Obvious Source Research Articles

Unraveling the riverine antibiotic resistome: The downstream fate of anthropogenic inputs

River networks are one of the main routes by which the public could be exposed to environmental sources of antibiotic resistance, that may be introduced e.g. via treated wastewater. In this study, we applied a comprehensive integrated analysis encompassing mass-flow concepts, chemistry, bacterial plate counts, resistance gene quantification and shotgun metagenomics to track the fate of the resistome (collective antibiotic resistance genes (ARGs) in a microbial community) of treated wastewater in two Swiss rivers at the kilometer scale. The levels of certain ARGs and the class 1 integron integrase gene (intI1) commonly associated with anthropogenic sources of ARGs decreased quickly over short distances (2-2.5 km) downstream of wastewater discharge points. Mass-flow analysis based on conservative tracers suggested this decrease was attributable mainly to dilution but ARG loadings frequently also decreased (e.g., 55.0-98.5 % for ermB and tetW) over the longest studied distances (6.8 and 13.7 km downstream). Metagenomic analysis confirmed that ARG of wastewater-origin did not persist in rivers after 5 ~ 6.8 km downstream distance. sul1 and intI1 levels and loadings were more variable and even increased sharply at 5 ~ 6.8 km downstream distance on one occasion. While input from agriculture and in-situ positive selection pressure for organisms carrying ARGs cannot be excluded, in-system growth of biomass is a more probable explanation. The potential for direct human exposure to the resistome of wastewater-origin thus appeared to typically abate rapidly in the studied rivers. However, the riverine aquatic resistome was also dynamic, as evidenced by the increase of certain gene markers downstream, without obvious sources of anthropogenic contamination. This study provides new insight into drivers of riverine resistomes and pinpoints key monitoring targets indicative of where human sources and exposures are likely to be most acute.

Development of Non-point Source Air Pollution Standard System in China

Non-point source air pollution refers to the air pollution type that have no obvious source, which is regarded as an important contributor to the atmospheric pollution problem. Comparing to the point-source and linear-source air pollution, the standardization in the relation to non-point air pollution China is relatively sluggish. The present paper collected and analysed the existing air pollution standards in China, and establish the non-point source pollution standard system in the accordance with different sectors such as industry, agriculture, construction, transportation and social life. Due to the overlapped functions and unclear jurisdiction of different administrative departments, as well as the lagging progress of the government-dominated standard, a paradigm shift of non-point source air pollution standardization should be from government-dominated to market-oriented model. The lessons learned for other developing countries includes expanding standardization to multi-aspects to realize full lifecycle control and management, building rapid responding mechanism of standardization to reconcile with industry and social transformation, integrating outdated standards into new versions, and establishing market-based standard system.

The Dystopian Imagination in Contemporary Spanish Literature and Film

The Dystopian Imagination in Contemporary Spanish Literature and Film

An investigation into high-speed train interior noise with operational transfer path analysis method

Passengers' demands for riding comfort have been getting higher and higher as the high-speed railway develops. Scientific methods to analyze the interior noise of the high-speed train are needed and the operational transfer path analysis (OTPA) method provides a theoretical basis and guidance for the noise control of the train and overcomes the shortcomings of the traditional method, which has high test efficiency and can be carried out during the working state of the targeted machine. The OTPA model is established from the aspects of "path reference point-target point" and "sound source reference point-target point". As for the mechanism of the noise transmission path, an assumption is made that the direct sound propagation is ignored, and the symmetric sound source and the symmetric path are merged. Using the operational test data and the OTPA method, combined with the results of spherical array sound source identification, the path contribution and sound source contribution of the interior noise are analyzed, respectively, from aspects of the total value and spectrum. The results show that the OTPA conforms to the calculation results of the spherical array sound source identification. At low speed, the contribution of the floor path and the contribution of the bogie sources are dominant. When the speed is greater than 300 km/h, the contribution of the roof path is dominant. Moreover, for the carriage with a pantograph, the lifted pantograph is an obvious source. The noise from the exterior sources of the train transfer into the interior mainly through the form of structural excitation, and the contribution of air excitation is non-significant. Certain analyses of train parts provide guides for the interior noise control.

