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Background Among respiratory diseases, asthma is one of the most burdensome disorder worldwide. Growing evidence disclose gut dysbiosis may contribute to asthma via the gut-lung axis. Constipation can lead to alteration of the gut microflora. The clinical impact of constipation on asthma has not been researched. Therefore, we aim to assess the risk of asthma in constipated patients by a nationwide population-based cohort study. Methods We analyzed 82421 constipated patients and 82421 individuals without constipation between 1999 and 2013 from the Taiwanese National Health Insurance Research Database. Analysis of propensity score was utilized to match age, gender, comorbidities, and medications at a ratio of 1:1. Besides, multiple Cox regression analysis was performed to evaluate the adjusted hazard ratio of asthma. Furthermore, sensitivity tests and a stratified analysis were conducted. Results The incidence of asthma was 10.8 per 1,000 person-years in the constipation group, which was higher than the rate of 5.6 per 1,000 person-years observed in the non-constipation group. After adjustment for age, gender, comorbidities, and medications, constipated patients had a 1.91-fold greater risk of asthma compared to those without constipation (adjusted hazard ratio [aHR]: 1.91 (95% C.I. 1.84-1.99). In subgroup analyses, patients aged 20-39 years had a 2.04-fold highest risk of asthma in the constipation cohort (aHR:2.04, 95% CI, 1.84-2.26). Besides, the severity of constipation is associated with an increased risk of asthma; the aHR was 1.76 (1.69-1.85), 2.15(2.03-2.27), and 2.29(2.10-2.49) for < 3 times, 3-12 times, and ≥12 times of laxatives prescription within one year, respectively. (p<0.001) Moreover, constipated patients had a higher likelihood of asthma, regardless of gender, comorbidities, and medications. Conclusion Constipation relates to a significantly increased risk of asthma. Physicians should be aware of the possibility of asthma in constipated people. Further research is warranted to investigate the possible pathological mechanisms of this association.

Objective To report a series of eight cases of severe acute respiratory syndrome due to 2019-nCoV infection (Covid-19- Bilateral infiltration) who were successfully treated with high-dose short-term corticosteroid therapy.

Background: Acute appendicitis (AA) is the most common cause of surgery performed for acute abdomen. The standard treatment for AA patients has been appendectomy for more than a century. use of broad-spectrum antibiotics, the medical treatment option has come to the fore in the treatment of uncomplicated AA. Aim: Evaluate whether WBC, platelet count, MPV, PDW, RDW, and C-reactive protein (CRP) values of patients diagnosed with uncomplicated AA clinically, with laboratory tests and radiologically with abdominal CT could be a marker for choosing medical or surgical treatment. Material and Method: 519 patients aged between 20 and 65 years who were diagnosed with uncomplicated AA by abdominal CT in our centre between January 2016 and January 2019 were retrospectively analysed. . The presence of at least one of the criteria of 7 mm or more appendix diameter and oedema or fluid accumulation around the appendix was accepted as uncomplicated AA. After the diagnosis of AA, 223 patients were treated medically, while 296 patients underwent laparoscopic appendectomy. The first group included patients who were treated medically and the second group included patients who underwent laparoscopic appendectomy. Results: Group 2 patients had higher mean platelet count (p <.005) and RDW (p = .003) values compared to Group 1 patients, while mean PDW (p <.001) values were lower compared to those of Group 1 patients. The differences between the mean WBC, CRP and MPV values of the groups were not statistically significant (p>0.05). Conclusions: The standard treatment for acute appendicitis is surgery. Recently, studies supporting antibiotic therapy have been conducted in patients diagnosed with AA. As a result, we think that PDW, RDW, and platelet values in patients diagnosed with uncomplicated AA may be a guide in choosing patients to be treated with surgery or antibiotics. Key Words: acute appendicitis, laparoscopic appendectomy, antibiotic therapy.

