The raw case fatality rate (CFR, reported number of COVID-19 deaths divided by the number of cases) is a useful indicator to quantify the severity or treatment efficacy in a locality. In many countries, the pandemic showed a two-wave pattern now, namely the daily reported cases once reached a low level and now went up. To our knowledge, no study has compared the CFR for the two waves. In this work, we report that in 53 countries or regions with the highest deaths, the CFR is reduced in 43 countries or regions in the on-going second wave. We discussed the possible reasons. Also, we compare the two-wave pattern of COVID-19 with the weekly influenza positive tests. The influenza activity in pre-pandemic era provided an indicator for climate in a country, since it is well-known that influenza is driven by weather. The sharp drop in 2020 influenza activity is an indicator of the effects of social distancing.
Rationale, aims, and objectives: The complexity of healthcare systems makes errors unavoidable. To strengthen the dialogue around how physicians experience and share medical errors, the objective of this study was to understand how experienced generalist physicians make meaning of and grow from their medical errors. Methods: This study used a narrative inquiry approach to conduct and analyze in-depth interviews from 26 physicians from the generalist specialties of emergency, internal, and family medicine. We gathered stories via individual interview, analyzed them for key components, and rewrote a ‘meta-story’ in a chronological sequence. We conceptualized the findings into a metaphor to draw similarities, learn from, and apply new principles from other fields of practice. Results: Through analysis we interpreted the story of an elite athlete (physician) who is required to make numerous decisions in a short period of time within the construct of a chaotic sports field (clinical environment) among spectators (the patient’s family) whilst abiding by existing rules and regulations. Through sharing stories of success and failure, the team coach (clinical mentor) helps optimize the players’ professional and psychological development. Similarly, through sharing and learning from stories, team members (colleagues) and junior team members (trainees) also contribute to the growth of the protagonist’s character and the development of the overall team (clinic/hospital) and sport (healthcare system). Conclusion: We draw parallels between the clinical setting and a generalist physician’s experiences of a medical error with the environment and practices within professional sports. Using this comparison, we discuss the potential for meaningful coaching in medical education.
Variation in solar ultraviolet (UV) radiation induces a wide-range of plant responses from the cellular to whole-plant scale. We demonstrate here for the first time that partial stomatal closure caused by UV exposure significantly increases leaf temperature independently of any increase in incident energy on the leaves. Significant leaf warming in response to UV radiation was consistent in tomato (Solanum lycopersicum L. ) across different experimental approaches. Exposure to UV radiation significantly decreased stomatal conductance and increased leaf temperature by up to 2°C in field experiments where solar UV was attenuated using filters. Smaller but significant increases in leaf temperature due to decreases in stomatal conductance occurred in multi-day controlled environment (CE) growth room experiments and in short-term (< 2 hours) irradiance response experiments, both using fluorescent lamps to provide UV treatments. We show that leaf warming due to partial stomatal closure is independent of any direct warming effects of UV manipulations. We discuss the implications of UV-induced warming both for crop production and understanding broader plant and ecosystem responses to UV radiation.
In recent decades, the rising severity of summer heatwaves has increased the co-occurrence of heat and drought stress leading to forest mortality and to reductions in crop yield. Plant responses to this combined stress can be unique from the response to either independent stress, yet few studies have investigated these responses in tree species. Our work examines adjustment of several primary metabolites and polyamine (stress indicating secondary metabolites) in paper birch and white spruce subjected to two seasons of repeated heatwaves, drought, and elevated CO2. Our objectives were to determine if the metabolic adjustments in response to heatwave+drought stress are: 1) unique or shared with either individual stress; 2) greater in birch compared to spruce; and 3) carried over into the following season. Our data show that white spruce displayed many metabolic responses that were unique to the combined stress, especially in the first year, while paper birch displayed few. Further, the unique responses in spruce seen in the first season stress exposure did not carry into the following season indicating possible stress memory. Our data highlights the importance of considering species-specific responses to multiple stressors when making predictions about forest response to future climate scenarios.
Please allow me call you mum,Inside or outside of the uterus,It is not my choice.My home located at the Fallopian tube,Not the uterus where I have been expecting,It is not my choice.The small room I am living,The pressure I am confronting,The poor nutrition I am absorbing,Mum, mum…I am so painful.I don’t want to live here.Mum, mum…I can’t breathe.But I can’t go away this way.Mum, mum…I am still alive.But who ever heard me crying?Mum, mum…What you may lose is not only your hope for the future,But also, the fertility for my future sisters and brothers,But it is not my choice.I also have the right to life,I also ever imagined the rich and colorful of the outside world,But I don’t know if I have the opportunity to see it.Though I live in such tragic,I still believe everyone is created equal,What makes me dangerous to life is not life itself,But the environment I am living.Who to be blamed is you–my mum,Sometimes you are innocent,But sometimes you could have done something to avoid it happening,But keeping silence.At the end,Together with the Fallopian tube,I was removed from your body.You are safe now,But will never be perfect.Painful,Not only at present,But may last a lifetime.
