We report a fatal case of methicillin-resistant Staphylococcus aureus (MRSA)-induced necrotizing pneumonia that was refractory to adequate vancomycin treatment (trough value, 13.1 µg/mL), drainage of a hydropneumothorax, and veno-arterial extracorporeal membrane oxygenation. MRSA infection can cause rapidly progressive disease with a high case fatality rate, even with appropriate treatment.

Sex is one of the important factors affecting gut microbiota. As key predators in agro-forestry ecosystem, many spider species show dramatically different activity habits and nutritional requirements between female and male. However, how sex affects gut microbiota of spiders is still unclear. Therefore, in this study, the compositions and diversities of gut bacteria, based on bacterial 16S rRNA gene sequencing, were compared between female and male Pardosa astrigera. We found that bacterial richness indices (P < 0.05) in female were significantly lower than male, meanwhile, β-diversity showed significantly different between female and male (P < 0.05). The relative abundance of Actinobacteriota and Rhodococcus (belongs to Actinobacteria) were significantly higher in female than male (P < 0.05). Whereas, the relative abundance of Firmicutes and Acinetobacter (belongs to Proteobacteria), Ruminococcus and Fusicatenibacter (all belong to Firmicutes), were significantly higher in male than female (P < 0.05). The results of PICRUSt2 showed that amino acid and lipid metabolisms were significantly higher in female than male (P < 0.05), whereas glycan biosynthesis and metabolism was significantly higher in male than female (P < 0.05). Our results imply that sexual variation is a crucial factor in shaping gut bacterial community in P. astrigera. Male P. astrigera dispersed more widely than the female hence the male had a higher bacterial diversity. While the distinct differences of bacterial composition mainly due to their different nutritional and energy requirements.

The noncovalent interactions between a redox-active molecule, phenyl-substituted dithiafulvene (Ph-DTF), and ten commonly encountered nitroaromatic compounds (NACs) were systematically investigated by means of density functional theory (DFT) calculations and ab initio molecular dynamics (AIMD) simulations. Our modeling studies examined their 1:1 complexes in terms of equilibrium geometries, frontier molecular orbitals (FMOs), nature of noncovalent forces, intermolecular charge transfer (ICT), interaction energies and related energy decomposition analysis. The computational results indicate that Ph-DTF can form thermodynamically stable supramolecular complexes with trinitro-substituted benzenes (e.g., 2,4,6-trinisuchtrotoluene and picric acid), but its interactions with mono- and dinitrobenzenes do not exhibit such stability. The selective binding properties are further corroborated by AIMD simulations. Overall, this computational work establishes a comprehensive understanding of the nature of noncovalent interactions of Ph-DTF with various NACs, and the results can be used as theoretical guidance for the rational design of selective receptors and/or chemosensors for certain NACs that are of great concern in current industrial applications and environmental control.

The present-day interest in the use of composite-steel joints in primary marine applications requires an in-depth knowledge of the fatigue performance of thick adhesive joints. This paper reports on experimental tests, quasi-static and fatigue, performed on unaged and aged bi-material double strap joints with thick adhesive bondlines. The specimens are monitored by Digital Image Correlation and Infrared Thermography techniques to evaluate the types and extent of damage that occur in the joint during fatigue loading. The S-N curve of the aged joint is evaluated along with it's fatigue limit. It is found that the unaged specimens fail due to cohesive damage, hackles and disbond at the adhesive-adherend interface and the aged specimens failed due to delamination within the composite. The specimens that survived fatigue loading showed similar residual strength as specimens that were not fatigue loaded.

Ebstein's anomaly is an uncommon congenital malformation that can associated with atrial septal defect and atrio-fascicular Mahaim. Here we report a known case of Ebstein's anomaly with atrial septal defect and concomitant atrio-fascicular Mahaim pathway who underwent atrial septal defect device closure and concurrent ablation of accessory pathway.

