Background: Simultaneous atrial fibrillation (AF) catheter ablation and left atrial appendage closure (LAAC) is sometimes recommended for both rhythm control and stroke prevention. However, the advantages of intracardiac echocardiography (ICE) guidance for this combined procedure have been scarcely reported. To evaluate the clinical outcomes and safety of ICE guided LAAC within a zero-fluoroscopy catheter ablation procedure. Methods and Results:From April 2019 to April 2020, 56 patients with symptomatic AF underwent concomitant catheter ablation and LAAC. ICE with a multi-angled imaging protocol mimicking the TEE echo windows was used to guide LAAC. Successful radiofrequency catheter ablation and LAAC was achieved in all patients. Procedure-related adverse event rate was 3.6%. During the 12-month follow-up, 77.8% of patients became free of arrhythmia recurrences and oral anticoagulants were discontinued in 96.4% of patients. No ischemic stroke occurred despite two cases of device-related thrombosis versus an expected stroke rate of 4.8% based on the CHA2DS2-VASc score. The overall major bleeding events rate was 1.8%, which represented a relative reduction of 68% versus an expected bleeding rate of 5.7% based on the HAS-BLED score of the patient cohort. The incidence of iatrogenic atrial septal defect secondary to a single transseptal access dropped from 57.9% at 2 months to 4.2% at 12 months TEE follow-up. Conclusion:The combination of catheter ablation and LAAC under ICE guidance was safe and effective in AF patients with high stroke risk. ICE with our novel protocol was technically feasible for comprehensive and systematic assessment of device implantation.

Object: Investigate the value of transesophageal echocardiography (TEE) in perimembranous ventricular septal defect (PmVSD) closure via a left parasternal ultra‐minimal trans intercostal incision in children. Methods: From January 2015 and December 2020, 212 children with PmVSD were performed device occlusion via an ultraminimal intercostal incision. TEE is used throughout the perioperative period, including TEE assessment, TEE-guided localization of the puncture site, TEE guidance. All patients were followed up using transthoracic echocardiography for over 6 months. Results: A total of 207 cases successfully occluded, the successful rate was 97. 64%. one hundred and forty-five patients had single orifice, and 62 patients had multiple orifices in the AMS. During the operation, the surgeon readjusted the device or replaced the larger device in 17 cases. After operation, there were 19 cases of slight residual shunts, 13 cases of pericardial effusion and 4 cases of pleural effusion. And all were back to normal during the 4- month follow-up period. Mild mitral regurgitation was presented in 1 patient and remained the same during the follow-up period. No other complications were found. Conclusions: TEE was used to evaluate and determine the defect in PmVSDs with an concentric occluder via a left parasternal ultra‐minimal trans intercostal incision. TEE guidance and immediate postoperative efficacy evaluation are of great value, which can effectively guide the treatment of PmVSD occlusion.

Objectives Pulmonary atresia (PA) with ventricular septal defect (VSD) and systemic-pulmonary collateral arteries (SPCA’s) has a variable anatomy with regard to the pulmonary vasculature, asking for an individualized surgical treatment. A protocol was applied consisting of staged unifocalization and correction. Methods Since 1989 39 consecutive patients were included (median age at first operation 13 months). In selected cases a central aorto-pulmonary shunt was performed as first procedure. Unifocalization procedures were performed through a lateral thoracotomy. Correction consisted of shunt takedown, VSD closure and interposition of an allograft between the right ventricle and the reconstructed pulmonary artery. Postoperatively and at follow up echocardiographic data were obtained. Results In 39 patients 66 unifocalization procedures were performed. Early mortality was 5%. Seven patients were considered not suitable for correction, four of them died. One patient is awaiting further correction. Correction was done successfully in 28 patients. Operative mortality was 3% and late mortality 11%. Median follow-up after correction was 19 years. Eleven patients needed homograft replacement. Freedom from conduit replacement was 88%, 73% and 60% at 5, 10 and 15 years respectively. Right ventricular function was reasonable or good in 75 % of the patients. Conclusions After complete unifocalization 30/37 patients (81%) were considered correctable. The main reasons for palliative treatment without correction were pulmonary hypertension and/or inadequate outgrowth of pulmonary arteries. Staged approach of PA, VSD and SPCA’s results in adequate correction and good functional capacity. RV function after correction remains reasonable or good in the majority of patients.

