Echinococcus multilocularis in its main definitive host, the red fox, and the distribution of human cases of alveolar echinococcosis (AE) within a highly endemic focus in southern Germany . Human cases were unequally distributed within the endemicity focus. The purpose of the study was to test whether this is reflected in the small-scale distribution of E. multilocularis in foxes.We describe the spatial distribution of Three areas with contrasting numbers of human cases were selected within the counties of Ravensburg and Alb-Donau, Baden-Württemberg, Germany. From 2018 to 2020, a total of 240 fox carcasses were obtained from traditional hunters in these areas. Carcasses were necropsied and examined for the presence of intestinal helminths. The statistical analysis was performed with SAS version 9.4, and the geo-mapping with QGIS version 3.16.0 Hannover.E. multilocularis in foxes was 44/106 (41.5%) in area I (commune Leutkirch and environs), 30/59 (50.8%) in area II (commune Isny and environs), and 31/75 (41.3%) in area III (commune Ehingen and environs). From 1992 to 2018, a total of nine human cases of alveolar echinococcosis were recorded in area I, five cases were recorded in study area III, and no cases were recorded in area II. No statistically significant differences between the areas were observed (P > 0.05) for intestinal infections with E. multilocularis, and no apparent spatial correlation with the small-scale distribution of human cases was found. Concerning other zoonotic helminths, Toxocara spp. were equally common, with prevalence of 38.7%, 47.4% and 48.0%, respectively, while the frequency of Alaria alata varied among the study areas (0.0–9.4%), probably reflecting the specific habitat requirements for the establishment of its complex life cycle.The prevalence of Echinococcus multilocularis is highly prevalent in foxes in all the studied areas. The varying number of human AE cases within these areas should therefore be caused by factors other than the intensity of parasite transmission in foxes. Echinococcus multilocularis [Human alveolar echinococcosis (AE) is a rare zoonotic disease, caused by the parasitic cestode ocularis –3. The pocularis , 4. In wocularis , 4, 5.Vulpes vulpes), in Baden-Württemberg and Bavaria were conducted from 1999 to 2010 and reported prevalence estimates of 37.0–55.5% E. multilocularis infections [Approximately 70–80% of human AE cases in Germany originate from the two southernmost federal states of Baden-Württemberg and Bavaria. Areas of highest infection risk are in the mountainous regions of the Alps and the Swabian Jura . The mosE. multilocularis includes predatory definitive hosts and herbivorous intermediate hosts. In Europe, definitive hosts are mostly red foxes (V. vulpes), occasionally raccoon dogs (Nyctereutes procyonoides), domestic dogs and cats, where the adult worms settle in the small intestine [Microtus arvalis) and other arvicoline rodents such as water voles (Arvicola spp.), bank voles (Myodes glareolus) or muskrats (Ondatra zibethicus). In intermediate hosts, oncosphere larvae hatch from the eggs in the intestine, penetrate the intestinal wall and are distributed in the body via the circulatory system. The first stages of further development into metacestodes take place almost exclusively in the liver parenchyma, where they form conglomerates of microscopic cysts, eventually leading to a solid, tumour-like structure that replaces liver tissue and may also grow into other organs, even forming metastases. In suitable intermediate hosts, the infection is typically fatal after a period of several months [The life cycle of ntestine . Parasitl months . EventuaHumans, by acting as ‘dead-end hosts’, take no part in the parasite’s life cycle: like real intermediate hosts, they ingest worm eggs through the faecal-oral route, which eventually leads to the development of infiltrative metacestodes, in 98% of cases located in the liver, causing AE . In contE. multilocularis and other zoonotic intestinal fox helminths with the distribution of human AE cases. The study was conducted in areas where data from the National Echinococcosis Registry show high prevalence of human AE during the period 1992–2018 The selection of the study regions was based on the voluntary National Echinococcosis Registry Germany and the human cases of AE recorded during the period from 1992 to 2018 . In the Based on the high number of cases, Leutkirch im Allgäu and environs and Ehingen (Donau) and environs were selected as study areas. Isny im Allgäu, which is adjacent to Leutkirch im Allgäu and environs, has no known registered human cases of the disease, but was also selected as a study area.The National Echinococcosis Registry Germany was established in 2016 as part of a project funded by the German Research Foundation (DFG) [The study and examination of foxes took place during the period August 2018–April 2020. During this period, foxes were shot during official hunting in the selected study regions Leutkirch im Allgäu and environs (study area I), Isny im Allgäu and environs (study area II) and Ehingen an der Donau and environs (study area III) and examined for the presence and infection level of helminths. After shooting, the foxes were stored at −20 °C and examined in a biosafety level 3 (S3) laboratory at the University of Hohenheim, Parasitology Section. Heavily decomposed foxes and foxes which were no longer able to be examined due to injuries to the intestine were excluded from the examination. In total, 27 out of 267 foxes had to be excluded for these reasons.The small intestines of foxes were removed from the carcasses, longitudinally opened and examined for intestinal helminths using the intestinal scraping technique (IST) . ExaminaStatistical analysis was performed using SAS statistical software version 9.4 . The mean, standard deviation (SD), minimum (Min), maximum (Max), and absolute and relative frequencies were calculated first as qualitative characteristics.α = 0.05. Values of P < 0.05 were considered significant. Patients’ place of residence 10 years before initial diagnosis was georeferenced according to the Universal Transverse Mercator (UTM) coordinate system. Geo-mapping of the shapefiles was performed using the QGIS version 3.16.0 Hannover geographical analysis system.Prevalence per 100,000 population was calculated based on population data from the 2011 census using the above formula. Differences in frequency distributions were calculated using the Chi-square and Fisher exact test statistics. All tests were two-sided. The significance level was set at From 1992 to 2018, a total of nine human AE cases were registered in study area I (Leutkirch im Allgäu and environs), including 5/9 (55.6%) female and 4/9 (44.4%) male, with a mean age of 54.5 ± 17.3 years at first diagnosis. The prevalence in area I during this period was 29.8 cases per 100,000 inhabitants. For 6/9 (66.7%) cases, diagnosis was accidental. Two of nine patients reported an agricultural occupation, and 7/9 (77.8%) reported ownership of dogs (Table n = 106), Isny im Allgäu and environs  and Ehingen an der Donau and environs . Total prevalence was 43.8% for E. multilocularis, 35.0%, for Taenia spp., 48.8% for Mesocestoides spp., 43.8% for Toxocara/Toxascaris spp., 19.2% for Uncinaria stenocephala and 5.4% for Alaria alata.From August 2018 to April 2020, a total of 240 foxes (from 267 collected carcasses) were examined from three study areas: (1) Leutkirch im Allgäu and environs  for A. alata, 32/106 (30.2%) for Mesocestoides spp., 38/106 (35.8%) for Taenia spp., 41/106 (38.7%) for Toxocara/Toxascaris spp. and 19/106 (17.9%) for U. stenocephala  were juvenile and 95/106 (89.6%) were adult; 48/106 45.3%) were male and 58/106 (54.7%) were female; 44/106 (41.5%) were infected with % were maE. multilocularis. Other intestinal helminths occurred at prevalence of 3/59 (5.1%) for A. alata, 19/59 (32.2%) for Taenia spp., 28/59 (47.4%) for Toxocara/Toxascaris spp., 33/59 (55.9%) for Mesocestoides spp. and 11/59 (18.6%) for U. stenocephala  were juvenile and 55/59 93.2%) were adult; 24/59 (40.7%) were male and 35/59 (59.3%) were female; 30/59 (50.8%) were infected with % were adf 3/59 5.% for A. E. multilocularis. Other intestinal helminths occurred at prevalence of 0/75 (0.0%) for A. alata, 52/75 (69.3%) for Mesocestoides spp., 27/75 (36.0%) for Taenia spp., 36/75 (48.0%) for Toxocara/Toxascaris spp. and 16/75 (21.3%) for U. stenocephala  were juvenile and 50/75 (66.6%) were adult; 43/75 (57.3%) were male, 31/75 (41.3%) were female, and 1/75 (1.3%) could not be allocated to any sex due to carcass damage; 31/75 (41.3%) were infected with 3.3% wereE. multilocularis, no statistically significant differences in prevalence were found between areas I and II, I and III, or II and III (P > 0.05). The E. multilocularis prevalence stratified by age and sex of foxes shows differences between the study regions  and between areas I and III . For A. alata, statistically significant differences existed between areas I and III , but not between areas II and III or areas I and II. For Taenia spp., Toxocara/Toxascaris spp. and U. stenocephala, no statistically significant differences in prevalence were found between the areas (P > 0.05) , but unlikely for large, macroscopically visible helminths .In the following we compare prevalence data for the various helminths from our survey with recently published results from other areas. It needs to be considered that in most recent studies –25, fox variants , 28. No E. multilocularis, the prevalence in our three study areas was very similar, indicating a homogeneous situation on a larger scale. Comparison with the above-mentioned study from 1993/1994, conducted with the same examination method [E. multilocularis in the region within the past 25 years. This may not be the case for Taenia, Mesocestoides and ascarid nematodes, which were more frequent in our sample than in the previous study. This is interesting information and indicates that, despite partly identical intermediate hosts and transmission mode to foxes, the response of various rodent-transmitted helminths to environmental parameters can differ. This has also been shown during an anthelmintic deworming study of foxes in the vicinity of our study region (in the Swabian Jura), where Taenia species recovered their pretreatment prevalence level far earlier than E. multilocularis and Mesocestoides spp. after the cessation of treatment [E. multilocularis in southern Germany and a low prevalence region in parts of northeastern Germany has remained stable for decades, as indicated by only 1.4% prevalence recently reported from foxes in the Uckermark [For n method , also shreatment . Compareckermark . This stckermark .E. multilocularis across Europe is contrasted by the remarkable uniformity of Taenia spp. frequency in foxes, where our prevalence data closely match recent data from northern Germany and various regions of Poland [Taenia with high reproductive potential in the definitive hosts, where even a small number of worms may be sufficient to infect the intermediate host community. Our prevalence data for Mesocestoides spp., although far higher than in the previous study in the same region [Mesocestoides showed the greatest variation of all examined helminths (30.2 to 69.3%). As neither the allocation to species is certain  are in the range of frequencies reported from other parts of Europe [Toxocara to foxes, but predation of rodents as paratenic hosts may play a more important role than previously assumed [U. stenocephala, is assumed to be mainly transmitted to the definitive host orally with soil containing L3 larvae, but, to an unknown extent, also through ingestion of rodents as paratenic hosts [A. alata was low in two of our study areas and the parasite was completely absent in one (Ehingen/Donau). The patchy distribution and uneven frequency of this parasite are also known from elsewhere [Sus scrofa) as paratenic hosts. They are mostly present in the connective tissue of wild boar musculature, and may become transmitted to humans upon ingestion of uncooked boar products [The highly uneven frequency of f Poland , 25. Thie region , are on tteratus ) nor thef Europe –25. Unli assumed . The comic hosts . Prevaleic hosts –25. As sproducts . There aE. multilocularis is evenly distributed within our sampling areas in a southern German high endemicity region for human AE. On small spatial scales, the distribution of human cases is heterogeneous, but fox infection is not. We conclude that other factors than the local intensity of the wildlife cycle are responsible for differences in human infection risk. We also show that the frequency of E. multilocularis in the study area has remained stable for the past 25 years, while other rodent- or soil-transmitted fox helminths, have increased in prevalence.We show that fox infection with


