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Recruiting and promoting women and racial/ethnic minorities could help enhance diversity and inclusion in the academic cardiothoracic (CT) surgery workforce. However, the demographics of trainees and faculty at US training programs have not yet been studied.Traditional, integrated (I-6), and fast-track (4+3) programs listed in the Accreditation Council for Graduate Medical Education (ACGME) public database were analyzed. Demographics of trainees and surgeons, including gender, race/ethnicity, subspecialty, and academic appointment (if applicable), were obtained from ACGME Data Resource Books, institutional websites, and public profiles. Chi-square and Cochran-Armitage trend tests were performed.In July 2020, 78 institutions had at least 1 CT surgery training program; 40 (51%) had only a traditional program, 20 (26%) traditional and I-6, 6 (8%) all 3 types of program, and 4 (5%) only I-6. The proportion of female trainees increased significantly from 2011 to 2019 (19% vs 24%, P.001), with female I-6 trainees outnumbering female traditional trainees since 2018. Significant increases by race/ethnicity were observed overall and by program type, notably for Asian and Hispanic individuals in I-6 programs and Black individuals in traditional programs. Finally, of the 1175 CT surgeons identified, 633 (54%) were adult cardiac surgeons, 360 (37%) assistant professors, 116 (10%) women, and 33 (3%) Black.The demographic landscape of CT surgery trainees and faculty across multiple training pathways reflects increasing representation by gender and race/ethnicity. However, we must continue to work toward equitable representation in the workforce to benefit the diverse patients we treat.

Background The first wave of COVID-19 in South Africa peaked in July, 2020, and a larger second wave peaked in January, 2021, in which the SARS-CoV-2 501Y.V2 (Beta) lineage predominated. We aimed to compare in-hospital mortality and other patient characteristics between the first and second waves. Methods In this prospective cohort study, we analysed data from the DATCOV national active surveillance system for COVID-19 admissions to hospital from March 5, 2020, to March 27, 2021. The system contained data from all hospitals in South Africa that have admitted a patient with COVID-19. We used incidence risk for admission to hospital and determined cutoff dates to define five wave periods: pre-wave 1, wave 1, post-wave 1, wave 2, and post-wave 2. We compared the characteristics of patients with COVID-19 who were admitted to hospital in wave 1 and wave 2, and risk factors for in-hospital mortality accounting for wave period using random-effect multivariable logistic regression. Findings Peak rates of COVID-19 cases, admissions, and in-hospital deaths in the second wave exceeded rates in the first wave: COVID-19 cases, 240·4 cases per 100 000 people vs 136·0 cases per 100 000 people; admissions, 27·9 admissions per 100 000 people vs 16·1 admissions per 100 000 people; deaths, 8·3 deaths per 100 000 people vs 3·6 deaths per 100 000 people. The weekly average growth rate in hospital admissions was 20% in wave 1 and 43% in wave 2 (ratio of growth rate in wave 2 compared with wave 1 was 1·19, 95% CI 1·18–1·20). Compared with the first wave, individuals admitted to hospital in the second wave were more likely to be age 40–64 years (adjusted odds ratio [aOR] 1·22, 95% CI 1·14–1·31), and older than 65 years (aOR 1·38, 1·25–1·52), compared with younger than 40 years; of Mixed race (aOR 1·21, 1·06–1·38) compared with White race; and admitted in the public sector (aOR 1·65, 1·41–1·92); and less likely to be Black (aOR 0·53, 0·47–0·60) and Indian (aOR 0·77, 0·66–0·91), compared with White; and have a comorbid condition (aOR 0·60, 0·55–0·67). For multivariable analysis, after adjusting for weekly COVID-19 hospital admissions, there was a 31% increased risk of in-hospital mortality in the second wave (aOR 1·31, 95% CI 1·28–1·35). In-hospital case-fatality risk increased from 17·7% in weeks of low admission (8000 admissions; aOR 1·24, 1·17–1·32). Interpretation In South Africa, the second wave was associated with higher incidence of COVID-19, more rapid increase in admissions to hospital, and increased in-hospital mortality. Although some of the increased mortality can be explained by admissions in the second wave being more likely in older individuals, in the public sector, and by the increased health system pressure, a residual increase in mortality of patients admitted to hospital could be related to the new Beta lineage. Funding DATCOV as a national surveillance system is funded by the National Institute for Communicable Diseases and the South African National Government.

Summary Background The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis is unclear, particularly in low-income and middle-income countries in Africa. South Africa has a national HIV prevalence of 19% among people aged 15–49 years and a tuberculosis prevalence of 0·7% in people of all ages. Using a nationally representative hospital surveillance system in South Africa, we aimed to investigate the factors associated with in-hospital mortality among patients with COVID-19. Methods In this cohort study, we used data submitted to DATCOV, a national active hospital surveillance system for COVID-19 hospital admissions, for patients admitted to hospital with laboratory-confirmed SARS-CoV-2 infection between March 5, 2020, and March 27, 2021. Age, sex, race or ethnicity, and comorbidities (hypertension, diabetes, chronic cardiac disease, chronic pulmonary disease and asthma, chronic renal disease, malignancy in the past 5 years, HIV, and past and current tuberculosis) were considered as risk factors for COVID-19-related in-hospital mortality. COVID-19 in-hospital mortality, the main outcome, was defined as a death related to COVID-19 that occurred during the hospital stay and excluded deaths that occurred because of other causes or after discharge from hospital; therefore, only patients with a known in-hospital outcome (died or discharged alive) were included. Chained equation multiple imputation was used to account for missing data and random-effects multivariable logistic regression models were used to assess the role of HIV status and underlying comorbidities on COVID-19 in-hospital mortality. Findings Among the 219 265 individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and known in-hospital outcome data, 51 037 (23·3%) died. Most commonly observed comorbidities among individuals with available data were hypertension in 61 098 (37·4%) of 163 350, diabetes in 43 885 (27·4%) of 159 932, and HIV in 13 793 (9·1%) of 151 779. Tuberculosis was reported in 5282 (3·6%) of 146 381 individuals. Increasing age was the strongest predictor of COVID-19 in-hospital mortality. Other factors associated were HIV infection (adjusted odds ratio 1·34, 95% CI 1·27–1·43), past tuberculosis (1·26, 1·15–1·38), current tuberculosis (1·42, 1·22–1·64), and both past and current tuberculosis (1·48, 1·32–1·67) compared with never tuberculosis, as well as other described risk factors for COVID-19, such as male sex; non-White race; underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy in the past 5 years; and treatment in the public health sector. After adjusting for other factors, people with HIV not on antiretroviral therapy (ART; adjusted odds ratio 1·45, 95% CI 1·22–1·72) were more likely to die in hospital than were people with HIV on ART. Among people with HIV, the prevalence of other comorbidities was 29·2% compared with 30·8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with increased COVID-19 in-hospital mortality risk in both people with HIV and HIV-uninfected individuals. Interpretation Individuals identified as being at high risk of COVID-19 in-hospital mortality (older individuals and those with chronic comorbidities and people with HIV, particularly those not on ART) would benefit from COVID-19 prevention programmes such as vaccine prioritisation as well as early referral and treatment. Funding South African National Government.