Prolapsed submucosal pyomyoma postpartum, a rare complication of fibroids

BackgroundPyomyoma is an unusual fibroid that usually develops during the puerperal or postmenopausal period. If not promptly diagnosed and treated, it can become life threatening. Although various conservative and surgical therapies have been discussed in the literature for this condition, there are very few reports related to the management of prolapsed pedunculated submucosal myoma.Case presentationIn this case report, an intramural fibroid transformed into a pedunculated submucosal pyomyoma, which prolapsed into the vagina after a miscarriage and caused life-threatening toxic shock. Apart from prompt antibiotic treatment, a transabdominal myomectomy rather than hysterectomy was performed due to the very large diameter of the pyomyoma. As a result, fertility was preserved, and the patient conceived naturally and delivered a healthy baby two years later.Discussion and conclusionsIt is important to maintain strong clinical suspicion for pregnant or postpartum women with a triad of pain, sepsis without an obvious source and a known diagnosis of leiomyoma. Timely recognition and prompt surgical treatment with antibiotics are necessary and could conserve the uterus for future fertility.

Airway Bleeding After Double-Lumen Tube Placement

A 78-YEAR-OLD, 45-kg, 165-cm woman, with a history of breast cancer treated with chemoradiation, and esophageal diverticulum, presented for robotic-assisted diverticulectomy. After anesthetic induction, a 37Fr left-sided, double-lumen tube (DLT) was placed without difficulty, and placement was confirmed with fiberoptic bronchoscopy. The tracheal tissue was noted to be mottled throughout. After the patient was placed in the left lateral decubitus position, the DLT position was confirmed once again, and single-lung ventilation was initiated, with inflation of the bronchial cuff with 2.5 mL of air and clamping of the tracheal limb. After entry and insufflation of the right chest, 3-5 mL of blood were noted to be emanating from the tracheal lumen, and the surgeon noted poor lung isolation. Fiberoptic evaluation noted sanguineous secretions, which, despite lavage, failed to identify an obvious cause of bleeding, and slow bleeding persisted. In an attempt to improve single-lung isolation, an additional 2 mL of air were added to the bronchial cuff. After addition of air to the bronchial cuff, bleeding ceased and no additional significant issues occurred during the rest of the surgical procedure. After completion of the surgery, bilateral lung ventilation was reinstated and the authors repositioned the patient supine. Given the lack of obvious bleeding source and the mottled appearance of the tracheal tissue, bronchoscopy was performed for pulmonary toilet and further evaluation. The DLT was exchanged for an 8.5-mm endotracheal tube under direct visualization. The following findings (Fig 1, Fig 2) were noted. What is the diagnosis? Fig 2Bronchoscopic view from the left main stem showing full thickness injury in the membranous portion of the bronchus. Anterior surface of esophagus is visible through defect (yellow star). View Large Image Figure Viewer Download Hi-res image

Atmospheric particulate represents a source of C8-C12 perfluoroalkyl carboxylates and 10:2 fluorotelomer alcohol in tree bark.