The purpose of this study was to determine the current status of patient care provided by Korean physical therapists (KPTs) in clinical practice by studying the outcome measures (OMs) used in physical therapy interventions among KPTs with experience in treating patients. A total of 225 KPTs with experience in treating patients in clinical settings participated in the study and completed the online questionnaire. The questionnaire included questions about the use of OMs and the reasons for using them, as well as the types, benefits, and barriers of OMs. The participants’ responses were analyzed and reported in terms of frequencies and percentages. A total of 220 questionnaires were analyzed. The results show that the majority of KPTs in clinical practice used OMs during interventions. The main reasons for using OMs were to check the patient’s condition and to determine the direction and effectiveness of treatment. In terms of the types of OMs used, the highest percentage of subjects used both patient-reported OMs (PROMs) and performance-based OMs (PBOMs). They chose OMs that were quick and easy to use and used them voluntarily. Barriers to and reasons for not using OMs were similar, including lack of benefits, lack of time, and problems with patient performance and uncooperative behavior. When analyzing the effect of demographic characteristics on the use of OMs, we found that physical therapists specializing in musculoskeletal and neurological systems, physical therapists with longer treatment times, and physical therapists who valued OMs were more likely to use them. Based on the results of this study, it is recommended that improvements in the work environment and healthcare system are needed to enhance the professionalism of KPTs working in the field of physical agent therapy by improving their awareness of Oms and improving the quality of physical therapy interventions. Outcome measures (Oms) are methods used to determine a patient’s current status  and are The two types of OMs are patient-reported outcome measures (PROMs) and performance-based outcome measures (PBOMs). PROMs are defined as a patient’s own assessment of their health status, without input from a doctor or therapist . PBOMs aInglis et al.  conducteAlthough there have been previous studies conducted on OMs for foreign physical therapists, there is a lack of research conducted on OMs utilized by Korean physical therapists. Therefore, the purpose of this study was to determine the current status of patient care provided by physical therapists in clinical practice by conducting a study on the OMs used during physical therapy intervention among Korean physical therapists who have experience in patient intervention and to provide a basis for the upward development of physical therapy in Korea and suggest future directions for the field.This study was approved by the Institutional Review Board of Nambu University (1041478-2023-HR-004). The purpose of this study was to determine whether Korean physical therapists, who have experience in patient intervention in clinical practice, use OMs and to analyze their reasons for doing so, the types of OMs used, the benefits, and barriers of using OMs, and the effect of general characteristics on their use of OMs.The selection criteria for this study included licensed physical therapists practicing in Korea with experience in physical therapy interventions. The exclusion criteria consisted of physical therapists without any experience in physical therapy interventions in clinical practice. The sample size for this study was determined using G*power 3.1.9.7 to allow for chi-squared analysis. With the highest degree of freedom being 7 among the survey items, an effect size of 0.3, a significance level of 0.05, and a power of 0.9, the calculated minimum sample size was 204 subjects. Considering a dropout rate of 10%, our aim was to recruit 225 subjects.The questionnaire used in this study was developed appropriately for the Korean clinical setting by collecting OMs items through a systematic review  and condThe survey was conducted over five days using an online Google Form. Subjects were recruited through online community sites and social media platforms commonly used by most physical therapists in Korea. The consent form prior to the start of the survey informed participants that participation was voluntary, that they could withdraw from the survey at any time, that there would be no penalty for withdrawal, and that their confidentiality would be protected. The purpose of the study was explained, consent to participate in the study and use of personal information was obtained, and they were asked to provide their license number to verify that they were a physical therapist. Participants who agreed to take part in the survey were able to do so via the QR code or survey address link provided in the recruitment announcement, and those who participated voluntarily took the survey, which took approximately 10 min to complete.Data from this study were analyzed using IBM SPSS software version 25.0. The responses to the general characteristics of the participants, whether they used OMs and their reasons for using it, and the types, benefits, and barriers of OMs were expressed as frequencies and percentages. Chi-square test and Fisher’s exact test were used to test for differences in the presence of OMs according to general characteristics, and logistic regression analysis was used to analyze the effect of significant general characteristics on the presence of OMs. The level of statistical significance was set at 0.05.p < 0.001), area of practice (p < 0.000), treatment time (p < 0.015), monthly salary (p < 0.019), and the importance of OMs (p < 0.000) . The highest percentage of participants had a bachelor’s degree (58.2%), and the highest percentage of physical therapists had five or fewer years of experience (54.1%). The largest number of physical therapists (104) worked in clinics and Korean medicine clinics (47.3%), with the majority of physical therapists working with the musculoskeletal system (55.5%) and the nervous system (34.5%). A large proportion (37.7%) treated clients for more than 15 min and less than 30 min. Most therapists were earning between KRW 2 and KRW 2.99 million per month (55.5%) or more than KRW 3 million per month (39.1%). Regarding the importance of OMs, the majority of physical therapists considered OMs to be very important (73.2%) or somewhat important (25.5%), and no physical therapists considered OMs to be negative. Chi-squared analysis revealed significant differences in gender (< 0.000) .A total of 84.1% of physical therapists reported they used OMs often (43.2%) and always (40.9%), and 15.9% of physical therapists rarely (12.3%) or never (3.6%) used OMs .The main reasons why participants used OMs were to check patient status (4.78 ± 0.43), determine treatment direction (4.72 ± 0.48), identify changes in patient status (4.7 ± 0.47), improve quality of care (4.46 ± 0.65), identify and document patient status, progress, and treatment effects (4.02 ± 0.97), compare treatment effects between patients (3.62 ± 1.2), communicate with other healthcare providers (3.16 ± 1.18), compare treatment effects between therapists (3.1 ± 1.46), and for research (2.13 ± 1.12).Altogether, 106 (57.3%) physical therapists used both PROMs and PBOMs, 59 (31.9%) physical therapists used only PBOMs, and 20 (10.8%) physical therapists used only PROMs. The conditions under which OMs were used were as follows: voluntary depending on the patient’s condition or environment (28.1%) or voluntary for all types of patients (22.7%). A total of 50.8% of participants used OMs voluntarily . The maiThe main benefits of using OMs listed by the participants were help with treatment planning (4.58 ± 0.53), help with treatment choice (4.54 ± 0.63), increased treatment efficiency (4.44 ± 0.62), help with therapists and patients communication (4.43 ± 0.69), better patient outcomes (4.41 ± 0.66), help with motivating and encouraging patients (4.39 ± 0.69), making patients feel that the therapists are thorough (4.36 ± 0.73), help in communicating with third-party payers and other healthcare providers (3.87 ± 0.9), and help with marketing the clinic/service (3.85 ± 0.99).The main barriers to OMs listed by the participants were that they are ineffective (3.57 ± 1.29), are difficult for patients to perform themselves (3.46 ± 0.95), require more effort than patients are capable of (3.42 ± 0. 94), have an insufficient treatment time (3.38 ± 1.02), are time-consuming (3.2 ± 0.97), can be hindered by an uncooperative patient attitude (3.01 ± 1.01), are time-consuming to analyze/calculate/evaluate (3 ± 0.98), and led to results that are difficult to trust (2.75 ± 0.88).The main reasons participants cited for not using OMs were lack of time (65.7%), lack of benefits (54.3%), and patient uncooperativeness (40%) .Other reasons given for not using OMs were that most of their patients are chronic and would rather be treated than use OMs, they do not want the hospital to use OMs, because it is a routine task, and because it is their time to treat patients.2 = 6.788, p = 0.560), and the explanatory power of the regression model was approximately 35.2% (Nagelkerke R2 = 0.352). The results of the analysis indicate that the musculoskeletal system , the neurological system , treatment times exceeding 45 min , treatment times ranging from more than 30 min to less than 45 min , and the perceived importance of OMs  significantly influenced whether physical therapists used OMs , MMT , and ROM (Range of Motion) scales ,17. ThesThe majority of Korean physical therapists use OMs when intervening with patients to improve the quality of care and monitor their condition. OMs are an essential component of EBP, and Korean physical therapists are found to practice them. The main factors associated with the use of OMs were physical therapists working in physical agent therapy, physical therapists with insufficient treatment time, and physical therapists who did not consider it important to use OMs. It is suggested that efforts by physical therapists and policy changes are needed to address barriers to the use of OMs. Further research should investigate the types of OMs tools that Korean physical therapists use when intervening with patients in clinical practice.