Flow regimes are critical for determining physical and biological processes in rivers, and their classification and regionalization traditionally seeks to link patterns of flow to physiographic, climate and other information. There are many approaches to, and rationales for, catchment classification, with those focused on streamflow often seeking to relate a particular response characteristic to a physical property or climatic driver. Rationales include such topics as Prediction in Ungauged Basins (PUB), helping with experimental approaches, and providing guidance for model selection in poorly understood hydrological systems. While scale and time are important considerations for classification, the Annual Daily Hydrograph (ADH) is a first-order easily visualized integrated expression of catchment function, and over many years is a distinct hydrological signature. In this study, we use t-SNE, a state-of-the-art technique of dimensionality reduction, to classify 17110 ADHs for 304 reference catchments in mountainous Western North America. t-SNE is chosen over other conventional methods of dimensionality reduction (e.g. PCA) as it presents greater separability of ADHs, which are projected on a 2D map where the similarities are evaluated according to their map distance. We then utilize a Deep Learning encoder to upgrade the non-parametric t-SNE to a parametric approach, enhancing its capability to address ‘unseen’ samples. Results showed that t-SNE was an effective classifier as it successfully clustered ADHs of similar flow regimes on the 2D map. In addition, many compact clusters on the 2D map in the coastal Pacific Northwest suggest information redundancy in the local hydrometric network. The t-SNE map provides an intuitive way to visualize the similarity of high-dimensional data of ADHs, groups catchments with like characteristics, and avoids the reliance on subjective hydrometric indicators.

The results of a meta-analysis are more than just the reported odds ratio, 95% confidence interval, and P value. Of equal importance is the fine print of the study which should include assessment of risk of bias, certainty in evidence, and heterogeneity in the individual point estimates and confidence intervals. These areas all have influence on the quality of the data in the analysis. Reading and understanding the fine print is important.

5 Key Points: Prior studies demonstrated a failure to identify and localize head and neck cancers via near-infrared (NIR) imaging of indocyanine green (ICG) with a robot-integrated platform. However, our group demonstrated success in visualization of neoplasms using a commercially available dedicated NIR camera system and a technique called second window ICG (SWIG), in which ICG is injected 24 hours pre-operatively.We aimed to evaluate the SWIG technique in patients undergoing transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) and compare two NIR camera systems.System 1 showed poor tumor-margin delineation with no fluorescence in 4/6 cases (66.7%) and only minimal fluorescence in the remaining 2 cases (33.3%).System 2 showed marked fluorescence in 5/6 cases (83.3%), with good margin definition in 4 cases (66.7%). In 2 cases (33.3%), System 2 also identified tumor that was not visible under white light.In this preliminary case series, we found that System 2 outperforms System 1 in NIR imaging with SWIG during TORS for oropharyngeal tumor resection.