In this study, we analyzed 30 legacy and emerging poly- and perfluoroalkyl substances (PFASs) in paired atmospheric particulate and bark samples collected around a Chinese fluorochemical manufacturing park (FMP), with the aim to explore the sources of PFASs in tree bark. The results showed that PFASs in atmospheric particulate and tree bark samples were consistently dominated by perfluorooctanoate (mean 73ng/g; 44pg/m3), perfluorohexanoate (47ng/g; 36pg/m3), perfluorononanoate (9.1ng/g; 8.8pg/m3), and 10:2 fluorotelomer alcohol (10:2 FTOH; 5.6ng/g; 12pg/m3). Spatially, concentrations of C8-C12 perfluoroalkyl carboxylates (PFCAs) and 10:2 FTOH all showed a similar and exponentially decreased trend in both bark and atmospheric particulate samples with the increasing distance from the FMP. For the first time, we observed strongly significant (Spearman's correlation coefficient=0.53-0.79, p<0.01) correlations between bark and atmospheric particulate concentrations for C8-C12 PFCAs and 10:2 FTOH over 1-2 orders of magnitude, suggesting that the continues trapping of atmospheric particulates resulted in the accumulation of these compounds in bark. Overall, this study provides the first evidence that atmospheric particulate is an obvious source of C8-C12 PFCAs and 10:2 FTOH in tree bark. This result may further contribute to the application of tree bark as an indicator of certain PFASs in atmospheric particulate.

Who owns the Heat? The Scope for Geothermal Heat to Contribute to Net Zero

To meet its greenhouse gas reduction commitment to net zero by 2050, the UK will need to diversify its energy supply. A move away from fossil fuels towards other forms of energy is required. At present, around 20% of the UK’s primary energy is generated by renewable resources, with the majority of this coming from bioenergy and nuclear energy. In the residential and public sectors, the main source of emissions is from the burning of gas for heating. One possible and obvious alternative energy source is that of geothermal heat, which presently remains underutilised in the UK energy mix, with ground source heat pumps and geothermal heat combined currently accounting for just 5.2% of overall renewable energy sources. This article explores the regulatory landscape for geothermal heat in the UK, taking as its main focal point the issue of definition and ownership. It examines the implications that the lack of a clear definition of ‘heat’, as a potential resource, has for the regulatory regime in the UK. The main argument is that the failure to define ‘heat’ along the lines of other natural resources explored for energy use creates a unique regulatory dynamic. This unique dynamic has the potential to prevent the full utilisation of geothermal heat and creates the need for reform of the way in which it is regulated.

Институциональное обеспечение противодействия коррупции: постановка проблемы

According to the position taken by the author of the article, the main condition for achieving systematic and effective measures to combat corruption is to bring them to the level of specific social systems (state power, education, health, science, culture, etc.). Although the problem of corruption is of national and even global importance, but the prevalence of general measures among anti-corruption practices is an obvious source of formalization, companionship and inefficiency. This position is linked in the article with the provision that a corruption is not a separate social system. At its core, a corruption of social institutions is a violation of their normal functioning and the production of results that are not suitable for society, including economic and social ones. The normality of the institutional functions implementation involves maintaining the necessary correspondence between the elements or institutions that make up the institution. They are divided into formal and informal institutions that have legal significance and do not have one. According to the author, it is due to the lack of the necessary correspondence between institutions in the institutional structure of specific social systems that the latter begin to systematically produce mass violations of formal norms, including corruption, to which the state and society respond first of all. At the same time, even more large-scale violations of norms that capture the micro-level of society remain in the shadows. In conclusion, the article highlights the main problem in the institutional ensuring anti-corruption. If formal norms are largely subjected to administrative influence, then the informal institutional space of the social system is formed culturally and historically and mainly by the forces of the public. Therefore, without the productive interaction of the state and society, which are the main forces that form the institutional structure, neither the necessary systemic institutional support in combating corruption, nor the desired and resulting consistency in this counteraction, is achievable.

A new quantum model of the magnetic field of the Hot Earth, Moon and terrestrial planets

Distribution of Pand Swaves velocities in the Earth’s inner core suggests that its matter has been quantum entangled since the origin of the Earth and the Solar system. This assumption we made allows us to develop the quantum model of the geomagnetic field evolution from its start to its disappearance. Unlike the generally accepted dynamo our model provides an obvious source of energy which is a phase transition and the thermal, mechanical and electrical energy released during it. The latter generates a double electric layer which rotation gives rise to the initial dipole field. Changing its direction the phase transition causes a reversal of the magnetic field. Magnetic and paleomagnetic data on the Earth, Moon, Mercury and Mars analyzed in the frameworks the Hot Earth model and features of their gravitation recorded at NASA project offered as conditions for the planets formation and evolution and so predictions for the further evolution of the Earth and its magnetic field.

