Tracheoesophageal fistula (TEF) is an abnormal connection between trachea and esophagus. Acquired TEF arise from trauma, caustic fluids ingestion, and iatrogenic injuries (ventilation, esophageal atresia repair, radiation, tracheal/esophageal stents). We discuss diagnosis, anesthetic management, and surgical correction of battery swallow-induced TEF, not previously reported in pediatric anesthesia and otorhinolaryngology literatures.

Arteriovenous fistulae (AVF) of the head and neck region are extremely rare, especially those that occur spontaneously. We present the case of a 58 year old female with a spontaneous postauricular AVF causing troublesome pulsatile tinnitus. In this case a simple surgical procedure completely cured the patient of her symptoms.

The authors report a case of ehrlichiosis involving a bone marrow specimen from a patient with chronic lymphocytic leukemia. Since Ehrlichia may cause a lymphohistiocytic reaction in bone marrow specimens, an infectious process may be easily confused with a lymphoid neoplasm, particularly in patients with a history of lymphoid malignancy.

Carotenoids are widely used in functional foods, cosmetics, and health supplements, and their importance and scope of use are continuously expanding. Here, we characterised carotenoid biosynthetic genes of the plant-pathogenic bacterium Pantoea ananatis, which carries a carotenoid biosynthetic gene cluster (including crtE, X, Y, I, B, and Z) on a plasmid. Reverse transcription–polymerase chain reaction (RT-PCR) analysis revealed that the crtEXYIB gene cluster is transcribed as a single transcript and crtZ is independently transcribed in the opposite direction. Using splicing by overlap extension with polymerase chain reaction (SOE by PCR) based on asymmetric amplification, we reassembled crtE–B, crtE–B–I, and crtE–B–I–Y. High-performance liquid chromatography confirmed that Escherichia coli expressing the reassembled crtE–B, crtE–B–I, and crtE–B–I–Y operons produced phytoene, lycopene, and β-carotene, respectively. We found that the carotenoids conferred tolerance to UV radiation and toxoflavin. Pantoea ananatis shares rice environments with the toxoflavin producer Burkholderia glumae and is considered to be the first reported example of producing and using carotenoids to withstand toxoflavin. We confirmed that the carotenoid production of P. ananatis is dependent on RpoS, which is positively regulated by Hfq/ArcZ and negatively regulated by ClpP, similar to an important regulatory network of E. coli (HfqArcZ → RpoS Ͱ ClpXP). We also demonstrated that Hfq-controlled quorum signalling de-represses EanR to activate RpoS, thereby initiating carotenoid production. Survival genes such as those responsible for the production of carotenoids of the plant-pathogenic P. ananatis must be expressed in a timely manner to overcome stressful environments and compete with other microorganisms. This mechanism is likely maintained by a brake with excellent performance, such as EanR.

Swine acute diarrhea syndrome coronavirus (SADS-CoV) is a newly identified swine enteropathogenic coronavirus that causes watery diarrhea in neonatal piglets, leading to significant economic losses to the swine industry. Currently there are no suitable serological method to assess the infection of SADV-CoV and effectiveness of vaccines, making an urgent need to exploit effect enzyme-linked immunosorbent assay (ELISA) to compensate for this deficiency. In this study, an indirect ELISA (S-iELISA) based on recombinant spike (S) protein expressed in Baculovirus was developed and evaluated. The reaction conditions of S-iELISA were optimized and cut-off value determined as 0.3711 by analyzing OD450nm values of 40 SADS-CoV-negative sera confirmed by immunoinfluscent assay (IFA) and Western Blot. The coefficients of variation of 6 positive sera within and between runs of S-iELISA were both less than 10% and cross-reactivity assays demonstrated that S-iELISA was non-cross-reactive with other swine viruses’ sera. Furthermore, the overall coincidence rate between IFA and S-iELISA was 97.3% based on testing 111 clinical serum samples. Virus neutralization test with 7 different OD450nm value sera showed that the OD450nm values tested by S-iELISA are positive correlated with virus neutralization. Finally, a total of 300 pig field serum samples were tested by S-iELISA and commercial kits of other swine enteroviruses showed that the IgG-positive for SADS-CoV, TGEV, PDCoV and PEDV were 81.7%, 54%, 65.3%, 6%, respectively. The results suggest this S-iELISA is specific, sensitive, repeatable and can be applied for vaccines evaluation and detection the SADS-CoV infection in swine industry.

