanism of the process. The first-principles calculations are carried out to explore the diffusion and internal adsorption of hydrogen on the WO-terminated surface of WO3 based on the density functional theory. The results show that hydrogen can diffuse from the WO terminal surface to the inside of WO3, the activation energy of diffusion is 46.682 Kcal/mol. It’s preferable for hydrogen to diffuse from the surface to the inside than diffuse within the WO3 lattice. The adsorption energy of hydrogen on the WO termination surface of WO3 is 15.093 Kcal/mol, the adsorption energy of hydrogen inside the WO termination surface of WO3 is 14.116 Kcal/mol, which means the hydrogen is easier to adsorb inside the WO3 lattice.

Objective: To compare emergency department (ED) presentations and hospital admissions for urgent early pregnancy conditions in Victoria before and after the onset of COVID-19 lockdown on 31 March 2020. Design: Population-based retrospective cohort study Setting: Australian state of Victoria Population: Pregnant women presenting to emergency departments or admitted to hospital Methods: We obtained state-wide hospital separation data from the Victorian Emergency Minimum Dataset and the Victorian Admitted Episodes Dataset from January 1, 2018, to October 31, 2020. A linear prediction model based on the pre-COVID period was used to identify the impact of COVID restrictions. Main outcome measures: Monthly ED presentations for miscarriage and ectopic pregnancy, hospital admissions for termination of pregnancy, with subgroup analysis by region, socioeconomic status, disease acuity, hospital type. Results: There was an overall decline in monthly ED presentations and hospital admissions for early pregnancy conditions in metropolitan areas where lockdown restrictions were most stringent. Monthly ED presentations for miscarriage during the COVID period were consistently below predicted, with the nadir in April 2020 (790 observed vs 985 predicted, 95% CI 835-1135). Monthly admissions for termination of pregnancy were also below predicted throughout lockdown, with the nadir in August 2020 (893 observed vs 1116 predicted, 95% CI 905-1326). There was no increase in ED presentations for complications following abortion, ectopic or molar pregnancy during the COVID period. Conclusions: Fewer women in metropolitan Victoria utilized hospital-based care for early pregnancy conditions during the first seven months of the pandemic, without any observable increase in maternal morbidity.

Quantum chemical calculations have been performed on B3 ring stabilized Y-Y interaction (Y = Be, Mg, Ca) to understand the possibility of binuclear sandwich type complex formation. Calculations indicate single reference character of the studied systems. The complexes have been found to be stable towards dissociation into different fragments. Thermodynamic consideration also indicates the favourability of their formation. Increase in aromaticity of the parent B3 ring upon complexation is observed which is expected to provide extra stability to the complexes.

In this case study, we report an 11-year-old male patient who had jaundice, hepatosplenomegaly, and chronic mild congenital non-autoimmune hemolytic anemia. In our patient, a novel homozygous missense mutation in the PIEZO1 gene was detected using a gene-targeted Next-Generation Sequencing panel: c.3364G>A (p.Glu1122Lys), confirming the diagnosis of DHS.

Climate change causes fluctuations in temperature and precipitation. As a result, it affects the discharge of rivers, the most important consequence of which is the tendency toward extreme events such as torrential rains and widespread droughts. River discharge is one of the most important climatic and hydrological parameters. Investigating the changes in this parameter is one of the main prerequisites in the management and proper use of water resources and rivers. Most trend detection studies are based on analyzing changes in the mean or middle of the data. They do not provide information on how changes occur in different data ranges. Therefore, to investigate parameter changes in a different range of the data series, various regression models were proposed. Frequentist quantile regression and Bayesian quantile regression models were used to estimate their trend and trend slope in different quantiles of discharge in different seasons of the year for Arazkouseh, Tamar, and Galikesh stations of Gorganroud basin in northern Iran with the statistical period of 1346–1396 (1966–2016). The results show that in most seasons of the year, high discharge rates for all 3 stations have decreased with a steep slope, and only in summer, Tamar and Galikesh stations have had an increasing trend, but low discharge rates have not changed significantly. Spatially, the discharge values at Arazkouseh station have a decreasing trend with a higher slope rate, and in terms of time, the most decreasing trend has been in spring. Comparing the models also shows that the Bayesian quantile regression model provides more accurate and reliable results than the frequency-oriented quantile regression model. In general, quantile regression models are useful for predicting and estimating extreme high and low discharge changes for better management to reduce flood and drought damage.

Objective. Clinicians and regulators are receiving reports of changes to menstrual periods following COVID-19 vaccination. However, it is unclear if the two are biologically linked. If they are, people using hormonal contraception are predicted to be less likely to report a change and spontaneously cycling people vaccinated prior to ovulation more likely. The objective was to test these hypotheses. Design. Retrospective cohort study. Setting. UK. Population. 1273 people who had received at least one dose of a COVID-19 vaccination, have periods or withdrawal bleeds and keep a record of the dates of these. Methods. Participants reported whether they use any hormonal contraception and, for each dose of the vaccine, on which day of their menstrual cycle they were vaccinated and details of how the timing and flow of their next period compared to their normal experience. Main outcome measures. Association between 1. the use of hormonal contraception and reported changes to timing or flow of the next menstrual period, and 2. the timing of vaccination within the menstrual cycle and reported changes to timing or flow of the next menstrual period. Results. The data from this cohort did not support the pre-specified hypotheses that people using hormonal contraception would be less likely to report a change, or that spontaneously cycling people vaccinated prior to ovulation would be more likely to report a change. Conclusions. This study did not detect strong signals supporting the idea that COVID-19 vaccination is linked to menstrual changes in most people. Funding. No specific funding.

We enrolled a patient diagnosed with blastic plasmacytoid dendritic cell neoplasm (BPDCN) . We have found that TET2, KRAS and BRAF may be involved in the development of the disease, and the combination therapy of Decitabine (DAC) and Arsenic acid (ASO) may be effective for BPDCN harboring the TET2 mutations.