Amino- and Alkoxybenziodoxoles: Facile Preparation and Use as Arynophiles.

We report here on the facile synthesis of amino- and alkoxy-λ3-iodanes supported by a benziodoxole (BX) template and their use as arynophiles. The amino- and alkoxy-BX derivatives can be readily synthesized by reacting the respective amines or alcohols with chlorobenziodoxole in the presence of a suitable base. Unlike previously known nitrogen- and oxygen-bound iodane compounds, which have primarily been employed as electrophilic group transfer agents or oxidants, the present amino- and alkoxy-BX reagents manifest themselves as nucleophilic amino and alkoxy transfer agents toward arynes. This reactivity leads to the aryne insertion into the N-I(III) or O-I(III) bond to afford ortho-amino- and ortho-alkoxy-arylbenziodoxoles, iodane compounds nontrivial to procure by existing methods. The BX group in these insertion products exhibits excellent leaving group ability, enabling diverse downstream transformations.

Status of treatment and outcome in Kawasaki disease in the Kinki area of Japan.

BACKGROUND: The treatment guidelines for acute Kawasaki disease (KD) have been revised several times. Moreover, the criterion used to define coronary artery abnormalities (CAAs) has changed from the coronary artery's internal diameter to the Z-score. Treatment for KD and methods for evaluating CAAs vary between hospitals, so we investigated the actual status of acute KD treatment and development of CAAs under the 2012 Japanese treatment guidelines for acute KD. METHODS: The 24th Japanese Nationwide Survey on Kawasaki Disease yielded 2618 patients who developed KD in the Kinki area in 2016. We sent a secondary questionnaire to each participating hospital and used the resulting data to investigate the frequency of CAAs according to Z-score, treatment by KD treatment stage, and predictors of CAAs. RESULTS: The response rate was 80.0%. The data for 1426 patients without major data deficiencies were examined. The frequency of CAAs was 3.0% when based on coronary artery internal diameters and 8.8% when based on Z-scores. Intravenous immunoglobulins combined with corticosteroids were administered as an initial treatment in 12.8% of cases and as a second-line treatment in 16.8% of cases. Corticosteroids, cyclosporine A, infliximab, and plasma exchange were used at similar frequencies for third-line treatment. A pretreatment maximum coronary artery Z-score of ≥1.9 and age <1 year were associated with significantly higher incidences of CAAs. CONCLUSIONS: Using the Z-score resulted in a threefold increase in the number of patients diagnosed with CAAs. A pretreatment maximum coronary artery Z-score of ≥1.9 and age <1 year are useful predictors of CAAs.

Epidemiology of child mortality and challenges in child death review in Japan: The Committee on Child Death Review: A Committee Report: The Committee on Child Death Review: A Committee Report.

We performed a retrospective survey and verification of the medical records of death cases of children (and adolescents; aged <18 years) between 2014 and 2016 in pediatric specialty training facilities in Japan. Of the 2,827 registered cases at 163 facilities, 2,348 cases were included. The rate of identified deaths compared with the demographic survey, was 18.2%-21.0% by age group. The breakdown of deaths was determined as follows: 638 cases (27.2%) were due to external factors or unknown causes, 118 (5.0%) were suspected to involve child maltreatment, 932 (39.7%) were of moderate or high preventability or were indeterminable. Further detailed verification was required for 1,333 cases (56.8%). Comparison of the three prefectures with high rates of identified deaths in Japan revealed no significant differences, such as in the distribution of diseases, suggesting that there was little selection bias. The autopsy rate of deaths of unknown cause was 43.4%, indicating a high ratio of forensic autopsies. However, sufficient clinical information was not collected; therefore, thorough evaluations were difficult to perform. Cases with a moderate or high possibility of involvement of child maltreatment accounted for 5%, similar to previous studies. However, more objective evaluation is necessary. Preventable death cases including potentially preventable deaths accounted for 25%, indicating that proposals need to be made for specific preventive measures. Individual primary verification followed by secondary verification by multiple organizations is effective. It is anticipated that a child death review (CDR) system with such a multi-layered structure will be established; however, the following challenges were revealed: The subjects of CDR are all child deaths. Even if natural death cases are entrusted to medical organizations, and complicated cases to other special panels, the numbers are very high. Procedures need to be established to sufficiently verify these cases. Although demographic statistics are useful for identifying all deaths, care must be taken when interpreting such data. Detailed verification of the cause of death will affect the determination of subsequent preventability. Verification based only on clinical information is difficult, so a procedure that collates non-medical information sources should be established. It is necessary to organize the procedures to evaluate the involvement of child maltreatment objectively and raise awareness among practitioners. To propose specific preventive measures, a mechanism to ensure multiprofessional diverse perspectives is crucial, in addition to fostering the foundation of individual practitioners. To implement the proposed measures, it is also necessary to discuss the responsibilities and authority of each organization. Once the CDR system is implemented, verification of the system should be repeated. Efforts to learn from child deaths and prevent deaths that are preventable as much as possible are essential duties of pediatricians. Pediatricians are expected to undertake the identified challenges and promote and lead the implementation of the CDR system. This is a word-for-word translation of the report in J. Jpn. Pediatr. Soc. 2019; 123 (11): 1736-1750, which is available only in the Japanese language.

