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Background Timika scoring system is a radiographic grading tool, widely employed for grading the severity of tuberculosis (TB). We evaluated the predictive accuracy of this tool for adverse treatment outcomes among TB patients in Indian setting. Methods We undertook a longitudinal analysis of cohort data under the RePORT-India consortium. Cohort having participants with active pulmonary TB were included. CXRs were independently scored by chest physicians. Timika scoring system had a total score of 140. The predictive nature of the tool was assessed using the ROC analysis. Results Around 364 laboratory confirmed TB patients were enrolled. The mean (SD) of overall Timika score was 62.3 (24.9). Sputum conversion was achieved among 218/260 (83.8%) patients available at end of intensive phase. AUC for Timika score was 0.53 (95% CI: 0.43–0.63) and for percent lung affected, was 0.56 (95% CI: 0.46–0.65). Unfavorable treatment outcome was observed among 67/287 (23.3%) at the end of continuation phase. AUC for percent lung affected was 0.62 (95% CI: 0.54–0.70) and for Timika score was 0.59 (95% CI: 0.51–0.67). Conclusion Both Timika scoring system and percent lung affected had poor predictive accuracy, highlighting the inability of a single CXR scoring system to predict the treatment outcome in Indian setting.

Introduction Triple-negative breast cancer (TNBC) in men is very rare. The clinical characteristics, prognostic factors, and overall survival of men with TNBC have not been characterized. Methods The study population consisted of men and women with a diagnosis of stage I-III TNBC between 2010 and 2016 in the National Cancer Database. Baseline demographic and tumor characteristics between men and women were compared using Pearson's Chi-Square test for categorical variables and Mann-Whitney U test for continuous variables. Kaplan–Meier and multivariate Cox proportional hazards regression model was used to compare survival and identify prognostic factors. Results A total of 311 men and 95,406 women with TNBC were included in the final analysis. The 3-year and 5-year overall survival was 74.8% and 68.8% in men, while it was 83.2% and 74.8% in women, respectively. In multivariate analysis, men were found to have a significantly worse overall survival compared to women (HR, 1.49, 95% CI, 1.19-1.86, P= .01). Older age at diagnosis, higher TNM stage, undergoing mastectomy and not undergoing chemotherapy or radiation were identified as independent negative prognostic factors in men with TNBC. Conclusion In one of the largest studies of men with TNBC, men were noted to have a poorer overall survival compared to women, despite adjusting for usual prognostic factors. Further research into differences in tumor biology, treatment patterns and compliance with therapy between men and women are needed to understand the underlying etiologies for the survival difference in TNBC.

Background Post-traumatic stress disorder (PTSD) develops after a person has experienced a traumatic event which can be highly accounted for amidst the ongoing COVID-19 pandemic. This study aims to estimate the prevalence of PTSD among the severe cases of COVID-19. Methods We included the observational studies done to estimate the burden of PTSD among severe COVID-19 patients. Data was extracted manually using structured data extraction form and analyzed in STATA version 14.2. A random-effects model was applied, and the final pooled data was reported as proportion with a 95% confidence interval. Multivariable meta-regression analysis was carried out, and a forest plot was utilized to represent the study-specific and pooled estimates for overall and subgroup analysis. Results We included 13 articles with 1,093 participants in our analysis. The pooled prevalence was estimated to be 16% (95%CI: 9% to 23%). We found a substantial heterogeneity between the studies that reported the outcome (I2=87.9%, p

Competitive advantage has been a perpetual area of research in strategic management in different forms. Business strategies in organizations have been underpinned to the objective of attaining competitive advantage. This study explores the academic literature to track the theoretical and chronological evolution of the notion of ‘competitive advantage’. This study also examines the emerging themes with insights obtained from a bibliometric analysis of the area. The insights generated from the bibliometric mapping and decadal conceptual evolution are integrated. The results indicate that although competitive advantage has been manifested in different forms over time, the newer areas of exploration are inclined in the direction of achieving social advantage along with superior financial performance. The findings from this study would facilitate in identifying the trajectory of themes in the study of competitive advantage and isolate potential areas of explorations for future research.

This paper presents enhanced design for Automation control of processes involved in a solar system which utilizes programmable logic controller to automate tracking system for obtaining maximum solar radiation. Three areas are involved in this proposed multi area system where first and second area considers solar power plant with thermal system based parabolic trough collector with fixed solar isolation and random isolation of solar energy whereas third area comprises of solar thermal system with dish Stirling realistic unit. Energy efficiency can be increased by using solar concentrator along with Stirling engine. Optimization of gain of the controller is by utilizing crow search novel algorithm. Crow search algorithm is an optimization technique, which provides better performance at complex time varying noisy condition and time in-varying noisy condition. The Proposed controller is evaluated by obtaining the optimized parameters of the system whose comparison is done by operating proposed controller with & without renewable sources of energy thereby revealing better performance for both conditions. Testing is done in different areas with fixed solar isolation and random stisolation of solar energy involved in solar thermal power plant based on parabolic trough collector. Gain and parameters of the controller of the solar power plant are optimized by utilizing automation for operation of solar concentrator with parabolic Trough collector. Data acquisition and monitoring is done by human machine interface (HMI) in order to report safe operation. The Simulation results of integrated solar thermal system involving dish Stirling with parabolic trough collector, shows that dynamic response of the proposed controller operating with renewable solar energy is better than that of non-renewable energy source.

This paper introduces a fault-tolerant solid-state transformer (SST) structure to combine the benefits of higher power density and robustness in medium-voltage DC (MVDC) electric distribution systems. A SiC-MOSFET-based 6 MW, 36/6 kV ISOSP (input series output series-parallel) modular stacked DC/DC SST is proposed using medium frequency (MF) transformer isolation. This structure renders the system with fault tolerance and the capability to operate normally even in a partial fault condition. Small-signal modeling, simulations, and Typhoon-HiL real-time system were performed to verify the operation of the converter. Experimental results from a scaled-down laboratory prototype prove the feasibility of the proposed isolated DC/DC structure and control system. Further, outcomes from 3-D finite element analysis done using COMSOL matched the 20 kHz MF transformer design used in the hardware. Overall, the proposed system can lead to significant improvement in power density in mission-critical MVDC applications such as subsea electrification.

Objective To investigate whether there is a difference in the ectopic/heterotopic pregnancy rate of blastocyst-stage frozen-thawed embryo transfers (FETs) compared with that of cleavage-stage FETs. Design A retrospective cohort study. Setting Not applicable. Patient(s) Women undergoing autologous FETs at either the blastocyst stage (n = 118,572) or the cleavage stage (n = 117,619), as reported to the Society for Assisted Reproductive Technology from 2004 to 2013. Intervention(s) None. Main Outcome Measure(s) Pregnancy outcomes, specifically ectopic pregnancy rates and heterotopic pregnancy rates. Result(s) Among those who became pregnant, there was a significantly lower incidence of ectopic/heterotopic pregnancies in blastocyst-stage FETs versus that in cleavage-stage FETs (0.8% vs. 1.1%). The differences in ectopic/heterotopic pregnancy rates remained statistically significant after controlling for confounders such as tubal factor infertility and number of embryos transferred. Conclusion(s) Blastocyst-stage FET was associated with a lower ectopic/heterotopic pregnancy rate compared with cleavage-stage FET.

