Disseminated tuberculosis (TB) in the pediatric population is relatively rare in the United States with variable nonspecific presentations. In this letter we discuss the case of 2-year-old child with a lung mass and central neurogenic hyperventilation with primary respiratory alkalosis as a rare pediatric presentation of disseminated tuberculosis with TB meningitis and pulmonary tuberculosis.
Oropharyngocutaneous fistula is an unfavorable complication that may occur after head and neck reconstruction. The authors used a “stick-shaped platysma flap” technique to close these narrow and deep intractable fistulas. It is a highly efficient and straightforward method to close intractable fistulas with minimal morbidity.
The similarity between intestinal tuberculosis and Crohn's disease could lead us to erroneously prescribe corticosteroid therapy. Therefore, it is essential to differentiate the two pathologies because of the therapeutic implications of Crohn's disease, which can lead to an explosion of tuberculosis symptoms.
Rosai-Dorfman disease (RDD) is a rare non-malignant histiocytosis disorder, commonly manifesting with massive painless cervical lymphadenopathy. Renal involvement develops in only four percent of patients with RDD. Generally, RDD is self-limiting and has a good prognosis; however, in patients with renal involvement, mortality rate can be as high as 40%.
High power, short duration ablation: at least for the right pulmonary vein carina, maybe not so fastGustavo S. Guandalini, MD a and Francis E. Marchlinski, MD aa Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PACorresponding author: Dr. Francis E. Marchlinski, Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, Pennsylvania 19104. E-mail: Francis.Marchlinski@pennmedicine.upenn.edu.The authors have no conflicts to disclose.Word count: 1,170.This research was supported by the Richard T and Angela Clark Innovation Fund in Cardiovascular Medicine.
The interface fracture toughness of SnSb11Cu6/20steel was measured by calculating the critical energy release rate and stress phase angle of the interface crack. A three-point bending test was used to introduce cracks into the bonding interface, and the cohesion model of the bonding interface was established through experimental data. Through finite element analysis of load-deflection curves with and without interface crack propagation, the crack initiation point is found. Then the energy calculation model of crack propagation is established, and the critical energy release rate is obtained using the virtual crack growth criterion. The calculation results of the stress phase angle show that the crack propagation is greatly affected by the normal stress after the babbitt alloy layer fractures. If the strength of the substrate material is weaker, the crack will continue to expand in the tangent perpendicular to the crack tip.
Letter to the Editor, BJOG Title: ESMiE confidential enquiry: Broader view besides focus on errors by birth-attendants.Re: Rowe R, Draper ES, Kenyon S, Bevan C, Dickens J, Forrester M, Scanlan R, Tuffnell D, Kurinczuk JJ. Intrapartum-related perinatal deaths in births planned in midwifery-led settings in Great Britain: findings and recommendations from the ESMiE confidential enquiry. BJOG 2020;127:1665–1675.Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKShort running title: ESMiE enquiry: broader viewEmail: email@example.com Tel: 07906620662Word count: 500Corresponding Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKStatement of interest: The author has no conflict of interest or funding to declare.
Re: Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis. Cardiotocography training is a complex intervention and requires complex evaluations: a letter to editor.Lightly K, Weeks AD, Scott HCorrespondence to Dr Kate Lightly – firstname.lastname@example.orgClinical Research Fellow, Sanyu Research Unit, University of Liverpool and Liverpool Women’s NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS.Professor Andrew D WeeksProfessor of International Maternal Health, Sanyu Research Unit, University of Liverpool and Liverpool Women’s NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS.Professor Hazel ScottDean of School of Medicine, School of Medicine, University of Liverpool, Cedar House, Liverpool, L69 3GE.Running title - CTG training requires complex evaluationsWe congratulate Kelly et al on their review on the effects of training in cardiotocography (CTG).i It is a critical step towards understanding how to correctly implement CTG training. However, we query the relevance of some of the included studies and whether using Kirkpatrick’s model adequately captures all of the relevant complexities. We believe that further work is needed to understand how such training will impact on practice.Some of the CTG research projects reviewed were poorly representative of the needs of clinicians tasked with improving fetal monitoring in their hospitals. For clinicians, their population of interest is practising clinicians who work on labour wards (sometimes infrequently); studies involving undergraduates alone may not be generalisable. Training in intermittent auscultation is also relevant. Considerable detail on the training intervention is required, including not only the format of teaching, but the duration, curriculum and proportion of relevant staff trained. Detail is also required of supporting interventions and context, as training alone is unlikely to impact change. Many would consider ‘no training’ unethical and therefore not a relevant comparator . In the UK, CTG training and competency is now required for all maternity staff.ii The ultimate aim of CTG (and therefore CTG training) is to detect the hypoxic fetus, so that timely intervention can be undertaken to avoid perinatal harm, without unnecessary intervention. Therefore, the outcomes of interest have to include intrapartum stillbirths, hypoxic ischaemic encephalopathy and mode of delivery.Kirkpatrick’s model was used in this review to evaluate training at four levels (reaction, knowledge, behaviour