Non-invasive intravital observation of lingual surface features using sliding oral mucoscopy techniques in clinically healthy subjects.

To investigate intravital morphological features of the broader area of the lingual mucosa in clinically healthy subjects, and to attempt to evaluate subclinical conditions, we evaluated detailed intravital morphological features of the lingual mucosa using our newly developed oral contact mucoscopy techniques. Clinically healthy subjects (female: 19-22 years, average age: 20.27 years, and n = 28) were enrolled. A position indicator stain was placed on the lingual mucosal surface, and sliding images were captured and then reconstructed. In addition, the lingual mucosa was divided into six areas, and morphometry of the fungiform and filiform papillae was performed. The results were statistically analyzed. There were two morphological features among clinically healthy subjects involving the filiform papillae: the length of the papillae and the degree of biofilm (tongue coat) deposition. We defined a modified tongue coat index (mTCI) with scores ranging from 0 (tongue coating not visible) to 0.5, 1, 1.5, and 2 (thick tongue coating) for six sections of the tongue dorsum. No subjects received a score of 2. Significant differences were found in the mTCI between the six sections of the tongue dorsum, especially between the posterior areas and the lingual apex. The fungiform papillae of some subjects exhibited elongated morphological changes. Our findings suggest that magnified lingual dorsum examination of a broader area is especially important in accurate screening for subclinical or transient conditions of potential lingual mucosal diseases. For this purpose, our new oral mucoscopy and non-invasive intravital observational techniques were especially effective.

Comparative Morphology of the Lingual Papillae and Their Connective Tissue Cores in the Tongue of Pallas's Squirrel (Callosciurus erythraeus thai, Kloss, 1917).

We observed the morphology of the papilla linguae (filiform, fungiform, foliate, and vallate) and underlying connective tissue cores (CTCs) in Pallas's squirrel (Callosciurus erythraeus thai) using light and scanning electron microscopy. The tongue was caudally elongated and lacked the lingual torus. Filiform papillae were densely distributed along the dorsal surface of the apex, and the rostral and caudal parts of the corpus, but were attenuated in the lingual root. Two or three vallate papillae that were rounded or elongated were situated at the boundary between the caudal part of the corpus and lingual root, and foliate papillae and associated cone-like processes were observable in the lateral margin of the caudal end. The epithelial surface of filiform papillae had a main process and a few associated processes that varied between short and elongated, depending on the location. Filiform papillae CTCs appeared to have a few processes that caudally surrounded a concavity and were morphologically variable based on location. Moreover, fungiform papillae CTCs appeared to be columnar cores and had a shallow convex curve at the top. The Pallas's squirrel's tongue exhibited transitional morphological characteristics between Rodentia and other mammalian species, in that they lacked the lingual torus and had CTCs of lingual papillae that were somewhat morphologically similar to those of other non-Glires species, especially treeshrews and tamarins, rather than those of other Rodentia species.

Risk factors for sodium valproate-induced renal tubular dysfunction.

OBJECTIVE: To explore the risk factors for the development of sodium valproate (VPA)-induced renal tubular dysfunction for early diagnosis and treatment. STUDY DESIGN: The subjects were selected from patients who were diagnosed with epilepsy and administered VPA. Blood and spot urine samples were collected and measured the concentration of VPA, the level of serum phosphorus, serum uric acid, serum free carnitine, serum cystatin-c, and urine ß2-microglobulin (BMG). Patients with urine BMG/creatinine levels above 219.2 were treated as renal proximal tubular dysfunction (RTD), with all others treated as non-RTD. RESULTS: Eighty-seven patients, 4-48 years, 53 men and 34 women, were studied. RTD group is 17 patients and non-RTD group is 70 patients. Univariate analyses revealed that the RTD patients were more likely to be bedridden, receiving enteral tube feeding, taking more anticonvulsants, and demonstrating significantly lower serum levels of free carnitine, uric acid, and phosphorus. Among them, bedridden, free serum carnitine, and phosphorus levels were associated with the development of RTD by multivariate analysis. CONCLUSIONS: Bedridden patients receiving VPA are susceptible to hypocarnitinemia, which can cause RTD and may lead to FS. Therefore, urinary BMG should be measured regularly in all patients receiving VPA to assess renal tubular function. An additional measurement of serum free carnitine level should be considered in patients who developed RTD. Supplementation of carnitine for those patients to prevent such complication deserves for further study.

Presence of BPIFB1 in saliva from non-obese diabetic mice.