Finally, the combustion processes of blends with proportions of 0%, 5%, 10%, 15%, and 20% biodiesel were simulated and compared by using the model. The study showed that the brake thermal efficiencies (BTEs) of biodiesel blends with 5%, 10%, 15%, and 20% of biodiesel were increased by 1.24%, 1.89%, 3.13%, and 3.82% at 50% load, respectively, compared with pure diesel. In addition, the soot emissions were decreased by 1.20%, 2.64%, 3.88%, and 4.65%, respectively. However, as the proportion of biodiesel in the biodiesel blends increased, the brake specific fuel consumption (BSFC) and NOx emissions increased. At 50% load, the BSFCs of biodiesel blends with 5%, 10%, 15%, and 20% of biodiesel increased by 0.61%, 1.34%, 1.42%, and 2.17%, respectively, compared with pure diesel. Additionally, the brake powers (BPs) were decreased by 0.64%, 1.31%, 1.88%, and 2.62% at 100% load, respectively.This work investigated and compared the impact on performance and emission characteristics of diesel engine fueled with five different proportions of biodiesel blends. Firstly, the three-dimensional simulation software CONVERGE was used to create a 3D simulation model of in-cylinder combustion for a diesel engine. Secondly, the experimental data of cylinder pressure and NO The diesel-biodiesel mechanism used is that of Liu et al. . This chk is the coefficient of conductivity of the molecule; Tb is the temperature of the wall, K; Prt is the Prandtl number of the molecule; Ta is the temperature of the liquid, K; μτ is the shear speed; y+ is the dimensionless distance.(9)Emission modelDuring the operation of the engines, there are always heat transfers taking place. In order to simulate this process more accurately in CONVERGE software, the OʹRourke and Amsden model was selected in this paper . The heax model is chosen in this paper  = Square root of [(0.48)2+(0.12)2 + (0.5)2 + (0.03)2 + (1.3)2 + (0.38)2 + (3.2)2] = 3.545%Total uncertainty of experiment = Square root of [The engine's economic characteristics can be significantly impacted by the use of biodiesel blends. Compared with D100, biodiesel blends can increase the BTEs of diesel engines. It is due to the improvement combustion caused by the oxygen content in the biodiesel. However, the increase of the proportion of biodiesel decreases the total calorific value of the biodiesel blend. Therefore, the addition of biodiesel decreases BP and increases BSFC in diesel engines compared with pure diesel.(2)The proportion of biodiesel in biodiesel blends plays a very important role. When the engine operates at 50% and 100% load, higher biodiesel concentrations in the biodiesel blend result in the increases of in-cylinder temperature and pressure peaks. This is because the high oxygen content of biodiesel enhances combustion. However, at 25% load, the oxygen content of the biodiesel blend has relatively little impact on combustion. Since the calorific value of biodiesel is lower than that of diesel, the addition of biodiesel leads to a lower heat release per unit volume of biodiesel blend. This in turn leads to lower in-cylinder combustion temperatures and pressure peaks as the biodiesel proportion increases.(3)x emissions can slightly increase due to the higher oxygen content and cylinder temperature that enhance NOx production.The biodiesel in biodiesel blends can significantly impact engine emissions. As the proportion of biodiesel in the biodiesel blend increases, soot, and CO emissions decrease at all loads. Compared with D100, the soot emissions for a diesel engine were decreased by 1.20%, 2.64%, 3.88%, and 4.65% for D95B5, D90B10, D85B15, and D80B20 blends, respectively. This is caused by the higher oxygen content in biodiesel, which promotes more complete fuel combustion. However, NOBiodiesel is potential renewable alternative fuel for automobiles . In the In future work, other additives and methods can be used to further improve the performance of biodiesel. Biodiesel has great potential and promise for commercial application from the perspective of sustainability and environmental protection. In summary, the application of biodiesel as a partial substitute for diesel in diesel engines can significantly decrease the emission of exhaust pollutants. It has important research significance for alleviating the energy crisis and decreasing environmental pollution. In addition, the results of this study provide valuable information for further optimization of biodiesel blends.Yanhui Chen: Conceived and designed the experiments; Performed the experiments; Contributed reagents, materials, analysis tools or data.Jian Zhang: Performed the experiments; Wrote the paper.Zhiqing Zhang: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.Weihuang Zhong: Ziheng Zhao: Jingyi Hu: Analyzed and interpreted the data.Data will be made available on request.Guangxi key research and development Foundation under the research grant 2023AB01092.The work is supported by the The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


First, to assess the number of spinal cord anomalies (SCA), specifically tethered spinal cord (TSC) in patients with anorectal malformations (ARM), identified with spinal cord imaging . Second, to report outcomes after TSC treatment.A retrospective mono-center study was performed. All ARM patients born between January 2000 and December 2021 were included. Screening for SCA consisted of spinal cord US and/or MRI. Radiology reports were scored on presence of SCA. Data were presented with descriptive statistics.In total, 254 patients were eligible for inclusion, of whom 234 (92.1%) underwent spinal cord imaging. In total, 52 (22.2%) patients had a SCA, diagnosed with US , MRI , or both US and MRI , of whom 12 (23.5%) with simple, 27 (52.7%) intermediate, and 12 (23.5%) complex ARM types. TSC was identified in 19 patients (8.1%), of whom 4 (21.1%) underwent uncomplicated neurosurgical intervention.SCA were present in 22% of ARM patients both in simple, as well as more complex ARM types. TSC was present in 19 patients with SCA, of whom 4 underwent uncomplicated neurosurgical intervention. Therefore, screening for SCA seems to be important for all ARM patients, regardless of ARM type.Level III. Anorectal malformations (ARM) are rare congenital disorders that occur in approximately 1–3 per 5000 live births yearly . In apprEarly identification of SCA in ARM patients is important, as their presence could potentially cause damage in the future when not recognized  , 17. TheAlthough most patients with SCA (including TSC) do not require surgical intervention, there is an ongoing debate on whether or not an early neurosurgical intervention (i.e. prophylactic untethering surgery) is beneficial for ARM patients , 22. A sThis was a retrospective cohort study, designed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines . Data weThis study was reviewed by the medical ethical commission and was not subject to the WMO statement (ref. no. W20_230 #20.576). Regarding the primary Emma Children’s hospital database, written information was provided to parents or legal guardians for all identified ARM patients, including a letter of objection. In case of objection, patients were removed from the database (n = 6).Data on patient characteristics, (non-)syndromic anomalies , type of ARM (according to Krickenbeck classification ), additiPatients were classified according to their type of ARM using the Krickenbeck classification with major clinical groups and rare/regional variants . For staPrimary outcome was the number of ARM patients in whom SCA were identified.Secondary outcomes were the number of US and/or MRI performed, the screening trend over time, factors associated with SCA, the number of ARM patients with TSC, and the number of ARM patients with symptomatic or asymptomatic TSC that underwent treatment and their functional outcomes.Statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 28 . Descriptive statistics were used for analysis of baseline characteristics. These were reported as proportions and percentages for binary or categorical variables, and as mean with standard deviation (SD) or as median with interquartile range (IQR) for continuous variables as appropriate. To evaluate changes over time in screening, patients were categorized into 3 time periods . To compare screening percentages over time, Chi-square for trend was used. Univariable and multivariable logistic regression analyses were performed to investigate associations between baseline characteristics  and SCA. Outcomes were reported as odds ratio (OR) with corresponding 95% confidence interval (95% CI). A p-value of < 0.05 was considered statistically significant. Missing or unknown data were described. In case of missing data in additional imaging studies (US and MRI), it was classified as ‘not performed’.In total, 255 patients were identified in the Castor EDC database of whom 1 was excluded due to death within 1 day after birth. The cohort therefore comprised of 254 patients ; 122 female (48.0%) and 132 male patients (52.0%), with a median age of 7.0 years (IQR 3.0–12.0) at latest follow-up. Eight different ARM types were identified , of which recto-perineal fistula occurred most often, encompassing 51 female patients (41.8%) and 58 male patients (43.9%). In 82 patients (32.3%), VACTERL-association (n = 42 (16.5%)) or syndromic anomalies (n = 40 (15.7%)) were identified. Nine patients (3.5%) deceased during the study period, of which 3 patients (33.3%) had a cloacal anomaly. Five patients died due to respiratory insufficiency , 1 due to bacterial meningitis (at age 3 years), and 1 due to abdominal compartment syndrome (at age 16 years). In 2 patients, the cause of death was not mentioned in the available medical record. A complete overview of identified ARM types is shown in Table In total, 234 patients (92.1%) underwent additional imaging studies (i.e. US and/or MRI) to identify SCA at any moment in time (i.e. prior to or after ARM correction surgery). Over the 3 time periods, percentage of screening with US was lower in the second period, whereas period 1 and 3 are similar . Over the 3 time periods, percentage of screening with MRI decreased . Some 168 patients (66.1%) underwent solely US, 13 patients (5.1%) underwent solely MRI, and in 53 patients (20.9%), both US and MRI were performed. In 20 patients (7.9%), data on additional imaging studies was missing.In total, SCA were identified in 52 of 234 patients (22.2%) that underwent screening with additional imaging studies (i.e. US and/or MRI). Over the 3 time periods, percentage of identified SCA remained similar . In the SCA patients group, 13 patients (25.0%) underwent solely US, 3 patients (5.8%) underwent solely MRI, and in 36 patients (69.2%), both US and MRI were performed. SCA were identified through US in 42 patients (80.8%), with median age at diagnosis of 2.0 days (IQR 1.0–7.3). With US, FT anomalies were diagnosed most often in 21 patients (50.0%). SCA were identified through MRI in 32 patients (61.5%) with median age at diagnosis of 8.5 weeks (IQR 1.0–39.0). With MRI, FT anomalies and conus anomalies were diagnosed most often, in 16 patients (50.0%) and 11 patients (34.3%), respectively. In 