Background Pediatric nonmalignant lymphoproliferative disorders (PLPDs) are clinically and genetically heterogeneous. Long-standing immune dysregulation and lymphoproliferation in children may be life-threatening, and a paucity of data exists to guide evaluation and treatment of children with PLPD. Objective The primary objective of this study was to ascertain the spectrum of genomic immunologic defects in PLPD. Secondary objectives included characterization of clinical outcomes and associations between genetic diagnoses and those outcomes. Methods PLPD was defined by persistent lymphadenopathy, lymph organ involvement, or lymphocytic infiltration for more than 3 months, with or without chronic or significant Epstein-Barr virus (EBV) infection. Fifty-one subjects from 47 different families with PLPD were analyzed using whole exome sequencing. Results Whole exome sequencing identified likely genetic errors of immunity in 51% to 62% of families (53% to 65% of affected children). Presence of a genetic etiology was associated with younger age and hemophagocytic lymphohistiocytosis. Ten-year survival for the cohort was 72.4%, and patients with viable genetic diagnoses had a higher survival rate (82%) compared to children without a genetic explanation (48%, P = .03). Survival outcomes for individuals with EBV-associated disease and no genetic explanation were particularly worse than outcomes for subjects with EBV-associated disease and a genetic explanation (17% vs 90%; P = .002). Ascertainment of a molecular diagnosis provided targetable treatment options for up to 18 individuals and led to active management changes for 12 patients. Conclusions PLPD defines children at high risk for mortality, and whole exome sequencing informs clinical risks and therapeutic opportunities for this diagnosis.

In the abundant literature on social entrepreneurship, little attention is paid to the creation process of hybrid social ventures, beyond the assumptions that they are originated by market failures and are born to alleviate a social problem. Using a qualitative approach based on semi-structured interviews, the authors derive a process model explaining the creation of hybrid social ventures through effectuation and bricolage. They show that these decision-making tools may play a role in the creation process and that the new venture may have the defining characteristics of opportunity creation. They conclude that for a new venture to be created as a hybrid firm, a dual mission-goal with a social problem as the trigger and a financial goal to ensure sustainability are required.

BackgroundFibrotic interstitial lung disease is an incurable disease with poor prognosis. We aimed to understand factors affecting decisions regarding referrals to specialist palliative care services and to address barriers and facilitators to referrals from healthcare professionals’ perspectives.MethodsA survey study of healthcare professionals, including respiratory physicians, interstitial lung disease nurse specialists, respiratory nurse specialists and palliative care physicians, was conducted using a questionnaire, entailing 17 questions.ResultsThirty-six respondents, including 15 interstitial lung disease nurse specialists completed the questionnaire. Symptom control, psychological/spiritual support, general deterioration and end-of-life care were the most common reasons for referrals to specialist palliative care services. Most respondents felt confident in addressing palliative care needs and discussing palliative care with patients. A few participants emphasised that experienced respiratory nurse specialists are well placed to provide symptom management and to ensure continuity of patient care. Participants reported that access to palliative care could be improved by increasing collaborative work between respiratory and palliative care teams.ConclusionsMost respondents felt that enhancing access to specialist palliative care services would benefit patients. However, palliative care and respiratory care should not be considered as mutually exclusive and multidisciplinary approach is recommended.

OBJECTIVE Current standard of care, patient self-report and clinician estimation, overestimates true inhaled corticosteroids (ICS) adherence. We compare self-reported inhaled ICS and short-acting beta 2-agonists (SABA) use with objective data from electronic medication monitors (EMMs). METHODS Adults with uncontrolled asthma and prescribed ICS and SABA were enrolled. At visit one, participants' ICS and SABA inhalers were fitted with EMMs to track real-time medication usage over 14 days. Participants were asked to complete paper diaries to self-report medication usage over the same period. Participant self-report of ICS adherence and SABA use versus objective ICS adherence and SABA use was compared using Wilcoxon signed-rank tests. RESULTS One hundred participants (80% female, mean age 48.5 years, 60% completed college, 80% privately insured) had complete data. Participant self-report (median (IQR): 0.8 (0.0, 2.0)) was greater than objectively measured (median (IQR): 0.43 (0.1, 2.1)) SABA use, but the difference was not statistically significant (P = 0.64). Participant self-report (median (IQR): 97 (67, 100)) was significantly greater than objectively measured (median (IQR): 75 (54, 93)) ICS adherence (P = 0.002). CONCLUSIONS Significant discrepancies between self-report and objective ICS usage were observed. EMM can provide clinicians with accurate data on ICS medication taking behavior, thus reducing medication regimen complexity, side effects, and costs.

Aims: Over the decades, antibiotic resistance has become a cross-border public health problem. This calls for the profiling of microorganisms, particularly bacteria implicated in antibiotic resistance, in order to improve clinical practice and reduce the incidence of therapeutic failure in the treatment of infectious diseases. Study Design: We conducted a retrospective cross-sectional study. Place and Duration of the Study: The study was made at the bacteriology laboratory at the Yaounde University Teaching Hospital, Cameroon during the period between January 2016 and June 2021. Methodology: All bacterial strains from the following biological fluids were included: blood, stool, urine, suppurations, probe tip and catheter tip. The antibiotic susceptibility of isolates was collected from the registers of the said laboratory. The data were encoded in Censuses and Survey Procession Software (CSPro) version 7.3 and analysed using the Statistical Package for Social Science (SPSS) version 25. Graphs and figures were made using Excel 2016 spreadsheet software. Results: A total of 1071 bacteria were enrolled in 955 patients. The age group most represented was 0-5 years (34.6%). Most of the isolates came from a blood sample. Among the isolates, Coagulase-negative Staphylococci (18.5%), Escherichia coli (17.7%), Staphylococcus aureus (14%) and Klebsiella pneumoniae (11.2%) were the most common. A total of 1071 bacteria were enrolled in 955 patients. The age group most represented was 0-5 years (34.6%). Most of the isolates came from a blood sample. Among the isolates, Coagulase-negative Staphylococci (18.5%), Escherichia coli (17.7%), Staphylococcus aureus (14%) and Klebsiella pneumoniae (11.2%) were the most represented. Between 2016 and 2020, almost remarkable resistance was observed to the class of penicillins (78% to 83%), cephalosporins (44% to 61%) and quinolones (43% to 100%) for Escherichia coli. For Staphylococcus aureus, resistance changes range from 68% to 77% for the penicillin class. Klebsiella pneumoniae showed an evolution ranging from 11% to 19% for aminosides. Conclusion: Although not all isolates showed a change in the level of resistance to all antibiotics that are frequently used in our study population, Nevertheless, it is important for national public health actors to establish active surveillance of antibiotic and even antimicrobial resistance and to implement a guide to the proper use of antibiotics for health professionals, and the community.

Background: To estimate the prevalence and impact of chronic edema (CE) in two Irish health care settings as part of LIMPRINT, an international study developed and co-ordinated by the International...

This article deals with the dynamics of the innate and adaptive immune response to severe acute respiratory syndrome coronavirus 2 (SARSCoV2) infection. SARSCoV2 is the viral factor that causes the current global coronavirus pandemic disease 2019 (COVID2019). In terms of person-to-person transmission, it is contacted by inhaling the sneeze droplets of infected people. Severe acute respiratory syndrome Coronavirus 2 attacks lung cells first in its binding mechanism because there are many conservative receptor entries, such as angiotensin converting enzyme 2. The presence of this virus in host cells triggers a variety of protective immune responses, resulting in leads to pneumonia and acute respiratory distress syndrome. In the SarsCoV2 infection process, virus replication, immune response, and inflammatory response are dynamic events that can change rapidly; leading to different results, involving the dynamic expression of pro-inflammatory genes, peaking after the lowest point of respiratory function and leading to a cytokine storm, research on the interleukin 1 (IL1) pathway has shown that it is a factor related in severe respiratory diseases. The weakened expression of cytokines associated with mild infections will also delay T cell immunity to SARSCoV2, thereby prolonging the infection time; this indicates that such afebrile (afebrile) infections and undifferentiated COVID19 cases may promote the virus in the community Spread. This review aims to provide a general overview of the dynamics involved in the human immune response to this viral infection. It also includes a brief description of its structure, discovery history and pathogenesis to facilitate the understanding of this article.