Background: Following the first detection of SARS-CoV-2 in passengers arriving from Europe on 19 March 2020, Madagascar took several mitigation measures to limit the spread of the virus in the country. Methods: Nasopharyngeal and/or oropharyngeal swabs were collected from travellers to Madagascar, suspected SARS-CoV-2 cases, and contact of confirmed cases. Swabs were tested at the national reference laboratory using real-time RT-PVR. Data collected from patients were entered in an electronic database for subsequent statistical analysis. All distribution of laboratory confirmed cases were mapped and six genomes of viruses were fully sequenced. Results: Overall, 26,415 individuals were tested for SARS-CoV-2 between 18 March and 18 September 2020, of whom 21.0% (5,553/26,145) returned positive. Among laboratory-confirmed SARS-CoV-2 positive patients, the median age was 39 years (CI95%: 28-52), and 56.6% (3,311/5,553) were asymptomatic at the time of sampling. The probability of testing positive increased with age with the highest adjusted odds ratio of 2.2 [95% CI: 1.9-2.5] for individuals aged 49 years and more. Viral strains sequenced belong to clades 19A, 20A, and 20B in favour of several independent introduction of viruses. Conclusions. Our study describes the first wave of the COVID-19 in Madagascar. Despite early strategies in place Madagascar could not avoid the introduction and spread of the virus. More studies are needed to estimate the true burden of disease and make public health recommendations for a better preparation to another wave.

Background: Cystic echinococcosis (CE) is commonly located in the liver and lungs of affected hosts. Surgical management is one of the best choices for the treatment of hydatidosis and using effective scolicidal agents during hydatid surgery is essential to prevent secondary infection. The present study was designed to investigate the in vitro scolicidal activity of methanol extract of Sideritis perfoliata against the protoscoleces of hydatid cysts. Methods: The protoscoleces were collected from slaughtered livestock in Adiyaman and the effect of three concentrations of the aerial part extract of S. perfoliata (0.1mg/ml, 0.2mg/ml, and 0.4mg/ml) was assessed over three different exposure periods. All tests were carried in dublicate. Finally, the mortality of protoscoleces was assessed by the eosin exclusion test (0.1% eosin staining). Methanol extract of S. perfoliata was assessed by Liquid Chromatography-Mass Spectrometry/Mass Spectrometry (LC-MS/MS). Results: The results showed that the scolicidal effect of this extract at exposure periods of 10, 20, and 30 min was 29.6, 32.5, and 43.6% at concentrations of 0.1mg/ml, 37.8, 50, and 58.1% at concentration of 0.2mg/ml and finally 57.9, 71.8, and 79.1% at concentration of 0.4mg/ml, respectively; indicating that the extract requiring a further time to display a potent protoscolicidal effects. Some phenolic acids such as fumaric acid (260,13mg/L), syringic acid (27,92mg/L) and caffeic acid (26,84mg/L) and a flavonoid, luteolin (11,23 mg/L) were detected in high concentrations. Conclusions: The present study has demonstrated that the methanol extract of S. perfoliata has high scolicidal power in vitro, although the low concentration of plant extract may provide a base for future treatment of hydatid cysts. However, more research on the in vivo efficacy of S. perfoliata extract and its potential side effects is recommended.

In this paper, we study an SIR epidemic model with ratio dependent incident rate function. We explore the impact of vaccination and treatment on the transmission dynamics of the disease. The treatment control strategies depend on the availability of maximal treatment capacity: treatment rate is constant when the number of infected individuals is greater than the maximal capacity of treatment and proportional to the number of infected individuals when the number of infected individuals is less than the maximal capacity of treatment. The existence and stability of the endemic equilibria are governed by the basic reproduction number and treatment control strategies. By carrying out rigorous mathematical analysis and numerical evaluations, it has been shown that (1) the sufficiently large value of the preventive vaccination rate can control the spread of disease, (2) a threshold level of the psychological (or inhibitory) effects in the incidence rate function is enough to decrease the infective population. Model system also undergoes a transcritical and a saddle-node bifurcation with respect to disease contact rate. In the presence of treatment strategies, system have multiple endemic equilibria and undergoes a backward bifurcation. The number of infected individuals decreases with respect to maximal treatment capacity and disease dies out from the system for large capacity of the treatment when constant treatment strategy is applied. Further, it is also found that the spread of disease can be suppressed by increasing treatment rate. Sensitivity analysis shows that the transmission and treatment rates are most sensitive parameters on the model system.