Tuberculosis (TB) is the leading infectious cause of death globally. The only licensed TB vaccine, Bacille Calmette-Guerin (BCG), has low efficacy against TB in adults and is not recommended in people with impaired immunity. The incorporation of the Mycobacterium tuberculosis (Mtb) secretion system ESX-1 into BCG improves immunogenicity and protection against TB in animal models, which is associated with the secretion of the ESX-1-dependent protein ESAT-6. However, the resulting strain, BCG::ESX1Mtb, has been deemed unsafe as a human vaccine, due to prolonged persistence and increased virulence in immunocompromised mice. In this study, we describe a new recombinant BCG strain that uncouples the beneficial aspects of ESAT-6 secretion from the detrimental ESX-1effects on virulence and persistence. The strain was constructed by fusing the ESAT-6-encoding gene esxA to the general secretion signal for the mycobacterial type VII secretion pathway protein PE25. This new strain, BCG::ESAT6-PE25SS, secretes full-length ESAT-6 via the ESX-5 secretion system, which in contrast to ESX-1 is also present in BCG. In vivo testing revealed that ESX-5-targeted ESAT-6 export, induces cytosolic contact, generates ESAT-6-specific T cells and enhances the protective efficacy against TB disease, but is associated with low virulence and reduced persistence in immunocompetent and immunocompromised mice. Additionally, compared to BCG::ESX1Mtb and parental BCG, mucosal administration of BCG::ESAT6-PE25SS is associated with more rapid clearance from the lung. These results warrant further studies to evaluate BCG::ESAT6-PE25SS as a potential live attenuated vaccine candidate for TB.

The second wave of COVID-19 pandemic has spread rampantly throughout India between April and May 2021, leading to high mortality rates. Identifying any change in the rate of vaccine hesitancy or refusal due to such mass casualty events will provide further insights on developing appropriate risk communication strategy. Hence, this study was undertaken to identify the vaccine hesitancy and refusal before and during the second wave of COVID-19 pandemic. We conducted a longitudinal study among 900 adults to know about their vaccine hesitancy and refusal pattern before (March 2021 - round-1) and during the second wave of COVID-19 pandemic (May 2021 - round-2). Telephonic interview was conducted using the pre-tested semi-structured questionnaire. There was an increase in the vaccine hesitancy (27.8% in round-1 to 32.7% in round-2) and refusal (25.6% in round-1 to 35.6% in round-2) during the second wave of pandemic in Puducherry. In adjusted analysis, vaccine hesitancy was found to increase by 1.19 times during the round-2 survey compared to round-1 survey (aIRR = 1.19; 95%CI: 1.03-1.37). We also found that the vaccine refusal increased by 1.40 times during the round-2 survey compared to round-1 survey (aIRR = 1.40; 95%CI: 1.22-1.62) after adjusting for age, place of residence, and occupation. We found that the confidence in COVID-19 vaccine efficacy and safety has declined over time leading to increase in the vaccine hesitancy and refusal in our study cohort, with more than one-third refusing to get themselves vaccinated during the second wave of pandemic.

The aim of this study was to describe the utilization patterns of brain tissue oxygen (PbtO2) monitoring following severe traumatic brain injury (TBI) and determine associations with mortality, health care use, and pulmonary toxicity. We conducted a retrospective cohort study of patients from United States trauma centers participating in the American College of Surgeons National Trauma Databank between 2008 and 2016. We examined patients with severe TBI (defined by admission Glasgow Coma Scale score ≤ 8) over the age of 18 years who survived more than 24 h from admission and required intracranial pressure (ICP) monitoring. The primary exposure was PbtO2 monitor placement. The primary outcome was hospital mortality, defined as death during the hospitalization or discharge to hospice. Secondary outcomes were examined to determine the association of PbtO2 monitoring with health care use and pulmonary toxicity and included the following: (1) intensive care unit length of stay, (2) hospital length of stay, and (3) development of acute respiratory distress syndrome (ARDS). Regression analysis was used to assess differences in outcomes between patients exposed to PbtO2 monitor placement and those without exposure by using propensity weighting to address selection bias due to the nonrandom allocation of treatment groups and patient dropout. A total of 35,501 patients underwent placement of an ICP monitor. There were 1,346 (3.8%) patients who also underwent PbtO2 monitor placement, with significant variation regarding calendar year and hospital. Patients who underwent placement of a PbtO2 monitor had a crude in-hospital mortality of 31.1%, compared with 33.5% in patients who only underwent placement of an ICP monitor (adjusted risk ratio 0.84, 95% confidence interval 0.76–0.93). The development of the ARDS was comparable between patients who underwent placement of a PbtO2 monitor and patients who only underwent placement of an ICP monitor (9.2% vs. 9.8%, adjusted risk ratio 0.89, 95% confidence interval 0.73–1.09). PbtO2 monitor utilization varied widely throughout the study period by calendar year and hospital. PbtO2 monitoring in addition to ICP monitoring, compared with ICP monitoring alone, was associated with a decreased in-hospital mortality, a longer length of stay, and a similar risk of ARDS. These findings provide further guidance for clinicians caring for patients with severe TBI while awaiting completion of further randomized controlled trials.

Extraction of eye gaze events is highly dependent on automated powerful software that charges exorbitant prices. The proposed open-source intelligent tool StimulEye helps to detect and classify eye gaze events and analyse various metrics related to these events. The algorithms for eye event detection in use today heavily depend on hand-crafted signal features and thresholding, which are computed from the stream of raw gaze data. These algorithms leave most of their parametric decisions on the end user which might result in ambiguity and inaccuracy. StimulEye uses deep learning techniques to automate eye gaze event detection which neither requires manual decision making nor parametric definitions. StimulEye provides an end to end solution which takes raw streams of data from an eye tracker in text form, analyses these to classify the inputs into the events, namely saccades, fixations, and blinks. It provides the user with insights such as scanpath, fixation duration, radii, etc.

Objective To describe the utility of wrist circumference in the identification of cardiometabolic risk in overweight and obese children. Methods A cross-sectional study was conducted in the obesity clinic of a tertiary care referral hospital over a two year period. All children and adolescents aged 5–17 years with nutritional overweight and obesity were recruited. Data pertaining to chronological age, sex, risk factors and family history were collected. Clinical assessment of anthropometry: Weight, height, body mass index (BMI), Tanner’s stage, wrist circumference, blood pressure, waist circumference and triceps skinfold thickness done as per standard criteria. Biochemical assessment of blood glucose, serum insulin, lipid profile, and Homeostatic Model for Insulin Resistance performed after 12 h of fasting. Results We recruited 118 subjects (mean age 10.9 years, 71.1% males, 87.3% obese and 12.7% overweight); 30 (25.4%) had metabolic syndrome. The mean z scores of wrist circumference of children who presented with and without metabolic syndrome was 2.7 ± 0.8 and 2.1 ± 0.7, respectively (p Conclusions Wrist circumference with 97th percentile as a cut-off is a useful tool to identify metabolic syndrome amongst overweight and obese children and adolescents.