Background: Pedestrians in Uganda account for 40% of road traffic fatalities and 25% of serious injuries annually. We explored the current pedestrian road traffic injury interventions in Uganda to understand why pedestrian injuries and deaths continue despite the presence of interventions. Methods: We conducted a qualitative study that involved a desk review of road safety policy, regulatory documents, and reports. We supplemented the document review with 14 key informant interviews and 4 focus group discussions with par- ticipants involved in road safety. Qualitative thematic content analysis was done using ATLAS. ti 7 software. Results: Five thematic topics emerged. Specifically, Uganda had a Non-Motorized Transport Policy whose implementation revealed several gaps. The needs of pedestrians and contextual evidence were ignored in road systems. The key program- matic challenges in pedestrian road safety management included inadequate funding, lack of political support, and lack of stakeholder collaboration. There was no evidence of plans for monitoring and evaluation of the various pedestrian road safety interventions. Conclusion: The research revealed low prioritization of pedestrian needs in the design, implementation, and evaluation of pedestrian road safety interventions. Addressing Uganda’s pedestrian needs requires concerted efforts to coordinate all road safety activities, political commitment, and budgetary support at all levels. Keywords: Pedestrian; safety intervention; qualitative; Uganda.

Background: Malaria is a life-threatening infectious disease of widespread burden. Malaria remains a leading communicable disease in the developing countries of the world. It occurs mostly in the tropical and subtropical regions and accounts for considerable morbidity and death. Malaria which is liable for a major amount of mortalities in endemic countries has been revealed to have both direct and indirect impacts on the haematologicalparameters.The study was done to compare the levels of haematological parameters of asymptomatic malaria patients based on age groups. Methods: The study is a cross-sectional study among asymptomatic malaria patients based on age groups. This study was conducted in Oda Road area of Akure, Ondo State. Two hundred (200) subjects were recruited for this study with each group comprising of 100 subjects for patients with asymptomatic malaria for the 2 age groups (16-30 years and 31-65 years). The data were presented in tables and as mean ± standard deviation and analyzed using student-test for parametric data and chi-square for non parametric data by statistical packages for social sciences (SPSS, Version 20.0) and level of significance set at as p≤ 0.05. Results: The results showed that subjects on age group 16-30 years were 100(50%) comprising of 50 males (25%) and 50 females (25). Also age group 31-65 years has 100 subjects (50%) comprising of 50 males (25%) and 50 females (25).The results showed significant difference in MCV (p=0.008), MCH (p=0.024) and no significant difference in PCV (p=0.675), WBC (p= 0.224), LYM (p=0.109), GRAN (p=0.061), MID (p=0.066), RBC (p=0.119), Hb (p=0.546), MCHC (p=0.262), PLT (p=0.783), when compared between age groups in years (16-30 and 31-65). Conclusion: The study showed increase in MCV and MCH of asymptomatic malaria patients within the age group of 31-65 years compared to asymptomatic malaria patients on 16-30 years age group. This shows that microcytic hypochromic anaemia may be experienced in asymptomatic malaria patients within the age group of 16-30 years more than in 31-65 years age group.

Background The current representation of female patients and racial and ethnic minorities in cardiovascular trials is unclear. We evaluated these groups’ inclusion in U.S. cardiovascular trials. Methods Using publicly available data from ClinicalTrials.gov , we evaluated cardiovascular trials pertaining to coronary artery bypass grafting (CABG), heart valve disease, aortic aneurysm, ventricular assist devices, and heart transplantation. This yielded 178 U.S. trials (159 completed, 19 active but not recruiting) started between September 1998 and May 2017, with 237,132 participants. To examine female patients’ and racial and ethnic minorities’ representation in these trials, we calculated participation-to-prevalence ratios (PPRs). Values of 0.8 to 1.2 reflect similar representation. Results All 178 trials reported sex distribution, whereas only 76 (42.7%) trials reported racial distribution and 52 (29.2%) trials reported ethnic (Hispanic vs non-Hispanic) distribution. Among all trials, participants were 28.3% female, 11.2% were Hispanic/Latino, 4.0% were African American, 10.4% were Asian, and 2.3% were other. The CABG PPR for female patients was 0.64, for Hispanic patients was 0.72, for African American patients was 0.28, and for Asian patients was 3.20. Between 2008-2012 and 2013-2017, the CABG PPR decreased for female patients (0.67→0.50) and African American patients (0.37→0.17) but increased for Hispanic patients (0.38→1.32) and Asian patients (3.51→4.57). Conclusions Participation in cardiovascular trials by female patients and minorities (except Asian patients) remains low. Given that inherent differences among the previously mentioned groups could affect outcomes, balance is clearly needed. The engagement of our surgical leadership, community, and industry to address these disparities is vitally important.

Introduction Pembrolizumab is a highly effective standard of care in PD-L1 overexpressing (≥ 50%) non–small-cell lung cancer. However, a substantial share of patients from everyday clinical practice is treated without clear evidence from clinical trials. Patients and Methods We performed a retrospective multicentric study including all consecutive patients from 6 certified lung cancer centers in Berlin, Germany, having received pembrolizumab as first-line palliative therapy from January 1 until December 31, 2017. Aims were to validate published clinical trials with a special focus on efficacy and outcome in patients with reduced performance status (PS), brain metastases, and steroids. Results A total of 153 patients were included (median age 69 years, 58% men, 69% adenocarcinoma). Rates for PS ≥ 2, brain metastases, and steroids were 24.8%, 20.9%, and 24.2%, respectively. Median objective response rate, progression-free and overall survival were 48.5%, 8.2 and 22.0 months for all patients and 52.4%, 8.8 and 29.2 months in patients fulfilling the inclusion criteria for the KEYNOTE-024 trial. Patients with a comorbidity-defined PS ≥ 2, symptomatic brain metastases requiring upfront radiotherapy, or baseline steroids had significantly reduced survival. In contrast, durable responses occurred with a tumor-related PS ≥ 2 or asymptomatic brain metastases. Grade 3/4 and 5 immune-related adverse events affected 13.7% and 2.0% of patients. Conclusion Real-world and clinical trial efficacy with upfront pembrolizumab correspond well. Pembrolizumab may sufficiently control asymptomatic brain metastases and may improve a cancer-related reduced PS. However, the frail share of patients with a comorbidity-defined PS ≥ 2, symptomatic brain metastases, or baseline steroids derives no relevant benefit.

