PURPOSE To retrospectively compare the safety and efficacy of radiofrequency ablation (RFA) with laparoscopic adrenalectomy (LA) in treating aldosterone-producing adenoma (APA) of the adrenal gland. MATERIALS AND METHODS From September 2009 to September 2013, seven patients, diagnosed with unilateral adrenal APA and underwent computed tomography (CT)-guided percutaneous RFA, were recruited in this retrospective study. Eighteen unilateral adrenal APA with the same tumor size (<25 mm) who underwent LA during the same interval were enrolled as control group. Treatment success was defined as complete tumor ablation on follow-up CT scan and normalization of serum aldosterone-to-renin ratio. We also compared "normalization ability" between RFA group and LA group. Normalization ability was defined as reduction in blood pressure, decrease in number of antihypertensive medicine use, reduction in serum aldosterone, and increase in serum potassium level. RESULTS There was no statistically significant demographic difference in both groups. The mean tumor size was 18 (8-25) mm in RFA and 19 (11-25) mm in LA groups, respectively. There was only one intra-procedure hypertensive crisis in the RFA group. No other complications needed further management in both groups. During an interval of 3-6 months of follow-up, the treatment success rate reached 100 % in the RFA group versus 94.4 % in the LA group. Normalization ability was statistically equivalent in the RFA and the LA group. Comparing with LA group, RFA group demonstrated with less post-operative pain (visual analog scale, 2.0 1.16 vs. 4.22 1.44, p < 0.001) and shorter operative time (105 34 vs. 194 58 min, p < 0.001). CONCLUSIONS CT-guided percutaneous RFA is effective, safe and is a justifiable alternative for patients who are reluctant or unfit for laparoscopic surgery for the treatment of APA.

Performers acutely need but lack tools to remotely rehearse and create live theatre, particularly due to global restrictions on social interactions during the Covid-19 pandemic. No studies, however, have heretofore examined how remote video-collaboration affects performance. This paper presents the findings of a field study with 16 domain experts over six weeks investigating how tele-immersion affects the rehearsal and performance of improvisational theatre. To conduct the study, an original media server was developed for co-locating remote performers into shared virtual 3D environments which were accessed through popular video conferencing software. The results of this qualitative study indicate that tele-immersive environments uniquely provide performers with a strong sense of co- presence, feelings of physical connection, and an increased ability to enter the social-flow states required for improvisational theatre. Based on our observations, we put forward design recommendations for video collaboration tools tailored to the unique demands of live performance.

Purpose: The feasibility of preparing an eslicarbazepine acetate suspension using Aptiom tablets for administration via enteral feeding tubes was evaluated. Methods: Eslicarbazepine acetate suspension (40 mg/mL) was prepared using Aptiom tablets after optimizing the tablet crushing methods and the vehicle composition. A stability-indicating high-performance liquid chromatography (HPLC) method was developed to monitor the eslicarbazepine stability in the prepared suspension. Three enteric feeding tubes of various composition and dimensions were evaluated for the delivery of the suspensions. The suspension was evaluated for the physical and chemical stability for 48 hours. Results: The reproducibility and consistency of particle size reduction was found to be best with standard mortar/pestle. The viscosity analysis and physical stability studies showed that ORA-Plus:water (50:50 v/v) was optimal for suspending ability and flowability of suspension through the tubes. The developed HPLC method was found to be stability indicating and suitable for the assay of eslicarbazepine acetate in the prepared suspension. The eslicarbazepine concentrations in separately prepared suspensions were within acceptable range (3%), indicating accuracy and reproducibility of the procedure. The eslicarbazepine concentrations in suspensions before and after delivery through the enteric feeding tubes were within acceptable range (4%), indicating absence of any physical/chemical interactions of eslicarbazepine with the tubes and a successful delivery of eslicarbazepine dosage via enteric feeding tubes. The stability study results showed that eslicarbazepine concentration in the suspension remained unchanged when stored at room temperature for 48 hours. Conclusion: The study presents a convenient procedure for the preparation of a stable suspension of eslicarbazepine acetate (40 mg/mL) using Aptiom tablets, for administration via enteral feeding tubes.

BACKGROUND Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux. METHODS In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted. RESULTS A total of 123 patients (96.9%) had successful surgery, and 4 patients (3.3%) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3%) and in-hospital mortality of 1 of 123 (0.8%). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4%). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5%). Half of the patients [62 of 123 (50.4%)] experienced postoperative heartburn, 11 of 123 patients (8.9%) experienced acid regurgitation, and 16 of 123 patients (13.0%) experienced nocturnal cough. CONCLUSIONS Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.