In this work, we investigate the continuum of one-sign solutions of the nonlinear one-dimensional Minkowski-curvature equation $$-\big(u’/\sqrt{1-\kappa u’^2}\big)’=\lambda f(t,u),\ \ t\in(0,1)$$ with nonlinear boundary conditions $u(0)=\lambda g_1(u(0)), u(1)=\lambda g_2(u(1))$ by using unilateral global bifurcation techniques, where $\kappa>0$ is a constant, $\lambda>0$ is a parameter $g_1,g_2:[0,\infty)\to (0,\infty)$ are continuous functions and $f:[0,1]\times[-\frac{1}{\sqrt{\kappa}},\frac{1}{\sqrt{\kappa}}]\to\mathbb{R}$ is a continuous function. We prove the existence and multiplicity of one-sign solutions according to different asymptotic behaviors of nonlinearity near zero.

A 51-year male patient presented with large skin masses of the chest wall that were pathologically proven to be chronic lymphocytic leukemia/small lymphocytic lymphoma(CLL/SLL) with Ki67:70%. The patient was treated with the time-limited Venetoclax/Obinutuzumab combination for 12 cycles and CLL/SLL including the skin component was set in complete remission.

Background/Aim: The purpose of this article is to review the published literature on single-port laparoscopic (SPL) ovarian cystectomy and to assess whether the reduced port number affects the ovarian reserve in comparison with the conventional multiport laparoscopic (MPL) ovarian cystectomy. Materials and methods: Serum anti-Müllerian hormone (AMH) had been proposed as the most accurate marker of ovarian reserve. A review of the current literature was performed based on the preoperative and postoperative AMH after SPL and MPL ovarian cystectomy in adult patients with benign ovarian cysts. Results: Ovarian cystectomy causes a non-statistically significant reduction in AMH levels four weeks postoperatively in the SPL group compared to MPL group[MD=0.11, 95%CI (-0.01, 0.24), p=0.07] . Operative time was significantly longer and blood loss was significantly higher in SPL group. No difference was found to major or overall postoperative complications between the two groups Conclusion: SPL cystectomy recommended as a safe surgical choice for patients who want to preserve their fertility.

Background. Right ventricular failure (RVF) is a severe event that increases perioperative mortality after Left Ventricle Assist Device (LVAD) implantation. RV function is particularly affected by the LVAD speed by changing RV preload and afterload as well as the position of the interventricular septum. However, there are no studies focusing on the relationship between pump speed optimization and risk factors for development of lateRVF. Methods. Between 2015 and 2019,50 consecutive patients received LVAD implantation at San Camillo Hospital in Rome. Of these, 38 who underwent pump speed optimization were included. Post optimization hemodynamic data were collected. We assessed: a new Hemodynamic Index (HI), calculated as follows HI=MAP x PCWP/CVP x RPM set/RPM max; risk factors for late RVF, which was defined as the requirement for 7 days or more of inotropic support. Results 10 patients had late RVF after LVAD implantation. 5 patients required diuretic therapy and speed optimization. In 3 patients inotropic support with adrenaline 0.05 g/kg/min was started. 2 patients required prolonged continuous veno-venous hemofiltration and high dosage inotropic support. Multivariate analysis revealed that a low HI (odds ratio 11.5, 95 % confidence interval,1.85-65.5,p[.003] was an independent risk factor for late RVF after LVAD implantation. Conclusion A low HI, according to our study, is a significant risk factor for the development of RVF after LVAD implantation. We suggest adopting this index during the follow-up to stratify the different hemodynamic profiles and modify the therapeutic strategies according to the different HI levels obtained for every single patient.

