Bronchoalveolar Lavage in Children: Still the Gold StandardShivanthan Shanthikumar1,2,3 and Sarath C Ranganathan1,2,3Respiratory and Sleep Medicine, Royal Children’s Hospital, Melbourne, AustraliaRespiratory Diseases, Murdoch Children’s Research Institute, Melbourne, AustraliaDepartment of Paediatrics, University of Melbourne, Melbourne, AustraliaCorresponding Author; Dr Shivanthan Shanthikumar; Respiratory Medicine, Royal Children’s Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia; [email protected]; The authors have no conflicts of interest to declareDear Editor,We read with great interest the recent article by Craven et al , entitled “High levels of inherent variability in microbiological assessment of bronchoalveolar lavage samples from children with persistent bacterial bronchitis and healthy controls .”1 In a small study of 18 children, funded by GlaxoSmithKline, the authors demonstrate variability in the results of bronchoalveolar lavage (BAL) collected from controls and children with protracted bacterial bronchitis (PBB). Specifically, they show that when the BAL was divided and sent to two laboratories the results were discordant in terms of both the organisms isolated and their relative abundance. From these data the authors draw conclusions which include questioning “assumptions about this procedure being the gold standard .” Whilst these data are of interest, there are significant limitations to their value especially when considering existing literature.One of the key findings of the study is the discordant results between laboratories. A lack of detail regarding the methods used at each site is a major limitation. It is recognised that laboratory processes can affect the yield of samples collected from patients with chronic airway infection, and the need for a consistent approach has led to disease specific consensus guidelines on this topic.2 The discordant results seen in the study could result from different laboratory handling of specimens, and hence the findings of this study could purely be explained by a difference in practice between two centres, not least of which was the transport of samples to the second laboratory in STGG. Molecular studies have identified that even media considered sterile can contain numerous organisms albeit in low densities.3 We note that it was laboratory 2 where additional bacteria were cultured from the BAL.Hare et al analysed BAL samples from 655 children collected and analysed at two different sites compared with 18 samples in the study of Craven et al .4 They compared bacterial pathogen load (control, negative, 102 colony forming units per ml (CFU/ml), 103 CFU/ml, 104 CFU/ml, 105 CFU/ml) and inflammatory markers to determine an appropriate definition for infection. They found that a bacterial pathogen load of ≥104 CFU/ml was associated with increased markers of inflammation and hence an appropriate threshold for defining infection. This was in keeping with previous studies.4 Whilst the authors contend the current paper does not support the use of ≥104 CFU/ml, given it only includes 13 children with PBB an explanation of the findings of Hareet al in their considerably larger study and other studies needs explanation.Another key finding of the study was the limited correlation between semiquantitative and quantitative methods of measuring bacterial pathogen load. Whilst there has not been direct comparison of different methods of determining bacterial pathogen load in PBB and other paediatric suppurative disorders, a large amount of data speaks to the validity of using a semiquantitative or qualitative approach. For instance, the previously discussed Hare et al study utilised a semiquantitative approach, and was able to clearly identify a threshold for lower airway infection that was associated with inflammation. In addition, the qualitative approach used by AREST CF (the long running study of CF patients cited in the article) to define infection is supported by the fact that this definition is associated with important clinical outcomes. For example, in a recent AREST-CF study analysing 1161 BAL from 265 children with CF, the presence of early life infection using the AREST-CF definition, was associated with future risk of structural lung disease severity.5Further, we have used molecular studies to assess the microbiome in CF and shown considerable agreement between pathogen-dominated microbiota and routine laboratory bacterial culture even though these samples were assessed by two different techniques, in two laboratories in different continents and analysed two decades apart in time.6Despite the data that contradicts the findings of their study, and while not discussed by the authors themselves, we do contend that use of both quantitative and semi-quantitative microbiologic cultures are likely problematic given that bacterial density is influenced by the dilution from the 0.9% saline used to lavage the target lobe. Dilution further depends on the volume of return retrieved on suctioning. The consensus has been that standardising for this dilution is not required but data supporting this are few.In summary, there are significant issues that limit the value of the key findings of the study by Craven et al . A large amount of published data in PBB and cystic fibrosis support the use of BAL as a biological specimen associated with important clinical outcomes. These studies have been conducted in multiple centres, over many years, and included many children. While the findings of Craven et alhighlight there can be inconsistencies in results, this potentially speaks to the methods used by the laboratories involved in handing the small number of samples. When these findings are compared to the large amount of evidence already generated, they should prompt evaluation of local practices and not just a reconsideration of whether BAL is the gold standard method of sampling the lower airway of children with suppurative lung disease. While we believe that BAL remains the gold standard for the detection of lower respiratory infection we do not believe it is a perfect test and its use and many limitations need to be considered and minimised.Therefore, we agree with the authors that interpretation of microbial culture results utilizing BAL samples can be challenging. However, we disagree that assumptions about this procedure being the “gold standard” fail to take into account its many limitations as despite these BAL remains the best test to detect endobronchial infection that is associated with lower respiratory inflammation especially in CF.