BACKGROUND: In recent years the Internet of Things (IoT) has become a popular technological culture in the physical education system. Though several technologies have grown in the physical education system domain, IoT plays a significant role due to its optimized health information processing framework for students during workouts. OBJECTIVE: In this paper, an advanced dynamic information processing system (ADIPS) has been proposed with IoT assistance to explore the traditional design architecture for physical activity tracking. METHOD: To track and evaluate human physical activity in day-to-day living, a new paradigm has been integrated with wearable IoT devices for effective information processing during physical workouts. Continuous observation and review of the condition and operations of various students by ADIPS helps to evaluate the sensed information to analyze the health condition of the students. RESULTS: The result of ADIPS has been implemented based on the performance factor correlation with the traditional system.

Despite their limitations, unfractionated heparin (UFH) and bivalirudin remain standard-of-care parenteral anticoagulants for percutaneous coronary intervention (PCI). We discovered novel direct thrombin inhibitors (DTIs) from tick salivary transcriptomes and optimised their pharmacologic activity. The most potent, ultravariegin, inhibits thrombin with a Ki of 4.0 pM, 445-fold better than bivalirudin. Unexpectedly, despite their greater antithrombotic effect, variegin/ultravariegin demonstrated less bleeding, achieving a 3-to-7-fold wider therapeutic index in rodent thrombosis and bleeding models. When used in combination with aspirin and ticagrelor in a porcine model, variegin/ultravariegin reduced stent thrombosis compared with antiplatelet therapy alone but achieved a 5-to-7-fold lower bleeding time than UFH/bivalirudin. Moreover, two antibodies screened from a naïve human antibody library effectively reversed the anticoagulant activity of ultravariegin, demonstrating proof-of-principle for antidote reversal. Variegin and ultravariegin are promising translational candidates for next-generation DTIs that may reduce peri-PCI bleeding in the presence of antiplatelet therapy., Bleeding complications limits the use of effective antithrombotics therapeutics. Here, the authors developed next-generation direct thrombin inhibitors with low bleeding risks as safe peri-percutaneous coronary intervention anticoagulants when used in combination with antiplatelets.

Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0% (83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0% (22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by 36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]). Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries. Funding Bill & Melinda Gates Foundation.

OBJECTIVE We aimed to determine the prevalence and find the risk factors associated with latent tuberculosis infection (LTBI) among the household contacts (HHC) of pulmonary TB patients. METHODS This cohort study was conducted from 2014 to 2019. Pretested standardised questionnaires and tools were used for data collection. The prevalence of LTBI among HHCs of TB patients was summarised as proportion with 95% confidence interval (CI). Mixed-effects generalised linear modelling function (meglm) in STATA with family Poisson and log link was performed to find the factors associated with LTBI. RESULTS In total, 1523 HHC of pulmonary TB patients were included in the study. Almost all HHC shared their residence with the index case (IC) for more than a year; 25% shared the same bed with the IC. The prevalence of LTBI among the HHC of TB patients was 52.6% (95% CI: 50.1-55.1%). In an adjusted model, we found that among HHC belonging to the age group of 19-64 years (aIRR = 1.2; 95% CI: 1.1-1.3; p-value: 0.02), to the age group >65 years (aIRR = 1.4, 95% CI: 1.1-1.9, p-value: 0.02) and sharing the same bed with the IC (aIRR = 1.2, 95% CI: 1.1-1.3, p value: 0.04) were independent determinants of LTBI among the HHC. CONCLUSION One in two household contacts of TB patients have latent tuberculosis infection. This underscores the need of targeted contact screening strategies, effective contact tracing and testing using standardised methods in high TB burden settings.

Schools respond to the complex needs of students exposed to traumatic and adverse experiences as part of an interconnected system of care that includes health care, child welfare, juvenile justice, housing and a variety of other community services. As legislation increasingly mandates inter-organisational collaboration, attention has turned to consider the ways in which educators and professionals of other disciplines and services interact. This paper analyses the partnership between an educator and a psychologist in the development, delivery and evaluation of a trauma-informed practice program for schools. Using a case study methodology, the research used qualitative analysis of the authors’ reflections on their partnership to identify factors that have enabled and sustained interdisciplinary educational work. The findings highlight key elements of sustainable interdisciplinary joint work—including knowledge sharing, opportunities for expansive learning, adapting to changing working relationships and overcoming systemic barriers for collaboration. These themes are discussed in the context of implementing trauma-informed practices in schools.

Objectives: There is a paucity of data on impact of therapy of Hashimoto’s thyroiditis (HT) on catch-up growth. The objective of the study was to determine whether delayed diagnosis of HT and overt primary hypothyroidism has an impact on the catch-up of children and adolescents. Material and Methods: We conducted a prospective observational study over 3 years, in the thyroid clinic of a referral unit in South India. We assessed chronological age (CA), auxological parameters, clinical presentation, bone age (BA), and predicted adult height (PAH) in subjects with Hashimoto’s thyroiditis and overt primary hypothyroidism. Management and follow-up done as per standard protocols and study parameters reassessed after 1 year of therapy. Results: We recruited 38 subjects and divided them into two groups – Group 1 with BA within 2 standard deviations (SD) of CA (n = 20) and Group 2 beyond 2 SD (n = 18). During 1 year follow-up, height Z-scores were −0.1 ± 1.4 (baseline) and −0.1 ± 1.1 (endpoint) and −1.7 ± 1.7 (baseline) and −1.3 ± 1.3 (endpoint) in Groups 1 and 2, respectively. BA: CA ratio changed from 1.0 ± 0.1 to 1.0 ± 0.1 in Group 1 (P > 0.05) versus 0.7 ± 0.2 to 0.9 ± 0.1 in Group 2 (P < 0.05). The number of children who were pre-pubertal: pubertal changed from 15:5 to 11:9 in Group 1 and 14:4 to 7:11 in Group 2. For Group 1, baseline PAH Z score was −0.5 ± 1.7 and endpoint PAH Z score was −0.7 ± 1.6 versus a target height Z score of −1.1 ± 1.1 (P > 0.05); Group 2, the baseline PAH Z score −1.1 ± 1.6 and endpoint PAH Z score −2.2 ± 1.4 versus target height Z-score of −0.4 ± 1.7. Conclusion: Delayed diagnosis and treatment of juvenile autoimmune hypothyroidism results in permanent loss of height potential.

Tuberculous epididymal mass is a condition that presents as a painless scrotal swelling. It resembles a testicular mass and is more often diagnosed after orchidectomy. About 22% of all genitourinary tuberculosis show epididymal involvement and 22% of epididymal tuberculosis are bilateral. This report reiterates the need for an increased awareness amongst the treating urologists that would enable an earlier diagnosis, appropriate treatment and may avert the need for orchidectomy in most cases. A 35-year-old diabetic male presented with rapidly enlarging right testicle associated with recent onset of pain over the testis. He also had fever and chills. At the age of 18, he was treated for pulmonary tuberculosis. The right testicle was enlarged, irregular and mildly tender. The right epididymis was also irregular and nodular, blended with the right testicle and indistinguishable from it. A clinical diagnosis of testicular tumour was made. Tumour markers were normal and he underwent high orchidectomy. Histopathological diagnosis confirmed right epididymal tuberculosis. This case report mainly highlights the need for a high index of suspicion amongst the treating physicians. A previous history of treatment for pulmonary tuberculosis should alert the physician to think in lines of tuberculous pathology in epididymis too. A prompt diagnosis and early, appropriate treatment would largely prevent removal of testicles in most cases.