Among the proteins encoded by the SARS-CoV-2 RNA, nsP3 (non-structural Protein3) is the largest multi-domain protein Its role is multifaceted and important for the viral life cycle Nonetheless, regarding the specific role of each domain there are many aspects of their function that have to be investigated SARS Unique Domains (SUDs), constitute the nsP3c region of the nsP3, and were observed for the first time in SARS-CoV Two of them, namely SUD-N (the first SUD) and the SUD-M (sequential to SUD-N), exhibit structural homology with nsP3b ("X" or macro domain);indeed all of them are folded in a three-layer alpha/beta/alpha sandwich On the contrary, they do not exhibit functional similarities, like ADP-ribose binding properties and ADP-ribose hydrolase activity There are reports that suggest that these two SUDs may exhibit a binding selectivity towards G-oligonucleotides, a feature which may contribute to the characterization of their role in the formation of the replication/transcription viral complex (RTC) and of the interaction of various viral "components" with the host cell While the structures of these domains of SARS-CoV-2 have not been determined yet, SUDs interaction with oligonucleotides and/or RNA molecules may provide a platform for drug discovery Here, we report the almost complete NMR backbone and side-chain resonance assignment (1H,13C,15N) of SARS-CoV-2 SUD-N protein, and the NMR chemical shift-based prediction of the secondary structure elements These data may be exploited for its 3D structure determination and the screening of chemical compounds libraries, which may alter SUD-N function

El leucismo consiste en la prdida completa de un pigmento en particular o de todos los pigmentos, excepto aquellos de partes blandas. Durante un estudio realizado en la selva baja del departamento de Madre de Dios (Per) se captur un ejemplar de Sturnira lilium, con pigmentaciones anormales. La coloracin general del espcimen es blanca, ojos negros y manchas grises irregulares en las membranas alares. Este es el primer caso de leucismo en un murcilago para Per y es el primer registro de esta condicin para esta especie.

[Figure: see text].

This review will present developments in simulation-based education (SBE) over the past decade with a focus on activity in the UK's National Health Service and the role of the national society (the Association for Simulation Practice in Healthcare). The article covers the evolution of strategic changes for the use of SBE in the UK and the operational challenges faced by clinicians and other faculty in SBE. The expansion of the evidence base to support SBE in healthcare both in technical skills and, more broadly, in interprofessional team training is explored. Finally, the wider role of simulation in patient safety and healthcare systems, including testing pathways and the development of cognitive aids and involvement of patients in SBE is considered.

Writing is one of the most difficult skills in language learning, particularly in learning English as a foreign language. The purposes of this qualitative study were to describe student teachers challenges in composing argumentative writing and to explain how they encountered those challenges at one public university teacher-training program in Jambi, Indonesia. The theoretical framework of cultural capital was used to guide the study while the data were collected through demographic profiles and semi-structured in-depth interviews with student teachers. Due to the Covid-19 pandemic, we only had access to invite 12 students to participate in our study-they were six male and six female student teachers. All participants in this study had taken English academic writing subjects and had been familiar with argumentative English writing. To analyze the data, within-case and cross-case analyses were used. The results of the data analysis produced eight salient themes including insufficient vocabulary and grammar, giving arguments, writing habits, parents occupation, the relationship between students, cognitive strategies, metacognitive strategies, and social strategies. The implications of the study are also discussed.

Infectious diseases, such as the coronavirus disease-19, SARS virus, Ebola virus, and AIDS, threaten the health of human beings globally. New viruses, drug-resistant bacteria, and fungi continue to challenge the human efficacious drug bank. Researchers have developed a variety of new antiviral and antibacterial drugs in response to the infectious disease crisis. Meanwhile, the development of functional materials has also improved therapeutic outcomes. As a natural material, chitosan possesses good biocompatibility, bioactivity, and biosafety. It has been proven that the cooperation between chitosan and traditional medicine greatly improves the ability of anti-infection. This review summarized the application and design considerations of chitosan-composed systems for the treatment of infectious diseases, looking forward to providing the idea of infectious disease therapy. [Image: see text]