COVID-19 disease, caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), first appeared in Wuhan, China, and spread throughout the world in a short period of time (1). On 30 January 2020, WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC) and than on 11 March 2020, WHO declared the Coronavirus as a pandemic. The pandemic was called as COVID-19.

Objectives: To explore Knowledge and perceptions about COVID-19, among Syrian refugee mothers in Irbid governorate, the first outbreak of coronavirus in Jordan. Methods: This is an exploratory cross-section study was conducted among Syrian refugee mothers, who were currently pregnant or have a newborn child. The data collected through an online survey in April 2020 in North Jordan. Results: A total of 389 Syrian refugee mothers have participated in the study. The study showed that 66% of mothers often access information regarding COVID-19. The main used resources for information, were Facebook pages’ posters (87%), WhatsApp groups’ messages (69%), Television News (53%). While 21% indicated that they access a professional database or governmental websites. In general, Syrian refugee mothers appear well knowledgeable about COVID-19 the transition ways and prevention measures, and aspects that should be considered when diagnosing Coronavirus cases. However, they appeared to have a lack of knowledge about the aspects that should be considered for the transition of COVID-19 between the mother and the child and the concepts about the smoking risks associated with COVID-19. Conclusions: There is less focusing on media on aspects or still understudying of concepts about the smoking risks associated with COVID-19 and concepts around the transition of COVID-19 between the mother and the child. Providing health education regarding COVID-19 to mothers in Irbid would be helpful.

We present an 11-year-old female with persistent hypoglycemia in the setting of new-onset type I diabetes mellitus, with further diagnosis of both Hashimoto's thyroiditis and Addison's disease for a diagnosis of autoimmune polyglandular syndrome type II, an autosomal dominant syndrome. Three years later, the child's mother was subsequently diagnosed.

Keratosis lichenoides chronica (KLC) is a rare dermatosis which represents different clinical characteristics between adult- and pediatric-onset cases. We described a childhood case of KLC with features typical for adult onset disease. Acitretin led to partial improvement of her skin (but not mucosal) lesions.

1. A time-consuming challenge faced by ecologists is the extraction of meaningful data from camera trap images to inform ecological management. Automated object detection solutions are increasingly, however, most are not sufficiently robust to be deployed on a large scale due to lack of location invariance across sites. This prevents optimal use of ecological data and results in significant resource expenditure to annotate and retrain object detectors. 2. In this study, we aimed to (a) assess the value of publicly available image datasets including FlickR and iNaturalist (FiN) when training deep learning models for camera trap object detection (b) develop a for training location invariant object detection models and (c) explore the use of small subsets of camera trap images for optimization training. 3. We collected and annotated 3 datasets of images of striped hyena, rhinoceros and pig, from FiN, and used transfer learning to train 3 object detection models in the task of animal detection. We compared the performance of these models to that of 3 models trained on the Wildlife Conservation Society and Camera CATalogue datasets, when tested on out of sample Snapshot Serengeti datasets. Furthermore, optimized the FiN models via infusion of small subsets of camera trap images to increase robustness for challenging detection cases. 4. In all experiments, the mean Average Precision (mAP) of the FiN models was significantly higher (82.33-88.59%) than that achieved by the models trained only on camera trap datasets (38.5-66.74%). The infusion of camera trap images into FiN training further improved mAP, with increases ranging from 1.78-32.08%. 5. Ecology researchers can use FiN images for training robust, location invariant, out-of-the-box, deep learning object detection solutions for camera trap image processing. This would allow AI technologies to be deployed on a large scale in ecological applications. Datasets and code related to this study are open source and available at: https://github.com/ashep29/infusion

EDITORIAL: Modern Atrial Fibrillation Care: Becoming a Pro at Using PROsSamuel F. Sears, PhD,1,2 Scarlett Anthony, BA,1 & Aditi Naniwadekar, MD21 Department of Psychology, East Carolina University, Greenville, NC2 Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC

Editorial – The third “Futures” issueThis month’s volume of AIChE Journal is the third “Futures” issue. I think now we’ve established a tradition. This is my favorite issue each year.Each year we invite a group of early career researchers to contribute their pioneering works. I have sought the input of the AIChE Journal editorial team and consulting editorial board to identify contributors. The criterion is that the prospective author be seven or less years removed from her or his initial appointment as an academic, industrial, or national lab researcher.During the publication year we have a session at the Annual AIChE meeting where several of the authors have the opportunity to present their research. (This being the year of COVID-19, these presentations will unfortunately be virtual.)The “Futures” issue parallels the annual “Founders” issue; while the “Founders” issue celebrates the scholarly legacies of the greats from our profession, the “Futures” issue recognizes the research of emerging scholars.I hope that you enjoy this third installment of the “Futures” series.On behalf of the AIChE Journal editorial team, we look forward to your input and suggestions. As always, thanks for your support of

Isomorphic titanium dichalcogenide TiX2 (X=S, Se, Te) compounds exhibit very diverse and anisotropic chemical and physical properties. The temperature dependent electrical resistivity of TiSe2 was found to exhibit anomalous behavior at low temperatures (< 200 K) which was connected to the emergence of a unique charge density wave (CDW), which was explained on the basis of 2a0×c0 superstructure formation, whereas bulk TiS2 and TiTe2 do not exhibit CDW instability. In order to understand their diverse nature, we have systematically investigated the electronic structure of titanium dichalcogenides by using the FPLAPW and PAW methods based on the density functional theory (DFT). The energy bands calculated by implementing the latest generalized gradient approximation (GGA) with PBE and TB-mBJ potentials confirm the semiconducting nature of TiS2 and metallic nature of TiSe2 and TiTe2, however the Wu-Cohen potentials show a semi-metallic nature for all three dichalcogenides. The diverse properties of TiX2 are governed by two bands, S/Se/Te p-band close to the Γ-point and Ti 3d-band around M (L)-points. The presence of electron and hole pockets at the Fermi energy level have been previously confirmed experimentally, although our calculated size and extent of overlap of these pockets was overestimated compared to experiments. Various physical parameters such as electrical conductivity, Seebeck coefficient etc. which depend sensitively on nature of states at the Fermi level also amply illustrate the diversity of the compounds. The electron localization function and Bader charge partitioning illustrate the increasing covalency with varying chalcogenide atom, which is consistent with the spectral features observed in the DOS. The lattice dispersion of the titanium dichalcogenides are calculated by using the PAW method with PBE potentials. The phonon band structure is correlated to the electronic band structure in order to explain the occurrence of CDW. In TiSe2, the presence of a phonon mode with imaginary frequency indicated lattice instability against distortion. The displacements of Ti-Se atoms of this phonon mode allows the mixing of states of the electron and hole pockets, which leads to lattice distortion i.e. a CDW structure which lowers the energy of the system. Although there is a weak imaginary mode, the mixing of states is absent in TiS2 due to absence of electron or hole pockets, whereas TiTe2 is structurally most stable.

In this paper, we study the stability of the zero equilibrium and the occurrence of flip bifurcation on the following system of difference equations: \[x_{n+1} =a_1\frac{y_n}{b_1+y_n} +c_1\frac{x_ne^{k_1-d_1x_n}}{1+e^{k_1-d_1x_n}},\]\\ \[y_{n+1} =a_2\frac{z_n}{b_2+z_n} +c_2\frac{y_ne^{k_2-d_2y_n}}{1+e^{k_2-d_2y_n}},\]\\ \[z_{n+1} =a_3\frac{x_n}{b_3+x_n} +c_3\frac{z_ne^{k_3-d_3z_n}}{1+e^{k_3-d_3z_n}}\] where $a_i$, $b_i$, $c_i$, $d_i$, $k_i$, for $i=1,2,3$, are real constants and the initial values $x_0$, $y_0$ and $z_0$ are real numbers. We study the stability of this system in the special case when one of the eigenvalues is equal to -1 and the remaining eigenvalues have absolute value less than 1, using center manifold theory.

The ascending aorta and arch have until recently been one of the last bastions of cardiovascular surgery, where life-threatening diseases impose the need for prompt correction and reversal of the impending adverse prognosis. Though a disease where dogmatic recommendations prevail, with upfront surgical intervention in the mind of every physician, type A acute aortic dissection (AAD) is a subject still blurred by many uncertainties. Endovascular intervention for the treatment of type A AAD are rapidly progressing and utilization of transcatheter therapies in the ascending aorta for treating type A AAD has demonstrated technical success in small studies, low early mortality rates, and relatively acceptable aorta-related mortality rates in the long-term. These findings strengthen the preponderant role of the endovascular heart surgeon on the management of these procedures, where a combination of wire skill training and surgical proficiency encompassing all technical options available makes it distinctive and resourceful, able to provide complete resolution to each multicomponent of this disease in one setting, besides the promptness to repair the inherent complications that are to accompany these interventions. Transcatheter procedures and open surgery are to coexist side by side and to be regarded as complementary rather than competing. Substantial more refinement and technological innovation will be necessary before endovascular repair of type A AAD comes to widespread use, the ideal timespan for cardiovascular surgeons to be involved, and prepared to take on the challenges of leading this new enterprise.

