Background Spontaneous sternal fracture is an extremely rare cause of chest pain during or after childbirth. To date, only three cases of sternal fracture during childbirth have been reported. This case report represents the first documented case of spontaneous sternal fracture among multiparous women. Case Description A 33-year-old multiparous woman with an uncomplicated medical history is described, who delivered a healthy fourth infant vaginally at 41 weeks of pregnancy. After the previous three deliveries, each child had been breastfed for more than a year, and the third delivery was eight months before conception, and she breastfed until 3 months of pregnancy. During the final stage of labor, while performing the Valsalva maneuver in the lithotomy position, she felt a sharp, severe chest pain. Postpartum work-up included cardioselective enzymes that were within reference values, and radiological work-up confirmed a non-displaced sternal fracture, which was treated conservatively with symptomatic therapy, with complete recovery after 6 weeks. Conclusions This case report suggests the need to consider sternal fracture as a differential diagnostic consideration in women who experience chest pain during or immediately after delivery. Changes in metabolism, especially calcium metabolism during pregnancy and lactation, can result in transient osteopenia and, with increased mechanical stress, cause bone fracture. Special attention should be paid to patients who breastfed immediately before conception or who breastfeed during pregnancy, to vitamin and mineral replacement therapy, adequate nutrition, and physical activity. Timely diagnosis of sternal fracture can significantly reduce the need for expensive and invasive diagnostic tests. Further research is needed on osteopenia in pregnant women, especially multiparous women who are breastfeeding immediately before conception or during pregnancy.

BACKGROUND AND AIMS Irritable bowel syndrome (IBS) is associated with substantial costs to society. Extensive data on direct costs (healthcare consumption) and indirect costs (health-related productivity loss) are lacking. Hence, we examined the socioeconomic costs of IBS and assessed which patient characteristics are associated with higher costs. METHODS Cross-sectional data from three Rome-defined Dutch IBS patient cohorts (n=419) were collected. Bootstrapped mean direct and indirect costs were evaluated per IBS patient using validated questionnaires (i.e., medical cost questionnaire and productivity cost questionnaire, respectively). Multivariable regression analyses were performed to identify variables associated with higher costs. RESULTS Quarterly mean total costs per patient were €2.156 (95% CI €1793-2541, [$2.444]), consisting of €802 (€625-1010, [$909]) direct costs and €1.354 (€1072-1670, [$1535]) indirect costs. Direct costs consisted primarily of healthcare professional consultations, with costs related to gastrointestinal clinic visits accounting for 6% and costs related to mental healthcare visits for 20%. Higher direct costs were significantly associated with older age (p=0.007), unemployment (p=0.001), IBS subtypes other than constipation (p=0.033), lower disease-specific quality of life (p=0.027), and more severe depressive symptoms (p=0.001). Indirect costs consisted of absenteeism (45%), presenteeism (42%), and productivity loss related to unpaid labor (13%) and were significantly associated with the male sex (p=0.014) and more severe depressive symptoms (p=0.047). CONCLUSION Productivity loss is the main contributor to the socioeconomic burden of IBS. Direct costs were not predominantly related to gastrointestinal care, but rather to mental healthcare. Awareness of the nature of costs and contributing patient factors should lead to significant socioeconomic benefits for society.

BACKGROUND AND AIM Intestinal permeability (IP) plays an important role in the pathophysiology of nonalcoholic fatty liver disease (NAFLD). We assessed site-specific (gastroduodenum, small intestine, colon and whole gut) IP in NAFLD patients and healthy controls (HC) and its association with the degree of hepatic steatosis, hepatic fibrosis and dietary composition in these NAFLD patients. METHODS In vivo site-specific IP was analysed with a validated multi-sugar test in NAFLD patients and HC. Furthermore, in NAFLD patients, hepatic steatosis (chemical shift MRI), hepatic fibrosis (transient elastography) and dietary composition (food frequency questionnaire) were assessed. RESULTS Fifty-two NAFLD patients and forty-six HC were included in this study. Small intestinal (P <0.001), colonic (P = 0.004) and whole gut (P <0.001) permeability were increased in NAFLD patients compared to HC. Furthermore, colonic permeability (P = 0.029) was significantly higher in NAFLD patients with clinically significant fibrosis compared to those without. Colonic permeability remained positively associated with the presence of clinically significant fibrosis (P = 0.017) after adjustment for age, sex and BMI. CONCLUSION Colonic permeability is increased in at least a subset of NAFLD patients compared to HC and is independently associated with clinically significant NAFLD fibrosis.