8 patients (15.4%), SCA were identified with MRI where US findings were undetermined or in of unclear anatomy (n = 7) or data was missing (n = 1) , conus anomaly (n = 3), hydromyelia (n = 3), TSC (n = 1), caudal regression syndrome (n = 1), and spinal lipoma (n = 1)). Overall, SCA were most often identified in patients with cloacal malformations (6 of 14 patients (42.9%)) and rare/regional variants (4 of 9 patients (44.4%)). An overview of number of patients with SCA identified though imaging studies according to type of ARM is shown in Tables In total, TSC was diagnosed by imaging studies  in 19 of 234 screened patients (8.1%) with median age at diagnosis of 3 days (IQR 2.0–8.0). Within the SCA patient group, over the 3 time periods percentage of identified radiological TSC increased . Radiological TSC was identified in 12 patients (63.2%), without the presence of symptoms during complete follow-up . In 7 of 19 patients (36.8%) symptoms associated to TSC were identified (i.e. sensibility and motor loss (n = 1) and increased reflexes (n = 1), in addition to neurogenic bladder disorder (n = 7)). The sensibility and motor loss were present since birth without progression over time. Therefore, no surgical intervention was performed. In 5 patients (26.3%), only a pediatric neurologist was consulted for determining treatment strategy, and in 11 patients (57.9%) both a pediatric neurologist and neurosurgeon were consulted. Consequently, 4 of 19 patients (21.1%) underwent neurosurgical intervention for TSC. The indication for neurosurgical intervention were bladder dysfunction and increased reflexes in 1 patient, bladder dysfunction in 1 patient, and the nature of the anomaly as seen on additional imaging studies in 2 patients. Symptoms associated to TSC were present in only 2 patients (50.0%) that underwent surgery and resolved postoperatively. Neurosurgical intervention included terminal filum cleaving (i.e. untethering) in all 4 patients at ages 1 year (n = 2), 2 years, and 7 years respectively. No complications after untethering surgery were encountered. In total, 15 asymptomatic patients (78.9%) underwent conservative (wait-and-see) treatment, without onset or progression of symptoms, and follow-up ranging from 3 to 16 years. An overview of the identified patients with TSC can be found in Table In our cohort of 254 ARM patients, approximately one fifth of the patients had a spinal cord anomaly; both patients with simple ARM types, as well as patients with more complex ARM types. In the majority of patients, our screening protocol with US and/or MRI was followed. SCA were identified solely with US in 39%, solely with MRI in 19%, and with US and MRI in 42% of the patients. Furthermore, in 15% of patients, SCA were identified on MRI where US findings were undetermined or of unclear anatomy. Radiological TSC was present in 19 patients, of whom 12 were asymptomatic and 7 symptomatic. In total, 4 patients with radiological TSC underwent uncomplicated neurosurgical intervention which resolved symptoms in 2 symptomatic patients.This study showed that SCA were present in 22% of ARM patients. In the literature, the prevalence of SCA in ARM patients ranged from 26 up to 60%, which is higher than in our study , 14, 18.In multivariable analysis, presence of syndromes or VACTERL-association and complex ARM type were shown to be independently associated with SCA. In line with our finding, a previously performed study showed higher prevalence of SCA in ARM patients with VACTERL-association, as well as in ARM patients with vertebral anomalies . FurtherRadiological TSC was diagnosed in 8% of the ARM patients that underwent additional imaging studies, which is low compared to previous studies, as numbers on prevalence of TSC in ARM patients ranged widely from 6 to 65% , 27, 28.In this 21 year cohort, a vast majority (92%) of ARM patients underwent additional imaging studies to identify SCA at any moment in time. Over time, screening with US was lower in period 2 (77.4%) compared to period 1 and 3 (both 91.8%). This might be due to a lack of registration and/or missing of US images in medical records. Furthermore, screening with MRI decreased significantly over the 3 time periods, which might be explained by the fact that US was performed more often, and pediatric radiologists became more experienced in US. Median age of SCA diagnosis differed between US (i.e. 2.0 days) and MRI (i.e. 8.5 weeks), which might be explained by the fact that in AmsterdamUMC since late 2014, US was implemented as standard initial screening for SCA in ARM patients ≤ 3 months of age. Compared to MRI, US is likely more accurate for SCA diagnosis in these young patients as US provides better resolution and dynamic imaging, as the mobility of the conus could be better assessed . FurtherThis study should be interpreted in the light of some strengths and limitations. First, this a large cohort from the past 21 years of patients with an extremely rare disease (i.e. ARM and TSC). Second, this study shows the data of a successfully implemented screening with US and/or MRI. Third, the consultation of a multidisciplinary team in case of uncertainties on classification of SCA improved the quality of the categorization and assessment of the encountered anomalies in this study. However, this study is prone to several limitations, of which most importantly information and registration bias, especially due to the large timeframe in which the study was executed. To reduce this to a minimum, data were extracted by two independent researchers , with a data check by other coauthors . Furthermore, due to the implementation of electronic patient records since late 2016, screening for SCA might be performed, or symptoms according to SCA and/or TSC might be present, but not adequately documented. In addition, if documentation on screening for SCA was missing, for analysis it was classified as ‘not performed’. Therefore, the incidence of SCA in our ARM population might be higher.In conclusion, 22% of ARM patients had a spinal cord anomaly. TSC was present in 8% of patients (n = 19), of whom 4 patients underwent uncomplicated neurosurgical intervention. Screening for SCA was performed in the majority of ARM patients and improved over time. More complex types of ARM and the presence of a syndromic anomaly or VACTERL-association were shown to be associated to the presence of SCA, but SCA were identified in both patients with simple ARM types, as well as patients with more complex ARM types. Therefore, this study emphasizes the importance of screening for SCA in patients with ARM, regardless of ARM type.


The rate ratios and 95% confidence intervals for the top middle panel, which depicts the rate ratios for psychosis-related claims as a function of state cannabis policy level for women, were depicted incorrectly. The rate ratios for medical with retail outlets should have appeared as 1.20  instead of 1.20 ; for recreational with no retail outlets, 1.20  instead of 1.36 ; and for recreational with retail outlets, 1.36  instead of 1.63 . This article has been corrected.1In the Original Investigation titled “State Cannabis Legalization and Psychosis-Related Health Care Utilization,”


The Australian immunisation schedule uses 13-valent pneumococcal conjugate vaccine (PCV13), while New Zealand (NZ) changed from PCV13 to 10-valent PCV (PCV10) in 2017. In NZ, cases of serotype 19A (not in PCV10) have been increasing since 2017. We compared invasive pneumococcal disease (IPD) epidemiology between Australia and NZ in 2017–2021.We collated IPD notification data from national surveillance systems. Between Australia and NZ, we compared IPD incidence rates and assessed the proportion of serotype 19A, and stratified for ethnicity and age.Between 2017 and 2021, the crude IPD incidence per 100,000 in Australia ranged from 4.3 to 8.4, and ranged from 6.9 to 11.4 in NZ. The highest age-adjusted IPD rates were observed in Australian Indigenous people (range: 27.3–35.5) followed by NZ Māori/Pacific peoples (range 19.7–30.4). For children <2 years, ethnicity-adjusted IPD rates were similar between Australia and NZ in 2017–2020. In 2021, however, the ethnicity-adjusted incidence in children <2 years was higher in NZ  than in Australia (23.3 95% CI: 19.5–27.1) (p < 0.01). In Australia, the proportion of serotype 19A remained 5%, whereas in NZ serotype 19A increased from 11.5% to 29.5% with the largest increase in children <2 years and 2–4 years.Despite higher risks in Indigenous populations in Australia compared to all other groups, the overall IPD rate in NZ is increasing, particularly among children. The numbers and proportions of IPD due to serotype 19A are increasing in NZ especially in children. These data support the NZ decision from December 2022 to change to PCV13.This research received no specific funding. Streptococcus pneumoniae”, “invasive pneumococcal disease”, “pneumococcal conjugate vaccine” and “impact”. We focused on studies published between January 1, 2002 and March 31, 2022 that studied the effect of 10-valent pneumococcal conjugate vaccine (PCV10) and 13-valent pneumococcal conjugate vaccine (PCV13) on invasive pneumococcal disease (IPD) incidence. In addition, we searched for studies based in the Asia–Pacific region.We searched PubMed for articles on invasive pneumococcal disease using the search terms “Both PCV10 and PCV13 are known to reduce the incidence of IPD. Previous studies have not found any superiority for either vaccine in reducing the overall burden of pneumococcal disease. The choice of vaccine should be influenced by local epidemiology and serotype distribution. In a number of countries that use PCV10, infections due to serotype 19A have been increasing. A recent systematic review evaluating the burden of pneumococcal disease among adults found a large regional variation of IPD incidence and a higher burden in older populations. Prevalence of serotypes varied across Asia–Pacific countries, with serotype 3, serotype 19A, and serotype 19F as the most frequently reported serotypes. However, there are no studies comparing neighbouring countries, Australia and Aotearoa New Zealand (NZ) with regards to their IPD epidemiology. While similar in many ways, their different national immunisation programmes (NIPs) from 2017 to 2021, namely PCV13 in Australia and PCV10 in NZ, provide a unique opportunity to assess the potential impact of PCV10 and PCV13 NIPs, while taking into account their different population structures.In this observational study based on surveillance data of notifiable IPD, we found that incidence was higher in NZ compared to Australia 2017–2021, particularly in more recent years. The IPD incidence was highest in young infants and elderly. In addition, specific ethnic groups have a higher burden of IPD, including Australian Indigenous people and NZ Māori/Pacific peoples. In NZ, serotype 19A is the most abundant serotype and is increasing in all age groups and ethnic groups.These data support the decision to change the NIP in NZ starting from December 2022 to include PCV13. In NZ, additional pneumococcal immunisations for adult Māori/Pacific peoples or for elderly are unfunded. As the incidence of