BACKGROUND: Social Anxiety Disorder (SAD) is among the most common anxiety disorders worldwide with data largely emerging from the Euro-American and Pacific Rim populations. In contrast, there is a dearth of studies among the populations of Arabian Gulf countries including Oman. This study has two interrelated aims: (i) to explore the prevalence of SAD among Omani adults, and (ii) to tease out the links between socio-demographic factors and SAD in Oman. METHODS: A cross-sectional study via an online survey was conducted among 1019 adult Omani nationals residing in Oman. The presence of SAD was assessed using the Arabic version of the Liebowitz Social Anxiety Scale (LSAS). RESULTS: Nearly half the participants (45.9%, n = 468) exhibited caseness for SAD as defined by LSAS. In the multivariate logistic analysis, participants below 40 years of age were 1.6 times (OR = 1.568, p = .026) more likely to have caseness for SAD than those who were 40 and older. Women were 1.3 times (OR = 1.348, p = .038) more likely to exhibit caseness for SAD than men. Participants who had secondary or undergraduate education were respectively 1.5 times (OR = 1.45, p = .014) and 2.5 times (OR = 2.509, p < .001) to have caseness for SAD than those who were graduates. CONCLUSION: The present data suggest that 45.9% of the participants reached the cut-off for caseness in LSAS, which is high compared to reports from other populations. The present accrued frequency is discussed within the context of the accrued response rate, socio-cultural factors as well as the tendency for self-reported measures to produce spurious results is also highlighted which, in turn, calls for studies that adopt more inclusive survey methods.

During the COVID-19 pandemic, health care systems around the world have received additional funding, while at other times, financial support has been lowered to consolidate public spending Such budget changes likely affect provision behavior in health care We study how different degrees of resource scarcity affect medical service provision and, in consequence, patients' health In a controlled lab environment, physicians are paid by capitation and allocate limited resources to several patients This implies a trade-off between physicians' profits and patients' health benefits We vary levels of resource scarcity and patient characteristics systematically and observe that most subjects in the role of physician devote a relatively stable share of budget to patient treatment, implying that they provide fewer services when they face more severe budget constraints Average patient benefits decrease in proportion to physician budgets The majority of subjects chooses an allocation that leads to equal patient benefits as opposed to allocating resources efficiently

Background: There are numerous studies dealing with analysis for the future patterns of COVID-19 in different countries using conventional time series models. This study aims to provide more flexible analytical framework that decomposes the important components of the time series, incorporates the prior information, and captures the evolving nature of model parameters. Methods: We have employed the Bayesian structural time series (BSTS) models to investigate the temporal dynamics of COVID-19 in top five affected countries around the world in the time window March 1, 2020 to June 29, 2020. In addition, we have analyzed the casual impact of lockdown in these countries using intervention analysis under BSTS models. Results: We achieved better levels of accuracy as compared to ARIMA models. The forecasts for the next 30 days suggest that India, Brazil, USA, Russia and UK are expected to have 101.42%, 85.85%, 46.73%, 32.50% and 15.17% increase in number of confirmed cases, respectively. On the other hand, there is a chance of 70.32%, 52.54%, 45.65%, 19.29% and 18.23% growth in the death figures for India, Brazil, Russia, USA and UK, respectively. In addition, USA and UK have made quite sagacious choices for lifting/relaxing the lockdowns. However, the pace of outbreak has significantly increased in Brazil, India and Russia after easing the lockdowns. Conclusion: On the whole, the Indian and Brazilian healthcare system is likely to be seriously overburdened in the next month. Though USA and Russia have managed to cut down the rates of positive cases, but serious efforts will be required to keep these momentums on. On the other hand, UK has been successful in flattening their outbreak trajectories.

OBJECTIVES Patients and their families frequently misclassify female physicians in the Emergency Department (ED) as non-physicians. Physician misidentification impacts the environment of care on multiple levels; including patient satisfaction and physician well-being. Implementing "DOCTOR" badges may be a low-cost tool to rectify these problems. METHODS The study was conducted in a large urban academic medical center. Badges with the title "DOCTOR" was distributed to 83 Emergency Medicine (EM) residents and 28 EM Attendings in the department. After 3 months, the residents and Attendings were surveyed to assess the efficacy of the intervention. Descriptive data, univariable, and multivariable analyses were conducted. RESULTS There were 98 respondents to the pre-intervention survey and 87 respondents to the post-intervention survey. 91% of EM physicians reported that they were misidentified by the patients and their families. Compared to male EM physicians, female EM physicians were disproportionately more likely to be misidentified as a non-physician 43% vs 97%, respectfully, 95% CI: [37,66], p < 0.0001. After wearing the "DOCTOR" badges, a postintervention survey showed decrease in misidentification of female EM physicians by patients and their families to 81.6%, a 15.4% decrease, p = 0.03. Being more valued was reported by 73.7% female physicians vs. 44.9% male physicians, 95% CI [7.9,46], p = 0.007. Similarly, 64.3% EM physicians felt less frustration with misclassification, 81.6% female physicians vs. 51% male physicians, 95% CI [10.5,47], p = 0.0033. CONCLUSIONS Female EM physicians are disproportionately misidentified by patients and their families and are more likely to feel undervalued when clarifying their roles. In only a span of 3 months, we found that the use of "DOCTOR" badges decreased misidentification and improved outcomes that may enhance physician wellness. Having EM physicians wear a "DOCTOR" badge may be a simple and effective long-term solution to this issue.