Fatigue cracks initiated from holes in several zones and structural components of the RRJ-95 aircraft frames were investigated. Using the method of quantitative fractography the crack growth duration in the brackets of the in-service airframe and in the wing panels during full-scale bench tests was estimated the spacing of meso-beach-marks (MBM) and fatigue striations. The applied program of bench test consisted of blocks of variable loads that were equivalent to the wing loading in flight and reproducing schematized flight-cycle. It was shown that the duration of fatigue crack propagation in several structural components of the RRJ-95 aircraft frames was approximately the same as for the crack nucleation duration. The total lifetime is sufficiently long for cracks in the structural components to be detected and reliably monitored with a large operating time interval between adjacent inspections.

Xiaodong Zhang1, MD, PhD, Ruike Yang1 2, MD, Luigi Di Biase1, MD, PhD, FHRS1 Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York2 Division of Cardiology, Department of Medicine, Henan Provincial People’s Hospital, Zhengzhou, ChinaCorrespondence : Dr Luigi Di Biase, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St, Bronx, NY 10467. E-mail address: [email protected] .Keywords : narrow complex tachycardia, dual atrioventricular nodal non-re-entrant tachycardia, dual atrioventricular nodal re-entrant tachycardia, autonomic nervous system

Background: Computer simulation model demonstrated that atrial fibrillation (AF) driver attached to the patchy fibrosis assessed by late gadolinium enhancement magnetic resonance imaging (LGE-MRI). However, it has not been well elucidated in patients with persistent AF. The aim of this study is to investigate whether radiofrequency (RF) application on the patchy LGE site (PLS) could terminate AF or convert to atrial tachycardia (AT) and improve the rhythm outcome. Methods: A total of 31consecutive persistent AF patients with PLS were enrolled (PLS ablation group, mean age: 69 ± 8 years, mean left atrial diameter: 42 ± 6 mm). AF direct termination or AT conversion during RF application on the PLS were defined as favorable response. The rhythm outcome was compared between the PLS ablation group and the propensity matched conventional ablation group. Results: Favorable response was found in 15 (48%) of 31 patients (AF termination in 7, AT conversion in 8 patients). AF recurrence at 12 months follow-up was significantly less in the PLS group as compared to the control group (4 (13%) of 31 patients vs. 11 (35%) of 31 patients, log-rank p = 0.019). In patients with favorable response, AT recurred in 1 (7%) of 15 patients but AF. Conclusions: The PLS ablation could terminate AF or convert to AT in half of the patients and improve the rhythm outcome as compared to the conventional ablation. No AF recurrence was documented in patients with a favorable response.

Background: The interplay between COVID-19 pandemic and asthma in children is still unclear. We evaluated the impact of COVID-19 on childhood asthma outcomes. Methods: The PeARL multinational cohort included 1,054 children with asthma and 505 non-asthmatic children aged between 4-18 years from 25 pediatric departments, from 15 countries globally. We compared the frequency of acute respiratory and febrile presentations during the first wave of the COVID-19 pandemic between groups and with data available from the previous year. In children with asthma, we also compared current and historical disease control. Results: During the pandemic, children with asthma experienced fewer upper respiratory tract infections, episodes of pyrexia, emergency visits, hospital admissions, asthma attacks and hospitalizations due to asthma, in comparison to the preceding year. Sixty-six percent of asthmatic children had improved asthma control while in 33% the improvement exceeded the minimal clinically important difference. Pre-bronchodilatation FEV1 and peak expiratory flow rate were improved during the pandemic. When compared to non-asthmatic controls, children with asthma were not at increased risk of LRTIs, episodes of pyrexia, emergency visits or hospitalizations during the pandemic. However, an increased risk of URTIs emerged. Conclusion: Childhood asthma outcomes, including control, were improved during the first wave of the COVID-19 pandemic, probably because of reduced exposure to asthma triggers and increased treatment adherence. The decreased frequency of acute episodes does not support the notion that childhood asthma may be a risk factor for COVID-19. Furthermore, the potential for improving childhood asthma outcomes through environmental control becomes apparent.

