Phylogenetic trees have been extensively used in community ecology. However, how the phylogenetic reconstruction affects ecological inferences is poorly understood. In this study, we reconstructed three different types of phylogenetic trees (a synthetic-tree generated using VPhylomaker, a barcode-tree generated using rbcL+matK+trnH-psbA and a genome-tree generated from plastid genomes) that represented an increasing level of phylogenetic resolution among 580 woody plant species from six dynamic plots in subtropical evergreen broadleaved forests of China. We then evaluated the performance of each phylogeny in estimations of community phylogenetic structure, turnover and phylogenetic signal in functional traits. As expected, the genome-tree was most resolved and most supported for relationships among species. For local phylogenetic structure, the three trees showed consistent results with Faith’s PD and MPD; however, only the synthetic-tree produced significant clustering patterns using MNTD for some plots. For phylogenetic turnover, contrasting results between the molecular trees and the synthetic-tree occurred only with nearest neighbor distance. The barcode-tree agreed more with the genome-tree than the synthetic-tree for both phylogenetic structure and turnover. For functional traits, both the barcode-tree and genome-tree detected phylogenetic signal in maximum height, but only the genome-tree detected signal in leaf width. This is the first study that uses plastid genomes in large-scale community phylogenetics. Our results highlight the outperformance of genome-trees over barcode-trees and synthetic-trees for the analyses studied here. Our results also point to the possibility of Type I and II errors in estimation of phylogenetic structure and turnover and detection of phylogenetic signal when using synthetic-trees.

Abstract Objective Surgery is the main treatment of visual loss related to cataracts. There are multiple intraocular lens (IOL) options with certain advantages. Patient education on IOL types is necessary to achieve a successful shared decision making process and meet the expectations of the individual patient. Decision aids (DAs) are used for patient education and we developed a novel DA to assist patients during IOL type selection for their cataract surgery. Methods The Ottawa Personal Decision Guide and the ‘Workbook on Developing and Evaluating Patient Decision Aids’ were used in the development of this DA. General characteristics of cataracts, surgical treatment, and details including advantages and disadvantages of varying IOLs were included in the content of the DA. The DA was further evaluated by 3 physicians (Delphi assessment- International Patient Decision Aid Standards (IPDAS) Collaboration standards) and 25 patients (questionnaire of 6 questions with Five-point Likert scale). Results The DA was finalized with feedbacks from the experts. A total score of 50/54 was achieved in Delphi group assessment. Patient perception of the DA was favorable and patients also recommended its use by other patients. Conclusions This novel DA to assist IOL selection for cataract surgery was well accepted by the patients. There is a potential to improve patients’ level of knowledge and diminish decisional conflicts. This potential can also increase patients’ contribution on the shared decision making process. A further prospective randomized trial to compare with the standard patient informing process is also planned.

Background: The aim of this study is to evaluate the importance of ischemia changed albumin, in foreseeing fetal asphyxia and comparing it between normal and preeclamptic pregnant. Method: We planned our study as a prospective case-controlled study between May 2011 and June 2013. We recruited 104 pregnant women complicated by preeclampsia and 110 healthy pregnant women in the study. Doppler ultrasonography, non-stress test and fetal biometric measurements were performed. Venous blood samples taken to measure ischemia modified albumin (IMA). The presence of fetal hypoxia/acidosis was analyzed by conducting post-natal cord blood gas examination and 1.-5. minutes APGAR scoring. Results: IMA levels in the preeclamptic group were found statistically high (p<0,0001). The correlations between umbilical artery doppler systolic/diastolic (S/D) ratio, brain sparing effect, non stress test and IMA analyzed. We have found IMA statistically high when S/D ratio is above 2 standard deviations (preeclampsia; 11.83±1.33 vs 19.62±1.56 p<0.001, control; 10.28±1.57 vs 18.09±2.13 p<0.001) or brain sparing effect started (preeclampsia; 25.59±2.48 vs 9.16±1.99 p<0.001, control; 16.37±1.97 vs 6.72± 1.53 p<0.001) or abnormal NST findings occurred (preeclampsia; 10.69±1.92 vs 20.72±1.15 p<0.001, control; 7,42±1,94 vs 9,72±2,19 p<0.001). Conclusions: Maternal IMA levels are found high in preeclamptic pregnant women and it can be used as a biomarker for determining fetal wellbeing. What’s already known about this topic? Hypertensive disease of pregnancy is the most frequently complication of pregnancy, being 5-10%. It is the most important reason for perinatal morbidity and mortality. Preeclampsia develops in an abnormal hypoxic intrauterine environment characterized by reperfusion and oxidative stress. To determine the fetal wellbeing, various tests were suggested, yet many of them provided a few benefits. What does this article add? The detected elevations in serum concentrations of IMA propose that measurements of this biomarker may be useful in assessing fetal hypoxia and predicting pregnancies which preeclampsia may develop

