We describe a case of unilateral phrenic nerve palsy due to SARS-COV-2 in a young child, which led to prolonged and complicated ventilation. The child was treated with methylprednisolone and IVIG, which led to a complete recovery of phrenic function. Temporary involvement of the phrenic nerve should be considered in children infected with SARS-COV-2 requiring prolonged ventilation. The phrenic nerve palsy is postulated to be due to peripheral nerve involvement by SARS-CoV-2. In South Africa, children under 12 years of age are not prioritized for SARS-CoV-2 vaccination. This case re-iterates that even though SARS-CoV-2 disease is mild in the vast majority of children there are more severe presentations which, in low- or middle-income countries, might even go unrecognized.

Background: Lung function in children with persistent asthma may be impaired during preschool and school ages. The aim of this study was to describe if some preschool IOS parameters are related to spirometry alterations on reaching school age. Methods: 66 children under six years old diagnosed with persistent asthma were studied prospectively with IOS during their preschool years and spirometry at school age. Results: The mean age was 4.9 years at the first evaluation and 7.9 years at the second evaluation, and 59.1% were male. During preschool, R5, Fres, AX, and D5-20 were found to have diagnostic accuracy (AUC>0.7) for predicting altered spirometry during school age (defined as FEV1 and/or FEV/FVC and/or FVC values below the lower limit of normality according to Quanjer predictive values). AX, D5-20, and R5 had the best LR+ to increase the probability of altered spirometry (50, 10, and 7.1, respectively). R5 was the best IOS parameter for discriminating bronchodilator response (BDR) in schoolchildren (AUC=0.7, LR+ = 3.7). Abnormal IOS increases the risk of having abnormal spirometry (RR=12.7, p= 0.002). This risk is even higher in atopic patients (RR= 21, p=0.003). Conclusion: The findings of this study indicate that some IOS parameters between 3 and 5 years of age are useful for predicting abnormal spirometry and BDR at school age.

Scalp avulsion injuries are one of the life-threatening traumatic injuries. There are no clear guidelines to determine which reconstructive method is superior to another in each condition. Our case demonstrates that relatively primitive methods like skin grafting can give greater results if done with circumspection.

Objectives Redo sternotomy and explantation of left ventricular assist devices (LVAD) for heart transplantation (HT) involve prolonged dissection, potential injury to mediastinal structures and/or bleeding. Our study compared a complete expanded polytetrafluoroethylene (ePTFE) wrap versus minimal or no ePTFE during LVAD implantation, on outcomes of subsequent HT. Methods Between July 2005 and July 2018, 84 patients underwent a LVAD implant and later underwent HT. Thirty patients received a complete ePTFE wrap during LVAD implantation (Group 1), and 54 patients received either a sheet of ePTFE placed in the anterior mediastinum or no ePTFE (Group 2). Results Baseline characteristics were similar between Groups 1 and 2. Surgeons reported subjective improvements in speed, predictability and safety of dissection with complete ePTFE compared with minimal or no ePTFE. Time from incision to initiation of cardiopulmonary bypass (CPB) were similar between groups (97±38 min vs 89±29 min, p=0.3). Injury to mediastinal structures during the dissection was similar between groups (10% vs 11%, p>0.9). While surgeons reported less intraoperative bleeding in Group 1 (43% vs 61%), this trend did not reach significance (p=0.1). In-hospital mortality, ICU length of stay and hospital length of stay were similar between both groups. Conclusions In patients undergoing LVAD explant-HT, there was a trend towards reduced surgeon reported intraoperative bleeding with ePTFE placement. Despite qualitatively reported greater ease and speed of mediastinal dissection with ePTFE membrane placement, time to initiation of CPB did not differ, likely because surgeons remained cautious, allowing extra time for unanticipated difficulties.

BACKGROUND Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects. CASE PRESENTATION We report the case of a 75-years-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a Pectoralis-Intercostal Rectus Sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 hours for postoperative pain management without others pain relievers. CONCLUSION Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.