change and organisational performance). However, it does not attempt to understand why interventions work, or the context, or the causal pathways between training and change in practice.iii Whether participants like training (‘reaction’) is of little relevance, and knowledge acquisition (‘knowledge’) is a proxy which does not equate with improved on the job performance and outcomes. Maternal and perinatal outcomes (‘performance’) were only collected in a small number of studies.CTG training is a complex intervention which aims to create change, not simply knowledge acquisition. We therefore believe that a formal Realist Evaluation is needed. This emerging methodology has been used successfully to understand healthcare change processes and supplement traditional Cochrane style reviews. It aims to understand why complex interventions work, how, for whom, in what context and to what extentiv. Collaboration with the relevant authors to gain detailed intervention descriptions, with a realist approach, may add some much needed explanatory power to this critical subject.Training alone is unlikely to impact change. Even the best educational package will fail without the necessary support - it needs an educational and working culture which supports learning and change, aligned and clear policies, and motivated, well supported drivers and leaders.How doctors learn and what supports them to put new knowledge into practice are key research questions. High quality, methodologically appropriate, properly funded studies are needed to address these questions. Not answering them means many research findings are redundant, as they simply will not be implemented.ReferencesI Kelly S, Redmond P, King S, Oliver‐Williams C, Lamé G, Liberati E et al. Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis. BJOG. 2021; 00: 1–12. https://doi.org/10.1111/1471-0528.16619ii NHS England. Saving Babies’ Lives Version Two. A care bundle for reducing perinatal mortality. London: NHS England 2019. [cited 2021 Feb 3]. Available from: www.england.nhs.ukiii Moreau KA. Has the new Kirkpatrick generation built a better hammer for our evaluation toolbox? Med Teach. 2017 Sep; 39(9): 999-1001. https://doi.org/10.1080/0142159X.2017.1337874iv Wong G, Westhorp G, Greenhalgh J, Manzano A, Jagosh J, Greenhalgh T. Quality and reporting standards, resources, training materials and information for realist evaluation: the RAMESES II project. Health Services and Delivery Research. 2017 5 (28): 1–108. https://doi.org/10.3310/hsdr05280.Acknowledgements – NilDisclosure of interests - NilContribution to authorshipKL wrote the first draft of this letter and then it was revised by AW and HS.Details of ethics approval – N/AFunding – Dr Lightly’s PhD entitled “Improving intrapartum fetal monitoring in India: A mixed methods approach” is funded by MRC/DfID/Wellcome Trust Joint Global Health Trials Fund. MR/R006/1801
Atmospheric and climate change will expose tropical forests to conditions they have not experienced in millions of years. To better understand the consequences of this change we studied photosynthetic acclimation of the neotropical tree species Tabebuia rosea to combined 4°C warming and twice-ambient (800 ppm) CO2. We measured temperature responses of the maximum rates of ribulose 1,5-bisphosphate carboxylation (VCMax), photosynthetic electron transport (JMax), net photosynthesis (PNet), and stomatal conductance (gs), and fitted the data using a probabilistic Bayesian approach. To evaluate short-term acclimation plants were then switched between treatment and control conditions and re-measured after 1–2 weeks. Consistent with acclimation, the optimum temperatures (TOpt) for VCMax, JMax and PNet were 1–5°C higher in treatment than in control plants, while photosynthetic capacity (VCMax, JMax, and PNet at TOpt) was 8–25% lower. Likewise, moving control plants to treatment conditions moderately increased temperature optima and decreased photosynthetic capacity. Stomatal density and sensitivity to leaf-to-air vapor pressure deficit were not affected by growth conditions, and treatment plants did not exhibit stronger stomatal limitations. Collectively, these results illustrate the strong photosynthetic plasticity of this tropical tree species as even fully-developed leaves of saplings transferred to extreme conditions partially acclimated.
Objectives We set out to create Consensus Guidelines, based on current evidence and relative risks of adverse effects and the costs of different treatments, that reflect the views of the British Rhinological Society (BRS) Council on where the use of biologics should be positioned within treatment pathways for CRSwNP, specifically in the setting of the National Health Service (NHS). Methods An expert panel of 16 members was assembled. A review of the literature and evidence synthesis was undertaken and circulated to the panel We used the RAND/UCLA methodology with a multi-step process to make recommendations on the use of biologics. Setting and participants N/A Results Recommendations were made, based on underlying disease severity, prior treatments and co-morbidities. A group of patients for whom biologics were considered an appropriate treatment option for CRSwNP was defined. Conclusions Although biologics are not currently available for the treatment of CRSwNP, the BRS Council have defined a group of patients who have higher rates of ‘failure’ with current treatment pathways, higher resource use and are more likely to suffer with uncontrolled symptoms. We would urge NICE to consider approval of biologics for such indications without applying further restrictions on use.
Lipoblastoma is a rare, benign, fatty tissue tumour that occurs in infancy and early childhood. Intrathoracic and mediastinal involvement of this tumour is rare, and an intracardiac location is even rarer. In this study, we report the case of a 15-month-old girl who presented with a tumour in the pulmonary valve. A complete resection of the tumour was undertaken, with a histopathology report confirming the diagnosis of lipoblastoma.
