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Lyme carditis (LC), a manifestation of early disseminated Lyme disease, most commonly presents with cardiac conduction abnormalities. It is a transient condition with good prognosis but in extremely rare cases may be life-threatening. We describe a 42-year-old man who presented with progressively worsening generalized weakness, presyncope and dyspnea on exertion for 2 weeks after sustaining a tick bite. He subsequently developed a ‘bull’s eye rash’ on his flank 2 days before his presentation. He was found to have symptomatic third-degree AV conduction blockade with a ventricular escape rhythm resulting in a brief cardiac arrest. Intravenous (IV) ceftriaxone was commenced empirically and a temporary transvenous pacemaker was placed. In a few days he showed dramatic, rapid improvement; the pacemaker was removed, and the patient was discharged on oral doxycycline to complete a 24-day course. This case is unique due to its occurrence in an urban hospital where such cases are uncommon. Cardiac arrest, although brief in this case, is a rare occurrence. Lyme carditis was a surprise diagnosis in our hospital due to the patient’s geographical dislocation during the COVID-19 pandemic.

Objective: Logopenic variant primary progressive aphasia (lvPPA) is commonly associated with Alzheimer's disease (AD) pathology. But lvPPA patients display different cognitive and anatomical profile from the common clinical AD patients, whose verbal episodic memory is primarily affected. Reports of verbal episodic memory difficulty in lvPPA are inconsistent, and we hypothesized that their lexical retrieval impairment contributes to verbal episodic memory performance and is associated with left middle temporal gyrus atrophy.Methods: We evaluated patients with lvPPA (n = 12) displaying prominent word-finding and repetition difficulties, and a demographically-matched cohort of clinical Alzheimer's disease (AD, n = 26), and healthy seniors (n = 16). We assessed lexical retrieval with confrontation naming and verbal episodic memory with delayed free recall. Whole-brain regressions related naming and delayed free recall to gray matter atrophy. Medial temporal lobe (MTL) subfields were examined using high in-plane resolution imaging.Results: lvPPA patients had naming and delayed free recall impairments, but intact recognition memory. In lvPPA, delayed free recall was related to naming; both were associated with left middle temporal gyrus atrophy but not MTL atrophy. Despite cerebrospinal fluid evidence consistent with AD pathology, examination of MTL subfields revealed no atrophy in lvPPA. While AD patients displayed impaired delayed free recall, this deficit did not correlate with naming. Regression analyses related delayed free recall deficits in clinical AD patients to MTL subfield atrophy, and naming to left middle temporal gyrus atrophy.Conclusion: Unlike amnestic AD patients, MTL subfields were not affected in lvPPA patients. Verbal episodic memory deficit observed in lvPPA was unlikely to be due to a hippocampal-mediated mechanism but appeared to be due to poor lexical retrieval. Relative sparing of MTL volume and intact recognition memory are consistent with previous reports of hippocampal-sparing variant cases of AD pathology, where neurofibrillary tangles are disproportionately distributed in cortical areas with relative sparing of the hippocampus. This suggests that AD neuropathology in lvPPA may originate in neuronal networks outside of the MTL, which deviates from the typical Braak staging pattern of spreading pathology in clinical AD.

ABSTRACT Assuring that cell therapy products are safe before releasing them for use in patients is critical. Currently, compendial sterility testing for bacteria and fungi can take 7–14 days. The goal of this work was to develop a rapid untargeted approach for the sensitive detection of microbial contaminants at low abundance from low volume samples during the manufacturing process of cell therapies. We developed a long-read sequencing methodology using Oxford Nanopore Technologies MinION platform with 16S and 18S amplicon sequencing to detect USP organisms and other microbial species. Reads are classified metagenomically to predict the microbial species. We used an extreme gradient boosting machine learning algorithm (XGBoost) to first assess if a sample is contaminated, and second, determine whether the predicted contaminant is correctly classified or misclassified. The model was used to make a final decision on the sterility status of the input sample. An optimized experimental and bioinformatics pipeline starting from spiked species through to sequenced reads allowed for the detection of microbial samples at 10 colony-forming units (CFU)/mL using metagenomic classification. Machine learning can be coupled with long-read sequencing to detect and identify sample sterility status and microbial species present in T-cell cultures, including the USP organisms to 10 CFU/mL. IMPORTANCE This research presents a novel method for rapidly and accurately detecting microbial contaminants in cell therapy products, which is essential for ensuring patient safety. Traditional testing methods are time-consuming, taking 7–14 days, while our approach can significantly reduce this time. By combining advanced long-read nanopore sequencing techniques and machine learning, we can effectively identify the presence and types of microbial contaminants at low abundance levels. This breakthrough has the potential to improve the safety and efficiency of cell therapy manufacturing, leading to better patient outcomes and a more streamlined production process.