Surgery for extensive thoracic aortic aneurysms is challenging. We report the case of a young woman with Takayasu’s arteritis who developed aortic dissection and was successfully treated with our novel extended arch repair method, which we termed “parabronchial approach”. Surgery was performed via a simple sternotomy. The left pulmonary artery was compressed caudally by a surgical assistant arm typically used for coronary artery bypass grafting. This method simplified the creation of a distal anastomosis to the descending aorta behind the left bronchus. Postoperative computed tomography revealed a distal anastomosis at the sixth thoracic vertebra . This parabronchial approach could reduce the frequency of choosing a highly invasive approach and can be a potential minimally invasive approach in cases requiring extensive thoracic aortic aneurysm repair.

In this study, we report a parapharyngeal diffuse large Bcell lymphoma in a human immunodeficiency virus (HIV) infected patient which had caused the patient to suffer from Garcin syndrome.

Mutations are the cause of several diseases as well as the underlying force of evolution. A thorough understanding of its biophysical consequences is essential. We present a computational framework for evaluating different levels of mutual information (MI) and its dependence on mutation. We used molecular dynamics trajectories of the third PDZ domain and its different mutations. MI calculated from these trajectories shows that: (i) the multivariate Gaussian distribution of joint probabilities characterizes the MI between residue pairs with sufficient accuracy. Nonlinearities in joint probabilities calculated by tensor Hermite polynomials up to the fifth order contribute insignificantly. (ii) Changes in MI between residue pairs show the characteristic patterns resulting from specific mutations. (iii) Triple correlations are characterized by evaluating MI between triplets of residues, certain triplets are strongly affected by mutation. (iv) Susceptibility of residues to perturbation are obtained by MI and discussed in terms of linear response theory.

Clinician bias on the low resource workfloorThis is a mini commentary on R Goldenberg et al.,In this study in two LMIC settings in Asia, expert panels who looked at cause of death of premature neonates, with significantly more information available, found far more birth asphyxia and less Respiratory Distress Syndrome than the discharging NICU physicians did. Some NICU physicians attributed respiratory distress in the premature neonate to RDS by default, especially if there was no other information to contradict this belief. Especially in the Pakistan setting, birth asphyxia did not seem to be on the mind of the physician.What could be possible explanations?The maternal population, illiteracy rates, low rates of NICU admission and high death rates in the Pakistan setting suggest an impoverished background population and very restrained resources.In such setting one could easily imagine diagnostic means and treatment options are limited. If there is also lack of staff, reduced availability of beds, and work overload (ref: authors correspondence), priorities have to be made who to admit and who to treat. Life expectancy and quality of life may play a role in triaging.Physicians who work in labourward settings without CTGs may recognize the viewpoint that obstetric management only be guided by the maternal condition. On several SubSaharan African labourwards I experienced that decisions were not (solely) to be based on the supposed fetal condition. To perform ‘an unnecessary caesarean section’, or on the other hand to try and salvage the life of a baby who then turns out to be brain damaged after a poor start, was not seen as good obstetric care. A premature baby with apparent severe birth asphyxia might consequently not be transferred to the NICU. A baby who is admitted may not carry the diagnosis birth asphyxia since, as the authors point out this may imply mismanagement. It could even go further: if potential fetal compromise is not relevant in the obstetric management, it may also not be picked up. The obstetric physician could in such situation easily develop a blind spot for birth asphyxia.Another cause of clinician bias in such low resource settings could be underestimation of the gestation, making RDS a more likely diagnosis. If gestational scans are not available, and last menstrual periods are unreliable (associated with illiteracy) gestational age is more often estimated by fundal height at presentation in labourward, or by the birthweight of the baby. Underestimation could be the case in Pakistan where 65% of babies were thought to be less than 32 weeks, only 12,5 % of the neonates were thought to be growth restricted which is associated with birth asphyxia, but nearly 63 % suffered with birth asphyxia according to the panel.These are several hypotheses how physicians in a low resource setting could form biases in their clinical thinking, which, when not corrected by other information, could lead to incorrect diagnoses and mismanagement. This correcting information could come from diagnostic tools, such as PCR tests Xchest, etc,. However, sufficient time and systems in place for proper handovers, e.g. between the obstetrician and pediatrician, an open mind and awareness of pitfalls, audit and reflection on one’s management, and training to stay up to date are just as important. Hopefully expert panel studies such as these, could stimulate awareness and be a motor to improved Obstetric and Pediatric Care in LMIC settings.