In order to study the fracture properties of dam concrete under post-peak cyclic loading, wedge splitting tests with three loading rates (0.001 mm/s, 0.01 mm/s, 0.1 mm/s) were performed on notched cubic dam concrete specimens. Meanwhile, the acoustic emission (AE) and digital image correlation (DIC) technologies were used to record the crack propagation process of specimens. Test results show that the fracture of dam concrete has a significant rate effect: with the loading rate increases, the peak load increases, the slope of the post-peak P-CMOD curve gradually decreases and the stiffness degradation of dam concrete becomes more serious. The cumulative AE count shows a step increasing trend and has a Kaiser effect. The Kaiser effect decreases with the post-peak cyclic loading procedure, and with the loading rate increases, the Kaiser effect increases. With the increasing of loading rate, AE energy fluctuates violently and b value fluctuates frequently, indicating the damage of dam concrete becomes more serious. As the loading procedure, the damage of the specimen accumulates gradually, and the strain recovery rate decreases gradually. With the loading rate increases, the strain recovery rate decreases and the permanent crack increases. Based on the fictitious crack model, the effective crack length shows a gradual and steady rising trend. As the loading rate increases, the growth rate of the effective crack length becomes large.

Catheter Ablation of Ventricular Arrhythmias in patients with Prior Mitral Valve Surgery: Challenging, but Feasible and Effective!Amrish Deshmukh, MD; Frank Bogun, MD; Jackson J. Liang, DOElectrophysiology Section, Division of Cardiology; University of Michigan, Ann Arbor, MIFunding: NoneDisclosures: None

Introduction: Opinion is divided about optimal early timing of the Fontan Operation (FO). While some studies have suggested 3 years-of-age, others have shown good outcomes below 2 years-of -age. We analyzed the impact of age ≤2-years as compared age >2-years on short-term outcome of the FO using a large national database. Methods: A retrospective analysis of the Kids Inpatient Database (2009-16) for the FO was done. The groups were divided into those who underwent FO at age ≤2-years (EF) as compared to age >2-years (LF). The data was abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used. Results: 3381 patients underwent FO during this period of which 1482 (44%) were EF. The mean ages of the EF and LF were 1.6 and 4.3, respectively (p< 0.001). LF were more likely to be non-White, female, and have Heterotaxy syndrome. HLHS was more common in EF. There was no difference in the discharge mortality, length of stay, disposition (majority went home), and mean total charges incurred. The overall discharge mortality was low at 0.7% (24/3381). In multivariate analysis: cardiac arrest, acute kidney injury, mechanical ventilation >96 hours, endocardial cushion defect and non-White ethnicity were predictors of a mortality and not age. Conclusion: Contemporary outcomes for FO are excellent with equivalent short-term outcomes in both the age groups. Occurrence of postoperative complications, non-white ethnicity and endocardial cushion defect diagnosis were predictive of a negative outcome.

A 54-year old male developed unexpectedy a severe penicillin allergy after 5 standard erysipelas treatments by intravenous benzylpenicillin and/or oral phenoxymethylpenicillin without any clinical symptoms of allergy during 16 years. During the 6th erysipelas treatment by intravenous benzylpenicillin, the patient experienced an anaphylactic reaction within 30 minutes.

