Title Guideline consultation generates inevitable challenges but invaluable communicationSignatoryPauline McDonagh Hull, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, CanadaLetterDear Sir, As first author of one of the BJOG letters cited in Dr. Murphy’s commentary on the ‘unwelcome consequences of guideline authorship’1 (‘Montgomery is missing from RCOG’s Assisted Vaginal Birth guideline ’2), and director of one of the organisations that submitted comments during the Royal College of Obstetricians and Gynaecologists’ consultation, I would appreciate the opportunity to clarify my involvement and position in the matters described, to avoid potential misinterpretations or assumptions where individuals and organisations have not been named. Dr. Murphy mentions ‘individuals who…believe that forceps should be abolished entirely’, and informs readers that this view ‘was reflected in one submission…from a patient advocacy organisation who suggested that planned caesarean section should be recommended to women as a means of avoiding AVB.’ She then notes our Montgomeryletter2 ‘repeated the same point about planned caesarean section they had made during the consultation process.’ For the record, the submission from my voluntary organisation, Caesarean Birth, did not suggest forceps should be abolished. I disagree with Dr. Murphy’s assertion that our letter was ‘hostile’, and we stand by the concerns expressed therein. However, where I do agree with Dr. Murphy is in relation to the irrefutable challenge ‘of reconciling polarised views’. While our criticism of the RCOG guideline may be perceived as ‘an agenda’ to ‘undermine authors’, it may also be perceived as a sincere effort to influence a hegemonic shift in maternity services in the face of unprecedented maternity litigation resulting from avoidable harm. These views may never be fully reconciled, but I believe we all share the same goal of improving health outcomes. Moreover, the RCOG has responded to criticism of its assisted vaginal birth and caesarean birth recommendations in the past; initially removing them from its website temporarily, and then permanently five years later.3Last year, the University of Aberdeen was awarded almost £1 million to develop a decision aid, to be offered to all women, for planning mode of birth.4 In my view, the option of planned caesarean birth should not be reserved for obstetricians or women who initiate discussions, as this does not constitute equitable care. Language in maternity services is changing too. While Dr. Murphy refers to ‘caesarean section’, both the RCOG and National Institute for Health and Care Excellence (NICE) adopted ‘caesarean birth’ for their respective 2021 guideline and 2022 Considering a caesarean birthpublications. Finally, when Dr. Murphy highlights the lack of remuneration for guideline authors, she echoes my own experience of countless hours in unpaid consultation, barring one significant difference. Only authors have the privilege of determining the final version. We also concur on the importance of providing stakeholders the opportunity for public debate. Prior to reading Dr. Murphy’s commentary, I was not aware of the complaint she received, and certainly support individual safeguarding as we all navigate the inevitable disagreements ahead. Nevertheless, open channels of communication and consultation remain a valuable and indispensable method to examine, and in some cases disrupt, established ways of thinking, and they must not be diminished.Reference s 1. Murphy DJ. The unwelcome consequences of Guideline authorship. BJOG 2023;00:1-2. 2. Hull PM, Thomas K, Skinner E, Dawes A, Christensen P. Re: assisted vaginal birth: green-top guideline no. 26: Montgomery is missing from RCOG’s assisted vaginal birth guideline. BJOG2020;127(10):1297–8. 3. Weston N. Making sense of commissioning Maternity Services in England – some issues for Clinical Commissioning Groups to consider . Royal College of Obstetricians and Gynaecologists, 14 August 2012. 4. Scientists awarded £1million to help women make childbirth choices. University of Aberdeen, 27 September 2022. https://www.abdn.ac.uk/news/16386/. Accessed 5 June 2023.

Background Individuals with cystic fibrosis (CF) often have psychological difficulties on top of their medically complex care, such as anxiety, depression, and medical mistrust. These have been shown to be associated with worse adherence, pulmonary function test results, and other health outcomes. In this pilot trial, we implemented a journaling program based on narrative therapy methodology to improve mental and physical health outcomes for individuals with CF. Methods Eight adolescents aged 12-17 with a confirmed diagnosis of CF followed in a single center cystic fibrosis clinic were emailed weekly journaling prompts that explored topics like: treatment adherence, feeling different with CF, anxiety, depression, and interpersonal relationships. Subjects were emailed surveys about their experience with the writing assignment, and baseline health data was collected from the electronic medical records. Results The average score for the Pediatric Symptom Checklist (PSC-17) decreased by 5.5 points, and the post-study average (mean 23.5, SD 12.2) fell to less than 28, which is the cutoff for screening positive for behavioral or emotional problems. Participants reported the study was enjoyable and had improvement in feelings of anxiety/depression. 100% of participants responded “Strongly Agree” to the statement “I recommend other people with CF to write about the topics from this study”. Conclusions The journaling intervention for individuals with CF was feasible and well received. Initial results show improvement in PSC-17 and other wellbeing measures. Further studies are needed to evaluate the impact of journaling on mental health and disease outcomes.