Background: We have previously reported that more than half of the patients who achieved desensitization after wheat rush oral immunotherapy (OIT) developed exercise-induced allergic reaction on desensitization (EIARD). However, data on EIARDs after slow OIT are lacking. Therefore, this study aimed to investigate the results of exercise provocation tests (EPTs) in patients after slow OIT for cow’s milk and wheat allergies. Methods: This was a retrospective chart review of 87 EPTs in 74 patients. The EPTs were performed in patients who were desensitized to at least 6,600 mg cow’s milk protein or 5,200 mg wheat protein with slow OIT and were identified to be at a high risk of EIARDs. EPTs were performed after ingestion of the maximum desensitization dose. The patients’ clinical characteristics and symptoms were analyzed. Results: The EPT results were positive for cow’s milk in 49% (21/43) of the patients and for wheat in 48% (15/31) of the patients. There was no significant difference in the clinical characteristics between the EIARD-positive and EIARD-negative groups. The specific IgE (sIgE) levels before OIT and the reduction rates of sIgE before and after OIT did not correlate with the outcomes of the EPTs. Among the EIARD-positive patients, 13 patients (cow’s milk, n=7; wheat, n=6) underwent a second EPT, and the EIARD disappeared in 8 patients (cow’s milk, n=4; wheat, n=4). Conclusion: EIARDs were observed after slow OIT for cow’s milk and wheat. Further research into the predictive factors of EIARDs in these patients is needed to understand its clinical manifestations.

A recent review on optimal strategies for preserving biodiversity within human-modified landscapes suggests that that forest cover needs to be restored or maintained to at least 40%. While we agree that it is paramount to protect and increase cover in forested biomes, no evidence is presented to support this 40% threshold. Furthermore, there are several issues regarding implementation of such policy or social-economic constraints that makes this suggestion unhelpful and potentially dangerous.

Purpose: Diffuse mega-aorta is challenging. Prior studies have raised concerns regarding the safety of the open two-stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to inter-stage mortality. This study evaluates the safety of the two-stage ET approach for management of extensive TAA. Methods: Between 2003–2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5±14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to-date has been performed in 54 patients (90%). (In the remaining patients, the elephant trunk was prophylactic for the long-term, with no plan for near-term utilization). Results: In-hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median inter-stage interval was 5 weeks (range: 0-14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (inter-stage mortality of 8.3%). There were no cases of aortic rupture in the inter-stage interval. Stage II was completed in 58 patients (including 4 unplanned) with 30-day morality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia. Conclusions: The overall mortality, including Stage I, inter-stage interval, and Stage II was 18.6%. This cumulative mortality for the open two-staged ET approach for treatment of extensive TAA is acceptable for aortic disease of this severity. Fear of inter-stage rupture should not preclude the aggressive Two-Stage approach to management of extensive TAA.

Background and Purpose: Pancreatic cancer is an exceptionally fatal disease. However, therapeutic drugs for pancreatic cancer have presented a serious shortage over the past few decades. Signal Transducer and Activator of Transcription-3 (STAT3) is persistently activated in many human cancers where it promotes tumor development and progression. Natural products serve as an inexhaustible source of anticancer drugs. Here, we identified the natural product Trienomycin A (TA), an ansamycin antibiotic, as a potential inhibitor of the STAT3 pathway with potent activity against pancreatic cancer. Experimental Approach: Utilizing the STAT3-luciferase (STAT3-luc) reporter system, we found that TA potently inhibits the transcriptional activity of STAT3. We subsequently investigated in vitro and in vivo inhibitory activity of TA against pancreatic cancer and its potential mechanism by using the molecular docking, SPR assay, MTS assay, colony formation assay, transwell migration/invasion assay, flow cytometric analysis, immunofluorescence staining, quantitative real-time PCR, western blotting, tumor xenograft model, H&E staining and immunohistochemistry. Key Results: TA directly bound to STAT3 and inhibited STAT3 (Tyr705) phosphorylation, leading to the inhibition of the STAT3 pathway. TA significantly inhibited the colony formation, proliferation, migration and invasion of pancreatic cancer cell lines. TA dramatically blocked pancreatic tumor growth. More importantly, TA did not show obvious toxicity at the effective dose in mice. Conclusions and Implications: TA exhibits antineoplastic activity by suppressing the STAT3 activation in pancreatic cancer. TA could be a novel therapeutic candidate for pancreatic cancer by blocking the STAT3 pathway.