Purpose: To describe youth time-use compositions, focusing on time spent in shorter and longer bouts of sedentary behavior and physical activity (PA), and to examine associations of these time-use compositions with cardiometabolic biomarkers. Methods: Accelerometer and cardiometabolic biomarker data from 2 Australian studies involving youths 7–13 years old were pooled (complete cases with accelerometry and adiposity marker data, n = 782). A 9-component time-use composition was formed using compositional data analysis: time in shorter and longer bouts of sedentary behavior; time in shorter and longer bouts of light-, moderate-, or vigorous-intensity PA; and “other time” (i.e., non-wear/sleep). Shorter and longer bouts of sedentary time were defined as

Objective Stillbirth is a potentially preventable complication of pregnancy. Identifying women at high risk of stillbirth can guide decisions on the need for closer surveillance and timing of delivery in order to prevent fetal death. Prognostic models have been developed to predict the risk of stillbirth, but none has yet been validated externally. In this study, we externally validated published prediction models for stillbirth using individual participant data (IPD) meta-analysis to assess their predictive performance. Methods MEDLINE, EMBASE, DH-DATA and AMED databases were searched from inception to December 2020 to identify studies reporting stillbirth prediction models. Studies that developed or updated prediction models for stillbirth for use at any time during pregnancy were included. IPD from cohorts within the International Prediction of Pregnancy Complications (IPPIC) Network were used to validate externally the identified prediction models whose individual variables were available in the IPD. The risk of bias of the models and cohorts was assessed using the Prediction study Risk Of Bias ASsessment Tool (PROBAST). The discriminative performance of the models was evaluated using the C-statistic, and calibration was assessed using calibration plots, calibration slope and calibration-in-the-large. Performance measures were estimated separately in each cohort, as well as summarized across cohorts using random-effects meta-analysis. Clinical utility was assessed using net benefit. Results Seventeen studies reporting the development of 40 prognostic models for stillbirth were identified. None of the models had been previously validated externally, and the full model equation was reported for only one-fifth (20%, 8/40) of the models. External validation was possible for three of these models, using IPD from 19 cohorts (491 201 pregnant women) within the IPPIC Network database. Based on evaluation of the model development studies, all three models had an overall high risk of bias, according to PROBAST. In the IPD meta-analysis, the models had summary C-statistics ranging from 0.53 to 0.65 and summary calibration slopes ranging from 0.40 to 0.88, with risk predictions that were generally too extreme compared with the observed risks. The models had little to no clinical utility, as assessed by net benefit. However, there remained uncertainty in the performance of some models due to small available sample sizes. Conclusions The three validated stillbirth prediction models showed generally poor and uncertain predictive performance in new data, with limited evidence to support their clinical application. The findings suggest methodological shortcomings in their development, including overfitting. Further research is needed to further validate these and other models, identify stronger prognostic factors and develop more robust prediction models. (c) 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Recipients' immune systems are triggered by blood and blood component therapy. Transfusion-related immunomodulation (TRIM) is a complicated immunological response to transfusion that results in immunosuppression. The mechanisms of TRIM include the presence of residual white blood cells and apoptotic cells, the infusion of immunosuppressive cytokines that are present in donor components or that occur during blood processing, the transfer of metabolically active growth factor-loaded particles and extracellular vesicles, and the presence of hemoglobin or extracellular vesicles binds to hemoglobin. TRIM variables include donor-specific factors and processing variables. TRIM can explain, at least partially, the controversial negative clinical results observed in patients with covid19. Many potential treatment methods have been used in clinical practice, including supportive interventions, immunomodulators, antiviral therapy, and infusion of convalescent plasma. Here, we summarize current potential treatments for COVID-19 infection-related diseases and discuss the clinical value of blood transfusion-related technologies for COVID-19 treatment in blood transfusion-related immune regulation.

Severe Acute Respiratory Syndrome Coronavirus 2 is a new type of coronavirus that can cause Coronavirus Disease 2019 (Covid-19) and is associated with an increased risk of thrombosis-related pulmonary embolism. Globally, doctors have revised their management strategies for suspected and confirmed PD in patients with Coronavirus disease (Covid-19) in 2019. Choosing the right drug and the right dose requires consideration of potential comorbidities, which can be explained by the direct and indirect pathological consequences of Covid-19, complement activation, cytokine release, endothelial dysfunction, and the interaction between different types of blood cells. Discuss the pathophysiological events, therapeutic mortality strategies, risk factors and clinical management of patients with Covid-19 pulmonary embolism.

Background The epidemiology of COVID-19 and its association with cardiometabolic disorders is poorly understood. This is a narrative review that investigates the effects of COVID-19 infection on insulin resistance in patients with diabetes. Methods An online search of all published literature was done via PubMed and Google Scholar using the MeSH terms “COVID-19,” “SARS-CoV-2,” “coronavirus,” “insulin resistance,” and “diabetes.” Only articles that were directly applicable to insulin resistance in COVID-19 and diabetes was reviewed. Results Current data shows an increased risk of mortality in patients with diabetes and COVID-19 compared to those without diabetes. COVID-19 triggers insulin resistance in patients, causing chronic metabolic disorders that were non-existent prior to infection. Conclusion Patients with diabetes are more susceptible to COVID-19 infection than those without diabetes. ACE2 expression decreases with infection, exaggerating Ang II activity with subsequent insulin resistance development, an exaggerated immune response and severe SARS-COV-2 infection.

Background: Immunization is the process by which a person’s immune system is fortified and made resistant to an infectious disease/ agent. Immunization saves millions of lives. It is the most important means of preventing childhood morbidity and mortality. This study investigated the knowledge and practice of childhood immunization among men with infants in Enugu Metropolis. Methods: A cross sectional descriptive study using multi stage sampling involving 81 men with infants in Ogbete Main Market Enugu. Data obtained were analyzed using SPSS version 22 adopting descriptive statistics and chi square to test difference and relationship between variables. P-values

Co-production across scientific and Indigenous knowledge systems has become a cornerstone of research to enhance knowledge, practice, ethics, and foster sustainability transformations. However, the profound differences in world views and the complex and contested histories of nation-state colonisation on Indigenous territories, highlight both opportunities and risks for Indigenous people when engaging with knowledge co-production. This paper investigates the conditions under which knowledge co-production can lead to improved Indigenous adaptive environmental planning and management among remote land-attached Indigenous peoples through a case study with ten Traditional Owner groups in the Martuwarra (Fitzroy River) Catchment in Western Australia’s Kimberley region. The research team built a 3D map of the river and used it, together with an interactive table-top projector, to bring together both scientific and Indigenous spatial knowledge. Participatory influence mapping, aligned with Traditional Owner priorities to achieve cultural governance and management planning goals set out in the Fitzroy River Declaration, investigated power relations. An analytical framework, examining underlying mechanisms of social learning, knowledge promotion and enhancing influence, based on different theories of change, was applied to unpack the immediate outcomes from these activities. The analysis identified that knowledge co-production activities improved the accessibility of the knowledge, the experiences of the knowledge users, strengthened collective identity and partnerships, and strengthened Indigenous-led institutions. The focus on cultural governance and management planning goals in the Fitzroy River Declaration enabled the activities to directly affect key drivers of Indigenous adaptive environmental planning and management—the Indigenous-led institutions. The nation-state arrangements also gave some support to local learning and decision-making through a key Indigenous institution, Martuwarra Fitzroy River Council. Knowledge co-production with remote land-attached Indigenous peoples can improve adaptive environmental planning and management where it fosters learning together, is grounded in the Indigenous-led institutions and addresses their priorities.