Mutations in the LaminA gene are the second most common inherited cause of Dilated Cardiomyopathy, a major form of heart failure. Here the authors show that disruption of the nuclear protein SUN1 in cardiomyocytes, by AAV mediated transduction of a SUN1 inhibitor, significantly suppress cardiomyopathy progression, providing a potential therapeutic route to treat this disease.

Introduction Myanmar, a conflict-affected geographically and ethnically diverse lower middle-income country, was in the donor transition phase for health prior to the political unrest of the last year. This study analyses the distribution of benefit and utilisation of basic childhood vaccinations from the highly donor-dependent Expanded Program on Immunization for populations of different socioeconomic status (SES).Methods We conducted a benefit incidence analysis with decomposition analysis to assess the equity of benefit. We used basic childhood immunisations—BCG, measles, diphtheria, pertussis and tetanus (DPT)/pentavalent, oral polio vaccine (OPV) and full vaccination—as measurements for healthcare use. Childhood immunisation data were collected from Myanmar Demographic and Health Survey. Cost of vaccines was obtained from UNICEF document and ‘Immunization Delivery Cost Catalogue’ and adjusted with regional cost variations. We reported Concentration Index (CI) and Achievement Index (AI) by SES, including wealth quintiles, maternal education and across geographic areas.Results Nationally, better-off households disproportionately used more services from the programme (CI–Wealth Index (CI-WI) for BCG, measles, DPT/pentavalent, OPV and full immunisation: 0.032, 0.051, 0.120, 0.091 and 0.137, respectively). Benefits had a pro-poor distribution for BCG but a less pro-rich distribution than utilisation for all other vaccines (CI-WI: −0.004, 0.019, 0.092, 0.045 and 0.106, respectively). Urban regions had a more pro-rich distribution of benefit than that in rural areas, where BCG and measles had a pro-poor distribution. Subnational analysis found significant heterogeneity: benefit was less equitably distributed, and AI was lower in conflict-affected states than in government-controlled areas. The major contributors to vaccine inequality were SES, antenatal care visits and paternal education.Conclusion Donors, national government and regional government should better plan to maintain vaccine coverage while improving equity of vaccine services, especially for children of lower SES, mothers with less antenatal care visits and lower paternal education living in conflicted-affected remote regions.

Forest resources are a salient and critical issue requiring ongoing attention by the Thai government. Community forest management (CFM) is a practice used to, among other things, resolve land use issues and regulate the extraction and use of non-timber forest product (NTFPs). Managing as a community forest can not only enhance the livelihoods of the local people but also improve their socio-economic condition. This research was conducted at the Ban Mae Chiang Rai Lum Community Forest located in Pa Mae Phrik National Forest Reserve in Thailand’s northern province of Lampang. We collected species biodiversity data of the forest’s total area of 3,925 ha using a systematic sampling method, and twenty-five 40 × 40 m (0.16 ha) survey plots were established in the community forest. Interviews of 159 household heads and/or other household representatives were conducted using a designed questionnaire. The questionnaire focused on information regarding the households’ NTFP utilization habits and engagement in CFM processes. A forest survey was conducted which found that there were 197 plant species, 144 genera, and 62 families in the community forest. Of these, 160 plant species were classified as having medicinal uses, 89 were used as food, 37 as extractives, 32 for firewood, and 12 for fibers. This study also revealed that unmonitored over-exploitation of NTFPs may negatively impact forest biodiversity. As surveyed, 68.55% of households depended on NTFPs. The value of the harvested NTFPs was 6.35% of the total community income. A positive correlation between NTFP income and CFM suggests that utilization of NTFPs combined with CFM can create income opportunities and promote participation in CFM. In addition, income earned from NTFPs and participation in CFM were directly related to the socio-economics of identifiable groups in this community. Laborers, merchants, and low-income families utilized NTFPs to a lesser degree. Single people, household heads, those with a bachelor’s degree, and low income families were less likely to participate in CFM while land owners were more likely to do so. This study implies that the harvesting of NTFPs should not go unchecked, especially of species that are threatened or likely to be threatened if over-harvested. Efforts to enhance lower income household utilization, to more equitably distribute the benefits, and to incentivize community involvement should be prioritized as doing so is crucial to maintaining a healthy supply of NTFPs and safeguarding the community forest biodiversity.