Objectives In 2018, the World Health Organisation (WHO) reported that almost 10 million people worldwide had tuberculosis (TB). The majority of the TB cases were concentrated in South East Asian Region (SEAR) countries. To curb this burden, the WHO has set interim targets to reduce TB incidence by 50% and mortality by 75% by 2025 (interim targets of the ‘End TB’ strategy). Hence, this study was conducted to determine the progress of SEAR countries towards reaching these interim targets for TB incidence and mortality. Methods Secondary data analysis was performed using information from the WHO Global Health Observatory and Global Health Estimates for all SEAR countries. ARIMA modelling was used to forecast TB incidence and TB mortality from 2000 to 2025. Joinpoint regression was performed to determine the average annual percent change. Results Based on the current trend, we estimated that the incidence and mortality of TB in SEAR countries will decline to 3.7 million (4.37 million in 2018) and 495,280 (650,979 in 2016) by 2025, respectively. Projected age-standardised TB incidence showed a significant decline in only four SEAR countries, with the maximal decline in Myanmar (47.3%) followed by India (23.4%) compared with 2015 estimates. Age-standardised TB mortality showed a declining trend in six SEAR countries, with the maximum decline found in Myanmar (60.3%) followed by Thailand (39.0%). Conclusions Current study findings show that it is highly unlikely for most SEAR countries to achieve the WHO recommended interim End TB targets of 50% reduction in incidence and 75% reduction in mortality by 2025.

This article mainly deals with the design and developments of marine micro-grid for cruise ship applications. The incorporations of the solar PV array with existing fossil-fuel‐based generators and the replacement of an engine-based propulsion system into the electric propulsion system have shown enormous improvements in the technical performance and optimal operations of the system. The proposed hybrid marine micro-grid (HMMG) system design and development has created more influences on the system investment flows and environmental pollutant mitigation. Here, the hybrid micro-grid model has been developed with necessary multi-objective functions and operating constraints. The optimum techno-economic feasibility analysis has been carried out with an energy-balanced loss of load probability algorithm, which proved that the planned energy management system has a highly commendable and efficient configuration to achieve good system performance with viable economics for a sustainable energy society.

Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.

To identify CT parameters useful for assessment of pulmonary hypertension (PH) in patients with severe aortic stenosis (AS).Retrospective study of 165 patients who had undergone right heart catheterization (RHC), and CTA of the thorax for preoperative aortic valve replacement (TAVR) planning. These were divided into groups based on mean pulmonary artery (PA) pressure (mPAP) of 25 mm Hg on RHC (85 cases and 80 controls). Diameters of main pulmonary artery diameter (MPAD), left pulmonary artery (LPA), right pulmonary artery (RPA), and maximal long axis and short axis diameters of the right atrium (RA) and ventricle (RV) were measured on the axial plane. Univariate and multivariate statistical analysis was utilized to identify metrics predictive of PH.MPAD, LPA, and RPA were higher in subjects with mPAP25 mm Hg (p 0.0001 for all). Thresholds of 30.5 mm for MPAD (68.4% sensitivity, 82.7% specificity), and 27.5 mm for LPA and RPA (LPA: 51.9% sensitivity, 78.8% specificity; RPA: 62.0% sensitivity, 78.8% specificity) provided the best discrimination of elevated mPAP. Compared to literature values for MPAD (28.9 mm in men and 26.9 mm in women), these thresholds provide lower sensitivity but greatly increased specificity. Inclusion of RA enlargement to MPAD increased specificity to 98.5%, while inclusion of RV enlargement increased specificity to 100%.Threshold to identify PH in patients with AS using PA enlargement is higher than previously reported range for normal. Inclusion of RA and RV enlargement improves the ability of CT to more accurately identify PH in patients with AS.

Background Bone fractures are a global public health issue; however, to date, no comprehensive study of their incidence and burden has been done. We aimed to measure the global, regional, and national incidence, prevalence, and years lived with disability (YLDs) of fractures from 1990 to 2019. Methods Using the framework of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we compared numbers and age-standardised rates of global incidence, prevalence, and YLDs of fractures across the 21 GBD regions and 204 countries and territories, by age, sex, and year, from 1990 to 2019. We report estimates with 95% uncertainty intervals (UIs). Findings Globally, in 2019, there were 178 million (95% UI 162-196) new fractures (an increase of 33.4% [30.1-37.0] since 1990), 455 million (428-484) prevalent cases of acute or long-term symptoms of a fracture (an increase of 70.1% [67.5-72.5] since 1990), and 25.8 million (17.8-35.8) YLDs (an increase of 65.3% [62.4-68.0] since 1990). The age-standardised rates of fractures in 2019 were 2296.2 incident cases (2091.1-2529.5) per 100 000 population (a decrease of 9.6% [8.1-11.1] since 1990), 5614.3 prevalent cases (5286.1-5977.5) per 100 000 population (a decrease of 6.7% [5.7-7.6] since 1990), and 319.0 YLDs (220.1-442.5) per 100 000 population (a decrease of 8.4% [7.2-9.5] since 1990). Lower leg fractures of the patella, tibia or fibula, or ankle were the most common and burdensome fracture in 2019, with an age-standardised incidence rate of 419.9 cases (345.8-512.0) per 100 000 population and an age-standardised rate of YLDs of 190.4 (125.0-276.9) per 100 000 population. In 2019, age-specific rates of fracture incidence were highest in the oldest age groups, with, for instance, 15 381.5 incident cases (11 245.3-20 651.9) per 100 000 population in those aged 95 years and older. Interpretation The global age-standardised rates of incidence, prevalence, and YLDs for fractures decreased slightly from 1990 to 2019, but the absolute counts increased substantially. Older people have a particularly high risk of fractures, and more widespread injury-prevention efforts and access to screening and treatment of osteoporosis for older individuals should help to reduce the overall burden. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.

Background Liver transplant recipients are at lifelong risk of immunosuppression-related cutaneous complications, such as malignancy and infection. Objective Our study aims to assess the epidemiology of dermatologic conditions among liver transplant recipients in an academic medical center in Singapore. Methods Medical records of liver transplant recipients on follow-up with gastroenterology and dermatology departments at the Singapore General Hospital between 2006 and 2021 were retrospectively reviewed. A literature review was subsequently performed on the keywords "liver transplant" and "dermatology." Results A total of 99 liver transplant recipients were identified in this study. Sixty-nine patients (70%) had at least 1 dermatologic condition. Inflammatory skin conditions were the most common (53%), followed by cutaneous infection (36%) and benign cutaneous tumors (30%). Malignant and premalignant lesions were the least common skin conditions reported (10%). Our study results concurred with many other studies reported worldwide, demonstrating a low cutaneous malignancy burden after liver transplantation. Limitations The study included a small population size in a single center and did not have a pre-existing protocol for pretransplant dermatologic surveillance. Conclusion Although the incidence of skin cancer after liver transplant in Singapore is low, the patients will benefit from long-term dermatology surveillance, given the long-term risks of infection and malignant skin conditions.