Multiple stressors in small streams in the forestry context of Fennoscandia: The effects in time and space

In this paper we describe how forest management practices in Fennoscandian countries, namely Sweden and Finland, expose streams to multiple stressors over space and time. In this region, forestry includes several different management actions and we explore how these may successively disturb the same location over 60–100 year long rotation periods. Of these actions, final harvest and associated road construction, soil scarification, and/or ditch network maintenance are the most obvious sources of stressors to aquatic ecosystems. Yet, more subtle actions such as planting, thinning of competing saplings and trees, and removing logging residues also represent disturbances around waterways in these landscapes. We review literature about how these different forestry practices may introduce a combination of physicochemical stressors, including hydrological change, increased sediment transport, altered thermal and light regimes, and water quality deterioration. We further elaborate on how the single stressors may combine and interact and we consequently hypothesise how these interactions may affect aquatic communities and processes. Because production forestry is practiced on a large area in both countries, the various stressors appear multiple times during the rotation cycles and potentially affect the majority of the stream network length within most catchments. We concluded that forestry practices have traditionally not been the focus of multiple stressor studies and should be investigated further in both observational and experimental fashion. Stressors accumulate across time and space in forestry dominated landscapes, and may interact in unpredictable ways, limiting our current understanding of what forested stream networks are exposed to and how we can design and apply best management practices.

Early recovery of botulism: one decade of experience

Background Botulism is a rare but serious disease, which appears in different forms. In this study, we reviewed the clinical features, laboratory data, and outcomes of patients who referred to our tertiary center. Materials and methods All confirmed cases of botulism referred to an academic referral center and a teaching hospital during 2009–2019, were retrospectively reviewed. Results Fifty-three cases of clinical or laboratory-confirmed botulism were examined in this study. Nineteen patients were confirmed by laboratory data (serotype A (89.5%) and serotype E (10.5%)). In seven cases, the cause of botulism was unclear. In two patients, systemic symptoms emerged after the therapeutic injection of botulinum neurotoxin. The majority of cases (83%) were caused by an obvious food source. In 66% of cases, the initial symptoms emerged within less than 36 h, while in 20.8% of cases, the symptoms developed within or after 36 h; however, in seven patients that their botulism sources were unclear, the onset could not be estimated. All patients showed cranial involvement and generalized manifestation, and 49.1% had gastrointestinal symptoms. Except for two patients who were not treated due to immediate drug reactions who manifested severe hemodynamic instability, the rest of the patients were treated with trivalent antitoxin (A, B, and E). The complete resolution of the symptoms during hospitalization was documented in 50.9% of the patients. About 17% of the patients were intubated. Two patients died due to massive bilateral pulmonary thromboembolism and cardiac asystole following respiratory failure. Conclusions Although the complete resolution of the symptoms usually takes several weeks, in our experience, most patients showed at least partial resolution upon discharge. Early treatment results in better outcomes.

Release of retained oaks in Norway spruce plantations. A 10-year perspective on oak vitality, spruce wood production and ground vegetation