Background Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been used to manage hypoxaemic respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. Limited data are available for patients treated with noninvasive respiratory support outside of the intensive care setting. Methods In this single-centre observational study we observed the characteristics, physiological observations, laboratory tests and outcomes of all consecutive patients with COVID-19 pneumonia between April 2020 and March 2021 treated with noninvasive respiratory support outside of the intensive care setting. Results We report the outcomes of 140 patients (mean±sd age: 71.2±11.1, 65% male (n=91)) treated with CPAP/HFNO outside of the intensive care setting. Overall mortality was 59% and was higher in those deemed unsuitable for mechanical ventilation (72%). The mean age of survivors was significantly lower than those who died (66.1 versus 74.4 years, p

Agroforestry is an intensive land management system that integrates trees into land already used for crop and animal farming. This provides a diverse range of ecosystem services by bridging the gaps between agriculture, forestry, and animal husbandry. It is an important approach to improve the environmental, economic, and social benefits of complex social−ecological systems in the Asia-Pacific region. This paper aims to examine the research trends in agroforestry and the current state of knowledge, as well as the research gaps in the ecosystem services of agroforestry in this region. A systematic mapping methodology was applied, where analysis units were academic articles related to agroforestry practices in the Asia-Pacific region. The articles published between 1970 and 2018 were collected through the international specialized academic database, SCOPUS. They were coded according to the types of agroforestry practices and ecosystem services. The research result indicates silvorable systems, especially plantation crop combinations, tree management, habitats for species, biological controls, and maintenance of genetic diversity and gene-pools, are the most prominent in the agroforestry research from the Asia-Pacific region. Approximately 60% of all research articles include case studies from India, China, Indonesia, and Australia. Research on agroforestry has changed following the international discourse on climate change and biodiversity. Therefore, this systematic map improves our understanding of the nature, volume, and characteristics of the research on ecosystem services with regard to agroforestry in the Asia-Pacific region. It provides scholars with a springboard for further meta-analysis or research on agroforestry and ecosystem services.

Deforestation and forest degradation are occurring continuously and posing serious threats to forests and people worldwide. In Myanmar, poor regulation and unsustainable extraction of non-timber forest products (NTFPs) is affecting millions of hectares of natural forests; overexploitation of forest resources is one of the main drivers of forest degradation. Although evidence shows that the extraction of NTFPs results in forest degradation, there have been few studies on what drives rural people to depend on NTFPs and how to address these drivers in terms of policies and measures. Policies and measures are nationally enacted policies and actions that countries undertake to address the causes of deforestation and forest degradation. This study identifies which factors determine the dependence on NTFPs in forest-dependent communities. From these factors, we derived policy implications for the main causes of overexploitation of NTFPs to provide suggestions for developing policies and measures in the design of national Reducing Emissions from Deforestation and Forest Degradation (REDD+) strategies. Focusing on the Taungoo District as a case of dependence on NTFPs by local communities, we conducted a qualitative and quantitative data collection procedure based on interviewing households in the local communities. NTFPs contributed the most to total household income and the main types of NTFPs exploited were charcoal making and bamboo selling. Households with lower education level, less agricultural land, less income from off-farm activities, lived under the poverty line or used only charcoal were more dependent on NTFPs in the study areas. Poverty and fuelwood usage were factors affecting NTFPs dependence for landowners while rice insufficiency, off-farm income and fuelwood usage most affected the NTFPs dependence for landless people. The results suggested that national strategies for REDD+ should take into account local features such as income opportunities and land tenure in order to make local people cooperate with the government to avoid deforestation and forest degradation.

