Introduction - Treatment abandonment contributes significantly to poor survival of children with cancer in low-middle-income countries (LMICs). In order to inform an approach to this problem at our Cancer Unit, we investigated why caregivers withdraw their children from treatment. Methods – In a qualitative study, in-depth interviews were conducted with caregivers of children who had abandoned cancer treatment at the Paediatric Cancer Unit (PCU) of Mbarara Regional Referral Hospital (MRRH) in South Western Uganda, between May 2017 and September 2020. Recorded in-depth interviews with caregivers were transcribed and analyzed to identify themes of caregiver self-reported reasons for treatment abandonment. Results - Seventy-seven out of 343 (22.4%) children treated for cancer at MRRH abandoned treatment during the study period; 20 contactable and consenting caregivers participated in the study. The median age of children’s caregivers was 37 years and most (65%) were mothers. At the time of this study, eight (40%) children were alive and 5 (62.5%) were males; with a median age of 6.5 years. Financial difficulties, other obligations, the child falsely appearing cured, preference for alternative treatments, belief that cancer was incurable, fear that the child’s death was imminent and chemotherapy side-effects were the caregivers’ reasons for treatment abandonment. Conclusions and Recommendation – Treatment abandonment among children with cancer in Uganda is, most times, as a result of difficult conditions beyond the caregivers’ control and needs to be approached with empathy and support.

Aim: Urinary incontinence is an important problem that can arise due to neurogenic or functional reasons and can negatively affect the psychological, social and personality development of children. This study was conducted in Eskişehir province, on secondary school students in order to determine the prevalence and nature of urinary incontinence at night and/or daytime. Methods: The study universe included all secondary school students attending state elementary schools in the city center of Eskişehir (N=34.000). Ethics Committee and Provincial Directorate of National Education approval was obtained before conducting the study, which was supported by Eskişehir Osmangazi University Scientific Research Projects Commission (2017-1876) . A data collection form prepared by the researchers, and a consent form were delivered in sealed envelope to the parents via the students. The study data were collected between 09.05.2018-30.05.2018. Only volunteers were included in the study. 6957 questionnaires which have been fully completed from the 7370 surveys have been taken into consideration. The statistical analysis was carried out using the SPSS soft ware package. Results: The number of children found to have urinary incontinence was determined to be 215 (3.1%). It has been determined that 33 children (0.5%) have urinary incontinence only at daytime, 61 children (0.9%) have urinary incontinence both at night and daytime, and 121 children (1.7%) have urinary incontinence only at night. It was observed that 56% of the children suffering from urinary incontinence had not applied to any health institution for treatment before. Conclusions: Children and families with urinary incontinence need medical information and support to cover the cause of the problem and suggestions for solutions. Accompanying pathologies in cases to be detected can be determined in the early period by means of school screenings and medical evaluation and support can prevent the psychosocial and personality development of children from being adversely affected.

Heart allotransplantation has become one of the methods of choice in the treatment of severe heart failure. In the face of its difficulties, such as the unmet balance between organ supply and demand, the use of xenotransplantation might be an attractive option in the near future, even more with the ongoing progress achieved regarding the avoidance of hyperacute rejection and primary organ disfunction, maintenance of xenograft function and control of xenograft growth. To make possible this translational challenge, some points must be taken into account indeed, and they are the equipoise of human benefit and animal suffering, the risk of unknown infections, a well prepared informed consent, ethical and religious beliefs, and the role of cardiac xenotransplantation in a ventricular assistance device era.