Impact of prior sternotomy on survival and allograft function after heart transplantation: a single-center matched analysisPrior sternotomy versus primary heart transplantEditorialE. Potapov, J. SteinIn the presented study, the authors showed that prior sternotomy in heart transplant candidates does not impact survival after heart transplantation (reference). The analysis was performed between 106 propensity score-matched pairs (212 patients).The results of published studies are contradictory and confusing. The small, single-center study published by Sert D, 2020, showed an increased early mortality in HTx recipients with prior sternotomy1, with no increased bleeding risk and a similar 4-year survival. In contrast, yet another single-center study with a similar design –no sternotomy vs. VAD-supported vs. prior sternotomy other than for VAD– published by Gaffey in 2015 showed no differences regarding early and long-term mortality, but a significantly higher risk of postoperative bleeding and a greater use of blood products2. A further single-center study with a comparable number of patients published in 2018 by Still S yet again showed that HTx recipients with prior sternotomy required more blood transfusions and showed an increased incidence in postoperative pneumonia, wound infection, and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of primary graft dysfunction with a subsequently higher short-term and 1-year mortality3. However, in these studies the impact of confounding variables was not eliminated.Having said that, the presented study attempts to overcome imbalances in confounding variables by comparing survival and complications between propensity score-matched patient groups. The matching procedure was based on established risk factors including recipients’ baseline characteristics, donor age, sex mismatch, risk scores, ECLS, PVR, serum creatinine, and serum bilirubin, and ultimately produced 106 matched pairs. However, the benefit of balanced confounders is achieved at the cost of a reduced number of patients and therefore less power to detect differences between patient groups. The lack of significant differences in this study cannot merely be explained by a low power, but is instead due to the similarity of effects: Authors report a 30-day mortality of 5.7 % for prior sternotomy vs. 7.5 % for first-time sternotomy and no impact of prior sternotomy on long-term survival with an HR of 0.87 [95% CI: 0.57, 1.56]. Contradicting the above-mentioned studies, these results do not even come close to indicating a trend towards worse long- and short-term survival for patients with prior sternotomy. This also holds true for long-term survival in the unmatched population of 131 patients with and 381 patients without redo surgery.Now how about a larger registry-based analysis? An analysis based on the UNOS database comprising 11,266 patients showed that prior sternotomy was associated with an excess 3.3 % mortality and higher morbidity within the first 60 days after heart transplantation, as measured by the frequency of dialysis, drug-treated infections, and strokes. Conditional 5-year survival after 60 days is unaffected by prior sternotomy4. Five years later, another group performed an analysis of the same UNOS database (meanwhile comprising 14,730 patients) and showed again that prior sternotomy is a risk factor for worse survival after cardiac transplantation, mainly due to an increased early postoperative mortality5.Why are we interested in knowing the effect of prior sternotomy on post-transplant outcomes? Since a prospective, randomized study is not possible due to ethical reasons, we have to rely on retrospective analyses. From a practical perspective, a comparison is meaningless – patients with prior sternotomy would never be refused for HTx due to this fact alone, even if we knew that morbidity and mortality in these patients may be higher.In our opinion, such an analysis may be performed to identify and support the advantages of less invasive LVAD implantation regarding the outcome of later HTx, as was performed in a first analysis of 46 patients (sic!, the lowest number of patients among the discussed studies) published by Riebandt J, 20216. The study showed that patients supported with LVAD implanted via full sternotomy required more packed red blood cells with no increased risk of bleeding, and subsequently developed more donor-specific antibodies, however, without any impact on short- and long-term survival, similar to the studies discussed above2,3.However, the virgin chest is not comparable to that of patients supported with an LVAD implanted via a less invasive approach, even if no7 or partial sternotomy8 is performed. In either of the groups the pericardium remains intact. Regardless of the technique used, the left pleura is opened, as is the pericardium around the ascending aorta and the apex of the right and left ventricles, and the graft is placed into the pericardial space, causing adhesions making any efforts to suggest, that the HTx in the “virgin chest”is similar to that after less invasive LVAD implantation not appropriate.Finally, the authors should nonetheless be congratulated on their outstanding surgical experience and the resulting very good outcomes in HTx – better than in the majority of centers worldwide.References1. Sert DE, Kervan Ü, Kocabeyoğlu SS, et al. Early and long-term results of heart transplantation with reoperative sternotomy. Turk gogus kalp damar cerrahisi dergisi 2020;28:120-6.2. Gaffey AC, Phillips EC, Howard J, et al. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. The Annals of thoracic surgery 2015;100:542-9.3. Still S, Shaikh AF, Qin H, et al. Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation. Interactive cardiovascular and thoracic surgery 2018;27:343-9.4. Kansara P, Czer L, Awad M, et al. Heart transplantation with and without prior sternotomy: analysis of the United Network for Organ Sharing database. Transplantation proceedings 2014;46:249-55.5. Axtell AL, Fiedler AG, Lewis G, et al. Reoperative sternotomy is associated with increased early mortality after cardiac transplantation. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2019;55:1136-43.6. Riebandt J, Wiedemann D, Sandner S, et al. Impact of Less Invasive Left Ventricular Assist Device Implantation on Heart Transplant Outcomes. Seminars in thoracic and cardiovascular surgery 2021.7. Potapov EV, Kukucka M, Falk V, Krabatsch T. Off-pump implantation of the HeartMate 3 left ventricular assist device through a bilateral thoracotomy approach. The Journal of thoracic and cardiovascular surgery 2017;153:104-5.8. Nersesian G, Potapov E, Starck CT, et al. Surgical Implantation Techniques of Modern Continuous Flow Ventricular Assist Devices. Surgical technology international 2021;37:263-9.