Introduction: Concurrent cardiocerebral infarction (CCI), a rare condition defined as simultaneous occlusions in the cerebrovascular and coronary vessels, has high mortality but very limited literature on optimum treatment methods. A better understanding of the natural history and effect of treatment would improve patient outcomes., Methods: Using our prospective stroke database from 2014 to 2018, ten consecutive patients with CCI were identified (incidence = 0.29%). We recorded patient demographics, cardiovascular risk factors, cardiac and cerebral occlusions, circumstances of admission and management of each patient. Patient notes and imaging findings were reviewed to determine the underlying cause of CCI., Results: Median National Institute of Health Stroke Scale score was 15 (range 4-27). Mean patient age was 59 years and 90% were men. Two patients were treated with intravenous tissue plasminogen activator (IV tPA) only and three underwent endovascular treatment in both the cerebral and coronary vessels sequentially. One patient underwent percutaneous coronary intervention (PCI) only and two underwent PCI after IV tPA therapy. Two patients were conservatively treated due to poor premorbid status. At the three-month follow-up, five patients had excellent functional outcomes (modified Rankin Scale 0-1) while three died., Conclusion: CCI is a rare but devastating clinical scenario, with high incidence of morbidity and mortality. Treatment strategy can impact patient outcome, and further research is warranted on the ideal acute and post-reperfusion treatments for CCI. In this series, IV tPA at stroke doses appeared to be the preferred initial step for its treatment, with subsequent coronary or cerebral endovascular therapy, if necessary., Competing Interests: None

Aims: The aim of the study was to report the clinical experience, 30-day mortality and acute outcomes of patients undergoing transcatheter aortic valve implantation (TAVI) in the Asia Pacific region., Methods and Results: The Asia Pacific TAVI registry is an international, multicentre, prospective, observational registry managed under the auspices of the Asian Pacific Society of Interventional Cardiology (APSIC). Patients undergoing TAVI in seven centres from Hong Kong, Japan, Philippines, Singapore and Taiwan, treated with TAVI devices for severe symptomatic aortic stenosis, were assessed. This first review presents the acute results and 30-day mortality. A multivariable analysis was also performed to identify independent predictors of early all-cause mortality. The enrolment was from 2009 to 2017 and a total of 1,125 patients were recruited. The 30-day mortality rate was 2.5%. Baseline logistic EuroSCORE more than 16 was independently associated with a 2.8-times increased risk of 30-day all-cause mortality (p=0.016). Post-procedural stroke (HR 4.9, p=0.008) was also associated with increased mortality., Conclusions: This initial report of the Asia Pacific TAVI registry demonstrated good acute success and low 30-day mortality. The preprocedural logistic EuroSCORE and post-procedural stroke incidence were strongly associated with acute mortality. Further attempts to reduce post-procedural stroke should be explored., Competing Interests: The authors have no conflicts of interest to declare.

