Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

The association between novel ST2, BNP, atrial fibrillation and heart failure

Background/Introduction

ST2, a novel marker of fibrosis has been proposed as a novel biomarker for heart failure. There is paucity of data suggesting its association with Atrial Fibrillation (AF), in particular, with regards to the its independent effect after adjustment for clinical factors and traditional biomarkers such as BNP. There is increasing evidence that inflammation and fibrosis are important players in the pathogenesis of AF, the most common arrhythmia that is associated with considerable morbidity.

Purpose

We sought to examine the association of ST2 with AF and its possible incremental value in combination with traditional biomarkers already used in routine clinical practice such as BNP.

Methods

Unselected patients presenting to a Cardiology service who had BNP for clinical reasons, concomitantly had ST2 sent. These patients included those with heart failure, acute coronary syndromes and AF, as well as patients attending cardioversion and cardiac catheterisation. The association between ST2, BNP and clinical factors was examined. ST2 was examined in tertiles as its distribution was highly skewed. Raised BNP was defined as usual (≥100 pg/ml).

Results

Of the 619 patients, the mean age was 69 years and 66% were male. The prevalence of co-morbidities were: Coronary heart disease - CHD (41%), Atrial Fibrillation – AF (30%), Heart Failure - HF (20%), Chronic Kidney Disease – CKD (23%). The mean eGFR was 68 ml/h and the mean LV ejection fraction was 55%. Both ST2 and BNP levels were significantly higher in patients with heart failure, CKD and AF. Mean levels of ST2 were (in ng/ml): HF vs no HF (65 vs. 38, p=0.0001) and in CKD vs. no CKD (49 vs. 41, p=0.001), CAD vs no CAD (43 vs. 42, p=0.3). Mean levels of BNP were (in pg/ml): HF vs no HF (579 vs. 131, p=0.0001), CKD vs. no CKD (379 vs. 173, p=0.0001), CAD vs. no CAD (239 vs. 206, p=0.5).

In patients with AF, levels of both ST2 and BNP were higher, as were their mean ages and prevalence of co-morbidities (see Table 1). Both ST2 and BNP correlated with AF (Pearson r=0.2, p<0.0001 for ST2 and r=0.5, p<0.0001 for BNP). There was also a graded association of ST2 with AF (15%, 33% and 40% across tertiles of ST2, p=0.0001).

Both ST2 and raised BNP were significant associated with AF in both univariable and multi-variable regression models, and remained independent predictors when adjusted for HF, CHD, LV EF and eGFR (Table 2, Model 2 – Relative risk ratio of AF with ST2 across tertiles 1.5, p0.005, and Odds ratio of AF with raised BNP 7.4, p<0.001). However, ST2 loses significance when BNP is added to the model in combination (Table 2 – Model 3).

Conclusions

Both ST2 and BNP are independent predictors of AF even after adjustment for heart failure and other clinical factors. When ST2 is used in combination with BNP, raised BNP appears to be a stronger predictor of AF than ST2.

Funding Acknowledgement

Type of funding sources: None.

Impact of epicardial adipose tissue accumulation on left ventricular mass and hypertrophy in non-obstructive coronary artery disease

Introduction

Increased left ventricular mass index (LVMi) and left ventricular hypertrophy (LVH) by echocardiography are common in obesity and important cardiovascular risk predictors associated with myocardial ischemia in non-obstructive coronary artery disease (CAD). Accumulation of epicardial adipose tissue (EAT) suggest a possible direct impact on LVMi and LVH.

Purpose

To explore the association between EAT volume, LVMi and LVH in patients with chest pain and non-obstructive CAD.

Methods

We included 129 patients with chest pain and non-obstructive CAD (<50% stenosis) by coronary computed tomography (CT) angiography. EAT volume was quantified using a semiautomatic analysis software on non-contrast cardiac CT images. Patients were grouped according to EAT volume, where high EAT volume was adjudicated when EAT volume was in the highest tertile (≥125 ml). Left ventricular mass was assessed by echocardiography, calculated by the Devereux formula and indexed for height in the allometric power of 2.7 (LVMi). LVH was defined as LVMi >46.7 g/m2.7 in women and >49.2 g/m2.7 in men. Coronary artery plaque burden was assessed as calcium score and segment involvement score on coronary CT angiography.