The values of factor VIII (FVIII) and factor IX (FIX) were evaluated among some primary school children in Owerri zone Imo State. The aim was to assess deficiency state or reduction in activity among these children. A total of two hundred and ten (210) venous blood samples were collected from primary school pupils whose parents consented to, and whose answers to the distributed questionnaires suggested symptoms of haemophilia. The samples were collected from pupils between the ages of five and thirteen years, and from different primary schools to represent different areas of Owerri (Works Layout Area, Nekede Area, Trans Egbu Area, and Akwukuma Area). Samples were preserved using trisodium citrate anticoagulant and transported to the haematology unit of the Federal Medical Centre Owerri within 3 hours for analysis which was done using Rayto semi auto coagulation analyzer RT 2204C with its normal ranges for factor VIII and IX activities as (50% - 200% and 70% - 200%) respectively. Out of the 210 samples collected, 16(7.6%) have

Objective To discuss and summarise the background and recent advances in the approach to bronchoscopic ablative therapies for lung cancer, focusing on focal parenchymal lesions. Background This series focusses on the challenges highlighted by increasing recognition of the prognostically more favourable oligometastatic disease rather than the more frequent, but prognostically poor, high tumour burden metastatic disease. While surgery, stereotactic body radiation therapy (SBRT), and trans-thoracic percutaneous ablative techniques such as microwave (MWA) and radiofrequency ablation (RFA) are well recognised options for selected cases of pulmonary oligometastasis, bronchoscopic approaches to pulmonary tumour ablation are becoming realistic alternatives. An underlying tenet driving research and implementation in this domain is that percutaneous ablative techniques are obliged to traverse the pleura leading to a high rate of pneumothorax, and risks also goes up for peri-vascular lesions. Historically low yield bronchoscopic targeting of isolated peripheral tumors have significantly improved by incorporating multi-modality high resolution imaging and processing, including navigation planning and real-time image guidances (ultrasound, electromagnetic navigation, cone-beam CT). Combining advanced image guidance with ablative technology adaptations for bronchoscopic delivery opens up the options for high dose local ablative therapies that may reduce transthoracic complications and provide palliative to curative options for limited stage primary and oligometastatic diseases. Methods We conduct a narrative review of the literature summarizing the history of bronchoscopic tumor ablation approaches, technical details including biologic rational for their uses, and current evidence for each modality, as well as investigations into future applications. Because of the relative paucity of prospective studies, we have been very inclusive in our inclusion of experiences from the published clinical databases. Conclusions Whilst surgical resection and SBRT remain the current mainstay of curative therapies for peripheral cancers, in the foreseeable future, developments and further research will see bronchoscopic ablative therapies become viable lung sparing alternatives in those deemed suitable. The future is bright.

Background Critical thinking (CT) is an essential competency for medical students. This study’s aim was to evaluate Chinese medical students’ disposition for CT and to explore the impact of current trends in medical education on students’ CT development. Methods We used multistage stratified cluster sampling to recruit a total of 1241 medical students among five different years of training and from three medical institutions in China. The Critical Thinking Disposition Inventory-Chinese Version (CTDI-CV) and self-reported information were used to collect cross-sectional data. Based on the data from the CTDI-CV, 112 medical students in clinical course training from a single institution continued one-year follow-up. Their one-year CTDI-CV score changes were collected regarding various medical education variables. Results The mean CTDI-CV score of the 1241 medical students was 287.04 with 729 (58.7%) students receiving a score of 280 or higher. There were statistically significant differences in schools attended(F = 3.84, P P P P P P P P Conclusions Chinese medical students generally exhibited positive CT dispositions. The cross-sectional survey and one-year longitudinal study indicated that students’ CT disposition diminished as they progressed through traditional medical training. Our study contributes to understanding the status of Chinese medical education of and influential factors on medical students’ CT disposition.

The optimal prognostic value of testosterone following androgen deprivation therapy (ADT) is controversial. We studied the effect of serum testosterone levels on clinical outcome in localized prostate cancer (PCa) treated with ADT and high-dose radiotherapy (HRT).The DART01/05 trial randomized 355 men with intermediate and high-risk PCa to 4 months of ADT plus HRT (STADT, N = 178) or the same treatment followed by 24 months of ADT (LTADT, N = 177). This study included patients treated with LTADT who had at least 3 determinations of testosterone during ADT (N = 154). Patients were stratified into 3 subgroups by testosterone level: minimum20 ng/dL; median 20-49 ng/dL; and maximum ≥50 ng/dL. Kaplan-Meyer and Cox regression analysis were used for overall survival (OS) and FineGray regression model for metastasis free survival (MFS), biochemical disease-free survival (bDFS) and time to TT recovery.There were no statistically significant differences in 10-year bDFS, MFS, or OS between the20 ng/mL and 20-49 ng/dL subgroups. Multivariate analysis showed that a median testosterone ≥50 ng/dL was significantly associated with a decrease in bDFS (HR: 6.58, 95%CI 1.28-33.76, p = 0.03). Time to testosterone recovery after ADT did not correlate with bDFS, MFS, or OS and was not significantly associated with any of the testosterone subgroups.Our results do not support the concept that additional serum testosterone suppression below 20 ng/dL is associated with better outcomes than 20-49 ng/dL. Time to testosterone recovery after ADT and HRT did not impact clinical failure.

Objective The aim of this study was to study the prospective association between N-terminal pro-brain natriuretic peptide (NT-proBNP) and changes in weight and obesity risk in a community-based population. Methods Data from 9,681 participants from the Atherosclerosis Risk in Communities Study were analyzed at two time points 6 years apart. Among people without obesity at baseline, multivariable logistic regression models were used to examine the association between baseline levels of NT-proBNP and incident obesity. A multivariable linear regression model was used to examine the association between changes in NT-proBNP (visit 2 serum and visit 4 plasma samples) and changes in weight. Results The prevalence of obesity increased from 28% to 35% in the 6-year follow-up period. Compared with individuals in the highest NT-proBNP quartile, those in the lowest were more likely to have obesity at baseline (odds ratio 1.25; 95% CI: 1.08-1.45) and, among people who did not have obesity at baseline, were more likely to develop obesity at follow-up (odds ratio 1.35; 95% CI: 1.07-1.69). Changes in NT-proBNP were inversely associated with weight change. Conclusions In this prospective study, lower levels of NT-proBNP were associated with higher risk of obesity, and changes in NT-proBNP were inversely associated with changes in weight. This suggests that natriuretic peptides or their pathways may be potential targets in the treatment of obesity.

Vaccine-induced thrombosis and thrombocytopenia (VITT) may follow immunisation with the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2. Autoantibodies to platelet factor 4 (PF4) may mediate VITT through antibody-dependent platelet activation, though the underlying etiology is uncertain. Anti-PF4 antibodies are also seen in heparin-induced thrombocytopenia, though most cases of VITT do not have prior heparin exposure. More than 20 million people in the United Kingdom (UK) have received the ChAdOx1 nCoV-19 vaccine.