This study explores the decade-long effects of release cutting around old retained oaks (Quercus robur L.) in a Norway spruce (Picea abies L. Karst) stand that was 33 year old when thinned. The impacts on both nature conservation values and spruce wood production were evaluated in a randomized block design. To release oaks from competition, stems of Norway spruce were cut around 33 oaks, in three different treatments: high release (HR), medium release (MR) and no release (NR). Trees within a circular sample plot (15 m radius from the oak) were measured at time of treatment and 10 years after. The treatment effects on stand development, oak vitality and understory vegetation were evaluated after ten years, using tree diameter, height measurements, oak crown and tree structure estimates as well as ground vegetation surveys. Release cutting did not impact spruce production within the sample plot, and given that there were no other obvious sources of spruce suppression in the stand, we speculate that release cutting has little to no impact at the stand scale. Oak crowns in the control plots (NR) became smaller after ten years, while the crowns expanded and colonized the gap in the release treatments. Simultaneously, the amount of dead wood in the crown increased among oaks in the control treatment, indicating dieback. Cover and species richness of vascular plants in the understory were significantly higher in the HR and MR treatments compared to NR. These results suggest that the creation of relatively wide gaps (greater than 2 m) around retained oak crowns is one efficient approach to maintain their conservation values in a spruce-dominated stand on a longer time frame. This will allow oaks to expand their crowns, increase their vitality and increase species richness and diversity of plants under the canopy. The economic loss of creating large gaps instead of no gaps may be negligible since the overall spruce production was not affected within 15 m of each oak.

High‐resolution distribution pattern of surface water nitrous oxide along a cruise track from the Okhotsk Sea to the western Arctic Ocean

AbstractNitrous oxide in the surface water was measured using an automatic underway system, along with measurements of surface water pCO2, dissolved oxygen, salinity, temperature, and sea ice coverage, along a cruise track through the Bering Sea and Chukchi Sea to the Canadian Basin during the 7th Chinese National Arctic Research Expedition. The results show that, overall, the regions along the cruise track are net sources of N2O to the atmosphere. Several N2O oversaturation maxima were observed along the cruise track, with an absolute maximum of approximately 60%. According to the hydrographic setting and the distribution patterns of pCO2, dissolved oxygen, and sea ice coverage in the study area, it was concluded that the N2O oversaturation maxima may result from hydrographic processes, such as mixing of different water masses, upwelling or convection, and possible production beneath the sea ice. Additionally, the lowest value of approximately 90% may result from dilution related to the melting of sea ice. An evaluation of the air–sea flux along the cruise track shows that the continental shelf and upwelling region are N2O sources, whereas the study area in the open Arctic Ocean does not show obvious source or sink characteristics.

Modeling Outcomes in Children With Biliary Atresia With Native Liver After 2 Years of Age.

Approximately 50% of infants with biliary atresia (BA) undergoing Kasai portoenterostomy show survival with native liver (SNL) at age 2 years. Predictors of disease progression after age 2 years are unknown, despite estimates of 20%‐30% undergoing liver transplant (LT) between age 2 and 18 years. We sought to address this knowledge gap by developing prognostic models in participants of the multicenter prospective National Institutes of Health‐supported Childhood Liver Disease Research Network. We extracted 14 clinical and biochemical variables at age 2 years to develop two models for future outcomes: 1) LT or death (LTD) and 2) first sentinel event (SE), either new onset ascites, hepatopulmonary syndrome (HPS), or gastrointestinal (GI) bleed. A total of 240 participants, enrolled between 2004 and 2017, were followed until a median age of 5.1 years (range, 2.0‐13.3 years). Of these participants, 38 underwent LT (n = 37) or death (n = 1); cumulative incidence, 23.7% (95% confidence interval [CI], 16.2%‐32.0%). Twenty‐seven experienced either new‐onset ascites (n = 13), HPS (n = 1), or GI bleed (n = 14). One participant had ascites and GI bleed concurrently; cumulative incidence, 21.5% (95% CI, 14.2%‐29.8%) by age 10 years. The Cox proportional hazard model predicted risk of LTD, using total bilirubin, albumin, platelet count, and history of either ascites or cholangitis (BA LTD model), with a C‐index of 0.88 (range, 0.86‐0.89). A cause‐specific hazard competing risk model predicted SE using platelet count and gamma glutamyltransferase levels (BA SE model) with a C‐index of 0.81 (range, 0.80‐0.84). Internal model validity was assessed using Harrell’s C‐index with cross‐validation. Conclusion: Stratification using these models identified risk of poor outcomes in patients with BA SNL after age 2 years. The models may identify those who would benefit from enhanced clinical surveillance and prioritization in clinical trials.