Snow density is one of the essential properties to describe snowpack characteristics. To obtain the spatial variability of snow density and estimate it accurately in different periods of snow season still remain as challenges, particularly in the mountains. This study analyzed the spatial variability of snow density with in-situ measurements in three different periods (i.e. accumulation, stable, melt period) of snow seasons 2017/2018 and 2018/2019 in the middle Tianshan Mountains, China. The performance of multiple linear regression model (MLR) and three machine learning models (i.e. Random Forest (RF), Extreme Gradient Boosting (XGB) and Light Gradient Boosting Machine (LGBM)) to simulate snow density has been evaluated. It was found that the snow density in melt period (0.27 g cm-3) was generally greater than that in stable (0.20 g cm-3) and accumulation period (0.18 g cm-3), and the spatial variability of snow density in melt period was slightly smaller than that in other two periods. The snow density in mountainous areas was generally higher than that in plain or valley areas, and snow density increased significantly (p < 0.05) with elevation in the accumulation and stable periods. Besides elevation, latitude and ground surface temperature also had critical impacts on the spatial variability of snow density in the middle Tianshan Mountains, China. In this work, the machine learning model, especially RF model, performed better than MLR on snow density simulation in three periods. Compared with MLR, the determination coefficients of RF promoted to 0.61, 0.51 and 0.58 from 0.50, 0.1 and 0.52 in accumulation period, stable period and melt period respectively. This study provide a more accurate snow density simulation method for estimating regional snow mass and snow water equivalent, which allows us to achieve a better understanding of regional snow resources.

The reintroduction of endangered plant species is an essential conservation tool. Reintroductions can fail to create resilient, self-sustaining populations due to a poor understanding of environmental factors that limit or promote plant success. Biotic factors, specifically plant-arthropod interactions, have been shown to affect the establishment of endangered plant populations. Lupinus nipomensis (Nipomo Mesa lupine) is a state of California (California Rare Plant Rank: 1B.1) and federally (65 FR 14888) endangered endemic plant with only one extant population located along the central California coast. How arthropods positively or negatively interact with L. nipomensis is not well known and more information could aid conservation efforts. We conducted arthropod surveys of the entire L. nipomensis extant population in spring 2017. Observed arthropods present on L. nipomensis included 17 families, with a majority of individuals belonging to Thripidae. We did not detect any obvious pollinators of L. nipomensis, providing support for previous studies suggesting this lupine is capable of self-pollinating, and observed several arthropod genera that could potentially impact the reproductive success of L. nipomensis via incidental pollination or plant predation.

The subphylum Myriapoda included four extant classes (Chilopoda, Symphyla, Diplopoda and Pauropoda), but very little work has been done to explore their phylogenetic relationships. Herein, we determined the complete mitochondrial genome of Polydesmus sp. GZCS-2019 (Myriapoda: Polydesmida) and the mitochondrial genomes are circular molecules of 15,036 bp, with all genes encoded on + strand. The A+T content is 66.1%, making the chain asymmetric, and exhibits negative AT-skew (-0.236). Several genes rearrangements were detected and we propose a new rearrangement model: “TD (N\R) L + C” based on the genome-scale duplication + (non-random/random) loss + recombination. Phylogenetic analyses demonstrated that Chilopoda and Symphyla both were monophyletic group, whereas Pauropoda was embedded in Diplopoda to form the Dignatha. Divergence time showed the first split of Myriapoda occurred between the Chilopoda and other classes (Wenlock period of Silurian). We combine phylogenetic analysis, divergence time, and gene arrangement to yield valuable insights into the evolutionary history and classification relationship of Myriapoda and these results support a monophyletic Progoneata and the relationship (Chilopoda + (Symphyla + (Diplopoda + Pauropoda))) within Myriapod. Our results help to better explain the gene rearrangement events of the invertebrate mitogenome and lay the foundation for further phylogenetic study of Myriapoda.

Background: Male circumcision is a common procedure, generally performed during the newborn period. Bleeding is an uncommon but feared complication of circumcision. Few reports have evaluated circumcision bleeding rates in patients with bleeding disorders. Objectives: To study circumcision bleeding rates in male subjects who were diagnosed later in life with delta-storage pool deficiency (δ-SPD). Methods: We retrospectively reviewed the medical records of male subjects (≤ 18 years of age) who were circumcised without hemostatic prophylaxis prior to δ-SPD diagnosis from 2000-2020. Bleeding rates and severity were the main outcomes evaluated. We collected demographic data, bleeding scores using a validated assessment tool, laboratory data, and platelet electron microscopy results. A descriptive analysis was performed. Results: Twenty-five male subjects were included. The median bleeding score at presentation was 3.5 (range,2-9). The diagnosis was confirmed using platelet electron microscopy. A value of <2 dense granules/platelet was considered abnormal. Circumcision was performed at a median age of 2 days (range, 1 day-4 months). None of the subjects had intraoperative or postoperative bleeding. With a bleeding rate of zero, we suggest that newborn males with a family history of δ-SPD may be safely circumcised without hemostatic prophylaxis. 