Rationale, aims and objectives 39 Evidence-based medicine (EBM) holds that estimates of effects of health interventions based on 40 high-certainty evidence (CoE) are expected to change less frequently than the effects generated 41 in low CoE studies. However, this foundational principle of EBM has never been empirically 42 tested. 43 Methods 44 We reviewed all systematic reviews and meta-analyses in Cochrane Database of Systematic 45 Reviews from January 2016 through May 2021 (n=3,323). We identified 414(207x2) and 384 46 (192x2) pairs of original and updated Cochrane reviews that assessed CoE and pooled 47 treatment effect estimates. We appraised CoE using the Grading of Recommendations 48 Assessment, Development and Evaluation (GRADE) method. We assessed the difference in 49 effect sizes between the original versus updated reviews as a function of change in CoE, which 50 we report as a ratio of odds ratio (ROR). We compared ROR generated in the studies that 51 changed CoE from very low/low (VL/L) to moderate/high (M/H) vs. MH/H VL/L. We also 52 assessed the heterogeneity and inconsistency (using the tau and I2 statistic), the change in 53 precision of effect estimates (by calculating the ratio of standard errors) (seR), and the absolute 54 deviation in estimates of treatment effects (aROR). 55 Results 56 57 We found that CoE originally appraised as VL/L had 2.1 (95%CI: 1.19 to 4.12; p=0.0091) times 58 higher odds to be changed in the future studies than M/H CoE. However, the effect size was not 59 different when CoE changed from VL/L M/H vs. M/H VL/L [ROR=1.02 (95%CI: 0.74 to 1.39) 60 vs. 1.02 (95%CI: 0.44 to 2.37); p=1 for the between subgroup differences]. aROR was similar 61 between the subgroups [median (IQR):1.12 (1.07 to 1.57) vs 1.21 (1.12 to 2.43)]. We observed 62 large inconsistency (I 2=99%) and imprecision in treatment effects (seR=1.09). 63 Conclusions 64 We provide the first empirical support for a foundational principle of EBM showing that low65 quality evidence changes more often than high CoE. However, the effect size was not different 66 between studies with low vs high CoE. The finding that the effect size did not differ between low 67 and high CoE indicate urgent need to refine current EBM critical appraisal methods

In the present work, we define a new anomaly, $\Psi$, termed semifocal anomaly. It is determined by the mean between the true anomaly, $f$, and the antifocal anomaly, $f^{\prime}$; Fukushima defined $f^{\prime}$ as the angle between the periapsis and the secondary around the empty focus. In this first part of the paper, we take an approach to the study of the semifocal anomaly in the hyperbolic motion and in the limit case correspoding to the parabolic movement. From here we find a relation beetween the semifocal anomaly and the true anomaly that holds independently of the movement type. We focus on the study of the two-body problem when this new anomaly is used as the temporal variable.\\ In the second part, we show the use of this anomaly —combined with numerical integration methods— to improve integration errors in one revolution. Finally, we analyze the errors committed in the integration process —depending on several values of the eccentricity— for the elliptic, parabolic and hyperbolic cases in the apsidal region.

We aim to report a patient with vertebral brown tumor in the context of primary hyperparathyroidism presented with shoulder pain. This is the first report of C5 involvement by Brown tumor in a primary hyperparathyroid patient and emphasizes the consideration of cervical vertebral evaluation in patients with persistent shoulder pain.

Various clinical forms of cutaneous leishmaniasis can be encountered such as: ulcerated, lupoïd, sporotrichoïd and other rare forms (eczematiform, erysipeloid, psoriasiform, verrucous, and pseudotumoral). We report an atypical presentation. Dermatologists should be aware when facing a verrucous mass, especially if the patient comes from an endemic country.