In this article, an approximate analytical solution of an integro-differential system of equations is constructed, which describes the process of intense boiling of a superheated liquid. The kinetic and balance equations for the bubble-size distribution function and liquid temperature are solved analytically using the Laplace transform and saddle-point methods with allowance for an arbitrary dependence of the bubble growth rate on temperature. The rate of bubble appearance therewith is considered in accordance with the Dering-Volmer and Frenkel-Zeldovich-Kagan nucleation theories. It is shown that the initial distribution function decreases with increasing the dimensionless size of bubbles and shifts to their greater values with time.
Proposals for SARS-CoV-2 virus vaccination priorities in the UK and in many other countries are heavily influenced by epidemiological models, which use outcome measures such as deaths or hospitalisation. Limiting the values under consideration to those attributable to the direct effects of infection has the advantage of simplifying the models and the process of decision-making. However, the consequences of the pandemic extend beyond outcomes directly attributable to SARS-CoV-2 infection. The alternative to vaccination (in addition the threat of illness and death) is restrictions on educational and work opportunities, access to services, recreational activities, affiliations and relationships with others, freedom of movement (including escaping abusive relationships), and other determinants of human experience. Capability theory gives emphasis to the freedoms that individuals have to express themselves (in doings and beings). Restrictions on freedoms restrict our capabilities. Capability theory has been used to provide a framework for the evaluation and comparison of international development approaches and in the evaluation of public health policy. There is a clustering of disadvantages associated with this pandemic that adds to pre-existing inequalities. Much of the disadvantage engendered in the SARS-CoV-2 pandemic is left out when public health policy is based on a limited range of metrics. Acknowledging the impact of policy across the range of human freedoms at both a national and international level has the potential to improve policy, facilitate the mitigation of direct and indirect adverse consequences, and improve public confidence in vaccine deployment strategies.
Abstract: Objectives: Our work assessed the prevalence of co-infections in patients with SARS-CoV-2. Methods: All patients hospitalized in a Parisian hospital during the first wave of COVID-19 were tested by mPCR if they presented ILI symptoms. Results: A total of 806 patients (21%) were positive for SARS-CoV-2, 755 (20%) were positive for other respiratory viruses. Among the SARS-CoV-2 positive patients, 49 (6%) had viral co-infections. They presented similar age, symptoms, except for fever (p=0.013) and headaches (p=0.048), than single SARS-CoV-2 infections. Conclusions: SARS-CoV-2 infected patients presenting viral co-infections had similar clinical characteristics and prognosis than patients solely infected with SARS-CoV-2.
We congratulate Kar et al. on their elegant study evaluating ex-vivo temperature profiles and the resulting thermal injury formation on the epiesophageal surface during radiofrequency (RF) ablation. In addition to being the first study to detail temperature profiles inclusive of the epiesophageal surface during RF ablation, we believe that the results add further concern to the use of temperature sensing technology in the quest to reduce esophageal injury. Three recent clinical trials have evaluated the efficacy of luminal esophageal temperature (LET) monitoring and found either no benefits, or signals of harm. On the other hand, two pilot RCTs suggest benefits of active cooling, and a large RCT, the IMPACT study, further confirms this benefit by finding an 83% reduction in esophageal lesion formation using an active cooling device. With no degradation in ablation efficacy, as well as a reduction/elimination of the need for fluoroscopy and reports of shortened procedure time with active cooling technology, the data of Kar et al., combined with growing clinical data, suggest that continued use of LET monitoring may be unjustified.
Background: Despite major advances in basic and advanced life supports, patients who survived from out of hospital cardiac arrest (OHCA) has still poor prognosis. Several inflammatory parameters have been used to determine early and long-term prognosis in patients with OHCA. C-reactive protein-to-albumin ratio (CAR) is also a novel marker of systemic inflammation. To our knowledge, there is no study evaluating the clinical importance of CAR in OHCA patients. Aims: To evaluate the effect of CAR on mortality in patients with OHCA. Methods: A total of 102 patients with OHCA were included in this study. The study population were divided into two groups as survivor (n = 43) and non-survivor (n = 59) during follow-up. Complete blood cell counts, biochemical and blood gas analysis were recorded for all patients. Neutrophil to lymphocyte ratio (NLR) was calculated as the ratio of neutrophil to lymphocyte. CAR was calculated as the ratio of CRP to the albumin. Results: NLR (P=0.012), CAR (P<0.001) and serum lactate level (P =0.002) were significantly higher whereas lymphocyte (P=0.008) and serum albumin (P<0.001) were significantly lower in non-survivor group compared to survivor group. Multivariate logistic regression analysis showed that NLR (odds ratio [OR]: 1.044, 95% confidence interval [CI]: 1.044-1.437, P=0.013), CAR (OR: 1.971, 95% CI: 1.327-2.930, P=0.001), and lactate level (OR: 1.268, 95% CI: 1.095-1.469, P=0.002) were independent predictors of mortality. Conclusions: We have demonstrated for the first time that CAR was an independent predictor of in-hospital mortality in OHCA patients.