Aims To evaluate the acute and chronic patterns of myocardial injury among patients with coronavirus disease-2019 (COVID-19), and their mid-term outcomes. Methods and results Patients with laboratory-confirmed COVID-19 who had a hospital encounter within the Mount Sinai Health System (New York City) between 27 February 2020 and 15 October 2020 were evaluated for inclusion. Troponin levels assessed between 72 h before and 48 h after the COVID-19 diagnosis were used to stratify the study population by the presence of acute and chronic myocardial injury, as defined by the Fourth Universal Definition of Myocardial Infarction. Among 4695 patients, those with chronic myocardial injury (n = 319, 6.8%) had more comorbidities, including chronic kidney disease and heart failure, while acute myocardial injury (n = 1168, 24.9%) was more associated with increased levels of inflammatory markers. Both types of myocardial injury were strongly associated with impaired survival at 6 months [chronic: hazard ratio (HR) 4.17, 95% confidence interval (CI) 3.44–5.06; acute: HR 4.72, 95% CI 4.14–5.36], even after excluding events occurring in the first 30 days (chronic: HR 3.97, 95% CI 2.15–7.33; acute: HR 4.13, 95% CI 2.75–6.21). The mortality risk was not significantly different in patients with acute as compared with chronic myocardial injury (HR 1.13, 95% CI 0.94–1.36), except for a worse prognostic impact of acute myocardial injury in patients Conclusion Chronic and acute myocardial injury represent two distinctive patterns of cardiac involvement among COVID-19 patients. While both types of myocardial injury are associated with impaired survival at 6 months, mortality rates peak in the early phase of the infection but remain elevated even beyond 30 days during the convalescent phase.

β-phase gallium oxide (Ga2O3) is an emerging ultrawide bandgap (UWBG) semiconductor (EG ∼ 4.8 eV), which promises generational improvements in the performance and manufacturing cost over today's commercial wide bandgap power electronics based on GaN and SiC. However, overheating has been identified as a major bottleneck to the performance and commercialization of Ga2O3 device technologies. In this work, a novel Ga2O3/4H-SiC composite wafer with high heat transfer performance and an epi-ready surface finish has been developed using a fusion-bonding method. By taking advantage of low-temperature metalorganic vapor phase epitaxy, a Ga2O3 epitaxial layer was successfully grown on the composite wafer while maintaining the structural integrity of the composite wafer without causing interface damage. An atomically smooth homoepitaxial film with a room-temperature Hall mobility of ∼94 cm2/Vs and a volume charge of ∼3 × 1017 cm-3 was achieved at a growth temperature of 600 °C. Phonon transport across the Ga2O3/4H-SiC interface has been studied using frequency-domain thermoreflectance and a differential steady-state thermoreflectance approach. Scanning transmission electron microscopy analysis suggests that phonon transport across the Ga2O3/4H-SiC interface is dominated by the thickness of the SiNx bonding layer and an unintentionally formed SiOx interlayer. Extrinsic effects that impact the thermal conductivity of the 6.5 μm thick Ga2O3 layer were studied via time-domain thermoreflectance. Thermal simulation was performed to estimate the improvement of the thermal performance of a hypothetical single-finger Ga2O3 metal-semiconductor field-effect transistor fabricated on the composite substrate. This novel power transistor topology resulted in a ∼4.3× reduction in the junction-to-package device thermal resistance. Furthermore, an even more pronounced cooling effect is demonstrated when the composite wafer is implemented into the device design of practical multifinger devices. These innovations in device-level thermal management give promise to the full exploitation of the promising benefits of the UWBG material, which will lead to significant improvements in the power density and efficiency of power electronics over current state-of-the-art commercial devices.

AIM The aim of the study is (a) To use collagen as a pulpotomy material in comparison with the gold standard formocresol-based pulpotomy, (b) to assess the clinical and radiographic success rate of formocresol pulpotomy and collagen-based pulpotomy, and (c) to compare the success rate of formocresol-based pulpotomy and collagen-based pulpotomy over a definitive interval of time. MATERIALS AND METHODS Totally 30 primary first or second molars indicated for pulpotomy after confirming with the operative diagnosis were taken as samples for this study. This split-mouth technique consists of two groups: Group 1-formocresol pulpotomy (n = 15), and group 2-collagen-based pulpotomy (n = 15). Both the procedures were done in the same patient on regular appointments. Pre- and postoperative radiographs were taken. The children were recalled for clinical and radiographic follow-up at 2, 4, and 6 months. The success of the procedure was assessed based on clinical signs (pain, tenderness to percussion, abscess, swelling, fistula, and pathologic mobility) and radiographic findings (radicular radiolucency, internal and external root resorption, periodontal ligament (PDL) space widening, and furcation radiolucency). The Chi-square test was used to compare the differences between the groups. RESULT The overall success rate for formocresol pulpotomy (n = 15) was 14, 13, and 10 for the second-, fourth-, and sixth-month review period, respectively. For collagen pulpotomy group (n = 15), the overall success rate was 14, 14, and 14 for the second-, fourth-, and sixth-month review period, respectively. The obtained data from the overall success rate were subjected to statistical analysis, and chi-square test was used. The p-value less than 0.1 was considered a statistically significant result. The chi-square value for the fourth- and sixth-month review was 0.37 and 3.33, respectively. CONCLUSION Statistically significant value was obtained from the sixth-month review period (p

Heteroepitaxy of β-phase gallium oxide (β-Ga2O3) thin films on foreign substrates shows promise for the development of next-generation deep ultraviolet solar blind photodetectors and power electronic devices. In this work, the influences of the film thickness and crystallinity on the thermal conductivity of (201)-oriented β-Ga2O3 heteroepitaxial thin films were investigated. Unintentionally doped β-Ga2O3 thin films were grown on c-plane sapphire substrates with off-axis angles of 0° and 6° toward ⟨1120⟩ via metal-organic vapor phase epitaxy (MOVPE) and low-pressure chemical vapor deposition. The surface morphology and crystal quality of the β-Ga2O3 thin films were characterized using scanning electron microscopy, X-ray diffraction, and Raman spectroscopy. The thermal conductivities of the β-Ga2O3 films were measured via time-domain thermoreflectance. The interface quality was studied using scanning transmission electron microscopy. The measured thermal conductivities of the submicron-thick β-Ga2O3 thin films were relatively low as compared to the intrinsic bulk value. The measured thin film thermal conductivities were compared with the Debye-Callaway model incorporating phononic parameters derived from first-principles calculations. The comparison suggests that the reduction in the thin film thermal conductivity can be partially attributed to the enhanced phonon-boundary scattering when the film thickness decreases. They were found to be a strong function of not only the layer thickness but also the film quality, resulting from growth on substrates with different offcut angles. Growth of β-Ga2O3 films on 6° offcut sapphire substrates was found to result in higher crystallinity and thermal conductivity than films grown on on-axis c-plane sapphire. However, the β-Ga2O3 films grown on 6° offcut sapphire exhibit a lower thermal boundary conductance at the β-Ga2O3/sapphire heterointerface. In addition, the thermal conductivity of MOVPE-grown (201)-oriented β-(AlxGa1-x)2O3 thin films with Al compositions ranging from 2% to 43% was characterized. Because of phonon-alloy disorder scattering, the β-(AlxGa1-x)2O3 films exhibit lower thermal conductivities (2.8-4.7 W/m·K) than the β-Ga2O3 thin films. The dominance of the alloy disorder scattering in β-(AlxGa1-x)2O3 is further evidenced by the weak temperature dependence of the thermal conductivity. This work provides fundamental insight into the physical interactions that govern phonon transport within heteroepitaxially grown β-phase Ga2O3 and (AlxGa1-x)2O3 thin films and lays the groundwork for the thermal modeling and design of β-Ga2O3 electronic and optoelectronic devices.