Little is known about the complications of COVID-19. What happens when a patient with carbon monoxide poisoning has complications from COVID-19 pneumonia (a disease that has emerged since 2019 and quickly caused a pandemic around the world)? We report a case of carbon monoxide poisoning with COVID-19 pneumonia resulting in secondary pneumomediastinum. The patient underwent systemic hyperbaric oxygen therapy for two weeks and most of his symptoms improved. This case illustrates the success of hyperbaric oxygen in the simultaneous treatment of COVID-19 pneumonia, pneumomediastinum, and carbon monoxide poisoning.

Objective: This retrospective observational cohort study aimed to assess the real-life application of bronchial challenge test (BCT) in the management of preschool children presenting with atypical recurrent respiratory symptoms (ARRS). Methods: We included children, aged 0.5-6 years referred to a pediatric-pulmonology clinic, who underwent BCT using methacholine or adenosine between 2012-2018 due to ARRS including uncertain severity of airway hyperactivity. BCT was considered positive based on spirometry results and/or wheezing, desaturation, and tachypnea reactions. We collected data on demographics, BCT results, pre-BCT treatment, post-BCT treatment change and post-BCT symptoms control. The primary outcome measure was the change in treatment post-BCT (step-up or step-down). Secondary outcome included clinical improvement observed 3-6 months after BCT. Results: A total of 228 children (55% males) with a mean age of 4.2±0.6 years underwent BCT (52% adenosine-BCT, 48% methacholine-BCT). Children referred for methacholine were significantly younger compared to adenosine (3.6±1.2 vs. 4.2±1.2 years, P<0.01). Methacholine and adenosine BCTs were positive in 95% and 61%, respectively. Overall, changes in management were observed in 122(53.5%) children following BCT, with 83(36.4%) being stepped up and 37(17%) being stepped down. Significantly more children in the methacholine group were stepped up compared to the adenosine (46% vs 28%, p=0.004). During the follow-up assessment, we observed a clinical improvement in 119/162 (73.4%) of the children. Conclusion: This study demonstrates the importance of BCT in the management of preschool children presenting to pediatric pulmonary-units with ARRS. The change in treatment and subsequent clinical improvement observed, highlight the added-value of BCT in this populations.

The stiffness of the tumor microenvironment (TME) is dynamic and drives metabolic reprogramming in cancer cells as a consequence of tumor progression. To demonstrate the possibility to modulate the mechano-metabolomic profile of breast cancers by tuning the mechanical property and dimensionality of extracellular matrices (ECMs), we cultured triple-negative MDA-MB-231 and luminal MCF-7 cells on 2D and in 3D hydrogels based on tyramine functionalized hyaluronic acid (HTA). Using high-throughput metabolomics analyses, we established that we can differentially regulate breast cancer mechano-metabolome. The stiff hydrogels resulted in upregulated lipid and amino acid metabolism along with increasing malignancy and chemoresistancy. Reprogramming in glucose metabolism is primarily observed in cells seeded on 2D hydrogels, whereas modifications in amino acid metabolism is predominant in cells embedded in 3D stiff hydrogels. These findings suggest that matrix stiffness and dimensions have decisive roles in reprogramming breast cancer metabolome, which is the hallmark of breast cancer development and progression.