Purpose of the Review.To highlight the role of oxidative stress in hypertensive disorders of pregnancy (HDP) and metabolic disorders of pregnancy (gestational diabetes mellitus). Recent Findings. In both preeclampsia (PE) and gestational hypertension (GH), oxidative stress leads to inadequate placental perfusion thus resulting in a hypoxic placenta, which generally leads to the activation of maternal systemic inflammatory response. In PE, this causes inflammation in the kidneys and leads to proteinuria. A proteinuria marker known as urinary 8-oxoGuo excretion is expressed in preeclampsia. In GDM, oxidative stress plays a role in the pathogenesis of the disease, as a result of over secretion of insulin during pregnancy. This uncontrolled secretion of insulin results in the production of lipid peroxidation factors that also mask the secretion of antioxidants. Therefore, ROS becomes abundant at cellular level and prevents the cells from transporting glucose to body tissues. Summary. There is a need for more research investigating the role of oxidative stress, especially in obstetrics-related conditions. More studies are required in order to understand the difference between the pathogenesis and pathophysiology of PE versus GH since investigations on the differences in genetic aspects of each condition are lacking. Furthermore, research to improve diagnostic procedures for GDM in pregnancy is needed.

Few can argue the marginalized status of physical education in today’s schools, making the advocacy skills of physical educators and preservice teachers (PSTs) increasingly important. This article ...

Background Medical school curricula are constantly evolving and change has potential positive and negative effects. At East Tennessee State University Quillen College of Medicine, a broader understanding of the effects of a curriculum change (reduction in clerkship length for one transitional year) was explored. Methods A broad, system-wide evaluation was used to evaluate impacts on all stakeholders. Curriculum management data, including qualitative and quantitative data and short-term and follow-up perspectives of stakeholders, were used for evaluation. Results Students evaluated the change positively. Academic performance in the transitional year was similar to the prior year. Differences in students’ clerkship evaluations were not statistically significant. Clerkship directors were concerned that students’ clinical experience suffered and noted that implementing changes was time consuming but recognized the benefits for students. Administrators dedicated a significant amount of time to planning the transitional year; however, the additional weeks at the beginning of fourth year made the scheduling process easier. Conclusion This article demonstrates an overall positive result with this tool for curriculum change but also indicates the impacts differed across stakeholders. Knowledge gained from this experience can help other schools successfully anticipate challenges and prepare for a variety of outcomes in implementing necessary curriculum change.

Ovarian vein thrombosis (OVT) is a rare condition occurring in 1/600 to 1/2000 pregnancies mainly in the postpartum setting[1,2]. However,it is a potentially life-threatening condition andcan occur in other circumstances, such as inflammatory diseases of the pelvis, gynecological tumors, after pelvic surgery, during sepsis, hypercoagulable state, or even sometimes without an underlying cause [2]. It is usually manifested by nonspecific abdominal pain, with or without fever, and must be recognized because of its potentially serious complications (pulmonary embolism) [2,5]. Currently, the diagnosis is done earlier thanks to imaging techniques making the prognosis better[3,4].

Although early coagulopathy increases mortality in adults with traumatic brain injury (TBI), less is known about pediatric TBI.To describe the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet levels of children with moderate to severe TBI to identify predictors of early coagulopathy and study the association with clinical outcomes.Using the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) TBI retrospective cohort, we identified patients16 yr old with a Glasgow Coma Scale (GCS) ≤13. We compared PT, APTT, platelets, and outcomes between children with isolated TBI and multiple trauma with TBI. We performed logistic regressions to identify predictors of early coagulopathy and study the association with mortality and poor functional outcomes.Among 370 children analyzed, 53/370 (14.3%) died and 127/370 (34.3%) had poor functional outcomes. PT was commonly deranged in both isolated TBI (53/173, 30.6%) and multiple trauma (101/197, 51.3%). Predictors for early coagulopathy were young age (adjusted odds ratio [aOR] 0.94, 95% CI 0.88-0.99, P = .023), GCS 8 (aOR 1.96, 95% CI 1.26-3.06, P = .003), and presence of multiple trauma (aOR 2.21, 95% confidence interval [CI] 1.37-3.60, P = .001). After adjusting for age, gender, GCS, multiple traumas, and presence of intracranial bleed, children with early coagulopathy were more likely to die (aOR 7.56, 95% CI 3.04-23.06, P .001) and have poor functional outcomes (aOR 2.16, 95% CI 1.26-3.76, P = .006).Early coagulopathy is common and independently associated with death and poor functional outcomes among children with TBI.

In this article, we present algebraic attacks against the Extension Field Cancellation ( $$\texttt {EFC}$$ ) scheme, a multivariate public-key encryption scheme which was published at PQCRYPTO’2016. First, we present a successful Grobner basis message-recovery attack on the first and second proposed parameters of the scheme. For the first challenge parameter, a Grobner-based hybrid attack has a $$2^{65}$$ bit complexity which beats the claimed 80 bit security level. We further show that the algebraic system arising from an $$\texttt {EFC}$$ public-key is much easier to solve than a random system of the same size. Briefly, this is due to the apparition of many lower degree equations during the Grobner basis computation. We present a polynomial-time method to recover such lower-degree relations and also show their usefulness in improving the Grobner basis attack complexity on $$\texttt {EFC}$$ . Thus, we show that there is an algebraic structural weakness in the system of equations coming from $$\texttt {EFC}$$ and hence makes the scheme not suitable for encryption.

Background: Blended learning (BL) is defined as the combination of both traditional face-to-face learning and synchronous or asynchronous e-learning approaches. The aim of this scoping review was to explore the literature to obtain a broad understanding of the use of BLin nursing and midwifery education in general, in Sub-Saharan Africa (SSA), and in particular Rwanda.Methods: The literature published between 2010 and 2019 were reviewed from six electronic databases using keywords including blended learning, nursing education, midwifery education, higher education, SSA, and Rwanda. Arksey and O'Malley's framework was used in this review.Results: The initial search identified 1,283 records. Eleven articles were selected for this review after the application of predetermined inclusion criteria. Almost all reviewed articles indicated that the integration of BLmethods improved the quality of nursing and midwifery education in general, and in SSAcountries including Rwanda.Conclusions: Initial research in this area highlights that moving from traditional classroom-delivered programs to the BLapproach is feasible and can promote the quality of nursing and midwifery standards of education. This scoping review highlights a paucity of research on BL in nursing and midwifery education, particularly in SSAcountries. Keywords: Blended learning, nursing and midwifery education, SSA, Rwanda

Early routine amniotomy, also known as artificial rupture of the amniotic membrane, is one of the procedures used to induce and accelerate labour before cervical dilation reaches four centimeters. Because of its benefits and risks, there are at least two schools of thought about this controversial issue. The purpose of this paper is to argue against early routine amniotomy as an unnecessary procedure that can have drastic and unintended outcomes associated with the labour process, the fetus, and the mother. This commentary paper articulates that early routine amniotomy is a questionable procedure because its risks outweigh its benefits. Therefore, routine early amniotomy should be discouraged among obstetrical procedures. Keywords: Amniotomy, artificial rupture of membrane, routine, labour, process

North Dakota is a significant producer of wind energy in the United States. In the first decades of this century, the state went from almost zero production to over 25% of its electricity sourced f...