Background: Antiepileptic drugs (AEDs) are widely used for the treatment of epilepsy, but they can be associated with the development of mainly delayed/non-immediate hypersensitivity reactions (HRs). Although these reactions are usually cutaneous, self-limited and spontaneously resolve within days after drug discontinuation, sometime HRs reactions to AEDs can be severe and life threatening. Aim: This paper seeks to show examples on practical management of AEDs HRs in children starting from a review of what it is already known in literature. Results: Risk factors include age, history of previous AEDs reactions, viral infections, concomitant medications and genetic factors. The diagnosis work-up consists of in vivo (Intradermal testing and Patch testing) and in vitro tests [serological investigation to exclude the role of viral infection, lymphocyte transformation test (LTT), cytokine detection in ELISpot assays and granulysin (Grl) in flow cytometry]. Treatment is based on a prompt drug discontinuation and mainly on the use of glucocorticoids. Conclusion: Dealing with AEDs HRs is challenging. The primary goal in the diagnosis and management of HRs to AEDs should be trying to accurately identify the causal trigger and simultaneously identify a safe and effective alternate anticonvulsant. There is therefore an ongoing need to improve our knowledge of HS reactions due to AED medications and in particular to improve our diagnostic capabilities.

Background: Current guidelines for the management of asymptomatic hypertension (HTN) in the inpatient setting recommend the use of oral antihypertensives. However, in clinical practice, intravenous (IV) antihypertensives are commonly utilized with little supporting evidence. The objective of this study was to evaluate literature examining the safety/efficacy of IV hydralazine and labetalol in hospitalized patients with non-emergent, asymptomatic HTN. Methods: The PRISMA guidelines were utilized to structure the systematic review. A search strategy composed of drug-, inpatient-, and HTN-related terms was conducted utilizing PubMed, Embase, and Scopus databases through May 2020. Full-text, English-language articles describing IV labetalol and/or hydralazine use for non-emergent HTN in an inpatient setting that focused on clinical outcomes (i.e. vitals, adverse effects, healthcare utilization) were included. Identified studies were screened/extracted using DistillerSR by two reviewers at each stage, and studies were evaluated qualitatively for the presence of bias. Results: From 3362 records identified in the search, a final set of 10 articles were identified. Four studies focused on labetalol (40%), five studies on hydralazine and labetalol (50%), and one study on hydralazine (10%). The included studies presented a variety of outcomes, but several trends were identified, including reduction in average blood pressure in eight (80%) studies, a risk of adverse effects in six (60%), and increased length of stay in one (10%). Discussion: The studies identified in this review raise concerns regarding the safety of IV hydralazine and labetalol in non-emergent HTN. Despite relatively broad clinical experience with these drugs, experimental investigations regarding their utility are recommended.

This case series identified a sub cohort of healthcare workers with COVID-19 who experienced a prolonged symptomatic course and remained unable to return to work for many weeks. It notes their demographic and clinical characteristics and suggest ways to support them returning to work in a graded and supported manner.

OBJECTIVE Postoperative stroke is a serious unsolved complication after acute type A aortic dissection repair. We investigated the incidence and risk factors of stroke and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS Between 2012 and 2019, 202 (56% men, median age 68 years) patients with acute type A aortic dissection underwent surgical repair. Clinical data, image findings,　methods of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS Of 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n=25). Brachiocephalic artery dissection was associated with a higher risk of stroke (odds ratio, 3.89, 95%CI 1.104-13.780; P= .035) having no relation with the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION Brachiocephalic artery dissection was an independent risk factor of stroke after acute type A aortic dissection repair.

When Thetis dipped her son Achilles into the River Styx to make him immortal, she held him by the Heel, which was not submerged, and thus created a weak spot that proved deadly for Achilles. Millennia later, Achilles Heel is part of today’s lexicon meaning an area of weakness or a vulnerable spot that causes failure. Also implied is that an Achilles Heel is often missed, forgotten or underappreciated, until it is under attack, and then failure is fatal. Paris killed Achilles with an arrow ‘guided by the Gods’. At the International Congress of the Immunology of Diabetes Society, 2018, five leading experts were asked to present the case for a particular cell/element that could represent the Achilles Heel of T1D. Their arguments are summarized here, to make this case.

