In this issue of BJOG, Mendoza and colleagues report in an observational study the occurrence of a preeclampsia-like syndrome in six out of eight pregnant patients with novel coronavirus disease (COVID-19) who were admitted to the Intensive Care Unit (ICU) with severe pneumonia (Mendoza M, et al. BJOG 2020). There were no symptoms of preeclampsia amongst the 34 pregnant women who had mild forms of COVID-19. Importantly, the authors recorded not only routine laboratory test results, but also measured biophysical and biochemical markers that are typically altered in women with preeclampsia (uterine artery pulsatility index on Doppler ultrasound, serum soluble fms-like tyrosine kinase-1 [sFLT-1] and placental growth factor [PlGF]). Such markers were normal in five of the six cases, in whom the symptoms of preeclampsia resolved after improvement of the maternal clinical situation.The intriguingly high cumulative incidence of preeclampsia symptoms in women with severe coronavirus disease needs to be interpreted with caution due to the observational nature of the study, the small number of pregnant women with severe infection and the possible role of confounding factors. The normal biomarker results in most cases, nevertheless, suggest that severe coronavirus disease can lead to symptoms that mimic those of preeclampsia in the absence of defective placentation, which is further corroborated by the resolution of the symptoms without the delivery of the placenta when overall clinical improvement occurs. It is plausible that such manifestations are the result of widespread inflammation and endothelial damage, in a process that has been denominated “cytokine storm”, responsible for many of the symptoms of the coronavirus-related organ injury (Mehta P, et al. Lancet 2020;395:1033-34) This mechanism includes activation of inflammation pathways that convert arachidonic acid to prostaglandins, thromboxane and eicosanoids, ultimately provoking significant cytokine release. The cascade of events, however, does not appear to influence the levels of specific preeclampsia angiogenic and anti-angiogenic markers such as sFLT-1 and PlGF.A normal sFLT-1: PlGF ratio in women with clinically suspected preeclampsia can be reliably used predict the short-term absence of disease (Zeisler H, et al. N Engl J Med 2016;374:13-22). Although the definition of preeclampsia has changed over the last 20 years to incorporate less specific clinical features of end-organ damage, biomarkers will likely become part of the disease definition in the years to come or, at least, a valuable tool to select subgroups of women at higher risk of preeclampsia-related morbidity and mortality who require closer monitoring or immediate delivery.While larger cohorts derived from national datasets or international registries of coronavirus disease in pregnancy will be essential to confirm or refute this association, the preliminary data published in this study indicate that delivery during severe coronavirus disease should not be based on preeclampsia symptoms alone, particularly at early gestational ages, and that the use of ultrasound and serum biomarkers such as the sFLT-1: PlGF ratio might help to guide clinical management by distinguishing hypertension and endothelial dysfunction caused by COVID-19-related inflammation from true preeclampsia.No disclosures: A completed disclosure of interest form is available to view online as supporting information.

Water transit time and young water fraction are important metrics for characterizing catchment hydrologic function and understanding solute transport. Hydrological and biogeochemical processes in karst environments are strongly controlled by heterogenous fracture-conduit networks. Quantifying the spatio-temporal variability of water transit time and young water fractions in such heterogeneous hydrogeological systems is fundamental linking discharge and water quality dynamics in the karst critical zone. We used a tracer-aided hydrological model to track the fluxes of water parcels that entered a karst catchment as rainfall, time-stamping each hour of rain input individually. Using this approach, the variability of transit times and water age distributions were estimated in the main landscape units in the karst catchment of Chenqi in Guizhou Province, Southwest China. The estimated mean young water (i.e <~2 months old) fractions were 0.39, 0.31 and 0.10 for output fluxes from the hillslope unit, catchment outlet and slow flow reservoirs (matrix and small fractures), respectively. Marked seasonal variability in sources of runoff generation and associated hydrological connectivity between different conceptual stores were the main drivers of young water fraction dynamics in each landscape unit. The water age and travel time distributions were strongly influenced by the water storage dynamics reflecting catchment wetness conditions. Even though the contribution of young water to runoff was greater, the older water turnover was generally accelerated at moderately high flows during wet season.