Double chambered left ventricle is an exceedingly rare congenital anomaly. We report a case diagnosed prenatally at 24 weeks of gestation and its postnatal evolution to left ventricular dysfunction.

Pseudoaneurysms of the aorta are rare complications of cardiac surgery, and sternal re-entry to address the pathology is particularly challenging. In this case, we describe a rare presentation of thoracic aortic pseudoaneurysm due to chronic erosion from a sternal wire, 10 years following the index operation. The patient was treated in two-stages, including carotid-subclavian bypass, followed by sternal re-entry with total arch replacement and frozen elephant trunk, employing cardiopulmonary bypass via femoral and axillary cannulation. Despite the high risks of rupture/haemorrhage associated with sternal re-entry, operative success for aortic pseudoaneurysms can be achieved with careful planning and safe bypass strategies.

Clinical Images:

Microalgae have emerged as one of the most promising options for biodiesel production over the past few decades. Lipid extraction from microalgae for biodiesel production as a bottleneck of biodiesel production technology was the main purpose of this study. In this study different methods of the cell wall disruption were compared. Then, two methods of ultrasound and bead mill were used as methods of the cell wall disruption. The maximum lipid extracted by ultrasound was 17.10% and by bead mill was 15.16% (based on microalgae biomass dry weight). After the cell wall disruption of microalgae, for lipid extraction, chloroform-methanol solvent combination was used as a high extraction method and hexane-ethanol solvent combination was used as an environmentally friendly method. In this regard, the effect of solvent to biomass ratio, temperature and extraction time was investigated and the optimal results for chloroform-methanol solvent combination were 8 ml/g, 45°C and 60 minutes, respectively, and for hexane-ethanol combination were 6 ml/g, 35◦C and 73 minutes, respectively. Under these optimal conditions, the highest amount of extracted lipid from Chlorella vulgaris with a moisture content of 87.50%, and ultrasound as a cell wall disruption method were obtained 20.39% and 16.41% (based on microalgae dry weight) with a combination of chloroform-methanol solvents and hexane-ethanol respectively. Also the highest extraction rates of 17.63% and 13.85% were obtained for the combination of chloroform-methanol and hexane-ethanol solvents, respectively by bead milling as cell wall disruption method

Background: The ability to perceive bronchial obstruction is variable in asthma. This is one of the main causes of inaccurate asthma control assessment, on which therapeutic strategies are based. Objective: Primary: To evaluate the ability of a clinical and spirometric telemonitoring device to characterize symptom perception profile in asthmatic children. Secondary: To evaluate its impact on asthma management (control, treatment, respiratory function variability) and the acceptability of this telemonitoring system. Method: 26 asthmatic children aged 6-18 years equipped with a portable spirometer and a smartphone application were monitored remotely for 3 months. Clinical and spirometric data were automatically transmitted to a secure internet platform. A medical team contacted the patient to optimize management. Three physicians blindly and independently classified the patients according to their perception profile. The impact of telemonitoring on the quantitative data was assessed at the beginning (T0) and end (T3 months) of telemonitoring, using matched statistical tests. Results: Patients could initially be classified according to their perception profile, with a concordance between the 3 observers of 64% (kappa coefficient: 0.55, 95%CI [0.39; 0.71]). After further discussion, a consensus was reached and resulted in 97% concordance (kappa coefficient: 0.97, 95%CI [0.91; 1.00]). There was a trend towards improvement in the ACT score, and a significant > 40% decrease in FEV1 and PEF variability, with good acceptance of the device. Conclusion: Clinical and spirometric telehome monitoring is applicable and can help define the perception profile of bronchial obstruction in asthmatic children. The device was generally well accepted.