Introduction COVID-19 in care homes has heightened the risk of staff burnout, undermining already problematic staff retention and low morale There has been an associated proliferation of resources and online initiatives to support frontline workers, however, few of these are directly targeted at the care home workforce Care home workers are highly skilled in caring for people with complex needs, but have very variable levels of formal training, and just over half of care homes in Scotland include registered nurses This project will rapidly collate existing resources and identify, direct from care home workers, their best practice, initiatives, and resources used to support resilience and retention during this pandemic and moving forward Methods 1) Rapid review of care home specific evidence and resources (including published research and social media);2) Online survey of Enabling Research in Care Homes (ENRICH) members across Scotland (n = 55);3) Case studies within six care homes to identify what is working well and what is not in terms of promoting resilience and emotional support Results The rapid review has identified a wide range of resources directed at supporting staff working in care homes;the survey and case studies will provide data on the key learning and resources that have supported staff, and outline the challenges identified There are many resources available but staff do not access these The role of the care home manager is key Key conclusions This comprehensive review of resources and initiatives will make a valuable contribution to policy and practice designed to reduce burnout and foster retention not just in care homes but more widely across health and social care

BACKGROUND: Ventilator associated pneumonia (VAP) caused by more than one microorganisms is not uncommon and may be potentially challenging, but the relevant data is scarce in ventilated neonates. We aimed to investigate the clinical characteristics and outcomes of polymicrobial VAP in the neonatal intensive care unit (NICU). METHODS: All neonates with definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and September 2020 were prospectively observed and enrolled for analyses. All clinical features, therapeutic interventions and outcomes were compared between the polymicrobial VAP and monomicrobial VAP episodes. Multivariate regression analyses were used to find the independent risk factors for treatment failure. RESULTS: Among 236 episodes of neonatal VAP, 60 (25.4%) were caused by more than one microorganisms. Polymicrobial VAP episodes were more likely to be associated with multidrug-resistant pathogens (53.3% versus 34.7%, P = 0.014), more often occurred in later days of life and in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. Otherwise most clinical characteristics of polymicrobial VAP were similar to those of monomicrobial VAP. The therapeutic responses and treatment outcomes were also comparable between these two groups, although modification of therapeutic antibiotics were significantly more common in polymicrobial VAP episodes than monomicrobial VAP episodes (63.3% versus 46.2%; P < 0.001). None of any specific pathogens was significantly associated with worse outcomes. Instead, it is the severity of illness, including presence of concurrent bacteremia, septic shock, and requirement of high-frequency oscillatory ventilator and underlying neurological sequelae that are independently associated with treatment failure. CONCLUSIONS: Polymicrobial VAP accounted for 25.4% of all neonatal VAP in the NICU, and frequently occurred in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. In our cohort, most clinical features, therapeutic responses and final outcomes of neonates with monomicrobial and polymicrobial VAP did not differ significantly. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12879-021-06673-9.

AIM: The purpose of the present study was to explore the experiences of a diverse group of mental health clinicians both in hospital and in the community, who were required to rapidly adopt virtual\care practices in the delivery of mental health services to children, adolescents, and their families. METHODS: Mental health clinicians (N = 117) completed the Clinician Virtual\Care Experience Survey assessing the following domains: ease of technology use, client/patient\provider interaction quality, and clinician wellbeing. RESULTS: Although over 70% of clinicians had not used virtual\care to deliver mental health services prior to the Coronavirus Disease 2019 pandemic, more than 80% felt it was easy to operate the virtual platforms. Clinicians were divided in their perceptions of the effectiveness of virtual\care, with only 42% reporting that they felt they were as effective in delivering healthcare services virtually as compared to in\person. Virtual\care was described as being more effective for specific populations, while challenges were described in building rapport and when delivering difficult or unexpected feedback. CONCLUSIONS: Clinicians felt there were some benefits of adopting virtual\care practices, while challenges were also identified. Understanding of the impact of virtual\care on service providers is essential in order to strengthen mental healthcare for children, adolescents, and their families even beyond the pandemic.