Results

High EAT volume was more common in men with higher BMI, waist circumference, serum triglycerides and higher prevalence of hypertension and obesity (all p<0.05). Age, coronary calcium score and coronary artery segment involvement score did not differ between groups. Patients with high EAT volume had higher LVMi compared to those with low EAT volume (42.5 g/m2.7 vs. 36.1 g/m2.7, p=0.003), while there was no difference in EAT volume among patients with or without LVH. In univariable logistic regression analysis, high EAT volume was associated with higher LVMi (OR 1.05 [95% CI 1.01–1.10] per g/m2.7, p=0.015). After adjusting for hypertension and obesity in a multivariable model, higher LVMi remained significantly associated with high EAT volume (Model 1, Table 1), but the association was attenuated after adjusting for sex (Model 2, Table 1).

Conclusion

High EAT volume was associated with increased LVMi in patients with non-obstructive CAD, independent of hypertension and obesity, while there was no association with LVH. This suggest that direct infiltration of adipose tissue in the myocardium may contribute to the development of increased LVMi.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Western Norwegian Regional Health Authorities Table 1

Long-term outcomes of intravenous drug use associated infective endocarditis: a contemporary 20-year study

Introduction

Intravenous drug use (IVDU) associated infective endocarditis (IE) is a clinically challenging case. Not only can the natural history of IE in the IVDU population be significantly different, making detection a diagnostic dilemma, additional social factors associated with this population can drastically change management, including suitability for surgery or long-term intravenous access for antibiotics Furthermore, the rates of IVDU are increasing globally, leading to increasing incidence of IVDU associated IE.

Purpose

With a lack of clear mangement guidelines for IVDU associated IE, our study assesses the differences in presentation, management and long-term prognosis of IE between the IVDU population and the non-IVDU population to help guide future care.

Methods

This is an observational cohort study on a prospectively collected database of 350 patients treated for IE at our centre between 1999 and 2015. Patients were followed-up until death or January 2021. The primary outcome was all-cause mortality. Continuous variables were compared using unpaired t-test. Categorical variables were compared using Chi-square test when sample size was >5 or Fisher's exact test when sample size was ≤5. Long-term survival data was analysed using Kaplan-Meier survival curves.

Results

The IVDU population was younger, more likely to have concurrent infections and other substance use, while the non-IVDU population was older with a higher level of overall comorbidity. IVDU patients were more likely to become reinfected (p-value=0.034) but had better long-term survival compared to the non-IVDU population (p<0.001). Survival estimates at 15-years were 64.98% (95% CI: 50.94–75.92%) for the IVDU population compared to 26.67% (95% CI: 19.76–34.05%) for the non-IVDU population (p-value<0.0001).

Conclusion

Despite having higher levels of reinfection, IVDU patients have better long-term outcomes of IE compared to non-IVDU patients. Therefore, IVDU patients should not have blanket restrictions on the management they are offered unless the individual has clear contraindications to a particular therapy.

Funding Acknowledgement

Type of funding sources: None.

143 Massive Intra-Hepatic Subcapsular Liver Haematoma Post-Laparoscopic Cholecystectomy- A Rare Complication of a Common Procedure'

Case Presentation

A 59-year-old female presented with symptomatic biliary colic. Her past medical history was noted for obesity (BMI>50). She underwent an elective LC with an uncomplicated intraoperative course; however, post-operatively she developed hypovolaemic shock with an acute haemoglobin drop requiring fluid resuscitation and blood transfusion. Emergency CT revealed a massive subcapsular haematoma measuring 21cm×3.1cm× 17cm at the right liver margin without evidence of ongoing bleeding. She was managed conservatively- as per a tertiary hepatobiliary surgery centre’s advice- with meticulous clinical observations, serial monitoring of haemoglobin, and repeat CT to assess for interval progressions. She progressed well with conservative management and did not require surgical or radiological intervention. A follow-up liver sonography performed eight weeks post-discharge confirmed a complete resolution.

Conclusion

Giant ISH is an exceedingly rare but life-threatening complication following LC which merits special attention. Our case demonstrates the necessity of close postoperative monitoring of patients undergoing LC and considering the possibility of ISH in those who experience refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post-LC ISH.