Development of pulmonary AV fistula (PAVF) after bidirectional glenn shunt (BDG) results in significant cyanosis, impaired exercise performance, and increased morbidity and mortality. We attempted to detect and quantify PAVF in post-BDG patients by saline contrast transesophageal echocardiography (TEE) and compare with pulmonary angiography and pulmonary vein oximetry. This was a prospective study done between 2017 and 2018. Twenty-five children who underwent BDG and planned for cardiac catheterization prior to Fontan completion were included in the study. All patients underwent pulmonary angiography, oximetry, and saline contrast TEE at the time of cardiac catheterization. Twenty-two patients had undergone unilateral BDG surgery and three were palliated by bilateral BDG. The mean oxygen saturation was 80 ± 5.2%. Thirteen patients (52%) had preserved antegrade pulmonary blood flow. Eighteen patients (72%) had PAVF by angiography and oximetry, while 19 (76%) had PAVF identified by contrast echocardiography. There was moderate correlation between the degree of pulmonary venous desaturation and grading of PAVF by contrast echocardiography. PAVF was predominantly located in the lower zones of the lungs. Higher grades of PAVF were not seen in patients with preserved antegrade flow after BDG. Angiographically detected PAVF showed a steady increase with increasing delay to cardiac catheterization from BDG. Significant reduction in systemic saturation was limited to advanced grades of PAVF in patients after BDG. Saline contrast TEE, pulmonary venous oximetry, and pulmonary angiography equally identified PAVF in patients after BDG. Prognostic utility of the same needs to be assessed by long-term follow-up of these subjects.

A compact 4 element MIMO antenna operating in three Sub-6 GHz 5G bands is proposed. The single element antenna consists of a square-shaped patch where circular and rectangular-shaped slot cuts are incorporated. The single element is symmetrically arranged along the horizontal direction and in mirrored fashion along the vertical and diagonal direction. The 4 element MIMO antenna achieves a symmetric structure on top with the connected ground at back. With no extra isolation element, the proposed FR-4 based design achieves compact size of 0.39λ02 (f0 = 3.72 GHz) operating in three frequency bands ranging from (2.65%) 3.72–3.82 GHz, (2.33%) 4.65–4.76 GHz and (4.75%) 6.16–6.46 GHz. The satisfactory isolation amongst inter-elements (≥ 16 dB) with directional radiation pattern and an average gain of 2.5 dBi is attained for proposed bands. Furthermore, the antenna meets the MIMO diversity criteria by achieving DG > 9.7, ECC

Timely detection of intruders ensures the safety and security of high valued assets within a protected area. This problem takes on particular significance across international borders and becomes challenging when the terrain is porous, rugged and treacherous in nature. Keeping an effective vigil against intruders on large tracts of land is a tedious task; currently, it is primarily performed by security personnel with automatic detection systems in passive supporting roles. This paper discusses an alternate autonomous approach by utilizing one or more Unmanned Vehicles (UVs), aided by smart sensors on the ground, to detect and localize an intruder. To facilitate autonomous UV operations, the region is equipped with Unattended Ground Sensors (UGSs) and laser fencing. Together, these sensors provide time-stamped location information (node and edge detection) of the intruder to a UV. For security reasons, we assume that the sensors are not networked (a central node can be disabled bringing the whole system down) and so, the UVs must visit the vicinity of the sensors to gather the information therein. This makes the problem challenging in that pursuit must be done with local and likely delayed information. We discretize time and space by considering a 2D grid for the area and unit speed for the UV, i.e. it takes one time unit to travel from one node to an adjacent node. The intruder is slower and takes two time steps to complete the same move. We compute the min–max optimal, i.e. minimum number of steps to capture the intruder under worst-case intruder actions, for different number of rows and columns in the grid and for both one and two pursuers.

Posterior Nut Cracker Syndrome (PCNS) is a rare clinical condition that occurs when the left renal vein gets compressed between the abdominal aorta and vertebral body. Posterior nutcracker phenomenon is a common anatomical abnormality, which is totally asymptomatic and diagnosed in a routinely performed abdominal imaging. The pressure gradient that develops between the renal vein and the inferior vena cava is the basic reason for all the features associated with this condition. Left renal venous entrapment would result in stagnation of blood in gonadal vessels that results in cascading effect resulting in a venous congestion and increased resistance to arterial blood flow in the kidney. Patients with pelvic congestion syndrome present with left loin pain and unilateral left varicocele. Gastrointestinal symptoms and arterial hypertension may also be the presenting symptoms. The symptoms depend upon the degree of pressure in renal veins and gonadal veins. When the dilated veins communicate with renal calyx, haematuria occurs. PNCS is best managed based on the severity of symptoms and the extent of clinical manifestations. Treatment options include conservative treatment, intra-vascular stents, chemical cauterisation, open surgical intervention and finally if everything fails, nephrectomy. PCNS is a rare entity that affects mostly females and can present with a variety of signs and symptoms. A high index of clinical suspicion is needed to achieve a prompt diagnosis. Conservative treatment is recommended for patients with mild symptoms. Severely symptomatic patients might benefit from endovascular treatment.

Objectives The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR). Background LG severe AS encompasses a wide variety of pathophysiology, including classical low-flow, LG (LF-LG), paradoxical LF-LG, and normal-flow, LG (NF-LG) AS, and uncertainty exists regarding the impact of AVR on each subclass of LG AS. Methods PubMed and Embase were queried through October 2020 to identify studies comparing survival with different management strategies (SAVR, TAVR, and conservative) in patients with LG AS. Pairwise meta-analysis comparing AVR versus conservative management and network meta-analysis comparing SAVR versus TAVR versus conservative management were performed. Results Thirty-two studies with a total of 6,515 patients and a median follow-up time of 24.2 months (interquartile range: 36.5 months) were included. AVR was associated with a significant decrease in all-cause mortality in classical LF-LG (hazard ratio [HR]: 0.42; 95% confidence interval [CI]: 0.36 to 0.48), paradoxical LF-LG (HR: 0.41; 95% CI: 0.29 to 0.57), and NF-LG (HR: 0.41; 95% CI: 0.27 to 0.62) AS compared with conservative management. SAVR and TAVR were each associated with a decrease in all-cause mortality in classical LF-LG (HR: 0.46 [95% CI: 0.38 to 0.55] and 0.49 [95% CI: 0.37 to 0.64], respectively), paradoxical LF-LG (HR: 0.42 [95% CI: 0.28 to 0.65] and 0.42 [95% CI: 0.25 to 0.72], respectively), and NF-LG (HR: 0.40 [95% CI: 0.21 to 0.77] and 0.46 [95% CI: 0.26 to 0.84], respectively) AS compared with conservative management. No significant difference was observed between SAVR and TAVR. Conclusions In all subclasses of LG AS, AVR was associated with a significant decrease in all-cause mortality regardless of surgical or transcatheter approach.