Background: The success of coronary artery bypass grafting surgery (CABG) is dependent on long-term graft patency, which is negatively related to early wall thickening. Avoiding high-pressure distension testing for leaks and preserving the surrounding pedicle of fat and adventitia during vein harvesting may reduce wall thickening. Methods: A single-centre, factorial randomised controlled trial was carried out to compare the impact of testing for leaks under high versus low pressure and harvesting the vein with versus without the pedicle in patients undergoing CABG. The primary outcomes were graft wall thickness, as indicator of medial-intimal hyperplasia, and lumen diameter assessed using intravascular ultrasound after 12 months. Results: 96 eligible participants were recruited. With conventional harvest, low-pressure testing tended to yield a thinner vessel wall compared to high-pressure (mean difference MD (low minus high) -0.059mm, 95%CI -0.12, +0.0039, p=0.066). With high pressure testing, veins harvested with the pedicle fat tended to have a thinner vessel wall than those harvested conventionally (MD (pedicle minus conventional) -0.057mm, 95%CI -0.12, +0.0037, p=0.066, test for interaction p=0.07). Lumen diameter was similar across groups (harvest comparison p=0.81; pressure comparison p=0.24). Low pressure testing was associated with fewer hospital admissions in the 12 months following surgery (p=0.0008). Harvesting the vein with the pedicle fat was associated with more complications during the index admission (p=0.0041). Conclusions: Conventional saphenous vein graft preparation with low pressure distension and harvesting the vein with a surrounding pedicle yielded similar graft wall thickness after 12 months, but low pressure was associated with fewer adverse events.

Bilateral antegrade selective cerebral perfusion has the undisputed advantage of being more physiological and theoretically ensuring complete perfusion of the whole brain. However, it requires longer execution times and manipulation of the epiaortic vessels. On the other hand, unilateral selective cerebral perfusion (u-ASCP) avoids the vessels manipulation, placement of catheters into the ostia of the great vessels which clutters the operative field and incurs both atherosclerotic and air embolism risk. Neverthless, an ongoing debate about which technique yields the best clinical outcomes is still open.