Abstract Global brachial plexus injury (GBPI) mainly affects adults and causes severe life-changing consequences that lead to the deterioration of patients’ quality of life. Several surgical approaches have been described and reported in the literature to improve patients’ functional ability. A literature review is done on PubMed/MEDLINE and Embase using specific keywords to retrieve relevant articles assessing different surgical approaches for GBPI management. Inclusion and exclusion criteria were applied, and eligible articles were included in the review. The literature survey revealed that various surgical options had been used to manage GBPI patients. In this concise review, we discuss and compare the different surgical approaches related to GBPI and its outcome in terms of restoring elbow flexion and extension, shoulder abduction, and wrist and hand function. The primary surgical intervention relies mainly on transferring single or multiple nerves with/without nerve grafts to restore the function of the targeted muscle. Different techniques using a variety of nerve donors and recipients are compared to assess the functional outcomes of each option. Moreover, further options are addressed for delayed GBPI injuries or failed nerve transfer procedures, as in free functional muscle transfer techniques. In addition, information about brachial plexus injury cases faced in our center is presented along with our center’s approach to diagnosing and managing partial and GBPI cases.

Abstract Biotic stress caused by pests on citrus trees has become a major problem for ecologists around the world, hence the need to develop ecological approaches to surmount this stress. To evaluate the effectiveness of diverse control methods on the pest Panonychus citri and its predators, Euseius stipulatus, Phytoseiulus persimilis, and Typhlodromus sp. Different treatments were applied in orchards planted by Citrus clementina in the Gharb area of Morocco (T0 = treated by water only, T1 = spirodiclofen (the molecular formula is C21H24Cl2O4). 0.5 L/ha, T2 = 5% black soap 125 L/ha, Its ingredients are: argan oil, olive oil, black olive, salt, water, vegetable potash, without chemicals. T3 = mixture of two detergents; Oni product is composed of the following ingredients (sodium C12-13 parenth sulfate, and sodium C14-17 alkyl sec sulfonate) and Tide product with the following ingredients (sodium C10-16 alkylbenzene sulfonate, propylene glycol and sodium borate). Results obtained during the follow-up period showed that the black soap, spirodiclofen, and two detergent treatments provided a decrease in the P. citri population in comparison with plot treated by water during the whole monitoring period. We found 5,044 mobile forms of P. citri in the plot treated by water only, 1,544 forms in the plot treated with spirodiclofen, 3,002 forms in the plot treated with black soap, and 1,567 mobile forms in the plot treated with two detergents. This study demonstrated that all three treatments had a negative effect on the predators that survived in comparison to the control (T0), while the negative impact of spirodiclofen on beneficial phytoseiid mites was greater than that of black soap and detergents. However, the increase in temperature according to the follow-up weeks showed a significant effect on the evolution of the density of the studied mites. Unfortunately, the chemical products like spirodiclofen used against various citrus pests are considered toxic to phytoseiids and to the agro-ecosystem in general. This comparison aims to detect the effectiveness of black soap and mixtures of two detergents on P. citri and their impacts on its predators: E. stipulatus, P. persimilis, and Typhlodromus sp. to replace the use of pesticides by these alternative methods, which remain effective and environmentally friendly.

: The paper presents the chemical composition of the fruits of three apple cultivars (Jonagold Decosta, Red Idared and Gala Schnitzer Schniga) fertilized with three treatment: T 1 (control‒without fertilization); T 2 (300 kg/ha NPK (6:18:36) + 150 kg/ha N (calcium ammonium nitrate‒CAN)) and T 3 (foliar nutrition-mixture organic-mineral fertilizer commercially named ‘FitoFert Kristal’ (0.6%) (10:40:10) + ‘FitoFert Kristal’ (0.6%) (20:20:20) + ‘FoliFetril Ca’ (0.5%) (N:Ca) in Bosnia and Herzegovina during two years (2020‒2021). Significant differences of contents of soluble solids, total sugars, inverted sugars, sucrose, total phenolic content, content of flavonoids and antioxidant activity were found among cultivar/treatment combinations, cultivars, treatments and years. Differences in total acids content among treatments and years were not statistically significant, but significant differences among cultivars and cultivar/treatment combinations were found. The contents of soluble solids, total sugars and sucrose were the highest in fruits of cultivar Jonagold Decosta, while the highest contents of inverted sugars, total acids, total phenolics, flavonoids and antioxidant activity were found in fruits of Red Idared cultivar. The fertilization treatment T 2 significantly influenced the content of soluble solids, total sugars, inverted sugars, total acids, total phenolic, flavonoids and antioxidant activity in the apple fruits. According to the results obtained, we can say that fertilization treatment T 3 do not have much effect on bioactive ingredients, with the exception of the sucrose content. Among mineral elements, four were macroelements that were represented present in large amounts: potassium (K) (1266.15 mg kg –1 to 1652.89 mg kg –1 ), calcium (Ca) (122.76‒474.90 mg kg –1 ), phosphor (P) (86.14‒124.84 mg kg –1 ) and magnesium (Mg) (57.36‒70.68 mg kg –1 ). On the other hand, four microelements were determined: boron (B) (1.06‒14.25 mg kg –1 ); iron (Fe) (2.79‒4.62 mg kg –1 ); manganese (Mn) (0.27‒0.46 mg kg –1 ) and zinc (Zn) (0.15‒0.48 mg kg –1 ). Results showed that contents of macroelements and microelements have been strongly affected by cultivar/treatment combinations, cultivars, treatments and years.