RARE CASE OF OVERLAPPING PRIMARY EFFUSION LYMPHOMA AND KAPOSI SARCOMA INFLAMMATORY CYTOKINE SYNDROME IN IMMUNOSUPRESSED PATIENT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Kaposi’s sarcoma-associated herpes virus (KSHV) is a potent oncogenic and immunomodulatory virus. We present a patient with high KSHV viral load with primary effusion lymphoma (PEL) and the rarely reported Kaposi’s sarcoma inflammatory cytokine syndrome (KSICS). CASE PRESENTATION: 31-year-old male with AIDS (CD4 of 45 cell/µL, viral load 170,000) and Kaposi Sarcoma treated with liposomal doxorubicin, admitted for shortness of breath (SOB), lower extremity (LE) and scrotal edema. Physical examination: tachycardia, bibasilar crackles, 3+ pitting edema of LE extending to the sacrum, and violaceous, erythematous KS lesions on the torso. Initial studies notable for anemia (Hgb 9.0 g/dl), otherwise unremarkable including brain natriuretic peptide and microbiology studies. A chest x-ray demonstrated bilateral pleural effusions with loculation on the left, which was later confirmed on a chest computed tomography scan, that also revealed enlarged mediastinal lymph nodes. Echocardiography showed preserved ejection fraction. A doppler ultrasound of LE was negative for deep vein thrombosis. During hospital course, patient became progressively anemic, hemodynamically unstable and profoundly SOB, ultimately requiring transfer to the intensive care unit where he was intubated and started on vasopressors. A thoracentesis with cytology positive for large pleomorphic lymphocytes, CD45+/HHV8+/EBER+ by immunohistochemistry. Flow cytometry showed monotypic B-cell population positive for HLA-DR, CD38, CD45 (dim), and kappa light chain (dim) restricted, consistent with a diagnosis of PEL. Serum studies demonstrated markedly elevated levels of IL6 and IL10 and the clinical presentation suggested a rare condition associated with KSHV, KSICS. The patient unfortunately died despite resuscitative efforts. DISCUSSION: PEL is the least common of all HIV related lymphomas and presents as lymphomatous growth in a liquid phase in a body cavity without extracavitary lesions. The pathogenic mechanism of KSHV is uncertain but almost all cases are associated with this virus. Malignant cells are monoclonal B cells that express CD38 and contain KSHV viral inclusions and the majority demonstrate EBV coinfection . Another disease diagnosed in patient is KSICS, a rarely reported systemic inflammatory syndrome associated with high KSHV viral load and elevated IL6 and IL10, secreted by infected cells. Presentation is similar to sepsis but without obvious source of infection. CONCLUSIONS: This case illustrates varying and overlapping presentations of KSHV infection in immunocompromised patient. Therapy does not exist and KS could not be treated due to the poor condition of patients. Patients have a high mortality rate and often misdiagnosed. Our patient received antibiotics for the presumptive sepsis before a diagnosis was made. It will be important to recognize this syndrome early to support attempts to develop effective therapies. Reference #1: Narkhede M, Arora S, Ujjani C. Primary effusion lymphoma: current perspectives. Onco Targets Ther. 2018;11:3747–3754. Published 2018 Jun 28. doi:10.2147/OTT.S167392 Reference #2: Polizzotto MN, Uldrick TS, Hu D, Yarchoan R. Clinical Manifestations of Kaposi Sarcoma Herpesvirus Lytic Activation: Multicentric Castleman Disease (KSHV-MCD) and the KSHV Inflammatory Cytokine Syndrome [published correction appears in Front Microbiol. 2017 Aug 21;8:1572]. Front Microbiol. 2012;3:73. Published 2012 Mar 2. doi:10.3389/fmicb.2012.00073 DISCLOSURES: No relevant relationships by Arsenije Kojadinovic, source=Web Response No relevant relationships by Prabhjot Mundi, source=Web Response No relevant relationships by Pahnwat Taweesedt, source=Web Response