Reply to “Additional Data Protection of the Esophagus During Catheter Ablation of Atrial Fibrillation”Mahmoud Houmsse, MD, and Emile G. Daoud, MDDepartment of Medicine, Division of Cardiology, Richard M. Ross Heart HospitalThe Ohio State University Medical Center, Columbus, OHRunning Title: Protection of EsophagusAddress for correspondence: Emile Daoud, MDDHLRI 473 W. 12th Avenue, Suite 200 Columbus, OH 43210-1252 Telephone: 877-478-2478 FAX : 614-293-5614E-Mail: [email protected]: NoneDisclosure: Emile Daoud and The Ohio State University have equity ownership and serve as consultants to S4 Medical Corp, which is manufacturing the Esoultion esophageal retractor.Disclosure: Mahmoud Houmsse has no conflict of interestWe Thank Dr.Clark and Dr. Kulstad for their interest in our recent review manuscript “protection of the esophagus during catheter ablation of atrial fibrillation”We agree with Dr. Clark and Dr. Kulstad that utilization of luminal esophageal temperature (LET) monitoring during atrial fibrillation ablation is inadequate method to avoid esophageal injury. These have been reported in multiple studies that were referenced in our manuscript. The newer published studies regrading monitoring LET during atrial fibrillation ablation, which were reported by Dr. Clark and Dr. Kulstad, have been published during our manuscript publication process. Nevertheless, these studies that reported by Dr. Clark and Dr. Kulstad showed same conclusion of inadequate LET monitoring in preventing esophageal injury 1-3.Regarding active cooling, Dr. Clark and Dr. Kulstad reported recent published studies. First study small pilot study that showed active cooling is much more protective than manual liquid instillation4. The second pilot RCT that compared LET and active cooling showed same outcome like the IMPACT study that we reported in our manuscript 5,6.We agree with Dr. Clark and Kulstad, growing interest in the area of esophageal protection during atrial fibrillation ablation.We do believe, as we stated in the conclusion of our manuscript, that “a reliable method to protect the esophagus is of clinical value, but the ancillary value of reducing physician concern during AF ablation, reducing interruption to ablation work flow, perhaps enhancing AF ablation results and simplifying post procedure management of patient symptoms are also of high importance. Considering the ease of use, minimal side effects, and low costs associated with esophageal protection devices, these features offer compelling evidence for use of esophageal protection as routine care for AF ablation”.

Objective Although it may have been criticized and questioned by numerous authors, external fixation holds its place in modern orthopaedics and traumatology. The aim of this paper is to show the applicability of the unilateral 3D external fixation in everyday practice. Methods For external fixation of the bones, we used unilateral 3D external fixators according to Mitkovic. Results In the Republic of Serbia, the Mitkovic unilateral 3D external fixation system has been used in over 30,000 cases. The indication field of applicability of this method is wide. External fixation method was mostly used for the treatment of open and closed tibial fractures at all levels, in open femoral fractures as a part of the “staging” protocol and in fractures of the upper limbs. We used external fixation for the treatment of nonunions, malunions, in the treatment of osteitis, septic pseudoarthrosis, angular knee deformities, post-traumatic deformities, for limb lengthening and in replantation surgery. Conclusion The unilateral external fixator enables 3D biomechanical stability and is suitable for use in everyday traumatology and orthopaedics practice.

Objective: To determine if children born preterm were at increased risk of influenza hospitalization up to age five. Methods: National registry data on all children born in Norway between 2008 and 2011 was used in Cox regression models to estimate adjusted hazard ratios (aHR) for influenza hospitalizations up to age five in children born preterm (<37 pregnancy weeks). HRs were also estimated separately for very preterm (<32 weeks), early term (37-38 weeks), and post-term (≥42 weeks) children. Results: Among 238 628 children born in Norway from January 2008 to December 2011, 15 086 (6.3%) were born preterm. There were 754 (0.3%) children hospitalized with influenza before age five. The rate of hospitalizations in children born preterm was 1.4 per 10 000 person-years (95% confidence interval [CI]: 1.1-1.7), and 0.6 per 10 000 person-years (95% CI: 0.5-0.6) in children born at term (≥37 weeks). Children born preterm had a higher risk of influenza hospitalization before age 5: aHR 2.33 (95% CI: 1.85-2.93). The risk increased with decreasing gestational age and was highest among those born very preterm; aHR 4.07 (95% CI: 2.63-6.31). Compared to children born at 40-41 weeks, children born early term also had an elevated risk of influenza hospitalization; aHR (37 weeks) 1.89 (95% CI: 1.43-2.40), aHR (38 weeks) 1.43 (95% CI: 1.15-1.78). Conclusion: Children born preterm had a higher risk of influenza hospitalizations before age five. An elevated risk was also present among children born at an early term. Children born preterm would benefit from influenza vaccinations.