Understanding the processes that enable species coexistence has important implications for assessing how ecological systems will respond to global change. Morphology and functional similarity increase the potential for competition, and therefore, co-occurring morphologically similar but genetically unique species are a good model system for testing coexistence mechanisms. We used DNA metabarcoding and High Throughput Sequencing to characterise for first time the trophic ecology of two recently-described cryptic bat species with parapatric ranges, Myotis escalerai and Myotis crypticus. We collected faecal samples from allopatric and sympatric regions and locations to describe the diet both taxonomically and functionally and compare prey consumption with prey availability. The two bat species had similar diets characterised by high arthropod diversity, particularly Lepidoptera, Diptera and Araneae, and a high proportion of prey that is not volant at night, which points to extensive use of gleaning. Diet overlap at the prey-item level was lower in locally sympatric than allopatric locations, supporting trophic shift under fine-scale sympatry. Furthermore, locally sympatric samples of M. escalerai had a marginally lower proportion of not nocturnally volant prey, suggesting that the shift in diet may be driven by a change in foraging mode. Our findings suggest that fine-scale coexistence mechanisms can have implications for maintaining broad-scale diversity patterns. This study highlights the importance of including both allopatric and sympatric populations and choosing meaningful spatial scales for detecting ecological patterns. We conclude that a combination of high taxonomic resolution with a functional approach helps identify patterns of niche shift.

Left ventricular surgical remodeling (LVSR) has been, for long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, manly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes an hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the Authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario

Background: Several factors affect the long-term outcome of Fontan procedure, but a high pulmonary artery pressure is still one of the most important limitation for proceeding to a Fontan circulation. Herein, we present our experience in Fontan patients with high preoperative pulmonary artery pressures. Methods: A retrospective analysis was performed in order to evaluate Fontan patients with a preoperative pulmonary artery pressure > 15 mmHg between 2009 and 2020. Sixteen patients were operated on with a mean preoperative pulmonary artery pressure of 17.5 ± 2.1 mmHg. Results: Mean age at the time of Fontan procedure was 7.8 ± 5.6 years. All of the patients had stage II cavopulmonary anastomosis prior to Fontan completion, with a mean interstage period of 4 ± 2.6 years. Fontan completion was achieved with a polytetrafluorethylene (PTFE) tubular conduit, two of which were intra-extracardiac. Fenestration was performed in 4 (25%) cases. Postoperative pulmonary artery pressures and arterial oxygen saturation levels were 11.2 ± 2.8 mmHg and 97.8 ± 2, respectively. Mean duration of pleural drainage was 3.9 ± 5.3 days. Any morbidity and mortality were not encountered during a mean follow up period of 4.8 ± 7.7 years. Conclusions: The mid-term results of stage III Fontan completion in patients with pulmonary artery >15 mmHg are encouraging. Pulmonary vascular resistance, not only pulmonary artery pressure may help to identify high risk patients before Fontan completion.

Long-term ecological studies have consistently reported slower than expected changes in biodiversity over time. One explanation for this phenomenon is that commonly used diversity measurements such as species richness are too coarse to detect mechanisms shaping community assembly. It remains unclear whether abundance based diversity measurements are susceptible to the same problem. To test this, we study temporal changes in abundance based diversity indices across 3341 observations from 880 plots from 15 long-term vegetation plot studies. We then partition diversity change into mechanisms of interest to ecologists: selection, drift, and immigration. We show that these mechanisms are an imperfect predictor of temporal diversity change, creating a mismatch between changes in species abundances and changes in diversity, particularly when shifts in diversity are rapid. To resolve this mismatch, we quantify a less studied mechanism “rarity shifts”, which measure how an individual’s contributions to diversity changes over time. We found rarity shifts are an important component of diversity change across many studies. Furthermore, rarity shifts tend to oppose other mechanisms, particularly selection. Therefore, rarity shifts obscure changes in relative abundance from abundance based diversity measurements, revealing why diversity changes appear slower than expected. Ultimately, understanding rarity shifts can lead to a more accurate understanding of the rate and nature of temporal diversity change in ecology and conservation.