serotype 19A is quickly increasing in the elderly in NZ, surveillance efforts should continue to closely monitor this group to help inform future policy changes on pneumococcal vaccinations.,After introduction of the pneumococcal conjugate vaccine (PCV), invasive pneumococcal disease (IPD) and subsequent pneumococcal mortality has been reduced globally. Yet in 2015, pneumococcal infections are still estimated to cause 294,000  deaths in HIV-uninfected children under 5 years.Several PCVs have been commercially available and cover different serotypes: 7-valent PCV (PCV7)  , 10-valent PCV (PCV10)  , 13-valent PCV (PCV13)  , and 15-valent PCV (PCV15) (contains PCV13 serotypes and serotypes: 22F and 33F) . Previous studies comparing the impact of PCV10 and PCV13 programmes until 2017 have not found superiority for either vaccine in the overall burden of pneumococcal disease.,,PCV13 has been used in the national immunisation programme (NIP) of Australia since 2011, initially with 3 primary doses, and then with 2 primary doses and 1 booster (2 + 1) since 2018. In Aotearoa New Zealand (NZ) PCV10 was used between 2011 and 2014, with a switch to PCV13 in 2014. In 2017 PCV10 was reintroduced, initially with a 3 + 1 schedule and then a 2 + 1 from July 2020 .5,6 NZ cWhen NZ switched to PCV10 in 2017 it was on the basis that immunogenicity studies suggested the inclusion of serotype 19F in PCV10 offered cross-protection for serotype 19A. In 2016, serotype 19A made up 17% of all IPD isolates in NZ.A recent systematic review studied adult pneumococcal disease in the Asia–Pacific region, though NZ data in that study were limited and no country comparison was performed.In the present study, we aimed to compare the impact of two different NIPs in countries with similar healthcare systems and COVID-19 experiences, while considering their disparate population structures and risks. Namely, we assessed the IPD incidence within Australia (PCV13) and NZ (PCV10) in 2017–2021, with a focus on age, ethnic groups, and the role serotype 19A has played in the IPD incidence.This is an observational study based on surveillance data from Australia and NZ between 1 January 2017 and 31 December 2021. We extracted IPD case notification data from national surveillance institutes  in NZ) and merged those with census data derived from Australian Bureau of Statistics and Statistics New Zealand. In NZ, all diagnostic laboratories contribute data to the surveillance system and serotyping is performed at ESR's Invasive Pathogens Laboratory. In Australia, all laboratories contribute to the surveillance system and serotyping is performed by one of 4 reference laboratories, depending on which state the sample was collected including NSW Health pathology, PathWest Laboratory Medicine, Microbiological Diagnostic Unit Public Health Laboratory at the University of Melbourne, and Queensland Health. The Australian reference laboratories report their data to the National Notifiable Diseases Surveillance System.S. pneumoniae if isolated from a normally sterile site, detected with nucleic acid testing from a sterile site, or (in NZ only) a newer generation S. pneumoniae antigen test on cerebrospinal fluid or pleural fluid.IPD was defined as a laboratory confirmed infection of Age was grouped into <2 years, 2–4 years, 5–64 years and ≥65 years. Ethnicity was defined as Australian Indigenous , Australian non-Indigenous, NZ Māori/Pacific peoples and NZ other ethnicities . Cases with missing ethnicity were excluded for this analysis .We estimated the crude annual incidence of IPD, which was expressed as incidence rates (IRs) per 100,000 and their 95% confidence intervals (CIs).This research received no specific funding.Between 2017 and 2021, the crude IPD rate in Australia ranged from 4.3 (95% CI 4.1–4.6) per 100,000 in 2020 to 8.4 (95% CI 8.0–8.8) per 100,000 in 2019 . In NZ, To determine the burden of disease by select risk groups within each country, we stratified crude IPD rates by both age and ethnicity , Fig. S1Within Australia, IPD incidence between 2017 and 2021 in Australian Indigenous people was higher than in Australian non-Indigenous people in children <2 years (crude IRRs ranged 1.9–2.4), 5–64 years (crude IRRs ranged 7.3–18.7) and people ≥65 years of age (crude IRRs ranged 2.7–7.2) . In NZ, The highest age-adjusted IRs were observed in Australian Indigenous people (ranging from 27.3 (95% CI 23.7–31.0) per 100,000 (in 2021) to 35.5 (95% CI 30.9–40.0) per 100,000 (in 2017)), followed by NZ Māori/Pacific peoples (ranging from 19.7 (95% CI 19.1–20.4) per 100,000 (in 2020) to 30.4 (95% CI 29.4–31.4) per 100,000 (in 2017)), NZ other (ranging from 4.4 (95% CI 3.7–5.0) per 100,000 (in 2020) to 7.9 (95% CI 7.0–8.8) per 100,000 (in 2018)) and Australian non-Indigenous people (ranging from 3.0 (95% CI 2.8–3.2) per 100,000 (in 2020) to 6.9 (95% CI 6.5–7.2) per 100,000 (in 2018/2019))  and S5. To control for the effects of different risks as they pertain to disparate ethnic groups, we also estimated ethnicity-adjusted rates within each country  and S7. In Australia, the proportion of PCV10 serotypes and of serotype 19A were 12% and 5%, respectively, and the proportions did not vary over the years : Fig. S2In NZ, during the study period the proportion of PCV10 serotypes decreased from 14.2% (74/521) to 5.3% (25/468) and the proportion of serotype 19A increased from 11.5% (60/521) to 29.5% (138/468) in 2021 . This inEarly assessments of preliminary data for 2022 (up to July) suggest a widening gap between NZ and Australia, particularly among children <2 years of age. The crude rate of IPD in NZ children <2 years of age was more than three-times higher than in Australia . In Australia the crude rate of IPD in children <2 years of age was 11.3 per 100,000 with 1.5% of isolates serotype 19A.In this comparison study of IPD epidemiology in Australia and NZ, we found that the crude incidence of IPD was higher in NZ compared to Australia during the years 2017–2021. Our data confirm that Australian Indigenous people are disproportionally affected by IPD, followed by NZ Māori/Pacific peoples. Despite higher risks in Indigenous populations in Australia compared to all other groups, the overall IPD rate in NZ is increasing, particularly among children. In NZ, the high increase of serotype 19A occurred in all ethnic groups and age groups whereas in Australia the proportion of serotype 19A remained low and stable over time.,,Comparing the IPD incidence to other high-income countries, the IPD incidence in Australia and NZ was similar to the IPD incidence in America (2019: IR 9.2), but was higher compared to European countries .,,,33The emergence of serotypes not included in vaccines following introduction of PCVs is described globally and is called serotype replacement.One large study showed that IPD incidence decreased globally during the COVID-19 pandemic in 2020.In July 2020, NZ switched from a schedule of three primary doses with no booster (3 + 0) to a schedule with two primary doses with 1 booster (2 + 1) for PCV10. It is yet unclear whether this schedule change will influence IPD incidence or 19A incidence. It is suggested though that the 2 + 1 schedule provides higher antibodies and may provide longer protection compared to the 3 + 0 schedule.Similar to other countries, a decline in immunisation coverage during the COVID-19 pandemic was observed in NZ.,Similar to other studies, our data confirm that Australian Indigenous people and NZ Māori/Pacific peoples are disproportionally affected by IPD.In our study, the largest difference in ethnicity was observed in people 5–64 years of age and ≥65 years of age. Although overall IPD incidence decreased in these age groups, the burden of disease in people ≥65 years of age was substantial . In Australia, people >70 years are eligible for PCV13 and Indigenous people >50 years are eligible for PCV13 and a 23-valent pneumococcal polysaccharide vaccine (23-PPV). In contrast, NZ does not fund additional pneumococcal immunisations for adult Māori/Pacific peoples or for elderly.As serotype 19A is increasing in the elderly, NZ surveillance should monitor serotype and IPD incidence in this group to inform policy on pneumococcal vaccinations. Further, the burden of disease should be considered as the influence of infant vaccinations can provide indirect immunity in older age groups.Should countries switch to a higher-valent PCV and when? The statement by the World Health Organization recommends only switching when the epidemiology of IPD changes significantly.Starting in December 2022, PHARMAC in NZ changed the infant immunisation schedule to PCV13. It is likely that a significant decrease in IPD incidence and serotype 19A incidence following this change from PCV10 will take a few years to be observed. In particular, catch-up immunisation for children <5 years is not part of the PCV programme change, therefore those who received PCV10 are still insufficiently protected from serotype 19A. Lastly, improving immunisation coverage, particularly in high-risk groups, should be a key aspect of any plan to reduce the impact of IPD due to serotype 19A.S. pneumoniae by newer generation antigen tests whereas the Australian case definition did not. As the number of cases detected by antigen tests was <2%, this has unlikely influenced our results. Second, we used aggregated data and individual data on medical history or immunisation status was not available, particularly in Australia. We acknowledge that children at high medical risk were previously eligible for PCV13 in NZ ,The main strength of our study is that surveillance data of IPD is of high-quality both in Australia and NZ. Also, we used a highly specific laboratory-confirmed definition of IPD. Although this definition does not represent the total disease burden of IPD, it ensures our results are not overestimated. This study has some limitations. First, the NZ case definition for IPD included detection of In this study based on surveillance data of IPD in Australia and NZ between 2017 and 2021, Australian Indigenous people followed by NZ Māori/Pacific peoples have a disproportionally higher burden of IPD. Despite higher risks in Indigenous populations in Australia compared to all other groups, the overall IPD rate in NZ is increasing, particularly among children. In addition, in NZ serotype 19A is the most common serotype and is increasing in all age and ethnic groups. Especially in NZ children <2 years, IPD incidence increased sharply, explained largely by the increase in serotype 19A. Our study supports the decision to change from PCV10 to PCV13 in NZ.Conceptualisation: N.N.H., T.W., A.A.Methodology: N.N.H., A.A., C.G., M.H., T.W.Formal analysis: N.N.H., A.A., C.G.Data curation: A.A., M.H.Writing – Original draft: NH, Writing – Review & Editing: A.A., C.G., M.H., T.W.survqueries@esr.cri.nz.The aggregate data underlying the study is presented in the This research was approved by the ethics committee of University of Otago (HD22/029). In Australia, research that is based on non-identifiable data such as this project is deemed as negligible risk research and is therefore exempt of ethical review.There are no declared conflicts of interest.