FOXM1-AKT Positive Regulation Loop Provides Venetoclax Resistance in AML

Forkhead box protein M1 (FOXM1) is a crucial regulator of cancer development and chemoresistance. It is often overexpressed in acute myeloid leukemia (AML) and is associated with poor survival and reduced efficacy of cytarabine therapy. Molecular mechanisms underlying high FOXM1 expression levels in malignant cells are still unclear. Here we demonstrate that AKT and FOXM1 constitute a positive autoregulatory loop in AML cells that sustains high activity of both pro-oncogenic regulators. Inactivation of either AKT or FOXM1 signaling results in disruption of whole loop, coordinated suppression of FOXM1 or AKT, respectively, and similar transcriptomic changes. AML cells with inhibited AKT activity or stable FOXM1 knockdown display increase in HOXA genes expression and BCL2L1 suppression that are associated with prominent sensitization to treatment with Bcl-2 inhibitor venetoclax. Taken together, our data indicate that AKT and FOXM1 in AML cells should not be evaluated as single independent regulators but as two parts of a common FOXM1-AKT positive feedback circuit. We also report for the first time that FOXM1 inactivation can overcome AML venetoclax resistance. Thus, targeting FOXM1-AKT loop may open new possibilities in overcoming AML drug resistance and improving outcomes for AML patients.

Prevalence of active HCV infection and genotypic distribution among the general population of district Mardan, Pakistan

Hepatitis C virus (HCV) is the serious global public health burden of liver disease. Approximately 170 million people in the world are infected with (HCV). In Pakistan, where the disease has high occurrence rate. The present study envisages an up-to-date prevalence of HCV and genotypic distribution in the general population of Mardan District, Khyber Pakhtunkhwa (KP), Pakistan. The blood samples from 6,538 individuals including 3,263 males and 3,275 females were analyzed for hepatitis C surface antigen by Immuno-chromatographic test (ICT), Enzyme-linked immunosorbent assay (ELISA), and reverse transcription-polymerase chain reaction (PCR). It was found that 396 (12.13%) out of 3263 individuals contained antibodies in their blood against HCV, while among the different age groups, the highest incidences of HCV antibodies were found in the 31-40 age group (11.01%). The ICT positive samples were further screened by nested PCR to determine the existence of active HCV-RNA. It was identified that 7.11% (3263) of the total population (6538) tested was positive, among which the 461 (14.07%) females possessed antibodies in their blood against HCV. Our data showed total HCV infection in the investigated population was 5.78%. Higher percentage of HCV prevalence was detected in males than females in the age group 31-40 and 41-50. To compare the prevalence of HCV genotypes age-wise in male and female genotype 3a was found most prevalent genotype followed by 1a, 2a and 3b, respectively.

Serological prevalence of hepatitis B virus (HBV) in Mardan district, Khyber Pakhtunkhwa, Pakistan

Hepatitis B virus infection is perilous among the five types of Hepatitis, as it remains clinically asymptomatic. The present study draws up-to-date prevalence of Hepatitis B virus (HBV) in the general population of Mardan, Khyber Pakhtunkhwa Pakistan. The blood samples from 4803 individuals including 2399 male and 2404 females were investigated. All the suspected samples were analyzed for hepatitis B surface antigen using Immuno-chromatographic test (ICT), Enzyme-linked immunosorbent assay (ELISA), and followed by Reverse transcription-polymerase chain reaction (RT-PCR). Results showed that 312 (13.00%) out of 2399 individuals contained antibodies in their blood against HBV, while among the different age groups, the highest incidences of HBV antibodies were found in the age of 21-30 groups (10.73%). Furthermore, the ICT positive samples were screened by nested polymerase chain reaction to detect the existence of active HBV-DNA. It was observed that 169 (7.04%) out of (2399) male of the total population (4803) tested was positive. On the other hand, the female 463 (19.25%) possessed antibodies in their blood against HBV. Accumulatively, our results showed a higher percentage of HBV prevalence in males than females in the age group 21-30 years. The total HCV infected in Mardan general population was recorded at 5.7% comprising both male and female.

Open-Label Phase II Prospective, Randomized, Controlled Study of Romyelocel-L Myeloid Progenitor Cells to Reduce Infection During Induction Chemotherapy for Acute Myeloid Leukemia

PURPOSE

Standard cytotoxic induction chemotherapy for acute myeloid leukemia (AML) results in prolonged neutropenia and risk of infection. Romyelocel-L is a universal, allogeneic myeloid progenitor cell product being studied to reduce infection during induction chemotherapy.