The development of an urban rail transit network conforms to the characteristics of logistic dynamic equations. Studying the evolution laws of urban rail transit networks and accurately reproducing the entire process of evolution can provide targeted guidance for rail transit network planning and phased construction. This article studies the structure and evolution laws of urban rail transit networks and finds that the evolution and development of urban rail transit networks are based on the evolution of lines, which aligns with the evolution characteristics of hyperedge-driven hyper networks. At the same time, the links between lines have the evolutionary characteristics of combining randomness and prioritization. On this basis, a hyper network model of urban rail transit was established with stations as nodes and lines as hyperedges. Based on the allometry growth relationship between transfer nodes and common nodes in urban rail transit networks, this paper proposes a hyper network evolution model of rail transit that can simulate the evolution process and generate a network similar to the existing network. Finally, a comparative analysis was conducted between the network generated by the model and four different levels of urban rail transit networks, including Beijing, Shanghai, Guangzhou, and Tianjin. The evolutionary network generated by the new model is highly consistent with the leading critical indicators of the existing network and has a high degree of similarity. A comparative verification was conducted with the evolution data of the Beijing Rail Transit Network (1984-2020) over a total of 45 years. Both network evolution processes were found to conform to the dynamic logistic equation, proving that the evolution model can reproduce the evolution process of the urban rail transit network, which has practical guiding significance for the study of rail transit network evolution.

Soil bacterial taxa have important functional roles in ecosystems (e.g., nutrient cycling, soil formation, plant health). Many factors influence their assembly and regulation, with land cover type (e.g., remnant vegetation, agriculture, urban parks) and plant-soil feedbacks being two well studied factors. However, changes in soil bacterial communities in situ over light-dark cycles have received little attention, despite plants and some bacteria having endogenous circadian rhythms that could influence soil bacterial communities. We sampled surface soils in situ across 24-hour light-dark cycles (at 00:00, 06:00, 12:00, 18:00) at two land cover types (remnant vegetation vs. cleared, grassy areas) and applied 16S rRNA amplicon sequencing to investigate changes in bacterial communities. We show that land cover type strongly affected soil bacterial diversity, with soils under native vegetation expressing 15.41-16.42% lower alpha diversity but 4.92-10.67% greater heterogeneity than soils under cleared vegetation. In addition, we report time-dependent and site-specific changes in bacterial network complexity and between 598-922 ASVs showing significant changes in relative abundance across times. Native site node degree (bacterial interactions) at phylum level was 16.0% higher in the early morning hours compared to the afternoon/evening. Our results demonstrate for the first time that light-dark cycles have subtle yet important effects on the composition of soil bacterial communities in situ and that land cover influences these dynamics. We provide a new view of soil microbial ecology and suggest that future studies should consider the time of day when sampling soil bacteria.

The new era of automation is obsoleting the antiquated manual systems rapidly. Global trends are shifting towards small integrated systems which are smarter, more user-friendly and remotely accessible. This project presents an intelligent battery management system for solar and off-peak energy systems to meet the global demands. This micro-controller-based battery management system stores off-peak and solar energy in the battery pack consisting of four batteries and aptly supplies this energy to drive DC and AC loads. The controller is programmed to automatically shift the load to the next battery in the sequence when the previous battery is discharged below the permissible limit. The controller also connects the discharged battery to a smart charging system that automatically starts charging to maintain an uninterruptible power supply. Moreover, the system has a monitoring and control mechanism that prevents intrinsic and extrinsic factors (such as temperature) from affecting the health of the batteries. The voltage difference among cells within a battery undermines the battery life severely. A smart charge equalizer is thus incorporated in the system to deter this detrimental effect. In addition, the state of charge of each battery is graphically illustrated through Internet of Things (IoT) so that any anomaly can be detected and treated, and remote access can be assured. Thus, this system provides a smart and effective way to store energy and use it efficiently. Keywords: Battery Management, Charge equalization, Uninterruptible power supply, Off-peak, Internet of Things (IoT), Arduino (microcontroller)

A document by Qiuping Wang. Click on the document to view its contents.

When two putative cryptic species meet in nature, hybrid zone analysis can be used to estimate the extent of gene flow between them. Two recently recognized cryptic species of banded newt (genus Ommatotriton) are suspected to meet in parapatry in Anatolia but a formal hybrid zone analysis has never been conducted. We sample populations throughout the range, with a focus on the supposed contact zone, and genotype them for 31 nuclear DNA SNP markers and mtDNA. We determine the degree of genetic admixture, introgression and niche overlap. We reveal an extremely narrow hybrid zone, suggesting strong selection against hybrids, in line with species status. The hybrid zone does not appear to be positioned at an ecological barrier and there is significant niche overlap. Therefore, the hybrid zone is best classified as a tension zone, maintained by intrinsic selection against hybrids. While the two banded newt species can evidently backcross, we see negligible introgression and the pattern is symmetric, which we interpret as supporting that the hybrid zone has been practically stationary since its origin (while extensive hybrid zone movement has been suggested in other newt genera in the region). Our study illustrates the use of hybrid zone analysis to test cryptic species status.