The COVID-19 infection adversely affects the cardiovascular system. Transthoracic echocardiography has demonstrated diagnostic, prognostic and therapeutic utility. We report biventricular myocardial strain in COVID-19. Methods: Biventricular strain measurements were performed for 12 patients. Patients who were discharged were compared with those who needed intubation and/or died. Results: Seven patients were discharged and five died or needed intubation. Right ventricular strain parameters were decreased in patients with poor outcomes compared with those discharged. Left ventricular strain was decreased in both groups but was not statistically significant. Conclusion: Right ventricular strain was decreased in patients with poor outcomes and left ventricular strain was decreased regardless of outcome. Right ventricular strain measurements may be important for risk stratification and prognosis. Further studies are needed to confirm these findings.

Recent studies using Ga-68-labeled fibroblast activation protein inhibitors (FAPI) PET have shown strong association between focal uptake of FAPI in myocardium and presence of coronary artery disease. We present an interesting case of a 76-year-old female with breast cancer with incidental uptake on FAPI PET in apex and septal wall of left ventricle myocardium correlating with findings of ischemia on dobutamine stress myocardial perfusion imaging and anatomical stenosis on coronary angiography.

The presence of fabrication errors in domain engineered quasi-phase-matching (QPM) device directly affects its performance in a nonlinear optical process. The existence of error in the aspect ratio...

Objective To evaluate trends in the use of epidural analgesia and nonopioid and opioid analgesics for patients undergoing lobectomy from 2009 to 2018. Methods We queried the Premier database for adult patients undergoing open, video-assisted, and robotic-assisted lobectomy from 2009 to 2018. The outcome of interest was changes in the receipt of epidural analgesia and nonopioid and opioid analgesics as measured by charges on the day of surgery. We also evaluated postoperative daily opioid use. We used multivariable logistic and linear regression models to examine the association between the utilization of each analgesic modality and year. Results We identified 86,308 patients undergoing lobectomy from 2009 to 2018 within the Premier database: 35,818 (41.5%) patients had open lobectomy, 35,951 (41.7%) patients had video-assisted lobectomy, and 14,539 (16.8%) patients had robotic-assisted lobectomy. For all 3 surgical cohorts, epidural analgesia use decreased, and nonopioid analgesics use increased over time, except for intravenous nonsteroidal anti-inflammatory drugs. Use of patient-controlled analgesia decreased, while opioid consumption on the day of surgery increased and postoperative opioid consumption did not decrease over time. Conclusions In this large sample of patients undergoing lobectomy, utilization of epidural analgesia declined and use of nonopioid analgesics increased. Despite these changes, opioid consumption on day of surgery increased, and there was no significant reduction in postoperative opioid consumption. Further research is warranted to examine the association of these changes with patient outcomes.

Background Optimizing analgesia after cesarean delivery is a priority and requires balancing adequate pain relief with the risk of analgesics-associated adverse effects. Current recommendations are for use of a multimodal, opioid-sparing analgesic regimen that includes neuraxial morphine combined with scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) and scheduled acetaminophen. Furthermore, recent studies recommend scheduled acetaminophen with as-needed opioids in lieu of acetaminophen-opioid combination drugs to reduce opioid consumption and optimize analgesia. However, the extent of utilization of this recommended regimen in the United States is unclear. We therefore performed this retrospective study to evaluate postoperative analgesic regimens utilized after cesarean delivery under neuraxial anesthesia, examine variability across institutions, evaluate changes over time in postoperative analgesic practice, and examine factors associated with the use of neuraxial morphine and of multimodal analgesia. Methods This retrospective cohort study was approved by the Duke University Institutional Review Board. Parturients who underwent cesarean delivery under neuraxial anesthesia from 2008 to 2018 were included. Data were extracted from a nationwide inpatient administrative-financial database (Premier Inc, Charlotte, NC) and included parturient characteristics, comorbidities, hospital characteristics, and charges for administered medications. The primary outcome was the postoperative analgesic regimen utilized during hospitalization, including utilization of neuraxial morphine and of multimodal analgesia for postoperative pain control. We also examined the factors associated with the use of neuraxial morphine and of the multimodal regimen incorporating neuraxial morphine, NSAIDs, and acetaminophen. Results Data from 804,752 parturients were analyzed. Of this cohort, 75.8% received neuraxial morphine, 93.2% received NSAIDs, 28.4% received acetaminophen, and 81.3% received acetaminophen-opioid combination drugs. Only 6.1% received the currently recommended regimen of neuraxial morphine with NSAIDs and acetaminophen, with this percentage increasing from 1.3% in 2008 to 15.0% in 2018. On the other hand, 58.9% received neuraxial morphine, NSAIDs, and an acetaminophen-opioid combination drug, with this regimen being utilized in 57.0% of cases in 2008 and 58.1% in 2018. The hospital in which the patient was treated accounted for 54.7% of the variation in receipt of neuraxial morphine and 41.2% in the variation in receipt of multimodal analgesia with neuraxial morphine, NSAIDs, and acetaminophen, with this variability in receipt of neuraxial morphine and of multimodal analgesia being largely independent of patient characteristics. Conclusions Relatively few parturients received the currently recommended multimodal analgesic regimen of neuraxial morphine with NSAIDs and acetaminophen after cesarean delivery. Additionally, the majority received acetaminophen-opioid combination drugs rather than plain acetaminophen. Further studies should investigate the implications for patient outcomes.

This paper presents the generation of modes of angular momentum of the orbital type using a proposed array antenna fed with Rotman lens of multiple layers of compact size. The gain of orbital angul...

Since its inception, Healthcare 4.0 has empowered the integration of advanced technologies to create and improve the quality of healthcare services. The delivery of healthcare services has come a long way from physical appointments with doctors to remote health monitoring and disease prediction, surgery assistive systems. This advancement has only been possible because of the integration of cutting-edge technologies like Tele-healthcare, software-defined networking and many more, with healthcare systems. In this survey, we have targeted some of the pioneering research works that could contribute significantly to the future development of Healthcare 4.0 systems. We have identified the significant research gaps and presented the modern state-of-the-art of healthcare systems, introducing the Healthcare IoT Application and Service Stacks. We have also discussed the latest paradigm of Wireless Body Area Networks, emphasizing its significance and how it can contribute to the development of next-generation healthcare applications using emerging technologies like Machine Learning, Blockchain, Cloud Computing, Internet of things, Edge/ Fog Computing, Tele-healthcare, Big Data Analytics, Software-Defined Networking and many more. We have performed a comparative study of different architectural implementations considering their advantages, shortcomings, and quality-of-service requirements. We emphasize the importance of the different emerging technologies in detail, discussing the opportunities available and their potential to create better healthcare solutions that can provide superior service quality. Finally, we highlight the fundamental need for establishing security and privacy in future healthcare systems. Overall, this survey provides a strong outlook into the development of the future of healthcare 4.0.