In recent years Next-Generation Sequencing (NGS) based methods to detect mutations in biotherapeutic transgene products have become a key quality step deployed during the development of manufacturing cell line clones. Previously we reported on a higher throughput, rapid mutation detection method based on amplicon sequencing (targeting transgene RNA) and detailed its implementation to facilitate cell line clone selection. By gaining experience with our assay in a diverse set of cell line development programs, we improved the computational analysis as well as experimental protocols. Here we report on these improvements as well as on a comprehensive benchmarking of our assay. We evaluated assay performance by mixing amplicon samples of a verified mutated antibody clone with a non-mutated antibody clone to generate spike-in mutations from ~60% down to ~0.3% frequencies. We subsequently tested the effect of 16 different sample and NGS library preparation protocols on the assay’s ability to quantify mutations and on the occurrence of false-positive background error mutations (artifacts). Our evaluation confirmed assay robustness, established a high confidence limit of detection of ~0.6%, and identified protocols that reduce error levels thereby significantly reducing a source of false positives that bottlenecked the identification of low-level true mutations.

Aim: To show if lower urinary tract symptoms (LUTS) could be symptoms of COVID-19 with validated questionnaires. Methods: The 96 COVID-19 patients who were hospitalized at a tertiary center were collected retrospectively. After the exclusion criteria, 46 patients were consisted as the study population. The male and female patients then fill formed the International Prostate Symptom Score and Urinary Symptom Profile respectively. All patients responded to these questions for the three period. Results: 27 female (58.6 %) and 19 male (41.4 %) COVID-19 patients answered the questions In the male patients, while there were no statistically significant differences in the total IPSS, the voiding IPSS score, and quality of life between the three periods (p=0.148; p=0.933, p=0.079, respectively), the storage IPSS scores had a significant difference between the three periods (p=0.05). In the female patients, low stream scores, were similar between the three periods (p=0.368). The scores of stress incontinence and an overactive bladder had a significant difference between the three periods (p=0.05 and p=0.05). Conclusion: LUTS, especially storage symptoms, might be one of the initial symptoms of COVID-19 and the clinicians should evaluate LUTS with other known symptoms of the virus when a patient is suspected of having COVID-19.

ABSTRACT Aim: To investigate the effect of COVID-19 on sexual dysfunction in women. Materials and Methods: The women diagnosed with COVID-19 and hospitalized at a tertiary hospital were included. They completed the Introductory Data Form, the Female Sexual Function Index-(FSFI), and the Short Form-36 Quality of Life Scale (SF-36). Results: 15 women between the ages of 19-49 who completed the treatment protocol, discharged at least 14 days before, and who had not been diagnosed as sexual dysfunction sexually active earlier were included to the study. It was detected that weekly sexual intercourse before and after COVID-19 significantly differed (p=0.047). The frequency of relationships decreased statistically after COVID-19. The mean value of the FSFI satisfaction score differs from COVID-19 before and after diagnosis (p=0.012). The mean satisfaction score before COVID-19 was 3.47, and after COVID-19 was 2.93. The score of the subgroups of FSFI did not differ from COVID-19 before and after diagnosis (p>0.050). The median value of SF-36 pain differs from COVID-19 before and after diagnosis (p=0.008). Conclusion: it was concluded that the frequency of sexual intercourse, sexual satisfaction in women decreased after COVID-19 disease, and the quality of life scores did not change in a statistically significant way.

Childhood cancer survivors are at increased risk for treatment-related late effects; data are lacking on how COVID-19 infection impacts this cohort. We assessed COVID-19-related symptoms; SARS-CoV-2 IgG seroprevalence; and rate of COVID-19-related hospitalization among 321 asymptomatic survivors of childhood cancer or transplantation seen for routine long-term follow-up between May-September 2020 in a New York City tertiary cancer center. While 11% (n=35) reported possible COVID-19-related symptoms, 7.8% (n=20) of those tested had positive SARS-CoV-2 IgG, and only 1 patient (0.3%) required COVID-19 related hospitalization. This report suggests that childhood cancer survivors are at low risk for COVID-19 complications.