The reported case is a 53-year-old woman with the history of long-standing rheumatoid arthritis who first presented with acute-onset dizziness and gait disturbance, periventricular linear and radial enhancement pattern on MRI and normal CSF analysis, successfully treated with an increase in the dose of oral steroids.

We report the clinical, imaging, echocardiography and muscle biopsy findings of a patient presenting by characteristics which have not been reported in previous Melas cases. This is the first reported case of MELAS accompanying with PFO, and the first case of MELAS with the progressive pattern of ischemic lesions.

Background Childhood cancer survivors face late health problems; despite advances in research, details on risk remain unclear. We describe the methodological aspects of the Dutch Childhood Cancer Survivor Study (DCCSS) cross-sectional clinical study (LATER 2 study). Procedure From the multi-center DCCSS LATER cohort of 6,165 five-year survivors diagnosed 1963-2001, we invited 4,735 eligible in 2016, as well as siblings and parents of survivors. Gaps in evidence identified during development of surveillance guidelines were translated into clinical research questions for 16 outcome-specific sub-projects. The regular care visit to the LATER outpatient clinic forms the backbone of outcome assessment complemented with research-defined measurements (physical examination, diagnostic tests, questionnaires). Furthermore, blood/saliva samples were taken for DNA extraction. Results In total, 2519 (53.2%) survivors participated in the LATER 2 study. Of those participating survivors, 49.3% was female. Median time since childhood cancer diagnosis was 26.9 years (range 14.8 to 54.7 years) and median attained age was 34.4 years (range 15.4 to 66.6 years). Conclusions The high-quality data generated in the LATER 2 study will provide valuable insights into risks of and risk factors for clinical and (psychosocial) health outcomes and factors for early recognition of (psychosocial) health outcomes in long-term childhood cancer survivors. This will contribute to fill in important gaps in knowledge and improve the quality of life and care for childhood cancer survivors.

Parasites form an integral part of food webs, however, mechanistic insights into the role of parasites for energy flow and community dynamics is currently limited by a lack of conceptual studies investigating host-parasite interactions in a community context. In aquatic systems, chytrids constitute a major group of fungal parasites and their free-living infective stage (zoospores) forms a highly nutritional food source to zooplankton. Consumption of zoospores can create an energy pathway from otherwise inedible phytoplankton to zooplankton (“mycoloop”). The impact of such parasite-mediated energy pathways on community dynamics and energy transfer to higher trophic levels is of high importance considering eutrophication and global warming induced shifts to dominance of unfavourable prey such as cyanobacteria. We theoretically investigated community dynamics and energy transfer in a food web consisting of an edible-nonhost and an inedible-host phytoplankton species, a fungal parasite, and a zooplankton species grazing on edible phytoplankton and fungi. Food web dynamics were investigated along a nutrient gradient for two cases: (1) non-adaptive zooplankton species representative for filter feeders like cladocerans and (2) zooplankton with the ability to actively adapt their feeding preferences like many copepod species. For both feeding strategies, the importance of the mycoloop for zooplankton increases with nutrient availability. This increase is smooth for non-adaptive consumers. For a consumer with an adaptive feeding preference, we observe an abrupt shift from almost exclusive preference for edible phytoplankton (dominant prey) at low nutrient levels to a strong preference for parasitic fungi at high nutrient levels. The model predicts that parasitic fungi can contribute up to 50% of the zooplankton diet in nutrient rich environments, agreeing with empirical observations on zooplankton gut content from eutrophic systems during cyanobacterial blooms. Our findings highlight the role of parasite-mediated energy pathway for predictions on energy flow and community composition under environmental change.

Speciation is a fundamental evolutionary process, which results in genetic differentiation of populations and manifests as discrete morphological, physiological and behavioral differences. Each species has had its own evolutionary trajectory, formed by many types of selection pressures and random drift, making the association of genetic differences between the species with the phenotypic differences extremely difficult. In the present study, we have used an in vitro model to analyze in depth the genetic and gene regulation differences between fibroblasts of two closely related mammals, the arctic/subarctic mountain hare (Lepus timidus Linnaeus) and the temperate steppe-climate adapted brown hare (Lepus europaeus Pallas). We discovered the existence of a species-specific expression pattern of 1,623 genes, manifesting in differences in cell growth, respiration, and metabolism. Interspecific differences in the housekeeping functions of fibroblast cells suggest speciation acts on fundamental processes, even in these two interfertile species. Our results help to understand the molecular constituents of a species difference on cellular level, which could contribute to the maintenance of the species boundary