A yearling Thoroughbred filly presented to a yearling sale with right front lameness and radiographs demonstrating a large axial palmar OCF (osteochondral fragment) of the proximal P2 associated with the PIP (proximal interphalangeal) joint and no evidence of secondary osteoarthritis. A follow up lameness examination included diagnostic anesthesia, radiography and ultrasonography. The filly was 3 out of 10 lame right forelimb. There was pain on flexion of the distal limb and a positive distal limb flexion test. Lameness was localised to the pastern region. Radiography confirmed the OCF and an ultrasound examination revealed the large OCF with small hyperechoic fragments of bone evident in the middle scutum associated with the insertion of the axial palmar ligament of the PIP joint and SSL (straight sesamoidian ligament). More proximally there was a core lesion to the body of the SSL. Such large axial palmar OCF with a comprehensive lameness examination have not been reported yet. This provides the veterinarian information to give a balanced opinion for risk for sale and future athletic performance.

Abstract: Keywords:

Acute arrest of hematopoiesis (AAH) is a rare disease of the blood system,which is a self-limited and reversible acute arrest of bone marrow hematopoietic function caused by various reasons such as drugs,infection,radiation,and usually manifested as a decrease in red blood cells and reticulocytes in the blood or a decrease in whole blood cells[1].The most common acute hemopoietic arrest caused by viral infection is parvovirus B19,In addition to parvovirus B19,it is also seen in Epstein Barr virus, cytomegalovirus,HIV,rubella and infectious hepatitis viruses.The development of AAH secondary to influenza A virus and Streptococcus pneumoniae infection is rare,To date,there have been no reports of AAH caused by influenza A virus and streptococcus pneumoniae infection.Due to the fact that this disease is easily misdiagnosed as aplastic anemia,timely and accurate diagnosis is crucial.The present study increased our knowledge of this rare disease and its characteristics,which will enable physicians to be aware of the development of AAH as a rare complication of influenza A virus and Streptococcus pneumoniae infection.

Observed body size shifts in ectotherms are mostly attributed to the temperature size rule (TSR) stating that warming speeds up initial growth rate but leads to smaller size when food availability does not limit growth. However, climate warming can decrease food availability and we have limited information on how temperature and food jointly influence life history traits and population fitness. We investigated under laboratory conditions the independent and interactive effects of temperature (20 °C and 30 °C) and food availability (restricted or ad libitum) on the growth, fecundity and survival of the medaka fish Oryzias latipes. We next used our empirical estimates of vital rates as input parameters of an Integral Projection model (IPM) to predict how modifications in vital rates translate into population demographic parameters. Warming leads to a higher initial growth rate and lower size leading to crossed growth curves between the two temperatures. Food-restricted fish were smaller than ad libitum fed fish throughout the experiment, leading to nested growth curves. Fish reared at 30 °C matured younger, had smaller size at maturity, had a higher fecundity but had a shorter life span than fish reared at 20 °C. Food restriction increased survival probabilities under both temperature conditions. According to the IPM, warming reduces generation time and increases mean fitness in comparison to the cold treatments. Food restriction increased generation time and fitness in the cold treatment but had no effect in the warm treatment. Our results show that temperature and food interact on vital rates and population demographics. This is important in the context of global warming, as resources are expected to change with increasing temperatures.

Abstract Aims and Objectives :The purpose of this paper is to investigate the current state of internet+ nursing for homebound older adults with Chronic illness Background: The prevalence of chronic disease is high, but the usage rate of internet + nursing for homebound older patients is suboptimal in China. Internet+ nursing aims to maximize olders’ quality of life. However, the service quality does not match this. Design: This is a cross-sectional observational study. Methods:A general information questionnaire and an Internet + nursing questionnaire were developed, and 738 older with chronic illness from six general hospitals in Zhejiang were randomly sampled and statistically analyzed. This study was conducted according to the STROBE guideline. Rresults : Overall, 287 people (38.92 %) were aware of Internet + nursing, with 132 (17.89 percent) having used Internet + nursing; 286 people (63.42 %) did not use internet + nursing. 63.42% were unaware of it, and 43.9 % had no idea how to use a smartphone. There is a high demand for “Internet+” nursing .Some factors, such as degree of education, Number of hospitalizations, Course of disease, Income level, contracted family doctor service, training received, and smartphone use, which have a statistically significant effect on the use of Internet + nursing. Conclusions: there is a high demand as well as low usage rate of Internet + nursing for older patients, and a mismatch between supply and demand. Relevance to Clinical Practice: Regulation and policy reforms are needed to optimize the discharge planning ,and develop high-quality “Internet+” continuous care for older adults with chronic illness. Patient or Public Contribution: Older patients with chronic diseases and registered nurses participated in the surveys of this study. Registered nurses facilitated community-based family doctor contracting by identifying and introducing the study to patients who were eligible for study participation.

