A 52-year-old female was admitted to rule out an acute coronary syndrome.Her Troponin, ECG, MPS were negative. Further testing she was found to have extremely high high-density lipoprotein level of 218 mg/dl.Due to the persistent nature of the chest pain, LHC was done with 50% stenosis of RCA.

Sympathectomy - A “one hit wonder” for life?Fabrizio R. Assis, M.D. Harikrishna Tandri, M.D.From Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

AllergyEditorial (invited)

Background: The success of subcutaneous immunotherapy (SCIT) mostly depends on regular injections. Our aim was to investigate adherence to SCIT with aeroallergens during the COVID-19 pandemic and demonstrate clinical consequences of treatment disruptions in real-life. Methods: Visual analogue scale for quality of life (VAS-QoL), VAS for symptom scores (VAS-symptom), medication scores (MSs) and total symptom scores (TSS-6) were recorded during the pandemic in 327 adult allergic rhinitis and/or asthmatic patients receiving maintenance SCIT and these scores were compared with the pre-pandemic data. Patients were grouped according to SCIT administration intervals; no delay (Group 1), <2 months (Group 2), and ≥2 month intervals (Group 3). Results: 104 (31.8%) patients (Group 3) were considered as non-adherent which was mostly related to receiving SCIT with HDMs and using public transportation for reaching the hospital. Median MS, VAS-symptom and TSS-6 scores of Group 3 patients during the pandemic were higher than the pre-pandemic scores (p=0.005, p<0.001, p<0.001, respectively) whereas median VAS-QoL scores of Group 3 during the pandemic were lower than the pre-pandemic scores (p<0.001). Median TSS-6 and VAS-symptom scores were the highest in Group 3 compared to other groups (p<0.001 for each comparison). Median VAS-QoL scores were the lowest in Group 3 compared to Group 1 and Group 2 (p<0.001, p=0.043, respectively). Conclusion: When precautions in allergy clinics are carefully applied, adherence to SCIT can be high during a pandemic. Patients must be warned about adhering to SCIT injections since delays in SCIT administration can deteriorate clinical symptoms.

Ecological theory recognizes the importance of the variety of species for maintaining the functioning of ecosystems and their derived services. We assert that when studying the effects of shifts in biodiversity levels using mathematical models, their dynamics must be sensitive to the variety of species traits but not to raw species numbers, a property that we call scale--invariance. We present a testing procedure for verifying scale--invariance of ecological network models ---with or without trait adaptation--- expressed as ODEs. Furthermore, we applied our test to several influential models used for evaluating biodiversity effects on ecosystem functioning. In most of the surveyed studies the equations failed our test. This raises doubts about the validity of previous results and calls for revisiting the theory derived from these studies. Our results foster the creation of artifact--free models, a necessary step towards building a more robust theory of biodiversity--driven ecosystem functioning.

A regional coupled approach to water cycle prediction is demonstrated for the 4-month period from November 2013 to February 2014 through analysis of precipitation, soil moisture, river flow and coastal ocean simulations produced by a km-scale atmosphere-land-ocean coupled system focussed on the United Kingdom (UK), running with horizontal grid spacing of around 1.5 km across all components. The Unified Model atmosphere component, in which convection is explicitly simulated, reproduces the observed UK rainfall accumulation (r2 of 0.62 for daily accumulation), but there is a notable bias in its distribution – too dry over western upland areas and too wet further east. The JULES land surface model soil moisture state is shown to be in broad agreement with a limited number of cosmic-ray neutron probe observations. A comparison of observed and simulated river flow shows the coupled system is useful for predicting broad scale features, such as distinguishing high and low flow regions and times during the period of interest but are shown to be less accurate than optimised hydrological models. The impact of simulated river discharge on NEMO model simulations of coastal ocean state is explored in the coupled system, with comparisons provided relative to experiments using climatological river input and no river input around the UK coasts. Results show that the freshwater flux around the UK contributes of order 0.2 psu to the mean surface salinity, and comparisons to profile observations give evidence of an improved vertical structure when applying simulated flows. This study represents a baseline assessment of the coupled system performance, with priorities for future model developments discussed.

A document by Jianghui Cai. Click on the document to view its contents.