Neural Tube Defects (NTDs) are congenital malformations resulting from abnormal embryonic development of the brain, spine, or spinal column. The genetic etiology of human NTDs remains poorly understood despite intensive investigation. CIC, homolog of the Capicua transcription repressor, has been reported to interact with ataxin-1 (ATXN1) and participate in the pathogenesis of spinocerebellar ataxia type 1. Our previous study demonstrated that CIC loss of function (LoF) variants contributed to cerebral folate deficiency by downregulating folate receptor 1 (FOLR1) expression. Given the importance of folate transport in neural tube formation, we hypothesized that CIC variants could contribute to increased risk for NTDs by depressing embryonic folate concentrations. In this study, we examined CIC variants from whole genome sequencing (WGS) data of 140 isolated spina bifida cases and identified 8 missense variants of CIC gene. We tested the pathogenicity of the observed variants through multiple in vitro experiments. We determined that CIC variants decreased FOLR1 protein level and planar cell polarity (PCP) pathway signaling in a human cell line (HeLa). In a murine cell line (NIH3T3), CIC loss of function variants down regulated PCP signaling. Taken together, this study provides evidence supporting CIC as a risk gene for human NTD.

The generalized finite difference method is a meshless method for solving partial differential equations that allows arbitrary discretizations of points. Typically, the discretizations have the same density of points in the domain. We propose a technique to get adapted discretizations for the solution of partial differential equations. This strategy allows using a smaller number of points and a lower computational cost to achieve the same accuracy that would be obtained with a regular discretization.

Toxic metal-contaminated wastewater is a major environmental issue that requires a practical and cost-effective technological solution. Heavy metal phytoremediation by constructed wetland is becoming more common around the world. Plants are used in phytoremediation to degrade, stabilize, and remove contaminants from soils, water, and waste. The key issues with managing heavy metal phytoremediation plants in an environmentally appropriate manner. The design of CWs for successful phytoremediation in heavy metals contaminated wastewater should not affect the local environment. By-product generation is another crucial part of phytoremediation’s success. Phyto-management has emerged as an alternative strategy in recent years. Phytoremediating plants ( C. indica and A. calamus) biomass has been successfully used in the manufacture of 70 fly-ash bricks. High rate of Cu (96 %), Zn (95 %), (Fe 93), and Cr (91 %) removal from Canna indica and Acorus calamus were found in the present study as compared to the Typha latifoliya, Myriophylhum aquaticum, Ludwigina palustris, Eichhornia crassipes, Schoenoplectus californicus, Cyperus papyrus, and Phragmites australis which indicates C. indica is the high potential for heavy metal removal and can be strongly used for industrial wastewater. In the way, the use of ornamental plants for phytoremediation of contaminated sewage wastewater would also change the landscape of the aquatic environment. This article summarises viable avenues in the method of using phytoremediating plant biomass for environmental protection.

Benthic macroinvertebrates are widely used to assess the ecological quality of fresh waters. This is because they are in direct contact with the aquatic environment and respond differently to pollutants and changes in the watershed, which are difficult to assess by toxicological or chemical monitoring alone. this study used benthic macroinvertebrate parameters to assess the quality of the nearshore waters of lake Kivu. Twenty-six metrics covering various aspects of the community were tested using whisker plots to compare their sensitivity in discriminating between reference and disturbed stations. Nine parameters (% EPT taxa, % Diptera taxa, % Chironomid taxa, % Insect taxa; % no Insects taxa, ratio EPT/Chironomid taxa, % moderate tolerant taxa, % very moderate tolerant taxa, Family Biotic Index) were found to be sensitive and were able to discriminate between reference and disturbed stations. All sensitive metrics, with the exception of the percentage of EPT taxa, were positively and/or negatively correlated with the physico-chemical parameters affected by the changes in the littoral zone. The combined values of the three calculated biotic indices (ASPT, BMWP and FBI) showed that the biological water quality varies from moderate to good in the reference stations and from average to poor in the disturbed stations. It is concluded that metrics based on benthic macroinvertebrates are effective for assessing water quality in the littoral zone of Lake Kivu in the context of the lack of historical water quality databases and specific tools for toxicological assessment. It is suggested to compare the performance of this approach with others currently used in bio-indication.