SARS-CoV-2 is an RNA coronavirus that causes severe acute pneumonia, also known as COVID 19 disease. The World Health Organization declared the COVID-19 outbreak in January 2020 and a pandemic 2 months later. Serological assays are valuable tools to study virus spread among the population and, importantly, to identify individuals that were already infected and would be potentially immune to a virus re-infection. SARS-CoV-2 Spike protein and its Receptor Binding Domain (RBD) are the antigens with higher potential to develop SARS-CoV-2 serological assays. Moreover, structural studies of these antigens are key to understand the molecular basis for Spike interaction with angiotensin converting enzyme 2 receptor, hopefully enabling the discovery and development of COVID-19 therapeutics. Thus, it is urgent that significant amounts of this protein became available at the highest quality. In this work we evaluated the impact of different and scalable bioprocessing approaches on Spike and RBD production yields and, more importantly, in these antigens’ quality attributes. Using negative and positive sera collected from human donors, we show an excellent performance of the produced antigens, assessed in serologic ELISA tests, as denoted by the high specificity and sensitivity of the test. We have shown that, despite of the human cell host and the cell culture strategy used, for production scales ranging from 1 L to up to 30 L, final yields of approx. 2 mg and 90 mg per liter of purified bulk for Spike and RBD, respectively, could be obtained. To the best of our knowledge these are the highest yields for RBD production reported to date. An in-depth characterization of SARS CoV-2 Spike and RBD proteins was also performed, namely the antigens oligomeric state, glycosylation profiles and thermal stability during storage. The correlation of these quality attributes with ELISA performance show equivalent reactivity to SARS CoV 2 positive serum, for all Spike and RBD produced, and for all the storage conditions tested. Overall, we provide herein straightforward protocols to produce high-quality SARS CoV-2 Spike and RBD antigens, that can be easily adapted to both academic and industrial settings; and integrate, for the first time, studies on the impact of bioprocess with an in-deep characterization of these proteins, correlating antigens glycosylation and biophysical attributes to performance of COVID-19 serologic tests. We strongly believe that our work will contribute to advance the current and recent knowledge on SARS-CoV-2 proteins and support the scientific society that is persistently searching for solutions for COVID-19 pandemics.

BACKGROUND: Irinotecan is a drug active against pediatric sarcomas with a toxicity profile that theoretically allows for its association with more myelotoxic drugs. We examined the feasibility of a dose-density strategy integrating irinotecan in standard chemotherapy regimens for patients with high-risk sarcomas. METHODS: Between November 2013 and January 2020, 23 patients < 21 years old with metastatic (11 children) or recurrent (12 children) sarcomas were treated with 9 IrIVA/IrVAC cycles. All newly-diagnosed patients received IrIVA (ifosfamide 3g/m2 on days 1 and 2, vincristine 1.5 mg/m2 on day 1, actinomycin D 1.5 mg/m2 on day 1, irinotecan 20 mg/m2 for 5 consecutive days starting on day 8). Two relapsed patients received IrIVA and 10 IrVAC (cyclophosphamide 1.5 g/m2 on day 1 instead of ifosfamide). Feasibility was assessed in terms of toxicity and time to complete the treatment. RESULTS: 17 rhabdomyosarcomas, 4 Ewing sarcomas, 2 desmoplastic round cell tumors received a total of 181 cycles (range 2-10). Grade 4 neutropenia occurred in 62.4% of the cycles. 13 patients had febrile neutropenia. Diarrhea occurred in 14 cycles. The median time to complete the treatment was 195 days (range 170-231), 83.4% of cycles were administered on time or with a delay <1 week. With a median follow-up of 2.6 years (range 0.2-5.0), 12 patients are alive, 9 complete remissions, 3 with the disease. Conclusions: A dose density strategy combining irinotecan with standard chemotherapy is feasible. This approach will be investigated in the next trial coordinated by the European pediatric Soft tissue sarcoma Study Group.

Rate dependent exit block across the pulmonary veins has been previously described immediately following catheter ablation. We report the case of rate dependent PV block seen at repeat ablation 7 years after the index procedure. To our knowledge, this is the first report of chronic rate dependent exit block (i.e. Rate dependent exit block discovered 7 years after circumferential PV antral isolation). We believe that, as with CTI ablation, rate independent pulmonary vein isolation should be confirmed.