The power line workers have a heavy physical workload. It is essential to know the impact of this perceived exertion on their satisfaction with life to improve their mental health.We aimed to evaluate the associations between perceived exertion at work and satisfaction with life among power line workers.We conducted a study among a group of power line workers from January to June 2022 using a self-administered questionnaire. We evaluated socio-professional characteristics, physical exertion with the Borg CR-10, and the satisfaction with life scale (SWLS).Seventy-four male line workers participated in the study. They were married in 67.6% of cases. The mean age was 39.3 ± 10.5 years. The average job tenure was 15.5 ± 11.2 years. The mean of perceived exertion was 6.1±1.9. High to very high exertion was found in 73% of participants. The mean score of satisfaction with life was 26.8 ±6.5. Five (12.6%) participants were dissatisfied to extremely dissatisfied. Fifty-six (75.9%) participants were satisfied to extremely satisfied. High perceived exertion was correlated with higher satisfaction with the lives of line workers .Power line workers with high perceived exertion were more satisfied with their lives. This can be explained by the positive impact of work on the lives of workers. The work environment is paramount to ensuring good mental health.None Declared


The aim of this study was to evaluate a new surgical technique by the European Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) Study Group.This study included 391 patients (47 [(12%]) male and 344 [(88%)] female) who had undergone endoscopic thyroid or parathyroid surgery via the vestibular approach between February 2016 and May 2022 at nine centers. The data were analyzed with regard to complications, surgery time and specimen retrieval.Overall, 376 (96.2%) TOETVA and 15 (3.8%) transoral endoscopic parathyroidectomy vestibular approach interventions were performed with an average surgery time of 145 (± 61.2) minutes and 509 nerves at risk. The specimens were retrieved via a transoral vestibular and retroauricular approach in 66 (16.9%) patients and via a transaxillary approach in 8 (2%). Benign histology including Grave’s disease was identified in 272 (69.6%) patients, 1 (0.3%) presented noninvasive follicular thyroid neoplasms with papillary-like nuclear features, and 103 (26.3%) showed differentiated thyroid carcinoma. Solitary parathyroid adenoma were removed in 15 (3.8%) patients. Conversion to open surgery was necessary in 13 (3.3%) and revision had to be performed in 2 (0.5%) patients. Transient recurrent laryngeal nerve palsy (RLNP) was present in 18 (4.6%) and permanent RLNP in 2 (0.5%) patients. Fifteen (3.8%) patients experienced transient hypoparathyroidism after thyroidectomy. No case of permanent hypoparathyroidism was observed. Postoperative surgical site infection occurred in 1 (0.3%) patient. Despite a higher rate of sensory and motor disorders and skin discoloration at discharge, permanent disorders were present in only 3 (0.8%) and 16 (4.1%) patients, respectively.Our results show that transoral endoscopic surgery, performed by experienced endocrine surgeons, is a safe alternative to conventional thyroid surgery. Since the 1880s, the Kocher cervical incision has been used as surgical access in thyroid and parathyroid surgery. To reduce the size of the scar, the surgical technique has been modified several times over the years, resulting in the development of minimally invasive open thyroid surgery with an incision of 3–5 cm  describeThe European TOETVA Study Group comprises nine institutions in Austria, Germany, Italy and Turkey. All patients who had undergone endoscopic thyroid or parathyroid surgery via vestibular approach from February 2016 to May 2022 at those centers were included in this study. Initial cases of patients undergoing TOETVA in each institution were included in this study. The selection of patients differed slightly from center to center; similar perioperative outcomes were identified among the patients.Data were collected by each institution. Furthermore, for clinics using the EUROCRINE platform, a special TOETVA module was provided for data entry and export. After approval from each institution, the data were pooled and analyzed retrospectively.The demographic data include age and sex . Intraoperative data were analyzed regarding surgery duration (in minutes), procedure applied, type of surgery , specimen retrieval , histology, intraoperative complications, conversion (defined as intraoperative change to unplanned open surgery), and revision (defined as reoperation due to complication). The reasons for conversion and/or revision were documented.The postoperative data include such complications as transient and permanent recurrent laryngeal nerve palsy (RLNP) and hypoparathyroidism, infection, bleeding, seroma, scars, skin discoloration, sensory disorders, motor disorders and duration of hospital stay.Both postoperative hypoparathyroidism and RLNP, respectively, with no recovery for over 6 months were defined as permanent. Intermittent neuromonitoring was used in all patients.TOETVA-associated complications were divided into the following groups: perioral, mandibular margin and neck. Motor disorder caused by injury to the mental nerve was categorized as hanging corner of the mouth  or limited motor function of the neck.p < 0.05 were considered statistically significant. Metric parameters were described by mean values, the corresponding standard deviation, minimum and maximum. Ordinal and nominal parameters were described by absolute and relative numbers.Data analysis was performed using SPSS® version 23.0 . Data with a significance level set to .Overall, 391 patients, 344 (88%) female and 47 12%) male, with 509 nerves at risk and a mean age of 40.8 ± 13.4 (15–77) years as shown in Table % male, wTOETVA was performed in 376 (96.2%) patients and TOEPVA in 15 (3.8%) patients. In 6 (1.5%) cases, TOEPVA was combined with thyroid surgery including 5 hemithyroidectomies and one total thyroidectomy.Total thyroidectomy was performed in 117 (29.9%) patients, subtotal thyroidectomy or Dunhill surgery in 9 (2.3%), hemithyroidectomy in 245 (62.7%), resection of the isthmus or median cyst in 11 (2.8%) and parathyroidectomy in 15 (3.8%) patients.Specimen retrieval was vestibular in 317 (81.1%), retroauricular in 66 (16.9%) and axillary in 8 (2%) patients. The mean operative time was 145 ± 61.2 (29–420) minutes.The average surgery time was 174 ± 70.7 (45–420) minutes for total and subtotal thyroid surgery, 135.3 ± 52 (29–370) for lobectomies, 113 ± 47.5 (65–216) for isthmus and median cyst resection and 115.4 ± 45.2 (45–180) minutes for parathyroidectomies. On average, combined surgeries of the parathyroid and thyroid gland lasted 112 ± 32.7 (70–160) minutes.2 embolism. Further, subcutaneous tumor seeding occurred in 1 (0.3%) case. Minor skin burn injury (without conversion) was seen in 2 (0.5%) patients. Main intraoperative data are depicted in Table Revision was necessary in 2 (0.5%) patients due to bleeding. Conversion was performed in 13 (3.3%) patients. In 6 (1.5%) patients, bleeding was the reason for conversion. Conversion was performed in 2 (0.5%) patients due to adiposity, combined with short neck and thyroid specimens of more than 40 ml volume, and in single cases (0.3%) due to tracheal tear, carcinoma, skin injury , endobag rupture or COAs seen in Table Sensory  and motor disorders were transient in 67 (17.1%) and 16 (4.1%) patients, respectively. In 1 (0.3%) patient, sensory disorder was temporarily described in the lobe of the ear. Among those with motor disorders, unilateral hanging of the mouth was transient in 4 (1%). In another case (0.3%), the transient motor disorder was prominent in the neck. Permanent sensory and motor disorders were present in 3 (0.8%) patients and in 1 (0.3%), respectively.Skin discoloration, pain, swelling and seroma were transient in 49 (12.5%), 20 (5.1%) and 25 (6.4%) cases and in 1 (0.3%) case, respectively. Postoperative infection was present in 1 (0.3%) patient.Other temporary postoperative complications, as depicted in Table Over the years, there was a keen interest in developing a procedure in thyroid surgery, which would leave no visible scar.Miccoli et al. were able to develop the first minimally invasive video-assisted thyroidectomy which has become a globally applied technique –9. WitzeAnuwong et al.  were theIn our pooled data analysis, we focused our attention on complications associated with TOETVA/TOEPVA and specimen retrieval. Our study presents the largest multicenter analysis of this topic in Europe.Table Mean operation time was 145 ± 61.2 min, as shown in Table Hospital stay Table  varied fFor the retrieval of larger specimens, TOETVA was combined with endoscopic cephalic-access thyroid surgery using the retroauricular approach, which was first performed in 2006 and is still considered a safe and feasible procedure with excellent cosmetic results , 15. ComAs shown in Table Transient RLNP was present in 18 4.6%) patients, and 2 (0.5%) showed permanent RLNP. In one patient who showed initially postoperative bilateral RLNP, an improvement was seen after six months with regression of the palsy on one side. Currently, this patient suffers from permanent unilateral RLNP and is receiving vocal training. Other TOETVA case series have produced similar results of transient and permanent RLNP of 1.3–7.6% and 0–2%, respectively .6% patie, 21, 22,Therefore, regarding the most common adverse events in thyroid surgery (RLNP and hypoparathyroidism), TOETVA and the conventional technique are to be considered comparable.Conversion had to be performed in 13 patients, as shown in Table During dissection and tunneling between chin and neck, an unintentional skin perforation occurred in 1 (0.3%) patient and was immediately sutured. However, the positioning of the central trocar led to a worsening of the skin lesion and widening of the wound. Consequently, the team decided to convert to open surgery.Similar to various multicenter studies describing conversion due to uncontrolled bleeding, our results yielded 6 (1.5%) conversions due to bleeding. In the current literature, another reason for conversion has been nodule size , 22. StiIn one of our first cases, conversion was performed because of an intraoperative malignant frozen section result to obtain adequate lymphadenectomy. In one (0.3%) case, conversion was carried out due to endobag rupture.In yet another patient (0.3%), tracheal injury was the reason for conversion. In this case, extensive thyroiditis was present. The thyroid tissue was firm and traction resulted in tracheal injury. Weng et al. reviewed the literature and found ten articles on tracheal injury following endoscopic thyroidectomy. In those cases, both intraoperative and delayed tracheal injury were reported . IntraopOne patient (0.3%) with papillary thyroid carcinoma, subcutaneous nodules and central compartment recurrence was identified during one and a half years after TOETVA. Intraoperatively, there was no tumor and/or endobag rupture. Therefore, the only explanation for this subcutaneous tumor seeding is tumor manipulation. Nevertheless, transoral thyroid surgery should not only be considered for benign disease. Although rarely, such situations may also occur in open surgery. To prevent cancer seeding and local recurrence, Anuwong et al. routinely used a specimen pouch to enclose the specimen before extraction . This pr2 embolism occurred due to an anterior jugular vein damage with an energy-based device tip during air pocket preparation. The surgeon immediately attempted to seal the vein, but end-tidal CO2 rapidly increased. Conversion was performed on the basis of the anesthetist’s request.In 1 (0.3%) case, CO2 embolism caused by an anterior jugular vein damage has been documented in the recent literature [2 for hemostasis of an unintentionally lacerated vein. Thus, CO2 entering the lacerated vein can be blocked [As possible in any endoscopic operation, Anuwong et al. described subcutaneous emphysema in 3.5% of their patients with complete resolution within 24 h. No other complications such as tracheal or esophageal injury were encountered . Neverthterature –33. To p blocked .Infection was a major concern in TOETVA due to possible contamination of wounds with bacteria of the oral cavity. Dionigi et al.  describeRevision was performed in 2 (0.5%) patients due to bleeding. In one (0.3%) of those patients, revision was performed under the same anesthesia. In contrast to open thyroidectomy, in which postoperative bleeding occurs in up to 1–2% , our resAs shown in Table Due to the retrospective character of this register study, several limitations are to be reported. First, our investigation was based on a female-dominated study population, which results in the inability to analyze gender-specific differences. Further, due to heterogeneity, no general inclusion and exclusion criteria for TOETVA can be defined in this register study. As data collection was center-based, no statement can be made on the volume and learning curve of a single surgeon. Follow-up was performed at different times in the clinics, thus eliminating the possibility to elaborate on the exact resolution time of complications.Although TOETVA is a novel surgical technique and still in a process of continuous development, it represents a feasible alternative in thyroid surgery with low complication rates. The current advantage is limited to the excellent cosmetic outcome. Further prospective trials with pooled data are needed to answer scientific questions and to analyze the specific aspects of this procedure.