Poor adherence to inhaled corticosteroids (ICSs) and overuse of short-acting betaTo assess whether patient self-monitoring via electronic medication monitoring and smartphone application plus remote clinician feedback influences ICS and SABA use.Adults with uncontrolled asthma and prescribed ICS and SABA were enrolled in this 14-week study. Inhalers were fitted with electronic medication monitoring to track real-time usage. After a 14-day baseline, participants were randomly assigned to the treatment group where they received reminders and feedback on ICS and SABA use via a smartphone application and clinician phone calls, or control group without feedback. Linear mixed models compared the baseline percentage of SABA-free days and ICS adherence to the last 14 study days.Participants (n = 100) had a mean age of 48.5 years, 80% were female, 68% white, and 80% privately insured. The percentage of SABA-free days increased significantly in the treatment group (19%; 95% CI, 12 to 26; P.01) and nonsignificantly in the control group (6%, 95% CI, -3 to 16; P = .18), representing a 13% (95% CI, 1-26; P = .04) difference. ICS adherence changed minimally in the treatment group (-2%; 95% CI, -7 to 3; P = .40), but decreased significantly (-17%; 95% CI, -26 to -8; P.01) in the control group, representing a 15% (95% CI, 4 to 25; P.01) difference.Patient self-monitoring via a digital platform plus remote clinician feedback maintained high baseline ICS adherence and decreased SABA use.

Minimum caseload standards for professionals examining breast screening mammograms vary from 480 (US) to 5000 (Europe). We measured the relationship between the number of women’s mammograms examined per year and reader performance. We extracted routine records from the English NHS Breast Screening Programme for readers examining between 1000 and 45,000 mammograms between April 2014 and March 2017. We measured the relationship between the volume of cases read and screening performance (cancer detection rate, recall rate, positive predictive value of recall (PPV) and discrepant cancers) using linear logistic regression. We also examined the effect of reader occupational group on performance. In total, 759 eligible mammography readers (445 consultant radiologists, 235 radiography advanced practitioners, 79 consultant radiographers) examined 6.1 million women’s mammograms during the study period. PPV increased from 12.9 to 14.4 to 17.0% for readers examining 2000, 5000 and 10000 cases per year respectively. This was driven by decreases in recall rates from 5.8 to 5.3 to 4.5 with increasing volume read, and no change in cancer detection rate (from 7.6 to 7.6 to 7.7). There was no difference in cancer detection rate with reader occupational group. Consultant radiographers had higher recall rate and lower PPV compared to radiologists (OR 1.105, p = 0.012; OR 0.874, p = 0.002, unadjusted). Positive predictive value of screening increases with the total volume of cases examined per reader, through decreases in numbers of cases recalled with no concurrent change in numbers of cancers detected. • In the English Breast Screening Programme, readers who examined a larger number of cases per year had a higher positive predictive value, because they recalled fewer women for further tests but detected the same number of cancers. • Reader type did not affect cancer detection rate, but consultant radiographers had a higher recall rate and lower positive predictive value than consultant radiologists, although this was not adjusted for length of experience.

This article investigates how safety is experienced, navigated and cultivated by women on Instagram. Using qualitative interview data, we explore women’s understanding and practices of keeping themselves and others safe when sharing information-rich images about their exercising bodies and fitness activities. Drawing on literatures from feminist leisure, sport and media studies, this article advances discussions about exercising women’s negotiations of risk and safety by considering digitally-mediated fitness experiences and the uses of “visibility and vulnerability” for creating cultures and communities of physical and emotional safety online and offline. Findings identify that knowledge of Instagram’s platform affordances and audiences, along with personal ethics, contribute to exercising women’s decision-making when posting self-produced physical activity content. We extend current thinking about the operations of visibility and vulnerability for women online by identifying the significance of spatial and relational elements to generating women’s feelings of safety on Instagram.

Objective To determine the serum concentration of soluble E-selectin (sE-selectin) in HIV associated preeclampsia. Study Design The study population (n = 72) consisted of normotensive pregnant (n = 36) and preeclamptic (n = 36) women stratified by HIV status (negative vs. positive). Serum concentrations of sE-selectin were quantified using the MilliPlex multiplex immunoassay method. Statistical analyses were conducted using GraphPad Prism software. Results When stratified by pregnancy type and HIV status, serum sE-selectin levels were elevated in the preeclamptic HIV-negative group compared to the normotensive HIV-negative group (p = 0.0070**). Gestational age, systolic blood pressure, diastolic blood pressure and baby weight were statistically different across the study groups (p Conclusion This study demonstrates an elevation of sE-selectin in preeclamptic HIV-negative compared to the normotensive HIV-negative group. However, when stratified by HIV status, there was no significant difference observed in preeclamptic HIV-positive and normotensive HIV-positive groups. The findings of this small-scale study suggest that sE-selectin may be used as a biomarker or an early identifier of preeclampsia. Studies with large numbers should be considered to confirm our findings.

Background Medical student exposure to laparoscopy is limited to observation despite the prevalence of minimally invasive techniques in practice. The high cost of laparoscopic simulation equipment, commonly called “box trainers”, limits undergraduate exposure to skill training. Methods Students at a Midwestern medical school were recruited to participate in an experimental laparoscopic skill training program. One cohort (n = 17) used a DIY box trainer design freely available on MedEdPORTAL. A second cohort (n = 17) used a commercially available equivalent. Pre- and post-training attempts for four tasks were scored and the difference was calculated. The average differences for each cohort were then contrasted statistically. Results Significant performance improvements (pre- and post-training) were demonstrated regardless of group allocation. The difference in performance between the cohorts was not significant for any task (p > 0.05). Conclusions This low-cost training program using DIY box trainers is as effective as commercially available equivalent box trainers for introducing laparoscopic skills to medical students.

This paper sought to investigate the valuation of rice farmers’ preferences and willingness to pay for climate-smart agricultural technologies in Southeast Nigeria. Two objectives and one hypothesis guided the conduct of the study. The examination of rice farmers’ willingness-To-Pay (WTP) for improved CSA technology services revealed greater proportion of the respondents to be strongly not willing to pay for over 77.8% of the CSA technologies while barely 7.4% were mildly willing to pay. Rice farmers were strongly not willing to pay for the following CSA technologies: rainwater harvesting, cover crops method, directed seeded rice, systems of rice intensification, use of solar pumps, etc, while the CSA technologies they were mildly willing to pay for are drip irrigation and drainage management. The major reason for respondent’s unwillingness to pay were: poverty (2.0%) and CSA technologies as the responsibility of the Government to farmers within the state (5.0%). For the estimated willingness to pay value, the mean monthly minimum WTP in South-East was estimated at ₦5176.7123 while the mean monthly maximum WTP for rice farmers was estimated as ₦10,926.95. Water-smart technologies (76.8%) was mostly preferred CSA technology. Based on the ordered probit regression analysis of factors influencing willingness to pay for CSA technology, primary occupation (X5), access to credit (X8) and distance to market (X12) were found to be significant. The study recommended that rice farmers should adapt to climate change, natural resource pressure and contribute to mitigating climate change.

ObjectivePrimary dysmenorrhea and secondary dysmenorrhea due to endometriosis share overlapping symptoms and likely demonstrate aspects of central sensitization. The present study aimed to identify distinct phenotypes of women who have dysmenorrhea with and without endometriosis to shed light on the unique mechanisms contributing to the pathogenesis of each condition.MethodsAn online survey was used to investigate the relationship between ratings of menstrual pain severity, menstrual symptoms (abdominal cramps, abdominal discomfort, low back pain, headache, body aches, bloating, nausea, diarrhea, increased bowel movements), widespread pain, and functional pain disability in a community sample of 1,354 women (aged 18–50) with menstrual pain in Australia.ResultsCompared with women without endometriosis, those with endometriosis had statistically significant higher menstrual pain severity (PConclusionsThe findings suggest that phenotypes specific to endometriosis can be identified.