Plant community productivity generally increases with biodiversity, but the strength of this relationship exhibits strong empirical variation. In meta-food-web simulations, we addressed if the spatial overlap in plants' resource access and movement of animals can explain such variability. We found that spatial overlap of plant resource access is a prerequisite for positive diversity-productivity relationships, but causes exploitative competition that can lead to competitive exclusion. Movement of herbivores causes apparent competition among plants, resulting in negative relationships. However, movement of larger top predators integrates sub-food-webs composed of smaller species, offsetting the negative effects of exploitative and apparent competition and leading to strongly positive diversity-productivity relationships. Overall, our results show that spatial overlap of plant resource access and animal movement can greatly alter the strength and sign of such relationships. In particular, the scaling of animal movement effects opens new perspectives for linking landscape processes without effects on biodiversity to productivity patterns.

Introduction. The concept of ventricular anatomy as a single muscular band was initially described by Francisco Torrent-Guasp in 1972 1 and since then, there have been multiple novel contributions to the understanding of the morphology and function of the heart. To date, this concept has been supported and denied by multiple groups of professionals reflecting both the enthusiasm and resistance to the new concept of the single muscle band model. Currently, the single muscular band is the model that meets all the requirements to explain the performance of cardiac mechanics, and its distinctive feature to determine the characteristics of the structure.

In this study, we investigate the sum-type singular nonlinear fractional q-integro-differential $m$-point boundary value problem. The existence of positive solutions is obtained by the properties of the Green function, standard Caputo $q$-derivative, Riemann-Liouville fractional $q$-integral and the means of a fixed point theorem on a real Banach space $(\mathcal{X}, \|.\|)$ which has a partially order by using a cone $P \subset \mathcal{X}$. The proofs are based on solving the operator equation $\mathcal{O}_1 x + \mathcal{O}_2 x = x $ such that the operator $\mathcal{O}_1$, $\mathcal{O}_2$ are $r$-convex, sub-homogeneous, respectively and define on cone $P$. As applications, we provide an example illustrating the primary effects.

The newly generalized energy storage component namely memristor is a fundamental circuit element so called universal charge-controlled mem-element is proposed for controlling the analysis and coexisting attractors. The governing differential equations of memristor are highly non-linear for mathematical relationships. The mathematical model of memristor is established in terms of newly defined fractal-fractional differential operators so called Atangana-Baleanu, Caputo-Fabrizio and Caputo fractal-fractional differential operator. A novel numerical approach is developed for the governing differential equations of memristor on the basis of Atangana-Baleanu, Caputo-Fabrizio and Caputo fractal-fractional differential operator. We discussed chaotic behavior of memristor under three criteria as (i) varying fractal order, we fixed fractional order, (ii) varying fractional order, we fixed fractal order and (ii) varying fractal and fractional orders simultaneously. Our investigated graphical illustrations and simulated results via MATLAB for the chaotic behaviors of memristor suggest that newly presented Atangana-Baleanu, Caputo-Fabrizio and Caputo fractal-fractional differential operator has generates significant results as compared with classical approach.

The paper is devoted to the Stackelberg control of a linear parabolic equation with missing initial conditions. The strategy involves two controls called follower and leader. The objective of the follower is to bring the state to a desired state while the leader has to bring the system to rest at the final time. The results are obtained by means of Fenchel-Legendre transform and appropriate Carleman inequalities.

Background: The transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is complex and multifactorial. We aimed to identify the risk factors for infection among the household contacts of index patients and to determine the incubation period, serial interval, and estimates of secondary infection rate. Methods: We conducted a study in three districts of Kerala among the inhabitants of households of reverse transcriptase polymerase chain reaction (RT-PCR)-positive coronavirus disease (COVID-19) patients between January and July 2021. COVID-19-positive patients and corresponding contacts were enrolled and followed up for 28 days to determine RT-PCR positivity and the presence of total antibodies against SARS-CoV-2 on days 1, 7, 14, and 28 from the date of enrolment. Results: The mean incubation period, serial interval, and generation time were 1.6, 3, and 3.9 days, respectively. The secondary infection rate was 43.0%. Individuals who worked outside the home were protected, whereas those who had kissed the COVID-19-positive patients during illness were more than twice at risk of infection than those who had not kissed the COVID-19-positive patients. Similarly, the contacts who had shared a toilet with the COVID-19-positive patients were more at risk than those who had not shared a toilet. However, the contacts who reported using masks were at a higher risk of infection in household settings. Conclusions Assessment of SARS-CoV-2 transmission in household settings is important, considering its high secondary infection rate. Close physical contact and toilet sharing increase the risk of infection. This study demonstrates shorter incubation period and serial interval.