IntroductionFlavivirus, is one of the common causes of mosquito-borne encephalitis the world over including India. The disease is endemic in many states of India, including Jharkhand. Mortality ranges from 30 to 40% in different studies and a large number of patients survive with permanent neuropsychiatric sequelae.Japanese encephalitis (JE), caused by a AimThe study aimed to evaluate the clinical spectrum, laboratory  features and outcomes of cases of JE admitted in our hospital.Methods and materialsThis is a retrospective observational study consisting of confirmed cases of JE admitted to the medical wards and critical care unit of Tata Main Hospital (TMH) from January to December 2022. The case records of patients were retrieved from Hospital Management System (HMS) and analysed for demographic characteristics, clinical presentations and treatment details along with outcome measures, which included length of stay (LOS), complications, and mortality.ObservationOf the 14 confirmed cases, six (43.9%) were males and eight (57.1%) were females. The average age of male and female patients was 41.8 ± 23.1 and 35.1 ± 20.5 years respectively. A total of 35.7% of the patients were in the age group of 21 to 30 years. The clinical manifestations in the decreasing frequency were altered sensorium in 11 (78.6%) patients, headache in six (42.8%) patients, generalised convulsions in four (28.6%) cases, vomiting in three (21.4%) cases and weakness in all limbs and of the right half of the body in one (7.1%) case each. Objective neurological findings noted were neck stiffness , cog-wheel rigidity , tremors , delirium , quadriparesis, facio-brachial dystonia and hemiparesis  patient each. Neutrophilic leucocytosis was observed in five (35.7%) patients and mild thrombocytopenia in two (14.3%) patients. The average C-reactive protein (CRP) level was 7.3 ± 6.6 mg/dL. Three (21.4%) patients had mild transaminitis. Cerebrospinal fluid analysis was abnormal in all patients with varying degrees of elevated protein and cell count, while adenosine deaminase (ADA) levels and sugar were normal in all patients. Magnetic resonance imaging (MRI) brain revealed bilateral thalamic T2 FLAIR (fluid-attenuated inversion recovery) hyperintensities in 11 patients (78.6%). The average length of hospital stay was 9.6 ± 4.7 days. Ten patients (71.4%) needed treatment in the critical care unit. Complications seen were acute respiratory distress syndrome , sepsis with multiorgan failure  and ventilator-associated pneumonia . The case fatality rate was one (7.1%). Six patients (42.9%) had residual neuropsychiatric sequelae.ConclusionJE continues to be a major health-related problem. Most cases are concentrated during the post-monsoon period, coinciding with a higher vector density. Patients from rural backgrounds were seen to be more susceptible. JE may present with varying severities of acute encephalitic syndrome. As there is no specific treatment, timely diagnosis is important to reduce the morbidity and mortality associated with this disease. Clinicians must be aware of the wide spectrum of presentation of this disease. A high degree of suspicion along with thorough clinical examination and appropriate investigations are needed to diagnose this condition early and prevent complications. Japanese encephalitis (JE), a mosquito-borne flavivirus encephalitis, is one of the leading forms of viral encephalitis worldwide. It is a major public health problem, due to its potential for causing epidemics, high mortality, leaving behind neurological sequelae and affecting young productive populations. Since its isolation from Japan in 1943, it has spread worldwide and is now most prevalent in South Asia, South-East Asia and the Western Pacific region. In South-East Asia, there are estimated 50,000 cases and 15,000 deaths annually, predominantly affecting children less than 10 years [Flaviviridae and genus Flavivirus. The virus contains three structural proteins - core protein (C), membrane protein (M) and glycosylated envelope protein (E), along with seven non-structural (NS) proteins - NS1, NS2A, NS2B, NS3, NS4A, NS4B and NS [It is caused by the Japanese encephalitis virus (JEV), an enveloped, single-stranded RNA virus belonging to the family In India, the virus was first isolated in humans from the Vellore district of Tamil Nadu, in 1955. In 1973, large outbreaks were described in the districts of Burdwan and Bankura in West Bengal, where 300 and 700 deaths respectively were reported. Since then, outbreaks have been reported from several states of India like Uttar Pradesh, Karnataka, Kerala, Odisha, Andhra Pradesh, Assam, Bihar, Jharkhand and Tamil Nadu. The trend of JE suggests that the problem is escalating in India and larger epidemics may occur in future.JEV is transmitted to humans through the bite of infected mosquitoes of the Culex species . The virus exists in an enzootic transmission cycle between mosquitoes, pigs and/or water birds. In Asia, pigs are the amplifying host, providing a link to humans through their proximity to housing. Rural areas closely linked to paddy fields and piggeries are considered to be high-risk areas for disease transmission. In India, transmission occurs all year round with increased cases observed during the rainy season and pre-harvest period in rice-cultivating regions.Most of the cases are mild or asymptomatic. The disease manifests mainly in children and young adults with high-grade fever, myalgias, headache and vomiting followed by various neurological symptoms like altered sensorium, spastic paralysis, seizures, coma and death in severe cases. The incubation period varies from six to 14 days. The initial presentation in children usually begins with gastrointestinal symptoms like abdominal pain, nausea and vomiting. The case-fatality ratio described in the literature is as high as 42% with high mortality in children less than 10 years and adults more than 65 years . Twenty Every year, sporadic cases have been reported from Jharkhand, indicating the endemicity of the disease in the state. Despite this, data especially regarding the clinical profile of adult cases of JE from this part of the state is limited. In light of this, we undertook the present study at Tata Main Hospital (TMH) with the aim of studying the clinical spectrum, laboratory  features and outcomes of cases of JE.This was a retrospective observational study. Patients who fulfilled the following inclusion criteria from January to December 2022 were included. The study population constituted patients admitted to the medical wards and critical care unit (CCU) of Tata Main Hospital (TMH), Jamshedpur, which is a 983-bedded industrial, tertiary care hospital in Jharkhand. The study was cleared by the Institutional Ethics Committee (IEC).Inclusion criteria1. Patients presenting with acute encephalitis syndrome (AES), characterized by acute onset of high fever, altered mental status and/or new onset of seizures as per WHO guidelines.2. Age 15 years and above3. JE IgM antibody positive in CSFExclusion criteria1. Age < 15 years2. CSF/serum negative for JE IgM antibodyMethodologyDetailed records of all patients including demographic characteristics like age, sex, presenting clinical features, past history, and personal and family history were noted from the medical records retrieved from the hospital management system. Findings of a complete physical examination, including a detailed neurological examination and progress, were noted. Routine blood investigations like complete blood picture including platelet count, liver function and renal function tests, CSF findings for protein, sugar, cells, bacteria and fungi, along with findings of radiological investigations were noted. The outcomes observed included the length of stay (LOS), response to therapy, neurological deficit, duration of critical care unit (CCU) stay, duration of ventilator days, complications related to various organs and mortality.Sample collection and antibody testingCSF samples of suspected cases were collected and sent from our hospital to the virology unit of the Microbiology Department of Mahatma Gandhi Memorial (MGM) Medical College and Hospital, Jamshedpur maintaining a cold chain. All the samples were tested for IgM antibodies with an IgM Antibody Capture (MAC) ELISA Kit supplied by the National Institute of Virology (NIV), Pune JE as a part of the National Vector Borne Disease Control Program (NVBDCP). If the optical density (OD) value of the tested sample was more than that of the negative control by a factor of five, the sample was considered positive for IgM. The test had a diagnostic sensitivity of 95% and a specificity of 98%.Statistical analysisCategorical variables were expressed as numbers and percentages, while continuous variables were described in terms of means, medians, ranges and standard deviations (SDs). As the total number of cases was small, the tests for statistical significance were not used and the P value was not calculated. Figure Of the total 42 cases of AES, 14 cases were those of confirmed JE, giving rise to case positivity of 40.5%. Of these, three were below 15 years and were excluded. Six (43.9%) were males and eight (57.1%) were females with male to female ratio being 0.75:1 as shown inNine out of 14 patients (64.3%) were admitted in the months of July to October Figure  indicatiMost of the cases  were from the Seraikela-Kharaswan district of Jharkhand Figure  and wereClinical featuresFever was the commonest presenting symptom seen in all the patients. It was associated with chills and rigours. The average duration of fever was 5.1 ± 2.8 days. Other symptoms in the decreasing order were altered sensorium in 11 (78.6%) patients, headache in six 42.8%) patients, generalised convulsions in four (28.6%) cases of which one (7.14%) patient had focal convulsions, vomiting in three (21.4%) cases and weakness of all limbs in one (7.14%) and of the right half of the body in one (7.1%) case  patients while thrombocytosis (platelet count of 5.43 lakh/cu mm) was observed in one (7.1%) patient. The lowest leucocyte count seen was 4,000/mm3, while the highest count was 17,400/mm3. The average leucocyte count was 9,992 ± 4,283.01/mm3. Neutrophilic leucocytosis was observed in five (35.7%) patients while the total WBC was within normal limits in nine (64.3%) patients. The average C-reactive protein (CRP) level was 7.3 ± 6.6 mg/dL, while the highest level observed was 23.4 mg/dL. Hypernatremia was seen in two (14.3%) patients. Three (21.4%) patients had a mild elevation of liver enzymes, of which one (7.1%) patient had an elevation more than five times the upper limit of normal (ULN). Serum creatinine was normal in all patients on admission except in those who had underlying chronic kidney disease (CKD).The average haemoglobin level was 10.2 ± 1.4 g/dL, while the average platelet count was 187,214 ± 118,285/mmCSF analysis3. The minimum WBCs noted were 8 cells/cu mm while the maximum noted were 380 cells/cu mm. One hundred per cent lymphocytes were seen in 11 patients (78.6%) while neutrophilic predominance was noted in three (21.4%) cases. CSF protein was increased in all 14 cases (100%) with a mean of 100.76 (± 27.28) mg/dL. Glucose and adenosine deaminase (ADA) levels were normal in all cases. Mean glucose and ADA levels were 73 ±14 mg/dL and 3.87 ±1.13 IU/L respectively. IgM ELISA for JE virus antibody was positive in all patients.CSF was colourless in all patients. The total leucocyte count was increased in all 14 cases (100%) with