S2854 Peripheral T-Cell Lymphoma, Not Otherwise Specified (PTCL, NOS) Presenting With Gastrointestinal Bleeding in an HIV Patient

INTRODUCTION: Peripheral T-Cell lymphomas (PTCL) are a rare type of Non-Hodgkin’s Lymphoma (NHL) with an incidence of < 1 case per 100,000 people in the USA. PTCL, not otherwise specified (NOS) is an EBV-associated malignancy, encompassing a spectrum of disorders that do not fulfill the criteria of other PTCL subtypes. Presentation of PTCL, NOS with gastrointestinal bleeding has only been described in rare case reports. CASE DESCRIPTION/METHODS: A 32-year-old female with congenital HIV, on highly active anti-retroviral therapy (HAART), presented with multiple episodes of hematochezia, diffuse abdominal pain and hypotension. After hemodynamic stabilization with multiple units of packed red blood cells and intravenous fluids, esophagogastroduodenoscopy and colonoscopy were performed revealing no obvious source of bleeding. Subsequently, CT scan and MRI of the abdomen delineated two segments of small bowel wall thickening, luminal narrowing and mesenteric lymphadenopathy. Capsule endoscopy showed scattered patches of erythematous mucosa in the small bowel without active bleeding or stigmata of bleeding. Afterwards, she underwent a small bowel push enteroscopy revealing a large, non-obstructing, infiltrative mass in the mid-jejunum which was successfully biopsied (Figure 1). Biopsy was consistent with PTCL, NOS with a high Ki-67 proliferation index (80-90%) and positive Epstein-Barr encoding regions-in situ hybridization (EBER-ISH) (Figure 2, 3). Further staging workup showed a normal bone marrow biopsy. PET-CT scan demonstrated intense FDG uptake in jejunum and small bowel segments in the left and right lower quadrants but no distant metastases. During the preparation for chemotherapy, she developed acute small bowel perforation. Given the rapid deterioration, definitive treatment was not feasible. After family discussions, she was transferred to inpatient hospice where she passed away. DISCUSSION: Push enteroscopy is an effective tool for the diagnosis of small bowel malignancies like PTCL. The presence of HIV increases the risk of PTCL by 15 times and adversely impacts the prognosis, with a median survival of around 1 year. Around 30% cases of PTCL, NOS are EBV positive and the presence of EBER-ISH portends worse outcomes. Induction with anthracycline-based chemotherapy regimens along with brentuximab vedotin (an antibody-drug conjugate against CD30) for CD30 + PTCL, and early consolidation with autologous stem cell transplant (ASCT) are the cornerstones of PTCL, NOS treatment.Figure 1.: Small bowel push enteroscopy: Panel (A) and (B) show a prominent mass lesion in the mid-jejunum. Panel (C) and (D) show the same area after biopsy and tattooing.Figure 2.: Small bowel mucosa with large pleomorphic cells infiltrating the lamina propria. Surface ulceration and extensive areas of punctate necrosis are also present. Figure (A) is X10 and Figure (B) is X25 magnification.Figure 3.: The large pleomorphic cells are positive for (A) CD3 (B) CD7 and (C) CD8 immunostains as well as (D) EBER-ISH (X25).

Bacterial infections and patterns of antibiotic use in patients with COVID-19.