INTRODUCTION South America is one of the regions most affected by the COVID-19 pandemic. Specific and affordable treatments are needed to treat SARS-CoV-2 infection. Evidence regarding the use of convalescent plasma in COVID-19 patients is still limited. We compared the safety and efficacy of COVID-19-convalescent plasma administration as a complement to standard treatment in the early management of patients with moderate SARS-CoV-2 infection. METHODS We carried out a random double blinded, placebo-controlled trial that compared standard treatment plus convalescent plasma (CP) or plus non-convalescent plasma in the management of COVID-19 patients. The main outcome was survival and secondary endpoints included: length of hospitalisation (LOH), days from treatment to discharge, time to clinical improvement or death within a 28-day period, and adverse reactions to treatment. RESULTS Administration of CP with antibodies against SARS-CoV-2 did not affect patient survival, RR = 1.003, 95% CI (0.3938, 2.555). These results led to terminate the RCT prematurely. However, early treatment of COVID-19 patients with CP tended to decrease the LOH while the delay in CP treatment was associated with longer hospitalisation. In addition, delay in CP treatment negatively affected the recovery of the respiratory rate. CONCLUSION Use of CP for the treatment of COVID-19 patients is safe and its early use can decrease the LOH and improve respiratory function. Early administration of antibody-rich CP could contribute to decrease the negative impact of COVID-19 pandemic in patients with impaired immune response.

BACKGROUND AND PURPOSE Aspiration of secretions containing bacterial pathogens into the lower respiratory tract is the main cause of ventilator-associated pneumonia. Endotracheal tubes with subglottic secretion drainage can potentially reduce this and, therefore, the incidence of ventilator-associated pneumonia. New evidence on subglottic secretion drainage as a preventive measure for ventilator-associated pneumonia has been recently published and to consider the evidence in totality, we conducted an updated systematic review and meta-analysis. DESIGN We searched computerized databases, reference lists, and personal files. We included randomized clinical trials of mechanically ventilated patients comparing standard endotracheal tubes to those with subglottic secretion drainage and reporting on the occurrence of ventilator-associated pneumonia. Studies were meta-analyzed for the primary outcome of ventilator-associated pneumonia and secondary clinical outcomes. MEASUREMENTS AND MAIN RESULTS We identified 13 randomized clinical trials that met the inclusion criteria with a total of 2442 randomized patients. Of the 13 studies, 12 reported a reduction in ventilator-associated pneumonia rates in the subglottic secretion drainage arm; in meta-analysis, the overall risk ratio for ventilator-associated pneumonia was 0.55 (95% confidence interval, 0.46-0.66; p < .00001) with no heterogeneity (I = 0%). The use of subglottic secretion drainage was associated with reduced intensive care unit length of stay (-1.52 days; 95% confidence interval, -2.94 to -0.11; p = .03); decreased duration of mechanically ventilated (-1.08 days; 95% confidence interval, -2.04 to -0.12; p = .03), and increased time to first episode of ventilator-associated pneumonia (2.66 days; 95% confidence interval, 1.06-4.26; p = .001). There was no effect on adverse events or on hospital or intensive care unit mortality. CONCLUSIONS In those at risk for ventilator-associated pneumonia, the use of endotracheal tubes with subglottic secretion drainage is effective for the prevention of ventilator-associated pneumonia and may be associated with reduced duration of mechanical ventilation and intensive care unit length of stay.

We develop nonlinear approximations to critical and relaxation phenomena, complemented by the optimization procedures In the first part, we discuss general methods for calculation of critical indices and amplitudes from the perturbative expansions Several important examples of the Stokes flow through 2D channels are brought up Power series for the permeability derived for small values of amplitude are employed for calculation of various critical exponents in the regime of large amplitudes Special nonlinear approximations valid for arbitrary values of the wave amplitude are derived from the expansions In the second part, the technique developed for critical phenomena is applied to relaxation phenomena The concept of time-translation invariance is discussed, and its spontaneous violation and restoration considered Emerging probabilistic patterns correspond to a local breakdown of time-translation invariance Their evolution leads to the time-translation invariance complete (or partial) restoration We estimate the typical time extent, amplitude and direction for such a restorative process The new technique is based on explicit introduction of origin in time as an optimization parameter After some transformations, we arrive at the exponential and generalized exponential-type solutions (Gompertz approximants), with explicit finite time scale, which is only implicit in the initial parameterization with polynomial approximation The concept of crash as a fast relaxation phenomenon, consisting of time-translation invariance breaking and restoration, is advanced Several COVID-related crashes in the time series for Shanghai Composite and Dow Jones Industrial are discussed as an illustration ? 2020 by the authors Licensee MDPI, Basel, Switzerland