Left ventricular pseudoaneurysm is a complication of acute myocardial infarction, especially after involvement of the inferior wall. The signs and symptoms are nonspecific. We report a case of a 69-year-old patient admitted for clinically important dyspnea. Transthoracic echocardiography showed pseudoaneurysm in the apical region, measuring 96x116 mm. Surgical correction was performed, using bovine pericardium and anchoring the ventricular orifice with 3-0 polypropylene sutures. It was not possible to perform coronary artery bypass grafting, as the distal beds of the proposed vessels were calcified. The patient was referred to the intensive care unit and discharged on the 17th postoperative day.

Animals are expected to select a breeding habitat using cues that should reflect, directly or not, the fitness outcome of the different habitat options. However, human-induced environmental changes can alter the relationship between habitat characteristics and their fitness consequences, leading to a maladaptive habitat choice. The most severe case of such nonideal habitat selection is the ecological trap, which occurs when individuals prefer to settle in poor-quality habitats while better ones are available. Here we studied the adaptiveness of nest box selection in a tree swallow (Tachycineta bicolor) population breeding over a 10-year period in a network of 400 nest boxes distributed along a gradient of agricultural intensification in southern Québec, Canada. We first examined the effects of multiple environmental and social habitat characteristics on nest box preference to identify potential settlement cues. We then assessed the links between those cues and habitat quality as defined by the reproductive performance of individuals that settled early or late in nest boxes. We found that tree swallows preferred nesting in open habitats with high cover of perennial forage crops, high spring insect biomass, and high density of house sparrows, their main competitors for nest sites. They also preferred nesting where the density of breeders and their mean number of fledglings during the previous year were high. Additionally, we detected mismatches between preference and habitat quality for several environmental variables. The density of competitors and conspecific social information showed severe mismatches, as their relationships to preference and breeding success went in opposite direction under certain circumstances. Spring food availability and agricultural landscape context, while related to preferences, were not related to breeding success. Overall, our study emphasizes the complexity of habitat selection behavior and provides evidence that multiple mechanisms may potentially lead to an ecological trap in farmlands.

Background: Asian Woollyneck Ciconia episcopus is large wading bird whose conservation status has been recently down-listed, despite a lack of general knowledge on its nesting ecology and breeding success. Thus, in this study we conducted the most comprehensive survey on the nesting ecology of this species to date. Methods: We located 39 nesting sites across 18 districts of Nepal and recorded nest tree characteristics for the nine tree species they nested in. We also used Maxent modelling to further understand factors important for nesting habitat suitability and to identify new areas for future surveys. Results: They most commonly nested in Simal Bombax ceiba (n =21), followed by Sal Shorea robusta (n=6) and Salla Pinus roxburghii (n=4). The mean height of the nesting tree, nest height and tree diameter were 29.8 ± 5.8m (±SD), 1.03 ± 0.35m & 25.3 ± 5.8 m respectively. Nesting and fledging success were additionally recorded from 31 nesting attempts at 19 of these nesting sites between 2016 and 2020. Woollyneck had an estimated nesting success probability of 0.81 ± 0.07 and a mean fledging success of 1.94 ± 0.25 (±SE) chicks per nest. MaxEnt modelling identified a total potential suitable nesting habitat area of 9.64 % (14228km2) of total area in Nepal, with this located within 72 districts (out of 77), mostly in the western part of Nepal. The modelling parameters suggest that slope, land-use, precipitation and forest were important determinants of nesting habitat suitability. Conclusions: The most likely district reported by the model for Woollyneck nesting habitat has not previously reported nests which suggests additional survey effort in this region is warranted. We recommend that priority should be given to conserve taller trees close to settlements and cropland, and future studies should consider the potential impact of climate change on nesting suitability of this species.

Freeman-Sheldon syndrome (FSS) is characterized by multiple joint contractures, characteristic facial features, such as microtia, defects of the hands and feet, such as clubfoot, and skeletal malformations. This report illustrates the case of a patient with FSS who was managed under local anesthesia with intravenous sedation for oral surgery.