Introduction: long-term observation of patients with ANCA-associated vasculitis (AAV) allows the identification of different longitudinal patterns of ANCA levels during follow-up. This study aimed to characterise these patterns and to determine their prognostic significance. Methods: all ANCA determinations performed in two university hospitals along a 2-year period were retrospectively reviewed. Patients were included in the analysis if they had high titers of anti-myeloperoxidase (anti-MPO) or anti-proteinase 3 (anti-PR3) antibodies at least once, they had ≥5 serial ANCA determinations, and they had AAV diagnosed by biopsy or ACR classification criteria. Patients’ time-course ANCA patterns were classified as monophasic, remitting, recurrent or persistent. Associations between ANCA patterns and prognostic variables (relapse rate and renal outcome) were analysed by univariate and multivariate statistics. Results: A total of 99 patients (55 with microscopic polyangiitis [MPA], 36 with granulomatosis with polyangiitis [GPA], and 8 with eosino¬philic granulomatosis with polyangiitis) were included. Median follow-up was 9 years. Among patients diagnosed with MPA or GPA, recurrent or persistent ANCA patterns were associated with a higher risk of clinical relapse (HR 3.7 [95% CI 1.5-9.1] and HR 2.9 [95% CI 1.1-8.0] respectively), independently of clinical diagnosis or ANCA specificity. In patients with anti-MPO antibodies, the recurrent ANCA pattern was associated with worsening renal function (OR 5.7 [95% CI 1.2-26.0]). Conclusion: Recurrent or persistent ANCA patterns are associated with a higher risk of clinical relapse. A recurrent ANCA pattern was associated with worsening renal function in anti-MPO-associated vasculitis.
Objectives: To reach consensus on evidence-based recommendations to develop HDP management pathways for Indonesian primary care. Design: A three-round Delphi survey Setting: N/A Population: Maternal health practitioners and experts, including GPs, midwives, nurses and health policy researchers from Indonesia and international background. Methods: Participants were asked to rate their agreement on whether each of 125 statements about HDP and HDP managements extracted from international guidelines were feasible in Indonesian primary care settings in a mix of quantitative and qualitative questions in three-rounds Delphi survey. A minimum of 70% agreement among participants was needed for a statement to be included for the HDP pathways that the pathways drafts were presented at the third-round survey. The participants’ free text questions responses and suggestions were analysed thematically. Main Outcome Measures: Agreement scores of the statements. Results: A total of 52 participants participated, 48, 45, and 37 of them completed the first, second and third-round survey respectively. The consensus was reached for 115 of the 125 statements on HDP definition, screening, management and long-term follow-up. The agreement scores ranged from 70.8-100.0% and potential implementation barriers were also identified. Drafts of HDP management pathways were also agreed upon and received suggestions from the participants. Conclusions: Most evidence-based HDP management recommendations achieved consensus represented in the developed HDP management pathways can be implemented in Indonesian settings. Further investigations are needed to explore the acceptability and feasibility of the pathways in practice.
The interesting report by Karagianni P et al on the finding of increased DNA methylation of H19 locus imprinting control region in saliva samples of Sjögren’s syndrome patients correlating with low complement C4 levels, may offer insights into how C4 level may be regulated in serpinopathies such as C1-inhibitor deficiency. An undetectable or low C4 level in patients with severe angioedema is a feature of C1-inhibitor deficiency (hereditary angioedema (HAE) type I with low to absent function and antigenic levels; HAE type II with point mutations in SERPING1 gene that affect the reactive centre loop affecting protein function only). However, C4 levels do not always clinically correlate with disease activity, and up to 6% patients do not have known mutations in the SERPING1 gene.
Soil ecological stoichiometry provides powerful theories to integrate the complex interplay of element cycling and microbial communities into biogeochemical models. One essential assumption is that microbes maintain stable C:N:P (carbon:nitrogen:phosphorus) ratios independent of resource supply, although such homeostatic regulations have rarely been assessed in individual microorganisms. Here, we report an unexpected high flexibility in C:N and C:P values of saprobic fungi along nutrient supply gradients, overall ranging between 7-126 and 20-1488, respectively, questioning microbial homeostasis. Fungal N:P varied comparatively less due to simultaneous reductions in mycelial N and P contents. As a mechanism, internal recycling processes during mycelial growth and an overall reduced N and P uptake appear more relevant than element storage. The relationships among fungal stoichiometry and growth disappeared in more complex media. These findings affect our interpretation of stoichiometric imbalances among microbes and soils and are highly relevant for developing microbial soil organic carbon and nitrogen models.