This study compared the microhabitat use, daily activity pattern and diet of Liolaemus etheridgei Laurent 1998 in two Polylepis woodlands: El Simbral (fragmented) and Tuctumpaya (unfragmented), in Arequipa, Southern Peru. In both populations, we did not detect positive selection for any microhabitat; however, the population at El Simbral showed a negative selection for Polylepys trees while the Tuctumpaya population showed negative selection for Polylepis trees and non-thorny bushes. In El Simbral, active individuals were detected between 9:00 and 15:59h, whereas in Tuctumpaya, we detected active individuals from 8:00 to 17:59h. In both populations, observations of active individuals dropped between 11:00 and 11:59h. We recorded 17 and 23 prey categories in the El Simbral and Tuctumpaya populations respectively. The most important animal prey category in each population was found to be Lygaeidae: Hemiptera, and was the only animal prey category that was selected for in El Simbral and Tuctumpaya. In addition, due to the proportions of plant material found, the El Simbral was found to be omnivorous, whereas the Tuctumpaya population was herbivorous. Trophic niche breadth was broader in Tuctumpaya (B_a= 0.202) than the El Simbral (B_a= 0.147) population, despite there being no significant differences in diet (Permanova: F = 1.036, P = 0.409, permutations = 9999), which is coherent with the high value of trophic niche overlap (O_(j,k) = 0.963). Our compiled data reveal that L. etheridgei shows no selection for any of the resources we define in Polylepis woodlands, on the contrary, it selects negatively against Polylepis trees and non-thorny bushes. The daily activity patterns indicate a bimodal pattern with peaks at 9:00-10:59 and 13:00-13:59 h. The diet of L. etheridgei consists mainly of plants (%W: 66.373), and the most important animal prey category is Lygaeidae: Hemiptera (%IRI = 55.3), which is selected positively.

Species traits influence their response to environmental conditions and the match between phenotypes and environment mediates spatial changes in species composition. These trait-environment linkages can be disrupted in human-modified landscapes. Human land-use creates habitat fragments where dispersal limitation or edge effects can exclude species that may otherwise suit a given macro-scale environment. Furthermore, stressful micro-environments in fragments may limit viable trait combinations resulting in stronger trait covariance compared to contiguous forest, especially in harsher macroenvironments. In a wet tropical forest landscape in the Western Ghats Biodiversity Hotspot of peninsular India, I compared fragments with adjacent contiguous forest for signatures of trait-mediated assembly of tree communities along macroenvironmental gradients. Using four key plant traits—seed size, specific leaf area (SLA), wood density, and maximum height—I evaluated changes in trait-mediated abundances and trait covariance across environmental gradients. Trait-mediated abundances primarily changed along the elevation gradient in contiguous forest, smaller-seeded, shorter, thinner-leaved species increased at higher elevations. In fragments, higher SLA species increased in more seasonal climate and decreased with higher precipitation, and larger seeds decreased at warmer sites. However, traits only weakly predicted abundances and only contiguous forests experienced significant compositional change via traits, driven by trait syndromes varying along a composite environmental gradient defined by elevation, water deficit, and soil C:N ratio. Covariance of seed size and maximum height along gradients of precipitation and temperature revealed divergent constraints on viable phenotypes in fragments and contiguous forest. Notably, local biotic conditions (functional diversity) had stronger effects than environment in explaining trait covariance. Overall, the results imply that trait syndromes and trait covariance, rather than single traits, determine the phenotypes best suited to different macroenvironmental conditions and should inform management or restoration goals in fragments.