Genome sequencing(GS) has been applied in the diagnosis of global developmental delay(GDD)/intellectual disability(ID). However, the performance in those with inconclusive results from chromosomal microarray analysis(CMA) and exome sequencing(ES) is unknown. We recruited 100 pediatric GDD/ID patients from multiple sites in China from February 2018 to August 2020 for GS. Patients have received at least one genomic diagnostic test prior to enrollment. Reanalysis of CMA/ES data was performed. The yield of GS was calculated and explanations for missed diagnoses by CMA/ES were investigated. Clinical utility was assessed by interviewing the parents by phone. The overall diagnostic yield of GS was 23%. Seven families could have been solved with reanalysis of ES data. 13 families were missed by previous CMA/ES due to improper method. Three remained unsolved after ES reanalysis due to allele dropout, complex variants missed by ES, and a CNV in untranslated regions. Follow-up of the diagnosed families revealed that nine families experienced changes in clinical management, including identification of targeted treatments, cessation of unnecessary treatment, and considerations for family planning. GS demonstrated high diagnostic yield and clinical utility in this cohort of undiagnosed GDD/ID patients, detecting a wide range of variant types of different sizes in a single workflow.

Objectives: Our primary objective to determine the cumulative retention of Ob/Gyns since the inception of the program, to determine the demographic and practice characteristics of all Ob/Gyns who have been trained by the Ghana postgraduate Ob/Gyn programs, and to compare the geographic distribution of Ob/Gyns throughout Ghana between 2010 when a prior study was conducted and the current practice locations of all graduates in 2017. Design: Cross-sectional, Quantitative Investigation Setting: Fieldwork for this study was conducted in Ghana between June 21, 2017, and August 20, 2017. Methods: A roster of certified Ob/Gyns, year certified, and email contact information was obtained from the Ghana College of Physicians and Surgeons, a roster of practice locations was obtained from Ghana Medical Board. Main Outcome Measures: retention of Ob/Gyns, geographic distribution of providers, fand comparisons between 2010 and 2017 Results: Significant geographic spread and increase in in-country medical programs have occurred over the seven-year period. In recent years, the Ghana College of Physicians and Surgeons surpassed that of the West African College of Surgeons. Conclusion: Establishing an Ob/gyn training program with national certification provides a cadre of certified Ob/Gyns that can be trained and retained in low-income settings. Moreover, this allows for long term commitment in multiple relevant sectors that may serve to establish a comprehensive obstetric and gynecology capacity beyond urban centers.

Background: Serotonin syndrome is a potentially life-threatening syndrome with manifestations spanning from mild adverse effects to life-threatening toxicity. The syndrome is caused by overstimulation of serotonin receptors by serotonergic drugs. Since the use of serotonergic drugs is increasing, primarily due to the widespread use of selective serotonin reuptake inhibitors, cases of serotonin syndrome have likely seen a parallel increase. The true incidence of serotonin syndrome remains unknown due to its diffuse clinical presentation. Objectives: This review aims to provide a clinically focused overview of serotonin syndrome, covering its pathophysiology, epidemiology, clinical manifestations, diagnostic criteria, differential diagnosis, and treatment as well as classifying serotonergic drugs and their mechanism of action. The pharmacological context is emphasized, as it is crucial for detection and management of serotonin syndrome. Methods: Focused review based on a literature search using the PubMed database. Findings and conclusion: Serotonin syndrome can occur through therapeutic use or overdose of a single serotonergic drug, or as a drug interaction between two or more serotonergic drugs. Central clinical features consist of neuromuscular excitation, autonomic dysfunction and altered mental status, occurring in a patient undergoing new or altered serotonergic therapy. Early clinically recognition and treatment are crucial to prevent significant morbidity.