Objective: Cardiotocography is used worldwide to evaluate foetal well-being during pregnancy and labour. In past guidelines, the management plan was determined based on the assessment of the most severe waveform of the deceleration. There are no guidelines for evaluating the integrated recurrent decelerations; however, we believe their assessment to be essential for predicting the status of the foetus. The objective of this study was to propose an indicator for performing medical interventions during labour by creating a scoring system that reflects integrated recurrent decelerations. Design: A retrospective cohort study. Sample: Full-term single foetus births from vaginal deliveries. Methods: iPREFACE score, the integrated score index to predict foetal acidemia by intrapartum foetal heart rate monitoring was calculated using cardiotocography findings from approximately 30 min before delivery. Main Outcome Measures: We examined the iPREFACE score and fetal acidemia association and calculated the cut-off iPREFACE scores for acidaemia using receiver operating characteristic curves. Results: The study included 469 delivery cases. Their iPREFACE scores exhibited a significant negative correlation with the umbilical artery blood pH (correlation coefficient -0.43). The cut-off iPREFACE scores for the umbilical artery blood with pH <7.20, <7.10, and <7.0 were 44, 46, and 67, respectively (the areas under the curve were 0.776, 0.962, and 0.996, respectively). Conclusions: The iPREFACE score may predict foetal acidaemia and could be used as an indicator for timely medical interventions during labour. Because assessments using a cardiotocography are quick and easy to perform, the iPREFACE score could be a valuable tool in clinical practice.
Abstract Background: Transthoracic echocardiography (TTE) in prone position is challenging. Innovative use of transesophageal echocardiography (TEE) probe to perform TTE for such patients was described; but reproducibility and correlation of the TTE measurements by this technique with those obtained by the standard supine TTE study are still unknown. Methods: We enrolled 30 non-COVID-19 individuals, with a mean (SD) age 35 (10.9) years and 11 females, to study the agreement between the transthoracic measurements of the left ventricular (LV), left atrial (LA) and aortic dimensions obtained in prone position using an external TEE probe versus the standard supine position using the conventional TTE probe. Results: There were no significant differences between LV end-diastolic and end-systolic diameters, septal wall thickness, posterior wall thickness and aortic root dimensions in the prone versus the supine positions. While the mean ejection fraction (EF) (60.3% vs. 63.1%, P = 0.014) and mean LA dimensions (1.8 vs. 1.9 cm/m2, P < 0.001) were significantly lower in the prone position. The mean time of scans was significantly longer in the prone as compared to the supine (12.5 vs 4.5 minutes, P < 0.001). All supine studies had good quality while in the prone position 4 studies were of poor quality, and one was non-diagnostic. Conclusions: Assessment of cardiac dimensions and systolic function in the prone position using transthoracic TEE probe was feasible. LV and aortic dimensions agreed well with the standard TTE in supine position, however, LA dimensions and EF were lower in the prone position.
In our work, the formation energies, band structures, densities of states, effective masses and optical absorption properties of pure BiOBr and 3d transition metals-doped BiOBr have been calculated using DFT+U method. Ti, V, Fe, Cr, Co, Ni and Cu doping can induce impurity energy levels, originating from spin-up or -down orbits of 3d TMs, within the forbidden band of BiOBr, but Sc, Mn and Zn atoms only change the electronic delocalization in the valence bandor conduction band region of BiOBr. Furthermore, with introduction of 3d TMs atoms, there exist the redshift phenomena for optical absorption band edge of BiOBr to different extents. The photo response priority order, structural stability and recombination probability of photoinduced carriers for 3d TMs-doped BiOBr are summarized. Our theoretical findings should well explain the experimental observations in the previous literatures, and provide promising prediction and significant guidance for the well-construction of BiOBr-based photocatalyst systems.
Introduction Although left atrial posterior wall isolation (LAPWI) in addition to pulmonary vein isolation is a well-accepted option for persistent atrial fibrillation (AF), complete isolation can be challenging. To evaluate performance of a modified ablation index (AI) (AI/bipolar voltage along the ablation line) for predicting durable LAPWI. Methods The study involved 55 consecutive patients, aged 65 ± 11 years, who underwent electroanatomic mapping-guided LAPWI for AF. Association between gaps (first-pass LAPWI failure and/or acute LAPW reconnections), voltage amplitude along the roof and floor lines, and thickness of the LAPW was investigated. Results Gaps occurred in 22 patients (40%) and in 26 (8%) of the 330 line segments assessed—11 in the center roof line segment, 6 in the center floor line segment, 4 in the right roof line segment, 4 in the right floor line segment, and 1 in the left floor line segment. Gaps were associated with relatively high bipolar voltage (3.38 ± 1.83 vs. 1.70 ± 1.12 mV, P < 0.0001) and a thick LA wall (2.52 ± 1.15 vs. 1.42 ± 0.44 mm, P < 0.0001). A modified AI ≤ 199 AU/mV, bipolar voltage ≥ 2.64 mV, wall thickness ≥ 2.04 mm, and roof ablation line ≥ 43.4 mm well predicted gaps (AUCs: 0.783, 0.787, 0.858, and 0.752, respectively). Conclusions High voltage zones, a thick LAPW, and a long roof ablation line appear to be determinants of gaps, and a modified AI ≥ 199 AU/mV along the ablation lines appears to predict acute durable LAPWI.