The realization of fractional quantum chemistry is presented. Adopting the integro-differential operators of the calculus of arbitrary-order, we develop a general framework for the description of quantum nonlocal effects in the complex electronic environments. After a brief overview of the historical and fundamental aspects of the calculus of arbitrary-order, various classes of fractional Schr\"odinger equations are discussed and pertinent controversies and open problems around their applications to model systems are detailed. We provide a unified approach toward fractional generalization of the quantum chemical models such as Hartree-Fock and Kohn-Sham density functional theory and develop fractional variants of the fundamental molecular integrals and correlation energy . Furthermore, we offer various strategies for modeling static- and dynamic-order quantum nonlocal effects through constant- and variable-order fractional operators, respectively. Possible directions for future developments of fractional quantum chemistry are also outlined..

In 2010, vulnerable golden bandicoots (Isoodon auratus) were translocated from Barrow Island, Western Australia, to a predator-free enclosure on the Matuwa Indigenous Protected Area. Golden bandicoots were once widespread throughout a variety of arid and semi-arid habitats of central and northern Australia. Like many small to medium-sized marsupials, the species has severely declined since colonisation and has been reduced to only four remnant natural populations. Between 2010 and 2020 the reintroduced population of golden bandicoots on Matuwa was monitored via capture-mark-recapture data collection which was used in spatially explicit capture-recapture analysis to monitor their abundance over time. In 2014, we used VHF transmitters to examine the home range and habitat selection of 20 golden bandicoots in the enclosure over a six-week period. We used compositional analysis to compare the use of four habitat types. Golden bandicoot abundance in the enclosure slowly increased between 2010 and 2014 and has since plateaued at approximately one quarter of the density observed in the founding population on Barrow Island. The population may have plateaued because some bandicoots escape through the fence. Golden bandicoots used habitats dominated by scattered shrubland over spinifex grass more than expected given the habitat’s availability. Nocturnal foraging range was influenced by sex and trapping location, whereas diurnal refuge habitat was consistent across sex and trapping location. Our work suggests that diurnal refuge habitat may be an important factor for the success of proposed translocations of golden bandicoots.

A knowledge of the exchanges of energy and water over the terrestrial surface is the first step to understand the ecohydrological mechanisms, particularly in water-limited ecosystems in the dryland environments. However, patterns of energy exchange and evapotranspiration (ET) are not well understood in the oasis-desert ecotone, which plays an important role in protecting oasis against the threat of desertification in northwestern China’s arid regions. Here the continuous measurements of surface energy fluxes were made using eddy covariance in conjunction with auxiliary measurements for two years (2014-2015) at a shrubland within an oasis-desert ecotone in the arid regions, northwestern China. Statistical analysis on 30-min time scale indicates that about 50% of daytime net radiation (Rn) over the shrubland is dissipated as H on average, which peaks in spring; one third Rn is consumed by soil heat flux (G). Only 9% of Rn was consumed for latent heat flux (λE), which peaks in summer (21% in 2014 and 16% in 2015), corresponding to the season with highest rainfall among all seasons. Daily mean ET is about 1 mm·d−1 during growing season of the shrub species. The rapid and transient increase in ET occurs following a rainfall event. A switch in surface soil moisture from 0.04 to 0.11 m3·m−3 causes an increase in Rn by about 11% and λE by 151% at the shrubland, respectively. Accumulated annual ET were 195 and 181 mm in 2014 and 2015, respectively, exceeding the corresponding P by about 87 and 77 mm, indicating that groundwater may be another important source of water for ET over the shrubland aside from P. These results provide valuable insight into the mechanisms of sustaining energy and water balance at the ecotone, and then produce some management guidelines for allocating water resources and protecting vegetation.

Complex civil structures require the cooperation of many building materials. However, it is difficult to accurately monitor and evaluate the inner damage states of various material systems. Based on a convolutional neural network (CNN) and the acoustic emission (AE) time-frequency diagram, we used the transfer learning method for classifying the AE signals of different materials under external loads. The results show the CNN model can accurately classify cracks that come from different materials based on AE signals. The recognition accuracy can reach 90% just by re-training the full connection layer of the pre-trained model, and its accuracy can reach 97% after re-training the top 2 convolutional layers of this model. A realization of cracking source identification mainly depends on the differences in mineral particles in materials. This work highlights the great potential for real-time and quantitative monitoring of the health status of composite civil structures.

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’.

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. Click on the document to view its contents.

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.

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.

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.

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.