Background: Adults with cardiopulmonary conditions are at increased risk for complications from influenza and respiratory syncytial virus (RSV) infection, but few data are available from middle-income countries. Methods: Using data from a prospective cohort study of influenza vaccine effectiveness among community-dwelling Thai adults aged ≥65 years, we estimated and compared the incidence of influenza and RSV in those with and without cardiopulmonary conditions. During May 2015-May 2017, older adults in a rural province in Thailand were followed weekly with year-round surveillance for acute respiratory illness (ARI), defined broadly as new onset or worsening of cough with or without fever, and hospitalized ARI. When ill, nasal self-swabs and/or nasopharyngeal swabs were collected for reverse-transcription polymerase chain reaction testing. We used Poisson regression to calculate incidence rate ratios (IRR), adjusting for age, sex, past healthcare-seeking behavior, weekly influenza activity, and influenza vaccination. Results: Overall, 3,220 adults with a median age of 71 years (IQR 68-76) were enrolled; 1,324 (41.1%) were male; and 313 (9.7%) had ≥1 underlying cardio-pulmonary condition, most commonly chronic obstructive pulmonary disease (131; 41.2%) or asthma (73; 23.3%). Compared to those without, participants with cardiopulmonary conditions had higher incidences of ARI, influenza, and RSV (Adjusted IRR: 1.83, 95% CI 1.63-2.05; 1.84, 95% CI 1.05-3.23; 2.02, 95% CI 1.10-3.72, respectively). Conclusion: Our findings show that older adults in rural Thailand with cardiopulmonary conditions have increased rates of ARI, influenza, and RSV infections, and support efforts to ensure this population has access to influenza vaccines and other respiratory illness prevention measures.

Introduction: Following the Covid-19 pandemic, the face-to-face meetings are delayed to a future date , which is still not clear. However, seminars, meetings, and conferences are necessary for updating our knowledge and skills. The web-based seminars (webinars) are the solutions to this issue. This study aimed to show the participant behavior when webinars present at the Covid-19 pandemic era. Methods: Between December 2017 – July 2020, 58 webinars were broadcasted via the Uropedia, electronic library of SUST. Data of all webinars were collected with the YouTube analytics and application of the Uropedia. Data of streaming webinars included participant behaviors such as content views, engagement time, total unique attendees, average engagement time, and the number of audience to leads. Data were split into two groups; group-1 is webinars before Covid-19 (before March 2020), group-2 is the webinars during Covid-19. Results: Total broadcast time and total page view number were found to be 112.6 hours (6761 min.) and 15919, respectively. The median participant age was 40.1 years. Median content view and median engagement time were found to be 261.0 min., and 12.2 min., respectively. Comparison of two groups revealed a significant increment in the content views (group 1;134.0 range=86.0-87.0 and group 2; 414.0 range=296.0-602.0, p<0.001) and the number of the unique attendees (group 1; 18.0 range=10.0-26.0 and group 2; 57.0 range=27.0-100.0, p<0.001) following Covid-19. However, the median engagement time of the audience did not seem to change with the Covid-19 pandemic (group 1; 11.5 range=10.0-13.3 min. and group 2; 13.2 range=9.4-18.1 min., p=0.12). Conclusion: The webinars are effective ways to share information and have many advantages, including low cost, reaching the high number of audiences. Audience number and page visits seemed to increase following the Covid-19 pandemic. However, The engagement time did not seem to affect a critical attitude of the audience