Objective: Epistaxis is the most common otolaryngological emergency and up to one third of patients in treated on an inpatient basis take oral anticoagulants (OAC). Direct oral anticoagulants (DOAC), an OAC subgroup, have been on the market since 2010 and are being increasingly prescribed due to the cardiologic and hematologic guidelines that favour them over vitamin K antagonists (VKA), the older of the OAC subgroups. The present study aims to investigate which subgroup of epistaxis patients taking OACs has a more favourable outcome. Design/Setting: A systematic review and meta-analysis were performed according to the PRISMA 2020 statement using the PubMed and Cochrane Library databases. Continuous data was analysed and standardized mean difference (SMD) was calculated according to Hedges’ g. Dichotomous data was analysed and the Mantel-Haenszel method was applied to establish the odds ratio (OR). Heterogeneity was assessed according to the I2 statistics. Main Outcome/Results: A total of 8 reports covering 1390 patients were included in the final synthesis. The pooled analysis demonstrated significantly shorter hospital stays in the DOAC group (SMD= -0.22, 95% CI -0.42 to -0.02, P= .03) and a significantly higher rate of posterior bleeding in the VKA group (OR= .39, 95% CI .23 to .68, P= .001). No statistically significant differences with regard to recurrence rates, admission rates, the need for transfusion, or surgical intervention (P= .57, .12, .57 and .38 respectively) were found. Conclusion: According to this meta-analysis, epistaxis patients taking DOACs have a more favourable outcome than patients taking VKAs.

Although insect herbivores are known to evolve resistance to insecticides through multiple genetic mechanisms, resistance in individual species has been assumed to follow the same mechanism. While both mutations in the target site insensitivity and increased amplification are known to contribute to insecticide resistance, little is known about the degree to which geographic populations of the same species differ at the target site in a response to insecticides. We tested structural (e.g. mutation profiles) and regulatory (e.g. the gene expression of Ldace1 and Ldace2, AChE activity) differences between two populations (Vermont, USA and Belchow, Poland) of the Colorado potato beetle, Leptinotarsa decemlineata in their resistance to two commonly used groups of insecticides, organophosphates, and carbamates. We established that Vermont beetles were more resistant to azinphos-methyl and carbaryl insecticides compared to Belchow beetles, despite a similar frequency of resistance-associated alleles (i.e. S291G) in the Ldace2 gene. However, the Vermont population had two additional amino acid replacements (G192S, F402Y) in the Ldace1 gene, which were absent in the Belchow population. Moreover, the Vermont population showed higher expression of Ldace1 and was less sensitive to AChE inhibition by azinphos methyl oxon than the Belchow population. Therefore, the two populations have evolved different genetic mechanisms to adapt to organophosphate and carbamate insecticides.

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We report a case that the airway can be completely sealed, when the endotracheal tube cuff pressure is 100 cmH2O. The diagnosis was made by the patient’s chest CT（X-ray computed tomography）, This case illustrates that the real cross-sectional area of airway from the case obviously exceeds the normal population.

COVID-19 has been linked to a number of cutaneous symptoms in COVID-19 patients. Although herpes zoster (HZ) was the first sign of COVID-19 infection in several patients, cases of HZ after COVID-19 vaccination are rare. We report case of 51 years old male with Herpes Zoster after Sinopharm (Vero Cell).

Thrombotic complications of SARS-CoV-2 have been increasingly recognized as an important component of COVID-19 in adults; however, they have been less evident in children. We report a case of a teenager with positive SARS‐CoV‐2 RT–PCR and underlying prothrombotic risk factors, including aromatase inhibitor therapy, who developed deep vein thrombosis resulting in pulmonary embolism. Laboratory tests revealed deranged coagulation parameters (high D-dimers and Factor VIII and low antithrombin). The patient required intensive care and was managed with anticoagulants, dexamethasone and antithrombin concentrate. Clinical condition and hemostatic profile gradually improved. A review of the available literature for similar cases is presented.