The purpose of this study was to investigate the caregiving burden experienced by older family caregivers of homebound older individuals with dementia in Hong Kong, Singapore, and Japan before the COVID-19 pandemic. The study examined their attitudes towards supporting older parents and involved 540 family caregivers. Various scales and questionnaires were used to assess factors such as memory and behavior problems, perceived support, general health, burden, cultural justification, and coping strategies. The results revealed that greater memory and behavioral problems in dementia patients negatively impacted caregivers' mental health and influenced their coping strategies. The study found no direct correlation between support for older parents and mental health but identified a positive association with specific coping strategies. The similarities among family caregivers in Hong Kong, Singapore, and Japan were noted, including age, education, occupational status, and shared cultural values like Confucianism and respect for elders. It was observed that caregivers prioritize their own quality of life while addressing the challenges related to caring for older parents.

We inter-compare four hydrological models in terms of their surface water response simulations and their ability to capture the particular features of humid Mediterranean climates. We selected the Maule River basin (central Chile), in particular the Longaví basin as the paradigm of humid Mediterranean climate to run the study. The area is under intensive irrigated agricultural exploitation, which jeopardizes groundwater recharge and may be further pressurized by precipitation changes due to global warming. The Longaví basin in the south of the Maule, was studied and its hydrological cycle was simulated using four simulation tools: GR4J, HBV-light, HEC-HMS and WEAP, hence including lumped as well as a semi-distributed approaches. For model performance assessment, the Longaví was sub-divided into three zones with comparable characteristics in terms of climate, physical soil properties and altitude classes. Daily hydro-meteorological forcing time series were provided by official institutions of Chile for the 1979 to 2015 period. The individual model efficiency was evaluated through usual deterministic performance indicators. The models exhibit different strengths in terms of hydrologic response simulations. The results obtained with GR4J, HEC-HMS and WEAP perform better during southern hemisphere Winter between June and October, while HBV-light produces stronger results during the November to May Summer season. The more heavily parameterized WEAP model tends to better represent the stream flow variability observed during the rainy season with respect to the dry season.

A formation adaption algorithm is proposed for obstacle avoidance and environment survey in three dimension space. Firstly, singular value feature of incidence matrix for feasible control graph is derived. Then, an effective diameter has been proposed to characterize the dimension of 3D formations, and been estimated under various operations including transition, rotation, scaling as well as inner motions. Finally, an optimal scale factor is figured out for uniform scaling on the basis of a similarity function. Numerical experiments demonstrate the effectiveness and efficiency of the proposed algorithm.

Emerald ash borer (EAB) ( Agrilus planipennis Fairmaire), an invasive, phloem-feeding beetle native to Asia, has killed hundreds of millions of ash ( Fraxinus spp.) trees in the USA and Canada since it was detected in southeast Michigan in 2002. Consistently high mortality of black ash ( Fraxinus nigra) and green ash ( F. pennsylvanica) is a particular concern given the role both species play in regulating soil moisture and shallow groundwater levels in riparian forests. Here we present the first longitudinal observations documenting hydrologic effects resulting from EAB-caused ash mortality in a riparian zone at the W.K. Kellogg Experimental Forest in southwest Michigan. From 2018-2022, we monitored soil moisture, depth to groundwater and meteorological observation at 15-min intervals throughout the growing season in two adjacent plots (gap, forest) in the Augusta Creek riparian zone. We estimated groundwater evapotranspiration (ET G) using a groundwater level fluctuation (WLF) method. Significant differences in volumetric soil moisture content (16-26% higher in the gap than forest), average depth to water (10 cm in the gap vs 70 cm below land surface in the forest) and mean daily ET G (0.6 in the gap vs 3.0 mm per day in the forest) persisted across four growing seasons. Prolonged saturation of the near surface is driving hydric soil formation, contributing to an ecosystem regime shift from forested riparian to herb and sedge-dominated wetland. These changes have important implications for riparian zone ecosystem services including nutrient cycling, sediment transport, and greenhouse gas emissions, especially when considering the extent of ash mortality already sustained in much eastern North America.