BACKGROUND AND PURPOSE Respiratory dysfunction in Parkinson's disease (PD) is often an underdiagnosed and untreated impairment associated with the disease. Clinically, a reactive approach to respiratory morbidity is taken, rather than preventative approaches that address underlying impairment/s. This systematic review identifies the current evidence to support nonpharmacological interventions to improve respiratory impairments in individuals with PD. METHODS The relevant literature was searched using a customised and systematic strategy. Randomised and nonrandomised control trials of nonpharmacological interventions targeting respiratory outcome measures in PD were included. Outcomes of interest were respiratory morbidity and mortality, respiratory muscle strength, spirometry measures, lung volumes, peak cough flow, and perception of dyspnoea. RESULTS Nonpharmacological interventions included: functional training, generalised strength training, respiratory muscle strength training, aerobic exercise, qigong, yoga, breath stacking, incentive spirometry and singing. Methodological quality of included studies varied. Meta-analyses of nonpharmacological interventions demonstrated significant effects for inspiratory muscle strength (mean difference [MD] 19.68; confidence interval [CI] 8.49, 30.87; z = 3.45; p = 0.0006; I2 = 2%), expiratory muscle strength (MD 18.97; CI 7.79, 30.14; z = 3.33; p = 0.0009; I2 = 23%) and peak expiratory flow (MD 72.21; CI 31.19, 113.24; z = 3.45; p = 0.0006; I2 = 0%). Best-evidence synthesis identified level 1 evidence supporting nonpharmacological interventions for improving peak cough flow and perceived dyspnoea. No studies were identified reporting outcomes of respiratory rate, inspiration:expiration ratio or respiratory morbidity or mortality in PD. CONCLUSIONS Nonpharmacological interventions improved respiratory muscle strength and peak expiratory flow in PD. Additional trials targeting respiratory dysfunction and longitudinal studies examining the relationship between respiratory dysfunction and morbidity and mortality rates in PD are required.

The Rimas by Juan Ramon pick up the thread from Becquer’s book with the same title departing from the dicotomy of the soul and the body in obvious preference for the first and rejection of the second. The mystery, what man ignores, but envisages —especially the poet—, slips through these works taking shadowy forms that belong to the spiritual and the dead. With the aim of unravelling knots knitted in them by the mystery, this article examines the two worlds that appear in both books: on the one hand, the world of the soul and death, and on the other, the world of the body and life. Further, it analyses its relation through the poet, who is appealed by the first through a «call» and whose attraction to it leads him to the «ecstasy». Finally, it treats the possible overcoming of both worlds by means of the dream.

OBJECTIVE To assess the association of severe hypoglycemia measured at baseline with cardiovascular disease (CVD) among community-dwelling older individuals with diabetes, a group particularly susceptible to hypoglycemia. RESEARCH DESIGN AND METHODS We included older adults with diabetes from the Atherosclerosis Risk in Communities (ARIC) study who attended visit 5 (2011–2013, baseline). Severe hypoglycemia at baseline was defined with use of first position ICD-9 codes from hospitalizations, emergency department visits, and ambulance calls. We examined cross-sectional associations of severe hypoglycemia with echocardiographic indices of cardiac structure-function. We prospectively evaluated the risks of incident or recurrent CVD (coronary heart disease, stroke, or heart failure) and all-cause mortality, from baseline to 31 December 2018, using negative binomial and Cox regression models. RESULTS Among 2,193 participants (mean [SD] age 76 [5] years, 57% female, 32% Blacks), 79 had a history of severe hypoglycemia at baseline. Severe hypoglycemia was associated with a lower left ventricular (LV) ejection fraction (adjusted β-coefficient −3.66% [95% CI −5.54, −1.78]), higher LV end diastolic volume (14.80 mL [95% CI 8.77, 20.84]), higher E-to-A ratio (0.11 [95% CI 0.03, 0.18]), and higher septal E/e′ (2.48 [95% CI 1.13, 3.82]). In adjusted models, severe hypoglycemia was associated with incident or recurrent CVD (incidence rate ratio 2.19 (95% CI 1.24, 3.88]) and all-cause mortality (hazard ratio 1.71 [95% CI 1.10, 2.67]) among those without prevalent CVD. CONCLUSIONS Our findings suggest that a history of severe hypoglycemia is associated with alterations in cardiac function and is an important marker of future cardiovascular risk in older adults.

Bovine liver supplements are sought after by consumers due to their nutrient-dense profile and high protein content. However, there is a lack of information regarding bovine liver supplement labeling practices. The objective of this study was to assess labeling practices and compliance with U.S. regulatory standards among commercially sold bovine liver supplements. The product labels for 49 bovine liver supplements were examined for required information, including a statement of identity; net quantity of contents; "Supplement Facts" label; ingredient statement; and name and place of business of manufacturer, packer, or distributor with domestic address or telephone number. Any claims made on the supplement labels were also reviewed for compliance. Overall, 59% of the products had at least one instance of noncompliance with U.S. labeling regulations. The main categories of noncompliance were missing a domestic mailing address or phone number (39% of products), noncompliant nutrient content claim (31% of products), and missing/noncompliant disclaimer for a nutritional support statement (6% of products). The lack of a mailing address or phone number is problematic because it prevents consumers from being able to report serious adverse events to the manufacturer. The majority (85%) of the nutrient content observed on product labels was found to be noncompliant. Noncompliant nutrient content claims are a major concern for consumers who rely on these claims to assess the nutritional benefits of a product. Overall, the results of this study revealed a lack of labeling compliance in bovine liver supplements, indicating a need for increased awareness and monitoring.

Pancreatic ductal adenocarcinoma (PDAC) is a lethal cancer that has proven refractory to immunotherapy. Previously, treatment with the DNA hypomethylating drug decitabine (5-aza-dC; DAC) extended survival in the KPC-Brca1 mouse model of PDAC. Here we investigated the effects of DAC in the original KPC model and tested combination therapy with DAC followed by immune checkpoint inhibitors (ICI). Four protocols were tested: PBS vehicle, DAC, ICI (anti-PD-1 or anti-VISTA), and DAC followed by ICI. For each single-agent and combination treatment, tumor growth was measured by serial ultrasound, tumor-infiltrating lymphoid and myeloid cells were characterized, and overall survival was assessed. Single-agent DAC led to increased CD4+ and CD8+ tumor-infiltrating lymphocytes (TIL), PD1 expression, and tumor necrosis while slowing tumor growth and modestly increasing mouse survival without systemic toxicity. RNA-sequencing of DAC-treated tumors revealed increased expression of Chi3l3 (Ym1), reflecting an increase in a subset of tumor-infiltrating M2-polarized macrophages. While ICI alone had modest effects, DAC followed by either of ICI therapies additively inhibited tumor growth and prolonged mouse survival. The best results were obtained using DAC followed by anti-PD-1, which extended mean survival from 26 to 54 days (P < 0.0001). In summary, low-dose DAC inhibits tumor growth and increases both TILs and a subset of tumor-infiltrating M2-polarized macrophages in the KPC model of PDAC, and DAC followed by anti-PD-1 substantially prolongs survival. Because M2-polarized macrophages are predicted to antagonize antitumor effects, targeting these cells may be important to enhance the efficacy of combination therapy with DAC plus ICI. Significance: In a pancreatic cancer model, a DNA hypomethylating drug increases tumor-infiltrating effector T cells, increases a subset of M2 macrophages, and significantly prolongs survival in combination with immune checkpoint inhibitors. See related commentary by Nephew, p. 4610