Bacterial coinfection is associated with poor outcomes in patients with viral pneumonia, but data on its role in the mortality of patients with coronavirus disease 2019 (COVID‐19) is limited. This is a single‐center retrospective analysis of 242 patients with confirmed COVID‐19 admitted to both intensive care and non‐intensive care settings. Bacterial coinfection was determined by the presence of characteristic clinical features and positive culture results. Multivariable logistic regression was used to analyze the association of concomitant bacterial infection with inpatient death after adjusting for demographic factors and comorbidities. Antibiotic use pattern was also determined. Bacterial coinfection was detected in 46 (19%) patients. Genitourinary source was the most frequent, representing 57% of all coinfections. The overall mortality rate was 21%. Concomitant bacterial infections were independently associated with increased inpatient mortality (OR, 5.838; 95% CI, 2.647‐12.876). Patients with bacterial coinfection were relatively older (71.35 ± 11.20 vs 64.78 ± 15.23; P = .006). A total of 67% of patients received antibiotic therapy, yet 72% did not have an obvious source of bacterial infection. There was a significantly higher rate of inpatient mortality in patients who received antibiotics compared to those who did not (30% vs 5%; P < .0001). Bacterial coinfection in COVID‐19 is associated with increased mortality.

Early observations on the impact of the COVID-19 lockdown on air quality trends across the UK

UK government implemented national lockdown in response to COVID-19 on the 23–26 March 2020. As elsewhere in Europe and Internationally, associated restrictions initially limited individual mobility and workplace activity to essential services and travel, and significant air quality benefits were widely anticipated. Here, break-point/segment methods are applied to air pollutant time-series from the first half of 2020 to provide an independent estimate of the timings of discrete changes in NO, NO2, NOx, O3, PM10 and PM2.5 time-series from Automatic Urban Rural Network (AURN) monitoring stations across the UK. NO, NO2 and NOx all exhibit abrupt decreases at the time the UK locked down of (on average) 7.6 to 17 μg·m−3 (or 32 to 50%) at Urban Traffic stations and 4 to 5.7 μg·m−3 (or 26 to 46%) at Urban Background stations. However, after the initial abrupt reduction, gradual increases were then observed through lockdown. This suggests that the return of vehicles to the road during early lockdown has already offset much of the air quality improvement seen when locking down (provisional estimate 50 to 70% by 01 July). While locking down O3 increased (7 to 7.4 μg·m−3 or 14 to 17% at Urban stations) broadly in line with NO2 reductions, but later changes suggest significant non-lockdown contributions to O3 during the months that followed. Increases of similar magnitudes were observed for both PM10 (5.9 to 6.3 μg·m−3) and PM2.5 (3.9 to 5.0 μg·m−3) at both Rural and Urban stations alike, but the distribution of changes suggests the lockdown was not an obvious direct source of changes in levels of either of these species during this period, and that more complex contributions, e.g. from resuspension and secondary aerosol, may be more likely major drivers for these changes.

FEBRE DE ORIGEM INDETERMINADA EM PUERPÉRIO: UM RELATO DE CASO

Febre de origem indeterminada é definida como temperatura corporal maior ou igual a 38,3 °C com duração mínima de três semanas sem um diagnóstico estabelecido, apesar de investigação apropriada. A febre de origem indeterminada permanece um dos mais desafiadores diagnósticos em medicina. A epidemiologia é ampla e dependente da etiologia, idade, geografia, exposição ambiental e status imune. As doenças infecciosas são as causas mais prevalentes em países em desenvolvimento, enquanto que em países desenvolvidos, as causas mais prováveis são devido às doenças inflamatórias não infecciosas. Descreve-se o caso clínico de uma paciente de 31 anos de idade, com quadro febril inexplicado instalado após uma semana da realização de cesárea de emergência. Nos exames laboratoriais apresentava leucocitose com desvio à esquerda, com hemocultura e urocultura negativas. Ao ultrassom pélvico transvaginal: Útero aumentado de volume com fundo ao nível da cicatriz umbilical. Cavidade endometrial com pequena quantidade de líquido e coágulos, sem conteúdo expansivo no interior, endométrio fino e ausência de coleções. A paciente foi submetida à extensa avaliação clínica e cirúrgica em busca do esclarecimento da origem do quadro febril, porém este permaneceu inexplicado.