a mean of 67.8 (± 106.5) cells per mmNeuroimagingInitial neuroimaging was done using a non-contrast computed tomography (NCCT) brain for all patients. NCCT brain was normal in eight out of 14 54.1%) patients while cerebral oedema was noted in five patients 35.7%). Magnetic resonance imaging (MRI) brain revealed bilateral thalamic T2 FLAIR (fluid-attenuated inversion recovery) hyperintensities in 11 patients 78.6%)  needed treatment in the critical care unit, while four (28.6%) were managed in the medical wards. Five patients (35.7%) developed complications like ARDS - acute respiratory distress syndrome , sepsis with MODS - multiorgan dysfunction syndrome  and VAP - ventilator-associated pneumonia . One patient expired giving rise to the case fatality rate of 7.1% and two patients were discharged against medical advice (DAMA). The rest of the patients were discharged in stable condition. However, six patients (42.9%) had residual neurological sequelae which included tremors in two (14.3%) patients, varying degrees of paralysis in three (21.4%) patients and cognitive impairment in two (14.3%) patients.In India, epidemics of JE have been reported from time to time in many parts of the country, and it continues to be a major public health problem. Approximately, 60 crores people in India live in JE endemic areas and 1,500 to 4,000 cases are reported every year, with many cases going unreported .A study of the seasonal distribution of cases revealed higher incidence from July to December, with 78.6% of cases being admitted in the months of July to November, while no cases were detected from March to June. Similar findings were noted by Bandyopadhyay B et al. , AnuradhThere was a slight female preponderance of the cases in our study. Similar results were found in a study by Bandyopadhyay B et al. from West Bengal . A studyIn our study, the clinical picture was characterised by fever in all patients followed by altered sensorium in 11 78.6%) patients. Convulsions were seen in four (28.6%) cases of which one (7.1%) had focal facio-brachial seizures, while three (21.4%) had Parkinsonian features like cog-wheel rigidity, and tremors were seen in two 14.3%) patients. In a study by Misra UK et al.  from Luc% patient8.6% patiThree (21.4%) patients in our study had an elevation of liver enzymes, while 93 (54.15%) patients had an elevation of alanine transaminase (ALT) , 48 (27.9%) patients had an elevation of aspartate transaminase (AST)  and four (2.3%) patients had serum bilirubin > 1mg/dL  in the study by Borah J et al. Thus, the elevation of both liver enzymes was seen in their study as against the study by Solomon T et al. .3, while mild to moderate polymorphonuclear leucocytosis  was observed in 89.83% of the patients in a study by Sarkari NB et al. [3 was observed in 56 (32.6%) patients with a mean value of 13,241 ± 5319/mm3 and thrombocytopenia (platelets less than 105/mm3) was noted in 35 (20.3%) adult patients in the study by Borah J et al. [In our study, neutrophilic leucocytosis was observed in five 35.7%) patients, with the average leucocyte count being 9,992 ± 4,283.01/mmB et al.  from Gor% patient3 with lymphocytic predominance in 72% patients.Abnormalities in CSF were seen in all our patients 100%) with an increase in protein and cell count with lymphocytic predominance. In a study by Borah J et al.  involvin0% with aNeuroimaging with NCCT brain revealed abnormalities in five (35.7%) patients, while MRI brain was abnormal in 13 patients (92.8%). Our findings were similar to those in a study by Kalita et al.  in patieSix (42.9%) patients in our study had residual neurological sequelae which included extrapyramidal symptoms like tremors, varying degrees of paralysis and cognitive impairment. In a study by Basumatary LJ et al. , among 1The mean duration of hospital stay in our study was 9.6 ± 4.7 days. One patient expired giving rise to the case fatality rate of 7.1%. The patient was a female of 32 years who presented with a GCS of 4/15 and had three episodes of generalised seizures on admission. Our case fatality was similar to that reported from Jharkhand by Verma A et al.  from OdiThis study highlights the need for increased awareness of JE amongst clinicians in Jharkhand. We suggest that the diagnosis of JE should be based on a high index of suspicion, thorough clinical evaluation and a constellation of laboratory parameters including imaging, as mentioned above. As the disease is associated with high morbidity and mortality, there is a need to ramp up surveillance and implement a robust immunization programme in Jharkhand.JE is a major public health problem. It is prevalent in this part of the country and should be considered in the differential diagnosis of a patient presenting with acute febrile illnesses and altered sensorium (AES). Its wide spectrum of clinical presentation along with the complexity of diagnosis makes it difficult to diagnose early. Lack of specific treatment along with high case fatality and abundance of neurological sequelae contributes to the disease burden. In the absence of specific treatment, early suspicion and supportive treatment may limit the morbidity and mortality associated with the disease. Implementation of a vaccination program along with rigorous surveillance systems and vector control are the only ways to limit the spread of the disease and prevent outbreaks.


To evaluate the association of isolated hypothyroxinemia in the first trimester with obstetric and neonatal outcomes and iron deficiency.th and 10th percentiles, respectively, and TT4 < 7.8 ng/dL. None of the pregnant women was treated with levothyroxine until the end of pregnancy.The study was prospective. Women who had become pregnant spontaneously were initially selected. Next, anti-thyroid peroxidase antibodies (TPOAb), free T4 (FT4), total T4 (TT4), TSH, and ferritin were measured. TPOAb-positive women were excluded. The final sample consisted of 596 women with serum TSH between 0.1 and 2.5 mIU/l. Hypothyroxinemia was defined as FT4 < 0.86 ng/dL and < 0.92 ng/dL, corresponding to the 5The women ranged in age from 18 to 36 years, with a median gestation of 9 weeks. T4 levels were not correlated with BMI or maternal TSH. Isolated hypothyroxinemia was observed in 4.3% (FT4 < 0.86 ng/dL), 9% (FT4 < 0.92 ng/dL), and 7% (TT4 < 7.8 ng/dL) of the pregnant women. The frequencies of obstetric and neonatal outcomes were similar in women with versus without hypothyroxinemia. In women without iron deficiency, 8.4%, 3.9%, and 6.5% had FT4 < 0.92 ng/dl, FT4 < 0.86 ng/dL and TT4 < 7.8 ng/dL, respectively. These frequencies of hypothyroxinemia were significantly higher among women with iron deficiency .This prospective Brazilian study found no association between isolated hypothyroxinemia in the first trimester of gestation and obstetric or neonatal outcomes, but an association was demonstrated with iron deficiency. When screening for thyroid dysfunction in pregnancy is indicated, it should be performed in the first prenatal visit, which usually occurs in the first trimester. Possible consequences of subclinical hypothyroidism and isolated maternal hypothyroxinemia also appear to be more worrisome when they occur in the first trimester of gestation, a period when the fetus still does not produce thyroid hormone and depends on maternal thyroxine (T4) . It is tth, 5th or 10th percentile . One thousand and eighty two pregnant women who underwent prenatal exams at a clinical analysis laboratory and who had become pregnant spontaneously were initially interviewed and examined . Women wAt the time of the study, and still today, T4 measurement is not necessary in women with TSH ≤ 2.5 mIU/L without TPOAb. There was also, and continues to be, no consensus recommendation regarding the treatment of hypothyroxinemia. Hence, in order to avoid interference with the results, the protocol was approved foreseeing the non-repetition of thyroid function tests during pregnancy and was thus executed. None of the pregnant women was treated with L-T4 until the end of pregnancy. Regarding iron supplementation, the women only received the recommended daily doses in all pregnant women without additional supplementation in those with iron deficiency.th and 10th percentiles of FT4 concentrations obtained for the initially selected 660 TPOAb-negative women  and TSH. The t-test or Mann-Whitney test and Fisher's exact test or the χThe characteristics of the 596 patients are shown in FT4 levels were not correlated with BMI (p = 0.6) or maternal TSH (p = 0.1). TT4 levels were also not correlated with BMI (p = 0.7) or maternal TSH (p = 0.15).Iron deficiency was diagnosed in 29 (4.8%) pregnant women. This frequency was 4.2% in women with FT4 ≥ 0.92 ng/dL. The frequencies of iron deficiency were significantly higher in women with FT4 < 0.86 ng/dL and < 0.92 ng/dL (hypothyroxinemia), 15.4% (p = 0.03) and 11.1% (p = 0.04), respectively. Women with TT4 < 7.8 ng/dL (hypothyroxinemia) also exhibited a higher frequency of iron deficiency than women with TT4 ≥ 7.8 ng/dL . In women without iron deficiency, 8.4%, 3.9% and 6.5% had FT4 < 0.92 ng/dL, FT4 < 0.86 ng/dL and TT4 < 7.8 ng/dL respectively. These frequencies of hypothyroxinemia were significantly higher among women with iron deficiency, 20.7% (p = 0.038), 14.8% (p = 0.032) and 17.2% (p = 0.045), respectively.Some characteristics of the present study should be highlighted. This was a prospective study. Hypothyroxinemia was defined using three different criteria of T4 concentration. Regarding TSH, a cutoff of 2.5 mIU/l was used since it is still the most accepted value for the first trimester of gestation ,5–7 and Regarding the association of hypothyroxinemia with iron deficiency, our results confirm the data of a Chinese observational study, which also evaluated women in the first trimester of gestation from an iodine-sufficient area . Since iWe found no association between isolated hypothyroxinemia in the first trimester of gestation and obstetric or neonatal outcomes. Casey and cols., comparing 16,011 women with normal TSH and T4 and 233 with hypothyroxinemia before 20 weeks of gestation, also observed no association between this alteration and any of the obstetric or neonatal outcomes analyzed . Cleary-We recognize some limitations of the study. First, the number of women with hypothyroxinemia may have been insufficient to obtain statistical significance of small differences compared to euthyroid women. Second, since this was not an intervention study, the objective was limited to demonstrating the association between iron deficiency and hypothyroxinemia, but we did not evaluate the effect of iron supplementation on T4 concentrations. Finally, we analyzed obstetric and neonatal outcomes but not parameters of fetal brain development, which could also be compromised by isolated hypothyroxinemia . AlthougIn conclusion, this prospective Brazilian study found no association of isolated hypothyroxinemia in the first trimester of gestation with obstetric or neonatal outcomes. Despite the need for confirmation in larger series, this result weakens the concern regarding serum T4 in pregnant women with normal TSH, i.e., with isolated hypothyroxinemia. In contrast, an association was demonstrated between hypothyroxinemia and iron deficiency. This finding suggests the importance of iron and possible repercussions of its deficiency on thyroid function and the need for intervention studies evaluating the effects of iron supplementation on thyroid status in pregnant women.