If it an’t broke, don’t fix itBerhane Worku MD1, Meghann M Fitzgerald21: Department of Cardiothoracic Surgery, Weill Cornell Medical College2. Department of Anesthesiology, Weill Cornell Medical CollegeAntifibrinolytics and TEGCorresponding Author:Berhane WorkuDepartment of Cardiothoracic SurgeryWeill Cornell Medical College525 East 68th Street M-404New York, NY 10065Despite evidence of associated morbidity and mortality, blood products are administered to over half of cardiac surgical patients, accounting for approximately 20% of their worldwide use1,2. These statistics attest to the ubiquitous and refractory nature of bleeding after cardiac surgery. In an attempt to curb the excessive use of blood products after cardiac surgery viscoelastic testing in the form of thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have been increasingly utilized. Rapid intraoperative assessment allows for targeted correction of coagulopathy due to residual heparinization, coagulation factor deficiency, hypofibrinogenemia, and platelet dysfunction. Hyperfibrinolysis can also be assessed, although management is rarely altered as the routine administration of lysine analog antifibrinolytics has been given a class I recommendation by the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists and has become the standard practice at most cardiac surgical centers.Cardiopulmonary bypass is known to result in transient t-PA and subsequent d-dimer level elevations (a marker of hyperfibrinolysis)3,4. The efficacy of the lysine analog antifibrinolytics, tranexamic acid andε-aminocaproic acid, have been extensively studied in this setting. D-dimer levels are significantly blunted by antifibrinolytics, and an abundance of literature demonstrates reductions in chest tube bleeding, blood product use, and reoperation for bleeding with the use of these agents4-6. A similar amount of evidence points to their safety, with no increase in thrombotic complications, including stroke, myocardial infarction, graft closure, or mortality seen5-7. A higher risk of seizures is noted with tranexamic acid, although this appears to be dose dependent and nonexistent with ε-aminocaproic acid2. If the ultimate goal is to reduce bleeding and blood product usage, it would seem that antifibrinolytics offer one way to do this safely.In the current manuscript, Sussman et. al. retrospectively analyze 78 cardiac surgical patients who had an intraoperative TEG performed with the goal of describing the distribution of fibrinolytic phenotypes in this population8. Forty five percent demonstrated physiologic fibrinolysis, 32% hypo fibrinolysis, and 23% hyperfibrinolysis (LY30 <0.8%, 0.8-3%, >3%). Forty seven percent received antifibrinolytic agents. Outcomes including “morbidity” and time with chest tube were higher in those who received antifibrinolytics. This is a perhaps the first study of its kind to describe the prevalence of hyperfibrinolysis in cardiac surgical patients as measured by point of care testing. It is also a very relevant study in an era in which the benefits of targeted therapy for coagulopathy are increasingly recognized.The current data suggests that half of patients undergoing cardiac surgery demonstrate physiologic fibrinolysis and a third demonstratehypo fibrinolysis (a theoretically pro thrombotic state)8. The worse outcomes seen in patients receiving antifibrinolytics suggests that their administration in the setting of a potentially prothrombotic state was to blame. However, several limitations merit mention. It appears that TEG is not routinely performed on all patients. The population under study may therefore reflect one undergoing more extensive surgery with more coagulopathy in whom TEG is more likely to be performed. Since the actual timing of the TEG is not detailed, the true baseline fibrinolytic phenotype of patients treated with antifibrinolytics is not clear as the TEG results may have been obtained after the initiation of antifibrinolytics. Furthermore, while surgical procedures performed weren’t delineated, patients receiving antifibrinolytics more frequently had “valve disease” and “heart failure” and underwent on-pump surgery. Patients receiving antifibrinolytic therapy were therefore sicker and likely underwent more extensive on-pump valve surgery, while patients who did not receive antifibrinolytics were most likely undergoing off-pump coronary bypass surgery. Finally, the increased “morbidity” in patients receiving antifibrinolytics appear to be bleeding related (thrombotic complications were not listed separately). Perhaps additional antifibrinolytics were needed.The authors are to be commended for recognizing a lack of complete understanding of coagulation in the cardiac surgical population and attempting to determine the benefit of targeted antifibrinolytic therapy. Any time a practice is performed indiscriminately, there is room for improvement. However, before we contemplate altering an evidence-based practice that reduces bleeding, we need to demonstrate a benefit for such a change. Not all bleeding is purely surgical or purely medical; there is overlap. Few areas of medicine highlight how much art prevails over our current scientific understanding. Too many times since the introduction of point-of-care testing, the surgeon and anesthesiologist battle over the merits of administering blood products to a clinically bleeding patient with a normal coagulation profile. Targeted correction of coagulopathy is conceptually attractive, but the reality is not as clearly defined. Reductions in bleeding seen with antifibrinolytics occur both in on-pump and off-pump surgery which should be enough proof to continue its application until better evidence and understanding emerges6. Certainly, there is more work to be done, but with regard to antifibrinolytics it seems fitting to recognize: If it ain’t broke, don’t fix it.REFERENCESAbdelmotieleb M, Agarwal S. Viscoelastic testing in cardiac surgery. Transfusion 2020;60:52-60Harvey R, Salehi A. Con: Antifibrinolytics should not be used routinely in low-risk cardiac surgery. J Cardiothorac Vasc Anesth 2016;30:248-251Gielen C, Brand A, van Heerde W, Stijnen T, Klautz R, Eikenboom J. Hemostatic alterations during coronary artery bypass grafting. Thromb Res 2016;140:140-146Slaughter T, Faghih F, Greenberg C, Leslie J, Sladen R. The effects of ε-aminocaproic acid on fibrinolysis and thrombin generation during cardiac surgery. Anesth Analg 1997;85:1221-6Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper J, Marasco S, McNeil J, Bussieres JS, McGuinness S, Byrne K, Chan MTV, Landoni G, Wallace S. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med 2017;376:136-48Zhang Y, Bai Y, Chen M, Zhou Y, Yu X, Zhou H, Chen G. The safety and efficiency of intravenous administration of tranexamic acid in coronary artery bypass grafting (CABG): a meta-analysis of 28 randomized controlled trials. BMC Anesthesiol 2019;19:104Kasrki J, Djaiani G, Carroll J, Iwanochko M, Seneviratne P, Liu P, Kucharczyk W, Fedorko L, David T, Cheng D. Tranexamic acid and early saphenous vein graft patency in conventional coronary artery bypass graft surgery: A prospective randomized controlled clinical trial. J Thorac Cardiovasc Surg 2005;130:309-14Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg in press