Coronary artery disease is a leading cause of morbidity and mortality worldwide. Despite significant advances in revascularization strategies and antiplatelet therapy with aspirin and/or P2Y 12 receptor antagonist, patients with acute coronary syndrome (ACS) continue to be at long-term risk of further cardiovascular events. Besides platelet activation, the role of thrombin generation (TG) in atherothrombotic complications is widely recognized. In this study, we hypothesized that there is an elevation of coagulation activation persists beyond 12 months in patients with ACS and chronic coronary syndrome (CCS) when compared with healthy controls. We measured TG profiles of patients within 72 h after percutaneous coronary intervention, at 6-month, 12-month and 24-month. Our results demonstrated that TG of patients with ACS (n = 114) and CCS (n = 40) were persistently elevated when compared to healthy individuals (n = 50) in peak thrombin (ACS 273.1 nM vs CCS 287.3 nM vs healthy 234.3 nM) and velocity index (ACS 110.2 nM/min vs CCS 111.0 nM/min vs healthy 72.9 nM/min) at 24-month of follow-up. Our results suggest a rationale for addition of anticoagulation to antiplatelet therapy in preventing long-term ischemic events after ACS. Further research could clarify whether the use of TG parameters to enable risk stratification of patients at heightened long-term procoagulant risk who may benefit most from dual pathway inhibition.

Cardiac syncope and epileptic seizure are two very similar presentations and difficult to differentiate without a proper history, physical examination and investigations. In a former study, 10 out of 22 episodes of induced ventricular tachycardia or fibrillation can result in stereotypical tonic-clonic movement with varied electroencephalography changes. We present a case which was diagnosed as ventricular tachycardia from seizure-like attack. It is to emphasise the importance of including ventricular tachycardia among other differential diagnoses of seizure-like activity in a patient with cardiovascular risks., (© Royal College of Physicians 2020. All rights reserved.)

New and rapid political and economic changes in Myanmar are increasing the pressures on the country's forests. Yet, little is known about the past and current condition of these forests and how fast they are declining. We mapped forest cover in Myanmar through a consortium of international organizations and environmental non-governmental groups, using freely-available public domain data and open source software tools. We used Landsat satellite imagery to assess the condition and spatial distribution of Myanmar's intact and degraded forests with special focus on changes in intact forest between 2002 and 2014. We found that forests cover 42,365,729 ha or 63% of Myanmar, making it one of the most forested countries in the region. However, severe logging, expanding plantations, and degradation pose increasing threats. Only 38% of the country's forests can be considered intact with canopy cover >80%. Between 2002 and 2014, intact forests declined at a rate of 0.94% annually, totaling more than 2 million ha forest loss. Losses can be extremely high locally and we identified 9 townships as forest conversion hotspots. We also delineated 13 large (>100,000 ha) and contiguous intact forest landscapes, which are dispersed across Myanmar. The Northern Forest Complex supports four of these landscapes, totaling over 6.1 million ha of intact forest, followed by the Southern Forest Complex with three landscapes, comprising 1.5 million ha. These remaining contiguous forest landscape should have high priority for protection. Our project demonstrates how open source data and software can be used to develop and share critical information on forests when such data are not readily available elsewhere. We provide all data, code, and outputs freely via the internet at (for scripts: https://bitbucket.org/rsbiodiv/; for the data: http://geonode.themimu.info/layers/geonode%3Amyan_lvl2_smoothed_dec2015_resamp).

Introduction: The care of children with cancer creates emotional and financial hardships for their families. There is a lack of information on the impact of childhood cancer on the family as a whole in Singapore. Thus, we set out to assess the financial impact as well as its psychosocial impact in our local context., Materials and Methods: All patients diagnosed and treated for cancer at the Departments of Paediatrics, KK Women's and Children's Hospital and National University Hospital, Singapore were eligible for this study. Families of these patients completed 2 self-administered questionnaires: (i) About-you and your-family and (ii) the Impact-On-Family scale. For the latter, the total score was obtained by the summation of all scores, where high scores correlated to high impact., Results: Seventy-nine parents were enrolled during the study period from October 2008 to February 2009. Being of Malay/Indian origin was associated with a high overall family burden. On the other hand, being of Malay/Indian origin was also associated with most successful at mastery when a child was diagnosed with cancer (P = 0.001). In addition, when compared to caregivers who remained employed, those who were asked to quit their job, experienced a higher Financial Burden (P = 0.03), a high Familial/Social Burden (P = 0.05) and a high Personal Strain (P = 0.03)., Conclusion: Childhood cancer impacted family life in Singapore at many levels. In particular, the factors involved are various cultural discourses; employment status of caregivers; and those whose leave/pay are affected.