Backgrounds Appendectomy is one of the most commonly performed surgeries worldwide. Sepsis is an major etiology of morbidity and mortality in children. Our preliminary research revealed a positive correlation among appendectomy and future risk of sepsis in adults. However, to date, the relationship among appendectomy and future risk of sepsis in children remains unknown. The aim of this research was to investigate the relationship among appendectomy and hazard of future sepsis in children. Methods We applied a nationwide population-based cohort to assess whether children who received appendectomy were at increased risk of subsequent sepsis. Overall, 57261 subjects aged below 18 undergoing appendectomy as appendectomy group and 57261 matched controls were identified as non-appendectomy group from the National Health Insurance Research Database in Taiwan. We use propensity score analysis to match age, sex, urbanization level, and parental occupation at the ratio to 1:1. Multiple Cox regression and stratified analyses were used to appraise the adjusted hazard ratio (aHR) for developing sepsis in children. Results Children who received appendectomy had a 2.63 times higher risk of developing sepsis than those who did not, and the risk was even higher in children aged under 6 years. Patients with <1 year follow-up showed a 5.64-fold risk of sepsis in the appendectomy cohort. Patients with 1–4 and ≥5 years’ follow-up showed a 2.41- and 2.02-times risk of sepsis. Conclusion Appendectomy was correlative to a 2.63-fold increased future sepsis risk in children, and the risk in younger patients aged <6 years was even higher. More studies to interpret the possible biological mechanisms of the associations among sepsis and appendectomy are warrant

Background: The aim of this study was to determine the predictive risk factors for development of severe bronchiolitis in patients with acute bronchiolitis with no previous chronic disease. Methods: Four hundred forty children aged 1-24 months hospitalized with acute bronchiolitis, were examined between February 2018 and February 2019 in this prospective study. Results: Eighty-five cases were regarded as severe bronchiolitis and 355 as mild-moderate bronchiolitis. Statistically significant differences were observed between the severe and mild-moderate bronchiolitis groups in terms of weight-for-age z-scores, history of bronchiolitis, hemoglobin levels, and time elapsed between onset of symptoms and admission. Weight-for-age z-scores, the mean time interval between onset of symptoms and admission, and mean hemoglobin values were lower in the severe bronchiolitis group while the mean number of bronchiolitis attacks was higher than in the mild-moderate bronchiolitis group. Logistic regression analysis determined that a low weight-for-age z-score increased the risk of severe bronchiolitis development 0.56-fold (CI: 0.409 – 0.760), a short duration between the onset of symptoms and admission increased the risk 0.62-fold (CI: 0.519 – 0.735), a frequent history of bronchiolitis increased the risk 1.81-fold (CI: 1.135 – 2.968) and low hemoglobin levels increased the risk 0.72-fold (CI: 0.537 – 0.969). Conclusion: Low weight-for-age z-scores, a short duration between the onset of symptoms and admission, a high number of previous attacks, and low hemoglobin levels were identified as independent parameters of severe bronchiolitis development. Key words: Bronchiolitis, Infant, Risk factors, Severity degree

Purpose: To evaluate the bowel habits of patients with acne vulgaris Method: In this case control study, socio-demographic characteristics of the participants (age, gender, marital status, educational status, profession, economic status, smoking-alcohol habits, chronic diseases, previous operations, people they live with, diet) were questioned and the global acne grading scores of the patients were calculated. Bristol Stool Scale, Rome III Criteria for IBS, International Physical Activity Questionnaire-Short Form, Hospital Anxiety Depression and KADF (dietary fiber information) scales fulfilled. Results: The patient group consisted 102 and the control group consisted 104 participants. The mean age was 20.9 ± 3.9 years old in the case group and 21.8 ± 5.0 years old in the control group. Patient and control groups were similar in terms of age and gender. Smoking rates were significantly higher in the patient group (p=0,035). The amount of coffee consumed per day were significantly higher in the patient group (p=0,040). According to the global acne grading scores, 55.9% (n = 57) had medium, 39.2% (n = 40) had mild, 3.9% (n = 4) had severe and 1% (n=1) had very severe acne. Anxiety scores were found to be significantly higher in the patient group (p = 0.005). When the case and control groups were compared for IBS presence, no significant difference was found (p = 0.317). Also, IBS was not related with acne severity (p = 0.162). Conclusion: Further large sample sized studies are needed on this subject, as there is strong evidence about brain–gut–skin axis existence.