Abstract Background: Transthoracic echocardiography (TTE) in prone position is challenging. Innovative use of transesophageal echocardiography (TEE) probe to perform TTE for such patients was described; but reproducibility and correlation of the TTE measurements by this technique with those obtained by the standard supine TTE study are still unknown. Methods: We enrolled 30 non-COVID-19 individuals, with a mean (SD) age 35 (10.9) years and 11 females, to study the agreement between the transthoracic measurements of the left ventricular (LV), left atrial (LA) and aortic dimensions obtained in prone position using an external TEE probe versus the standard supine position using the conventional TTE probe. Results: There were no significant differences between LV end-diastolic and end-systolic diameters, septal wall thickness, posterior wall thickness and aortic root dimensions in the prone versus the supine positions. While the mean ejection fraction (EF) (60.3% vs. 63.1%, P = 0.014) and mean LA dimensions (1.8 vs. 1.9 cm/m2, P < 0.001) were significantly lower in the prone position. The mean time of scans was significantly longer in the prone as compared to the supine (12.5 vs 4.5 minutes, P < 0.001). All supine studies had good quality while in the prone position 4 studies were of poor quality, and one was non-diagnostic. Conclusions: Assessment of cardiac dimensions and systolic function in the prone position using transthoracic TEE probe was feasible. LV and aortic dimensions agreed well with the standard TTE in supine position, however, LA dimensions and EF were lower in the prone position.

Plant pathogens often adapt to plant genetic resistance so characterization of the architecture under-lying such an adaptation is required to understand the adaptive potential of pathogen populations. Erosion of banana quantitative resistance to a major leaf disease caused by polygenic adaptation of the causal agent, the fungus Pseudocercospora fijiensis, was recently identified in the northern Caribbean region. Genome scan and quantitative genetics approaches were combined to investigate the adaptive architecture underlying this adaptation. Thirty-two genomic regions showing host se-lection footprints were identified by pool sequencing of isolates collected from seven plantation pairs of two cultivars with different levels of quantitative resistance. Individual sequencing and phenotyping of isolates from one pair revealed significant and variable levels of correlation be-tween haplotypes in 17 of these regions with a quantitative trait of pathogenicity (the diseased leaf area). The multilocus pattern of haplotypes detected in the 17 regions was found to be highly varia-ble across all the population pairs studied. These results suggest complex adaptive architecture un-derlying plant pathogen adaptation to quantitative resistance with a polygenic basis, redundancy, and a low level of parallel evolution between pathogen populations. Candidate genes involved in quantitative pathogenicity and host adaptation of P. fijiensis were highlighted in genomic regions combining annotation analysis with available biological data.

Background: Saudi Arabia (SA) reported its first case of COVID-19 on 2 March 2020. Mortality varied nationwide: by 14 April 2020 Medina had 16% of SA’s total COVID-19 cases and 40% of all COVID-19 deaths. A team of epidemiologists investigated to identify factors impacting survival. Methods: We reviewed medical records from two hospitals: Hospital A in Medina and Hospital B in Dammam. All patients with a registered COVID-related death between 1 March -22 April 2020 were included. We collected data on demographics, chronic health conditions, clinical presentation and treatment. We analysed data using SPSS. Results: We identified 76 cases: 38 cases from each hospital. More fatalities were among non-Saudis at Hospital A (89%) versus Hospital B (82%, p<.001). Hypertension prevalence was higher among cases at Hospital A (42%) versus Hospital B (21%) (p<.05). We found statistically significant differences (p<.05) in symptoms at initial presentation among cases at Hospital A versus Hospital B, including: body temperature (38º C vs 37º C), heart rate (104 bpm vs 89 bpm), and regular breathing rhythms (61% vs 55%). Less cases (50%) at Hospital A received heparin versus Hospital B (97%, p-value< 0.001). Conclusion: Patients who died at Hospital A typically presented with more severe illness and were more likely to have underlying health conditions. Migrant workers may be at increased risk due to poorer baseline health and reluctance to seek care. This highlights the importance of cross-cultural outreach to prevent deaths. Health education efforts should be multilingual and accommodate all literacy levels.