Background: Symptomatic intracranial atherosclerotic disease (sICAD) is associated with risk of recurrence of cerebral ischemic events in 4-19% of stroke patients annually. Previous studies indicate elevated high-sensitivity C-Reactive Protein (hs-CRP) and lipoprotein-associated phospholipase A2 (Lp-PLA2) to be associated with risk of recurrence. Objective: This prospective, observational study investigated serum levels of hs-CRP and the activity of Lp-PLA2 in patients with sICAD in predicting the risk of long-term stroke recurrence. Methods: We enrolled 48 patients with sICAD at 3 months from onset. The demographics, clinical, and imaging characteristics were recorded. Serum hs-CRP and Lp-PLA2 activity were assessed using automated high-sensitivity C-reactive protein assay and photometric technique, respectively. Patients were followed up at 6 months and 1 year and the presence of new vascular events was recorded. Results: The mean age of our study population was 59.5 ± 10.3 years and 91.7% were men. Four patients developed recurrent strokes during follow-up. The mean Hs-CRP was elevated in patients with events than in patients without events (5.9 ± 10.4 mg/L vs. 1.7 ± 2.4 mg/L, P=0.03). However, there was no significant association of mean Lp-PLA2 activity (118.3±42.9 nmol/min/ml vs. 111.9 ± 34.2 nmol/min/ml, P=0.73) with recurrence. Elevation of hs-CRP (3.02 ± 4.8 mg/L vs. 0.95 ± 0.57mg/L, P=0.02) and Lp-PLA2 activity (120.1±40.3 nmol/min/ml vs. 103.3 ± 23.9 nmol/min/ml, P=0.04) was correlated with high-grade stenosis in these patients. Conclusion: Our study suggests serum levels of hs-CRP may serve as a predictor of long-term stroke recurrence risk in sICAD and elevation of hs-CRP and Lp-PLA2 correlated with the severity of stenosis in symptomatic intracranial atherosclerotic disease.

Contact resistivity quantifies the charge transport barrier, which is one of the key parameters for choosing the carrier selective contact for silicon solar cells. Optically transparent and electrically selective contacts such as transition metal oxide (TMO)-based contacts are employed in solar cell applications. Therefore, the extraction of contact resistivity for such Schottky contacts requires apposite validation. In this article, we have extracted the contact resistivity of TiOx/LiFx/Al stack over n-type c-Si wafer using two conventional techniques: 1) Shockley's transfer length method (TLM) and 2) Cox and Strack method (CSM). The extracted contact resistivity is validated by comparing with the solar cell's contact resistivity ( true contact resistivity) and fill factor (FF). We found that TLM overestimates the contact resistivity for highly resistive TiOx films, due to the asymmetrical nature of the TMO barrier and correlated with the reported experimental data. In contrast, CSM extracts more accurate contact resistivity for TiOx contacts when total resistance is extracted closer to the J mpp (38 mA cm−2). Besides, we recommend including the passivating layer along with the contacts (in the case of passivating contacts) to extract the actual contact resistivity felt by the solar cell.

In the present study, subclinical mastitis (SCM) and clinical mastitis (CM) prevalence for various countries in the World were calculated by using online and offline databases. The SCM and CM prevalence studies reported during 1967-2019 were collected, reviewed, and a meta-analysis was done in R-Software. A total of 222 and 150 studies from the World and 103 and 37 studies from India on SCM and CM, respectively were included. The pooled prevalence of SCM and CM were 42% [Confidence Interval (CI) 38-45%, Prediction Interval (PI) 10-83%] and 15% [CI 12-19%, PI 1-81%] in the World respectively, 45% [CI 40-49%, PI 11-84%] and 18% [CI 14-23%, PI 3-60%] in India respectively. Continent-wise analysis indicated a higher prevalence of SCM in North America and CM in Europe and among the countries, a higher SCM prevalence in Uganda and CM in the United Kingdom was observed. Further, species-wise indicated a higher SCM and CM prevalence in buffaloes of the World than the cattle. Based on method-wise, SCM and CM prevalence were high in somatic cell count and clinical examination, respectively in the World. The SCM prevalence was higher than CM and indicated the importance of SCM in dairy cattle. This might result in low milk productivity in dairying and may set off losses to dairy farmers. Hence, there is an urgent need to reduce the SCM and CM prevalence by implementing scientific dairy management, good feeding practices, and timely therapeutic interventions for increasing the benefits from dairying to the farmers in the World.

Determining the timing of intracranial injuries in general, and abusive head trauma (AHT) in particular, is important to the care of children with traumatic brain injury. Additionally, identifying the time of the injury provides important information as to who might have, and who did not, inflict the trauma. Understanding the appearance and evolution of intracranial findings on neuroimaging has been an important factor in assessing the time of the injury. However, a number of studies in the last two decades have both suggested greater uncertainty about the reliability of this process and advanced our knowledge in this area. In this review, the authors consider the biophysical factors that contribute to the appearance and evolution of intracranial hemorrhage and, in particular, subdural hemorrhage (SDH). The traditional view of SDH is predicated largely on prior studies of intracerebral hemorrhage, although a number of variables make this comparison untenable. Moreover, more recent studies have suggested a number of factors that could alter the density (CT) or signal intensity (MRI) and produce mixed density/intensity SDH. These factors need to be considered in interpreting neuroimaging studies. A number of these recent studies evaluating serial neuroimaging in children with AHT have modified our understanding of intracranial hemorrhage and its evolution in this context. Taken together, the studies to date, having important limitations, provide only broad ranges over which to time injuries. The authors conclude that neuroimaging studies at this time are not likely, in isolation, to be able to accurately pinpoint a specific time of injury; rather, neuroimaging can only provide a range of possible times and should instead be used as a means to supplement or corroborate timing based on clinical presentation and other imaging findings.

Background: Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival. Methods: We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index. Findings: Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3-74·0) in 2000 to 37·1 (33·2-41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8-29·5) in 2000 to 17·9 (16·3-19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05-10·30) in 2000 and 5·05 million (4·27-6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53-4·02]) in 2000 to 48% (2·42 million; 2·06-2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71-0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27-1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35-2·58; 37% [95% UI 32-43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier. Interpretation: Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress. This article was supported by the European Research Council, ERC 848325. Alberto Ortiz was supported by FIS/Fondos FEDER (PI18/01366, PI19/00588, PI19/00815, DTS18/00032, ERA-PerMed-JTC2018 (KIDNEY ATTACK AC18/00064 and PERSTIGAN AC18/00071, ISCIII-RETIC REDinREN RD016/0009). Daniela Ribeiro acknowledges the financial support from the European Union [FEDER funds through COMPETE, POCI-01-0145-FEDER-029253). Joan B Soriano acknowledges support from the Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain Funding: Bill & Melinda Gates Foundation