Using annual water balance analyses may mask intra-annual variability in runoff generation, which could limit our understanding of the similarities and differences between water- and energy-limited catchments. This may be especially limiting in comparisons between catchments close to the threshold between water- and energy-limitation. For this study, we examined runoff generation as a function of catchment storage in four watersheds, with focus on two that exist close to these thresholds to identify how year-to-year variability in storage resulted in intra-annual variations of runoff generation efficiency. Specifically, we focused on one energy-limited catchment in the humid subtropics and one water-limited in a Mediterranean climate. We used measured and calculated daily water balance components to calculate variations in the relative magnitude of daily storage. We isolated precipitation events to draw connections between storage and runoff generation at intra-annual scales and compared our findings to the same metrics in two intensely energy-limited landscapes. We observed distinct stages in daily storage across water years in watersheds at the threshold, where systems experienced wet-up, plateau, and dry-down stages. During the wet-up, precipitation was partitioned to storage, and runoff ratios ( RR) were low. In the plateau, storage was filled, precipitation was partitioned to runoff, causing high RRs. During the dry-down, storage decreased as precipitation was partitioned to evapotranspiration and runoff, causing low RRs. The critical role of evapotranspiration during the growing season resulted in relatively higher RRs during the wet-up than during the dry-down for a given storage value. Thus the same storage amount was partitioned to evapotranspiration or runoff differently throughout the year, depending on the storage stage. Despite their different positions on opposite sides of the threshold, the similarity between the two focus catchments suggests a potential characteristic behavior of systems at the threshold common to both humid and semi-arid landscapes.

Background Antenatal corticosteroids (ACS) are recommended in threatened preterm labour to improve short term neonatal outcome. Preclinical animal studies suggest detrimental effects of ACS exposure on offspring cardiac development; their effects in humans are unknown. Objectives To systematically review the human clinical literature to determine the effects of ACS on offspring cardiovascular function. Main results Twenty-six studies including 1921 patients were included, of which most were cohort studies of mixed quality. The type of ACS exposure, gestational age at exposure, dose and number of administrations varied widely. Offspring cardiovascular outcomes were assessed from one day to 36 years postnatally. The most commonly assessed parameter was arterial blood pressure (18 studies), followed by echocardiography (8 studies), heart rate (5 studies), electrocardiogram (ECG, 3 studies) and cardiac magnetic resonance imaging (MRI, 1 study). There were no clinically significant effects of ACS exposure on offspring blood pressure. However, there were insufficient studies assessing cardiac structure and function using echocardiography or cardiac MRI to be able to determine an effect. Conclusions Administration of ACS is not associated with long-term effects on blood pressure in exposed human offspring. The effects on cardiac structure and other measures of cardiac function were unclear due to the small number of studies, study heterogeneity and mixed quality. Given the emerging preclinical evidence of harm following ACS exposure, there is a need for further research to assess central cardiac function in human offspring exposed to ACS. Keywords: Antenatal corticosteroids, ACS, cardiovascular, offspring, blood pressure

A patient with lung cancer was administrated osimertinib. She developed symptomatic heart failure due to Takotsubo-cardiomyopathy (TC). As her condition improved after discontinuing osimertinib, TC was thought to be caused by osimertinib. Re-occurrence of TC was seen after re-administraing half dose of osimernitib.

An accurate and stable data-driven model is proposed in this work for fatigue life prediction in presence of mean stresses. In the model, multiple independent extreme learning machines are trained using different training data and neural network configurations, and are then combined equally in an ensemble to model the complex correlations between fatigue life, material properties and mechanical responses. Meanwhile, theoretical prediction, as a representation of domain knowledge, is integrated to optimize the data-driven processes of model training and prediction, diversifying the information source of fatigue life modeling. Extensive experimental results covering thirteen metallic materials and a wide range of mean stress levels are collected from the open literature for model training and evaluation. The results demonstrate that the proposed model can achieve high accuracy and good stability [simultaneously](javascript:;), even with a small training dataset, showing great applicability for fatigue life prediction under mean stress loading conditions.