PATIENTS AND METHODS

One hundred sixty-three patients with de novo AML (age ≥ 55 years) receiving induction chemotherapy were randomly assigned on day 0 (d0), of whom 120 were evaluable. Subjects received either romyelocel-L infusion on d9 with granulocyte colony-stimulating factor (G-CSF) starting daily d14 (treatment group) or G-CSF daily alone on d14 (control) until absolute neutrophil count recovery to 500/µL. End points included days in febrile episode, microbiologically defined infections, clinically diagnosed infection, and days in hospital.

RESULTS

Mean days in febrile episode was shorter in the treatment arm from d15 through d28 (2.36 v 3.90; P = .02). Similarly, a trend toward decreased microbiologically defined infections and clinically diagnosed infection in the treatment arm was observed from d9 to d28 (35.6% v 47.5%; P = .09), reaching a statistically significant difference from d15 to d28 (6.8% v 27.9%; P = .002). Because of this, antibacterial or antifungal use for treatment of an infection was significantly less in the treatment group (d9-d28: 44.1% v 63.9%; P = .01). Significantly fewer patients in the treatment arm received empiric antifungals from d9 tod28 (42.4% v 63.9%; P = .02) and d15-d28 (42.4% v 62.3%; P = .02). Patients in the treatment arm also had 3.2 fewer hospital days compared with control (25.5 v 28.7; P = .001). Remission rates and days to absolute neutrophil count recovery were similar in the two groups. No patients in the romyelocel-L plus G-CSF group died because of infection compared with two patients in the control arm. No graft-versus-host disease was observed.

CONCLUSION

Subjects receiving romyelocel-L showed a decreased incidence of infections, antimicrobial use, and hospitalization, suggesting that romyelocel-L may provide a new option to reduce infections in patients with AML undergoing induction therapy.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Food handlers: an important reservoir of protozoans and helminth parasites of public health importance

Food handlers plays a primary role in the transmission of pathogenically important protozoans and helminth parasites. This study was aimed to evaluate the prevalence of intestinal pathogenic protozoans and helminth parasites among food handlers in and around University of Malakand, Lower Dir, Pakistan. Stool samples were collected from 642 food handlers (all of male) in a cross-sectional study from January to November, 2017. Wet Mount Techniques and concentration methods by using salt and formol-ether solutions. Three hundred and eighty four cases (59.8%) were found infected with one more parasites. Most of the individuals were found infected with helminth (47.6%) as compared to intestinal protozoans (0.93%). Seventy two cases (11.2%) of the cases presented mixed infection with both intestinal protozoan and helminth parasites. The order of prevalence for intestinal helminth was Ancylostoma duodenale (n = 258, 40.1%), followed by Taeniasa ginata (n=96, 14.9%) Ascaris lumbricoides (n = 54, 8.40%) and Trichuris trichura (n=30, 4.60%). For intestinal protozoa, Entamoeba histolytica/dispar (n = 36, 5.64%) was the only protozoan detected. Mono-parasitism was higher than poly-parasitism. Family size income and education level were the factors significantly (P<0.05) associated in the parasites prevalence. Current research showed that IPIs are primarily the foodborne pathogens still an important public health problem in Pakistan. Effective control programs on parasitic diseases transfer and their associated factors are recommended.

Automated source of squeezed vacuum states driven by finite state machine based software

In the last few decades, much effort has been made for the production of squeezed vacuum states in order to reduce quantum noise in the audio-frequency band. This technique has been implemented in all running gravitational-wave interferometric detectors and helped to improve their sensitivity. While the detectors are acquiring data for astrophysical observations, they must be kept in the operating condition, also called "science mode," that is, a state that requires the highest possible duty-cycle for all the instrumental parts and controls. We report the development of a highly automated setup for the generation of optical squeezed states, where all the required control loops are supervised by a software based on finite state machines; we took special care to grant ease of use, stability of operation, and possibility of auto-recovery. Moreover, the setup has been designed to be compatible with the existing software and hardware infrastructure of the Virgo detector. In this paper, we discuss the optical properties of this squeezing setup, the locking techniques, and the automation algorithms.