The positive effects of green infrastructure in the urban environment are nowadays widely known and proven by research. Yet, greening, which serves to improve the indoor climate and people’s well-being, is integrated very limited in public facilities such as schools. Reasons for this are seen in a lack of knowledge and financing opportunities. A focus, among others, of the MehrGrüneSchulen research project is the interdisciplinary development of cost-effective greening solutions for schools. The designs were developed in close collaboration with students of a technical college (HTL) and a horticultural school. This study describes the development process and presents the results of the first implementations of greening systems at the HTL-building complex and at nine other schools in Austria.

ITk detector, the new ATLAS tracking system at High Luminosity LHC, will be equipped with 3D pixel sensor modules in the innermost layer (L0). The pixel cell dimensions will be either 25 × 100 μm2 (barrel) or 50 × 50 μm2 (endcap), with one read-out electrode at the centre of a pixel and four bias electrodes at the corners. Sensors from pre-production wafers (50 × 50 μm2) produced by FBK have been bump bonded to ITkPixV1.1 chips at IZM. Bare modules have been assembled in Genoa on Single Chip Cards and characterized in laboratory and on beam.

Background: Response to the outbreak of poliomyelitis in mid-1950 led to recognition and consequent development of critical care. Seventy years later the humankind was struck by COVID-19, another major challenge for critical care medicine which was especially big in Low-Resources-Settings where more than two thirds of the world population live, including the population of the Republic of Srpska (RS). Design and methods: The main aim was to show an overview of all interventions in order to boost hospitals’ capacities to the level which is sufficient to manage high amount of critically ill COVID-19 patients in the RS. A before-after cohort study design was conducted to evaluate the effects of interventions for increase in preparedness and capacity of ICUs for admission and treatment of COVID-19 critically ill patients in nine hospitals in the RS. Results: Following interventions, the biggest and university affiliated hospital in the RS has increased ICU capacities: total number of ICU beds increased by 38% and number of ventilators by 114%. Availability of machines for veno-venous extracorporeal membrane oxygenation (vvECMO) increased by 100%. Number of doctors who were involved in treatment of critically ill patients increased by 47% and nurse/patient’s ratio reached 1:2.5. Similarly, all other hospitals experienced boosting of ICU beds by 189% and ventilators by 373% while number of doctors increased by 108% and nurse/patient’s ratio reached 1:4. Conclusion: All interventions implemented during COVID-19 pandemic outbreak in the RS resulted in increasing capacity for treatment of critically ill patients, but the education of health care professionals was identified as the most important conducted intervention.

High-throughput sequencing provides sufficient means for determining genotypes of clinically important pharmacogenes that can be used to tailor medical decisions to individual patients. However, pharmacogene genotyping, also known as star-allele calling, is a challenging problem that requires accurate copy number calling, structural variation identification, variant calling, and phasing within each pharmacogene copy present in the sample. Here we introduce Aldy 4, a fast and efficient tool for genotyping pharmacogenes that uses combinatorial optimization for accurate star-allele calling across different sequencing technologies. Aldy 4 adds support for long reads and uses a novel phasing model and improved copy number and variant calling models. We compare Aldy 4 against the current state-of-the-art star-allele callers on a large and diverse set of samples and genes sequenced by various sequencing technologies, such as whole-genome and targeted Illumina sequencing, barcoded 10x Genomics, and Pacific Biosciences (PacBio) HiFi. We show that Aldy 4 is the most accurate star-allele caller with near-perfect accuracy in all evaluated contexts, and hope that Aldy remains an invaluable tool in the clinical toolbox even with the advent of long-read sequencing technologies.

BACKGROUND Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. METHODS WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. FINDINGS Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. INTERPRETATION In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. FUNDING European Society of Intensive Care Medicine, European Respiratory Society.