Background: Bruxism is significantly associated with craniofacial pain, feeling of stiffness or fatigue of the jaw and neck pain. Various physiotherapeutic strategies are used in the treatment of bruxism, however, it is not clear which method leads to greater decrease in pain. Objective: The aim of this study is to compare the effects of two physiotherapy methods (manual therapy (MT) and Kinesio taping with manual therapy (KTMT)) in patients with bruxism. Methods: Patients were randomized into MT or KTMT groups. Evaluations were performed at baseline and following four weeks of physiotherapy. Muscle thickness and stiffness were assessed via shearwave ultrasonography; pain thresholds were evaluated using algometer. Sleep quality was assessed using Pittsburgh Sleep Quality Index and Quality of life was assessed with Likert scales regarding the associated symptoms. Results: Significant improvements were found in muscle stiffness, pain threshold, sleep quality, quality of life (p<0.05) in both MT and KTMT group. Pain in bilateral temporalis and right occipital region of the trapezius muscle decreased more in the KTMT group compared to the MT group (p<0.05). No significant differences in muscle thickness (p>0.05) were found in either of the groups. Conclusion: Both MT and KTMT methods were effective in the treatment of bruxism. KT used in conjunction with MT has additionally decreased jaw pain and temporal region pain when compared to MT intervention only. Therefore, if jaw pain is the primary complaint of a patient, our results recommend including KT application in the physiotherapeutic treatment program.

Aims of the study: To test the feasibility of a group psychosocial intervention called Learning Through Play (LTP) plus Culturally adapted Cognitive Behaviour Therapy (CaCBT) for depressed Kenyan mothers with children aged 0-36 months. Methods used to conduct the study: This study was a single-arm mixed methods feasibility study to test an integrated parenting intervention for maternal depression in a low-income rural area of Fumbini village in Kilifi District of Kenya. Women between the ages of 18 and 45 years with children up to three years were screened for depression using PHQ-9 (Patient Health Questionnaire). Those scoring above 10 on PHQ-9 were interviewed using the Revised Clinical Interview Schedule (CIS-R) to confirm the diagnosis of depression. Assessments were carried out at baseline and the end of the intervention (3 months), followed by qualitative interviews with 12 women. Qualitative interviews were analysed using thematic analysis from a social-constructionist theoretical lens. Results of the study: The LTP Plus was both feasible and acceptable with high satisfaction among the participants. Qualitative results showed that the women perceived the intervention as beneficial in reducing the symptoms of depression, coping with stress and negative emotions. The results also indicated that there was a reduction in scores on PHQ-9, GAD-7 with an increase in perceived social support, health-related quality of life and an improvement in mothers’ knowledge about child development at the end of the intervention. Conclusions drawn from the study and clinical implications: This study represents the first feasibility research on integrated parenting intervention in Kenya. The results indicated that culturally adapted LTP plus CaCBT is feasible and acceptable in a low-income setting of Kenya. There is now a need to study the clinical and cost-effectiveness of LTP plus CaCBT in an appropriately powered larger randomised control trial, with a longer follow-up period.

Objective: There is lack of evidence on the burden of and factors associated with non-adherence to anti-diabetic medication among individuals living with diabetes in low-and middle-income countries (LMICs). Therefore, we carried out a systematic literature review and meta-analytic synthesis to estimate non-adherence to anti-diabetic medication reported among adults in LMICs and to explore factors affecting non-adherence. Methods: We systematically searched MEDLINE and Embase to identify studies investigating non-adherence to anti-diabetic medications published between January 2000 and May 2020. Cross-sectional studies that had been conducted among individuals with diabetes in LMICs were eligible for the selection process. Critical appraisal of the included studies was carried out using the Newcastle Ottawa Scale. Meta-analysis was carried out using Stata 14.2. Random effects model was used to compute the pooled proportion at 95% confidence interval. Results: Forty-three studies met the inclusion criteria, of which 13 studies were used in meta-analysis. The pooled proportion of non-adherence to anti-diabetic medications using the eight-item Morisky Medication Adherence Scale (MMAS) was 43.4% (95% CI: 17.5–69.4; p=0.000) and 29.1% (95% CI: 19.8–38.4; p=0.000) when using the cut-off at 80 or 90%. The pooled proportion of non-adherence was 29.5% (95% CI: 25.5–33.5; p=0.098) when using the four-item Morisky Medication Adherence Scale. The factors for non-adherence based on World Health Organization demonstrated considerable variation of non-adherence to ant-diabetic medication in LMICs depending on the methods used to estimate non-adherence. Conclusions: These findings demonstrate a significantly higher proportion of medication non-adherence among individuals with diabetes in LMIC settings when MMAS-8 item scale was used and low when 80-90% cut-off scales were used. Various factors, such as disease factors, therapy-related factors, healthcare system factor, patient-centered factors, and social and economic factors contributed to non-adherence. Therefore, comprehensive multifaceted strategies are urgently needed to address factors associated with anti-diabetic medication non-adherence.