Impact of race on outcomes in intermediate-risk acute myeloid leukemia

PURPOSE

Racial disparities in acute myeloid leukemia (AML) have been reported but the relative contribution of disease versus patient-specific factors including comorbidities and access to care is unclear.

METHODS

We conducted a retrospective analysis of patient characteristics, treatment patterns and outcomes in a racially diverse patient cohort controlling for cytogenetic risk group. Patients were classified into four groups: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic and Other.

RESULTS

We evaluated 106 patients from 84 zipcodes incorporating demographics, clinicopathologic features, treatment patterns and outcomes. We identified significant differences in BMI and geographic poverty based on ethnoracial group, while prognostic mutations in NPM1 and FLT3 did not differ significantly. Utilization of intensive chemotherapy and transplant rate did not differ by ethnoracial group. However, there was a significantly higher use of alternate donor transplants in minority populations. There was a notably increased rate of clinical trial enrollment in NHW patients compared to other groups. In log-rank analysis, NHW patients had increased overall survival (OS) compared to NHB, Hispanic and Other patients (31.6 months vs. 16.7 months vs. 14.3 months, vs 18.1 months, p = 0.021). In bivariate analysis, overall survival was negatively influenced by advanced age and race. Obesity and zip code poverty levels approached statistical significance in predicting OS. In multivariate analysis, the only factors independently influencing OS were race and allogeneic stem cell transplant.

CONCLUSION

These results suggest that race impacts survival in intermediate-risk AML, highlighting the need to dissect biologic and nonbiologic factors that contribute to this disparity.

Cutaneous leishmaniasis-Awareness, knowledge and practices among general population in rural and urban areas in Malakand region, Pakistan

Malakand region is an endemic area for cutaneous leishmaniasis (CL). However, there are limited number of studies of this disease in Pakistan. Therefore, a study was conducted to understand the level of awareness attitude and practice among the residents of Makaland towards CL and the disease vectors. This study adopted a cross-sectional approach with a total of 400 respondents (n=93 rural and n= 307 urban). Overall, the population in Malakand region (61.2%) were well-informed in the role of sand fly in transmitting diseases, but most lack knowledge on the vector's behavior and almost a quarter (24.5%) were unable to provide knowledge on proper control measures. Alarmingly, the practice and attitudes of the general population was not satisfactory as close to half (49.8%) of the population did adopt any control method. This study calls for increase in awareness through health education campaign to reduce the risk of cutaneous leishmaniasis outbreaks in the future.

Presentation of a diagnostically challenging case of chronic eosinophilic leukemia with marrow dysplasia and ringed sideroblasts

Chronic eosinophilic leukemia, not otherwise specified can be challenging to differentiate from hypereosinophilic syndrome and myelodysplastic syndromes with elevated eosinophilia. We present a diagnostically challenging case of chronic eosinophilic leukemia, not otherwise specified that initially seemed like a myelodysplastic syndrome but progressed to eosinophilic tissue infiltration and overt eosinophilic dyspoiesis. In addition, we discuss the morphologic and molecular findings that can overlap among these entities that made the diagnosis difficult in the case presented.

COVID-19 pandemic and its positive impacts on environment: an updated review

In December, 2019 in Wuhan city of China, a novel coronavirus (SARS-CoV-2) has garnered global attention due to its rapid transmission. World Health Organization (WHO) termed the infection as Coronavirus Disease 2019 (COVID-19) after phylogenic studies with SARS-CoV. The virus causes severe respiratory infections with dry cough, high fever, body ache and fatigue. The virus is primarily transmitted among people through respiratory droplets from COVID-19 infected person. WHO declared this COVID-19 outbreak a pandemic and since February, 2020 affected countries have locked down their cities, industries and restricted the movement of their citizens to minimize the spread of the virus. In spite of the negative aspects of coronavirus on the globe, the coronavirus crises brought a positive impact on the natural environment. Countries where the movement of citizens was seized to stop the spread of coronavirus infection have experienced a noticeable decline in pollution and greenhouse gases emission. Recent research also indicated that this COVID-19-induced lockdown has reduced the environmental pollution drastically worldwide. In this review, we have discussed some important positive impacts of coronavirus on environmental quality by compiling the recently published data from research articles, NASA (National Aeronautics and Space Administration) and ESA (European Space Agency).