Recent research has demonstrated that synthetic methanotroph-photoautotroph cocultures offer a highly promising route to convert biogas into value-added products. However, there is a lack of techniques for fast and accurate characterization of cocultures, such as determining the individual biomass concentration of each organism in real-time. To address this unsolved challenge, we propose an experimental-computational protocol for fast, easy and accurate quantitative characterization of the methanotroph-photoautotroph cocultures. Besides determining the individual biomass concentration of each organism in the coculture, the protocol can also obtain the individual consumption and production rates of O2 and CO2 for the methanotroph and photoautotroph, respectively. The accuracy and effectiveness of the proposed protocol was demonstrated using two model coculture pairs, Methylomicrobium alcaliphilum 20ZR - Synechococcus sp. PCC7002 that prefers high pH high salt condition, and Methylococcus capsulatus - Chlorella sorokiniana that prefers low salt and neutral pH medium. The performance of the proposed protocol was compared with a flow cytometry based cell counting approach. The experimental results show that the proposed protocol is much easier to carry out and delivers faster and more accurate results in measuring individual biomass concentration than the cell counting approach without requiring any special equipment.
Plants can absorb water through their leaf surfaces, a phenomenon commonly referred to as foliar water uptake (FWU). Despite the physiological importance of FWU, the pathways and mechanisms underlying the process are not well known. Using a novel experimental approach, we parsed out the contribution of the stomata and the cuticle to FWU in two species with Mediterranean (Prunus dulcis) and temperate (Pyrus communis) origin. The hydraulic parameters of FWU were derived by analyzing mass and water potential changes of leaves placed in a fog chamber. Leaves were previously treated with abscisic acid to force stomata to remain closed, with fusicoccin to remain open, and with water (control). Leaves with open stomata rehydrated two times faster than leaves with closed stomata and attained three to four times higher maximum fluxes and hydraulic conductance. Based on FWU rates, we propose that rehydration through stomata occurs primarily via diffusion of water vapor rather than in liquid form even when leaf surfaces are covered with a water film. We discuss the potential mechanisms of FWU and the significance of both stomatal and cuticular pathways for plant productivity and survival.
We present a novel case of an urticaria multiforme-type drug reaction to the new cystic fibrosis medication Trikafta (elexacaftor + tezacaftor + ivacaftor). Equipped with this information, clinicians may be more prepared to counsel and treat patients if they experience similar symptoms after beginning Trikafta.
Background: From sepsis to COVID-19-induced multi-organ failure, inflammation and immune system activation play an important role. It has been argued that inflammation and over-activation of the immune system could be mediating a pro-oxidant microenvironment that can induce cytotoxic effects that potentiate tissue damage favoring organic deterioration. Aims: To investigate whether induction of oxidative stress by COVID-19 infection could inhibit mitochondrial function and cause cellular damage in leukocytes. Methods: We evaluated plasma levels of nitric oxide, hydrogen peroxide and protein carbonylation using spectrophotometry, in addition to evaluating mitochondrial function and cell death by fluorescence microscopy and leukocyte morphology, in COVID-19 patients at two time points: viremia and severe sepsis with multi-organ failure. Results: COVID-19 induces increased oxidative stress markers that activate cellular damage processes. In the viremia stage, was observe with an increase in peroxide (28.9%), nitric oxide (370.3%) and carbonylated proteins (61.8%), which was correlated with an increase in inhibition of mitochondrial function (66%), early apoptosis (212%) necrosis (405%), and leukocytes-reactivity. The severe sepsis stage with multi-organ failure also showed a further increase in levels of peroxide (46.4%) with a slight decrease in nitric oxide (216.2%) but with more carbonylated proteins (102%), regarding what was observe in viremia. This oxidative process was correlate with less inhibition of mitochondrial function (32.4%) and an increase in late apoptosis (463%), and morphology changes evidencing damage in the leukocytes. Conclusion: SARS-CoV-2 induced damage promotes levels of oxidative stress markers and mitochondrial dysfunction that potentiate morphological changes and cell death in leukocytes. These cellular effects could be integrating into the physiopathology of COVID- 19. These processes explain the rapid changes in the immune system, and that present an initial over-activation and early massive death due to SARS-CoV-2 infection, promoting endothelial-alveolar damage that would cause multi-organ failure.