Introduction: Trauma is the most common cause of death in childhood. Tissue damage, ischemia-reperfusion injury and inflammatory response are mainly responsible for increasing serbest oxiygen radicals. In this study, we aimed to investigate the use of thiol-disulfide and ischemia-modified albumin levels as a diagnostic laboratory parameter in trauma children. Method: Of 202 children, 101 of them were hospitalized in pediatric surgical intensive care unit with trauma and 101 of others were healthy children. Levels of native thiol (-SH), total thiol (SH + SS), dynamic disulfide (SS), dynamic disulfide (SS) / total thiol (SH + SS), albumin and ischemic modified albumin (IMA) were measured from the sera of patients and healthy volunteers. For statistical analyses, SPSS 17.0 was used. Mann-Whitney U and paired correlation test were used where appropriate. p <0.05 was considered significant. Results: The mean age of the patients in the trauma group (Boys: 61 Girls: 40) was 7,88 years and the control group was 8,00 years. In trauma group, 86 of children were exposed to blunt trauma, 15 of children had penetrating trauma and 54 patients had multiple trauma. Surgical procedures were performed in 17 patients. In the trauma group, native thiol, total thiol, dynamic disulfide / total thiol, albumin and IMA levels were significantly lower than that of control (p <0.001) and their dynamic disulfide (p = 0.001) was higher compared to the control. There was no difference thiol-disulfide parametres in trauma groups sub-division as surgery(n=17) vs. follow-up(n=84) groups or multiple trauma(n=54) vs. isolated organ trauma(n=47) groups, or penetrating(n=15) or blunt trauma(n=86) groups. Conclusion: Thiol-disulfide balance and IMA levels show changes in favor of oxidative stress in children with trauma, however, it cannot be used as a laboratory marker that helps to show the system and organ affected by the trauma and to decide the surgical intervention.

Background: Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to use of free flaps. Method: In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single center. Results: Reconstructions were performed with secondary healing (n=2), negative pressure wound therapy and skin grafting (n=2), free flaps (n=6), and local and distant flaps (n=4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. Conclusion: Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. Use of special digital imaging techniques facilitates flap surgery and helps minimize the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Superthin free flaps offer a distinct advantage in skillful hands. Use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favorable outcomes.

Background. Effective communication regarding the use of medications in a hospital environment is a process that contributes to the promotion of patient safety. Despite its importance, especially for medication reconciliation, written communication about the use of medications in medical records remains insufficiently investigated. Aim. To describe the documentation in medical records regarding the medication use process by pharmacists, physicians and nurses on admission, during the hospital stay, and on hospital discharge.Method. A retrospective cross-sectional chart review study was carried out in medical records of patients admitted to a teaching hospital in Northeast Brazil. The study considered all patients admitted between December 2016 and February 2017, aged 18 or older and hospitalized for at least 48 hours. The clinical notes made by pharmacists, physicians and nurses were examined at three transition points of care. Data were collected using a developed questionnaire and aimed at gathering the use of medications prior to hospital admission, changes in the prescribed medications in hospital stay and discharge, as well as prescription non-conformities. Non-conformities were considered as any irregularities reported by the healthcare team involving the medication use process. Communication failures between the three healthcare professionals were also analyzed and classified. Results. This study included 202 patients with a mean age of 51.48 (SD 6.42, range: 19-97) years. There was no record of a patient or relative interview on allergies and adverse drug reactions in 54 (26.8%) physician notes, 44 (21.9%) nursing notes, and 8 (22.9%) of pharmacist notes. Moreover, 1,588 changes in prescriptions were identified during data collection, but only 390 (24.5%) of these changes were justified. Conclusion. Medication-related information in medical records was incomplete and inconsistent in the clinical notes of the three studied professions, especially in the pharmacists’ documentation. Future studies should focus on investigating the consequences of interprofessional communication in patient care.