Genetic differentiation has been observed in marine species even when no obvious barriers to gene flow exist. The study of highly differentiated outlier loci can provide information on how genetic variation might contribute to local adaptation. A locus which aligned to a predicted zona pellucida sperm-binding protein 3 gene (ZP3) in Atlantic cod was previously identified in Pacific cod populations as a high differentiation outlier. In other marine species, ZP3 is involved in reproductive isolation, local adaptation, and has neofunctionalized as an antifreeze gene, but the function of this genomic region is not understood in Pacific cod. We sequenced a 544 bp region of ZP3 in 230 Pacific cod collected from throughout their geographic range. Here we show that ZP3 haplotypes exhibit strong spatial structure and there is evidence for divergent selection at this locus in samples collected from the Bering Sea region. The potential for adaptation to different thermal regimes is particularly relevant given that Pacific cod have demonstrated high natural mortality during recent ocean warming events.

Objective To identify modifiable and non-modifiable risk factors for severe obstetric anal sphincter injury (OASI) following vaginal delivery. Design Retrospective case-control study. Setting Single center maternity clinic in South-Eastern Norway Population Women diagnosed with OASI following singleton vaginal birth after 30 weeks’ gestation (n = 421) and matched controls (n = 421) during 1990-2002. Methods Data were extracted retrospectively from an institutional birth registry. For each woman with OASI the first subsequent vaginal singleton delivery matched for parity was elected as control. Potential determinants for OASI were assessed by conditional logistic regression analyses. Main outcome measure OASI, defined as 3rd or 4th degree obstetric anal sphincter lesions. Results Among modifiable factors amniotomy was the strongest independent determinant for OASI in both primi- (adjusted odds ratio [aOR] 4.84; 95% CI 2.60–9.02) and multiparous (aOR 3.76; 95% CI 1.45–9.76) women, followed by augmentation with oxytocin (primiparous: aOR 1.63; 95% CI 1.08–2.46, multiparous: aOR 3.70; 95% CI 1.79–7.67). Vacuum extraction and forceps delivery were independently associated with OASI in primiparous women (vacuum: aOR 1.91; 95% CI 1.03–3.57, forceps: aOR 2.37; 95% CI 1.14–4.92), and episiotomy for OASI in multiparous women (aOR 2.64; 95% CI 1.36–5.14). Conclusions Amniotomy may be a hitherto unrecognized independent modifiable risk factor for OASI and should be further investigated for its potential role in preventive strategies for OASI. Funding Innlandet Hospital Trust research fund, grant number 150434. Keywords Obstetric anal sphincter injury; OASI; Birth; Birth injury; Modifiable risk factor; Amniotomy.

Metabarcoding provides a powerful tool for investigating biodiversity and trophic interactions, but the high sensitivity of this methodology makes it vulnerable to errors, resulting in artefacts in the final data. Metabarcoding studies thus often utilise minimum sequence copy thresholds (MSCTs) to remove artefacts that remain in datasets; however, there is no consensus on best practice for the use of MSCTs. To mitigate erroneous reporting of results and inconsistencies, this study discusses and provides guidance for best-practice filtering of metabarcoding data for the ascertainment of conservative and accurate data. The most common MSCTs identified in the literature were applied to example datasets of Eurasian otter (Lutra lutra) and cereal crop spider (Araneae: Linyphiidae and Lycosidae) diets. Changes in both the method and threshold value considerably affected the resultant data. Of the MSCTs tested, it was concluded that the optimal method for the examples given combined a sample-based threshold with removal of maximum taxon contamination, providing stringent filtering of artefacts whilst retaining target data. Choice of threshold value differed between datasets due to variation in artefact abundance and sequencing depth, thus studies should employ controls (mock communities, negative controls with no DNA and unused MID-tag combinations) to select threshold values appropriate for each individual study.

Potential cancer risk with omalizumab: a disproportionality analysis

Background and aims: Activation wavefront is rapid and uniform in normal myocardium. Fibrosis is associated with deceleration zones (DZ) and late activated zones. Our aim was to study the right ventricular outflow tract (RVOT) endocardial activation duration (EAD) in sinus rhythm, and assess the presence of DZs, in patients with PVCs and controls. Methods: We studied 29 patients with idiopathic PVCs from the outflow tract, subjected to catheter ablation and an activation and voltage map of the RVOT in sinus rhythm. A control group of 15 patients without PVCs that underwent ablation of supraventricular arrhythmias was also studied. The RVOT EAD and number of 10 ms isochrones were assessed. DZ were defined as a zone with>3 isochrones within 1 cm radius. Low voltage areas (LVA) defined as areas with local electrogram amplitude <1.5mV. Results: The two groups did not differ in relation to age, gender or number of points in the map. EAD and number of 10 ms isochrones were higher in the PVC group; 56 (41-66) ms vs 39 (35-41) ms, p=0.001 and 5 (4-8) vs 4 (4-5), p=0.001. Presence of DZs and LVAs were more frequent in the PVC group; 20 (69%) vs 0 (0%), p<0.0001 and 21 (72%) vs 0 (0%), p<0.0001. Patients with LVAs had longer EAD 60 (52-67) vs 36 (32-40) ms, p<0.0001. Conclusions: EAD was longer and DZs were more frequent in patients with PVCs and were associated with presence of LVAs.