Acute Lymphoblastic Leukemia (ALL) is the most common pediatric cancer and the most common subtype of pediatric leukemia, the high toxicity, relapse and refractory disease of many patients require the development of novel therapeutic approaches. New therapeutic approaches such as targeted immunotherapy in combination with Hematopoietic Stem Cell Transplantation (HSCT) must be taken in count to revolutionize the management of numerous ALL subtypes, improve treatment outcomes and maintain low toxicity without losing the effectiveness of the treatment. We evaluated a novel therapeutic approach in Mexico, the outpatient administration of blinatumomab infusion in patients with relapsed/refractory acute lymphoblastic leukemia (R/R ALL).

Reply to: Clinical trials: A plea to cooperative groups, consortia,

This review covers the isolation, structural determination, plausible biosynthetic pathways, and biological activities of 166 natural terpenoids including 57 sesquiterpenoids, 65 diterpenoids, 15 sesterterpenoids, and 29 triterpenoids from January 2017 to December 2022.

Introduction: Pulmonary vein isolation is not sufficient for the treatment of non-paroxysmal atrial fibrillation (AF). We aimed to clarify the effects of pulmonary vein isolation and left atrial low-voltage area ablation on acute termination of AF and freedom from AF. Methods: Ninety-five patients with non-paroxysmal AF were prospectively divided into left atrial substrates modification-first (LASM-first, n=47) and pulmonary vein isolation-first (PVI-first, n=48) groups. All patients underwent ablation during AF with acute AF termination as the procedural endpoint. In the former, LASM was performed, and PVI was performed only if AF termination was unsuccessful. In the latter, PVI was performed to observe whether AF was terminated, and if not, LASM was performed. In non-terminating AF, electrical cardioversion was performed. The patients were followed up 3, 6, and 12 months after ablation. Results: More patients reached the procedural endpoint with LASM alone than with PVI alone (45% vs. 15%; P < 0.01). Of the 95 patients, acute termination of AF occurred in 67 patients (70.5％) after PVI combined with LASM. At a median follow-up of 15 months, 69 of 95 patients (72.6％) achieved freedom from AF. More patients with AF termination with LASM alone achieved freedom from AF when compared to those who had undergone PVI alone (86% vs. 43%; P=0.04). Conclusions: LASM terminated non-paroxysmal AF in nearly half of the cases, with a better rate of freedom from AF when compared to cases without AF termination. However, for PVI, AF termination did not lead to better AF freedom rate.

Background: Patients with AF and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short-term anti-thrombotic drugs are used post-procedure to offset the risk of device-related thrombus, evidence for this practice is limited. Objectives: To investigate optimal post-implant antithrombotic strategy in high bleeding-risk patients. Methods: Patients with AF and high-risk for both stroke and bleeding undergoing LAAO were advised their peri-operative drug therapy by a multi-disciplinary physician panel. Those deemed to be at higher risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no antithrombotics or aspirin-alone. The remaining patients received standard care (STG)with a 12week course of dual-antiplatelets or anticoagulation post-implant. We compared mortality, device-related thrombus, ischemic stroke and bleeding events during the 90 days post-implant and long-term. Event-free survival was assessed using Kaplan-Meier survival analysis, with logrank testing for statistical significance. Results: 75 pts underwent LAAO of whom 63pts(84%) had a prior serious bleeding event. The 42pts on minimal treatment were older(74.3±7.7vs71.2±7.2) with higher HASBLED score (3.6±0.9vs3.3±1.2) than the 33pts having standard care. There were no device-related thrombi or strokes in either group at 90 days post-procedure; STG had more bleeding events (5/33vs0/42,p=0.01) with associated deaths (3/33vs0/42,p=0.05). During long-term follow up (median 2.2yrs), all patients transitioned onto no antithrombotic drugs (43pts(61%)) or a single-antiplatelet (29pts(39%)). There was no evidence of early minimal treatment adversely affecting long-term outcomes. Conclusions: Short-term anti-thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.