A 38‐year‐old patient with gravida 2, para 1 was referred to our hospital for perinatal management. At 37 weeks gestation, we diagnosed vasa praevia with meandering foetal vessels. Emergent caesarean section was performed. Obstetricians should be familiar with vasa praevia with meandering foetal vessels despite its rare occurrence.

A 31-year-old male Caucasian patient developed reinfection with SARS-CoV-2, 2 ½ months after an initial episode of ICU admission for respiratory support due to COVID-19. The second episode was in the form of malaise, aphthous gingival ulcer, and desquamating palmar lesion.

Aim of the Study: Multiple sclerosis (MS) is an autoimmune disorder causing demyelination in axons. Available therapies target different molecules, but not all have therapeutic effects on disease progression, and this effect can only be seen after a long-time administration. Interferon beta (IFN-β), an MS therapy for many years, slows down the disease progression and reduces disease symptoms by targeting T cells. Yet, a considerable portion of the patient has experienced no therapeutic response to IFN-β. It is necessary to determine disease-specific biomarkers which allow early diagnosis or treatment of MS. Here, it was aimed to determine the effects of interleukin 10 (IL10) and 23 (IL23A) as well as forkhead box P3 (FOXP3) genes on MS after IFN-β therapy. Materials & Methods: Peripheral blood mononuclear cells (PBMCs) were extracted to isolate CD4+ and CD25+ T cells. Cytotoxicity assays were performed on each cell type for determining optimum drug concentration. Then, cells were cultured and determined drug concentration was administered to the cells to measure gene expressions with RT-PCR. Results: It was found that the cytotoxic effect of IFN-β was more efficient as the exposure time was expanded regardless of drug concentration. Moreover, CD25+ T lymphocytes were more resistant to IFN-β. IL23A was down-regulated, whereas FOXP3 was up-regulated at 48h in CD4+ T cells. For CD25+ T cells, the graded increase of FOXP3 was obtained while IL10 expression was gradually decreased throughout the drug intake, significantly. Conclusion: Although considerable change in expression was obtained, the long-term IFN-β effect on both genes and cells should be determined by follow-up at least a year. Keywords: MS, IFN-β, IL23A, FOXP3, IL10, T cells

Although there is a considerable body of knowledge about allergen immunotherapy (AIT), there is a lack of data on the reliability of real-world evidence (RWE) in AIT and consequently, a lack of information on how AIT effectively works in real life. To address the current unmet need for an appraisal of the quality of RWE in AIT, the European Academy of Allergy and Clinical Immunology Methodology Committee recently initiated a systematic review of observational studies of AIT, which will use the RELEVANT tool and the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE) to rate the quality of the evidence base as a whole. The next step will be to develop a broadly applicable, pragmatic “real-world” database using systematic data collection. Based on the current RWE base, and perspectives and recommendations of authorities and scientific societies, a hierarchy of RWE in AIT is proposed, which places pragmatic trials and registry data at the positions of highest level of evidence. There is a need to establish more AIT registries that collect data in a cohesive way, using standardised protocols. This will provide an essential source of real-world data that can be easily shared, promoting evidence-based research and quality improvement in study design and clinical decision-making.