Introduction: There are a lack of potentially inappropriate medications (PIMs) predictors among the geriatric population with cardiovascular disease (CVD). Objective: This study was focussed on finding out the predictors and prevalence of PIMs use in the older adult patients hospitalized with cardiovascular disease. Methods: This prospective cross-sectional study included 250 older adult patients (mean age 69.03± 5.76 years) with the CVD having age 65 years or more, admitted in the cardiology/medicine department of a tertiary care hospital. PIMs were identified as per Beers criteria 2019. Binary Logistic regression analysis was used to determine the predictors of PIMs use in older adult patients. Results: Results indicate a very high PIM prescription rate of more than 62.4% (n= 156) with Proton pump inhibitor, short acting insulin according to sliding scale, Enoxaparin <30ml/min as the most commonly prescribed PIMs. On Binary logistic regression, important predictors for PIMs use were found to be females (odds ratio [OR] 2.36, 95% confidence interval (CI) 1.36- 4.09, P= 0.002), three diagnosis (OR 4.29, 95% CI 1.31- 14.0, P= 0.016), ≥4 diagnosis (OR 4.8, 95% CI 1.49- 15.44, P= 0.009), 7-9 days of hospital stay (OR 4.74, 95% CI 1.07- 20.96, P= 0.04), ≥ 9 medications per day (OR 0.09, 95% CI 0.01- 0.50, P= 0.006). Conclusion: The prevalence of PIMs in older adults with cardiovascular disease is very high, and females with CVD have emerged as a potential PIM indicator. The study also indicates a lack of awareness towards Beer criteria in health care workers (physicians/pharmacists/nursing staff) leading to PIM.

Objective: In this study, we aim to evaluate the content and quality of the most relevant YouTube videos related to Holmium laser enucleation of the prostate (HoLEP) surgery. Materials and Methods: The keywords ‘HOLEP’, ‘laser enucleation’ and ‘prostate enucleation’ were used to perform a search on YouTube. Non-English language videos, videos with less than 4-minute duration, and repetitive videos were excluded. The reactions of the viewers to the videos were evaluated by recording the ‘total views’, ‘views/month’ and ‘likes and dislikes’ parameters. The data were divided into two groups based on the source of upload: Group 1 consisted of healthcare providers and Groups 2 comprised commercial companies and for-profit organizations. Results: A total of 117 videos were included in the study. A significant portion of the videos (77.7%) had been uploaded by healthcare providers. There was no statistically significant difference between the uploading groups in terms of the DISCERN and GQS scores (p=0.484 and p=0.108, respectively). However, the PEMAT understandability and actionability scores were statistically significantly higher in Group 2 (p=0.004 and p=0.022, respectively). In addition, when the misinformation scale was evaluated, there were significantly more videos with high-degree misinformation in Group 2 (5.5% vs 33.3, p=0.001). Conclusion: On video sharing platforms, such as YouTube, the number of reliable videos with accurate and appropriate guidance about diseases and treatments should be increased, and these videos should be allowed to be posted after they have been approved by relevant institutions, including healthcare associations and universities.

Chronic rhinosinusitis (CRS) is a common clinical syndrome that produces significant morbidity and costs to our health system. The study of CRS has progressed from an era focused on phenotype to include endotype based information. Phenotypic classification has identified clinical heterogeneity in CRS based on endoscopically observed features such as presence of nasal polyps, presence of comorbid or systemic diseases and timing of disease onset. More recently, laboratory-based findings have established CRS endotype based upon specific mechanisms or molecular biomarkers. Understanding the basis of widespread heterogeneity in the manifestations of CRS is advanced by findings that the three main endotypes, Type 1, 2 and 3, orchestrate the expression of three distinct large sets of genes. The development and use of improved methods of endotyping disease in the clinic is ushering in an expansion of the use of biological therapies targeting Type 2 inflammation now and perhaps other inflammatory endotypes in the near future. The purpose of this review is to discuss the phenotypic and endotypic heterogeneity of CRS from the perspective of advancing the understanding of the pathogenesis and improvement of treatment approaches and outcomes.

The utilization and popularization of biodiesel are always limited by its poor cold flow properties. Both bio-based alcohol and diesel from direct coal liquefaction (DDCL) has potential to enhance the cold flow properties of biodiesel. Ternary blends of waste cooking oil biodiesel (BWCO) with DDCL and bio-based ethanol (ET) or 1-butanol (BT) for improving the cold flow properties of biodiesel. The pour point (PP), cold filter plugging point (CFPP), and cloud point (CP) of BWCO-ET, BWCO-BT, and BWCO-DDCL binary blends, and BWCO-ET-DDCL and BWCO-BT-DDCL ternary blends were comparatively assessed. Ternary phase diagrams were also applied into analyze the blending effect of the three components on the cold flow properties of biodiesel. Results showed that both DDCL, ET and BT can remarkably enhance the cold flow properties of BWCO. BT and DDCL presented a better synergistic depression effect. For ternary blends in 20:10:70 blending ratio, BWCO-BT-DDCL exhibited the lowest PP, CFPP, and CP of −23 °C, −19 °C, and −17 °C, respectively. The crystallization behavior and crystal morphology of blended fuels are also observed via a polarizing optical microscope, and find that DDCL together with BT in biodiesel can effectively retard the aggregation of large crystals and inhibit crystals growth.

One of the hallmarks of COVID-19 is the cytokine storm that provokes primarily pneumonia followed by systemic inflammation. Emerging evidence has identified a potential link between elevated levels of interleukin-17A (IL-17A) and disease severity and progression. Considering that per se IL-17A can activate several inflammatory pathways, it is plausible to hypothesize an involvement of this cytokine in COVID-19 clinical outcomes. Thus, this cytokine can represent a marker of disease progression and/or a target to develop therapeutic strategies. This hypothesis paper aims to propose this “unique” cytokine as a silent amplifier of the COVID-19 immune response and (potentially) related therapy.

A case series of 22 patients with confirmed SARS-CoV-2 infection and Corona Virus Disease 2019 (COVID-19) symptoms was followed in a primary care clinic. We provided quantitative and longitudinal profiling for SARS-CoV-2 IgM and IgG with a point of care device. Half the patients had a history of anosmia or ageusia. IgM and IgG responses were highly heterogeneous quantitatively and temporally. We determined that clinical symptomatology of chemosensory loss correlated with lesser but sustained titers of IgM and IgG whereas normal chemosensation correlated with transiently higher but rapidly declining antibody levels.

Background The delivery of Radiation therapy (RT) needs a level of coordination and planning which can be challenging in resource-limited settings. In this retrospective study we describe the profile of children undergoing radiation and analyze deviation from accepted norms. Procedure Data on all children (< 18 years age) with cancer who completed RT from Jan 2009 to Dec 2019 were retrieved. Diagnostic groups with more than 5 patients, were included in the analysis for deviations in RT (Time to start (TTS); total dose delivered (TDD) in Grays; and time to complete (TTC)). We investigated reasons for deviation. Results 207 received RT as front-line treatment (68% Indian, 59% male and 32% received treatment preceding RT outside). Most common diagnosis were brain tumors (44%), lymphoma (13%). leukemia and soft tissue sarcoma (10% each). 23.6% had deviation in TTS, 6.0% in TDD and 24.7% in TTC while 43.4% had at least one deviation in any of these three parameters. Deviation in TTS varied significantly by location of preceding treatment and by cancer (greatest deviation in sarcomas) with issues around access to healthcare the most common reason. Deviation in TTC varied significantly by cancer (greatest deviation in sarcomas and medulloblastoma) with myelotoxicity the most common reason. Conclusions Our study adds to the limited literature on RT quality for children with cancer in LMIC. Certain cancers (sarcomas and medulloblastoma) and patient groups (preceding treatment outside our institute) had the maximum deviation. Barriers to accessing care and myelotoxicity were the two main reasons for this deviation.