We previously showed that mRNA expression of BPIFB1 (Bpifb1), an antibacterial protein in the palate, lung, and nasal epithelium clone protein family, was increased in parotid acinar cells in non-obese diabetic (NOD, NOD/ShiJcl) mice, which is an animal model for Sjögren's syndrome. However, we did not previously assess the protein levels. In this report, we confirmed the expression of BPIFB1 protein in the parotid glands of NOD mice. Immunoblotting of subcellular fractions revealed that BPIBB1 was localised in secretory granules in parotid glands from NOD mice, and was almost not in parotid glands from the control mice. BPIFB1 had N-linked glycan that reacted with Aleuria aurantia lectin, which caused two types of spots with a slightly different pI and molecular weight. The expression of BPIFB1 protein was also demonstrated by immunohistochemistry. BPIFB1 was detected in the saliva from NOD mice but not in the saliva from the control mice, indicating individual constitution. BPIFB1 in saliva may be applied to other research as a diagnostic marker.

Urinary 8-Hydroxy-2'-Deoxyguanosine: A Biomarker for Radiation-Induced Oxidative DNA Damage in Pediatric Cardiac Catheterization.

OBJECTIVE: To determine the utility of urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) as a sensitive biomarker for radiation-induced cellular DNA damage in children undergoing cardiac catheterization. STUDY DESIGN: We enrolled pediatric patients with congenital heart diseases requiring cardiac catheterization in conjunction with healthy children and children under sedation as control. Demographic, clinical, laboratory and invasive hemodynamic data, urinary 8-OHdG levels, and radiation exposure measurements were collected prospectively. RESULTS: Nineteen patients, 10 healthy children and 9 children under sedation, were studied. In 19 patients who underwent cardiac catheterization, the median level of 8-OHdG in urine obtained at 24-48 hours after the procedure was significantly higher than at baseline (44.0 vs 17.3 ng/mg creatinine, P = .0001). Furthermore, the urinary 8-OHdG level after the procedure increased in 18 of the 19 study subjects. In contrast, there was no significant difference in 8-OHdG levels between the 2 spot urine samples obtained at arbitrary intervals of 24-48 hours in 10 healthy children (P = .7213), and at baseline and 24-48 hours following echocardiography in 9 children under sedation (P = .1097). Stepwise multiple regression analysis revealed that the cumulative air kerma during the cardiac catheterization was the variable which was strongly and significantly associated with the ratio of post- to precardiac catheterization urinary 8-OHdG levels among the evaluated variables (R(2) = 0.7179, F = 11.0256, P = .0007). CONCLUSIONS: Urinary 8-OHdG could be a useful biomarker for radiation-induced cellular DNA damage in children undergoing diagnostic cardiac catheterization.

Highly efficient narrow-band green and red phosphors enabling wider color-gamut LED backlight for more brilliant displays.

In this contribution, we propose to combine both narrow-band green (ß-sialon:Eu(2+)) and red (K(2)SiF(6):Mn(4+)) phosphors with a blue InGaN chip to achieve white light-emitting diodes (wLEDs) with a large color gamut and a high efficiency for use as the liquid crystal display (LCD) backlighting. ß-sialon:Eu(2+), prepared by a gas-pressure sinteing technique, has a peak emission at 535 nm, a full width at half maximum (FWHM) of 54 nm, and an external quantum efficiency of 54.0% under the 450 nm excitation. K(2)SiF(6):Mn(4+) was synthesized by a twe-step co-precipitation methods, and exhibits a sharp line emission spectrum with the most intensified peak at 631 nm, a FWHM of ~3 nm, and an external quantum efficiency of 54.5%. The prepared three-band wLEDs have a high color temperature of 11,184 - 13,769 K (i.e., 7,828 - 8,611 K for LCD displays), and a luminous efficacy of 91 - 96 lm/W, measured under an applied current of 120 mA. The color gamut defined in the CIE 1931 and CIE 1976 color spaces are 85.5 - 85.9% and 94.3 - 96.2% of the NTSC stanadard, respectively. These optical properties are better than those phosphor-cpnverted wLED backlights using wide-band green or red phosphoprs, suggesting that the two narrow-band phosphors investigated are the most suitable luminescent materials for achieving more bright and vivid displays.

Comparative morphology of the lingual papillae and their connective tissue cores in the tongue of the American mink, Neovison vison.

We observed the morphology of the lingual papillae (filiform, conical, fungiform, and vallate papillae, and lateral organ) and their connective tissue cores (CTCs) in the American mink (Neovison vison) using light and scanning electron microscopy. Filiform papillae were distributed on the apex linguae and rostral regions of the corpus linguae. Conical papillae were distributed over the caudal region and absent in the radix linguae. Numerous ridges were present in the radix linguae. Four to six vallate papillae were situated at the border between the corpus and radix linguae. Instead of foliate papillae, a pair of lateral organs was situated on the caudal edge of the corpus. The epithelial surface of each filiform papilla consisted of a single main process and 10-12 accessory processes. Notably, filiform papillae in the apex linguae exhibited morphological variation, and some were dome-like and lacked processes. In contrast, filiform papillae on the rostral part were not variable, were extended to a sharp tip, were associated with an eosinophilic stratum corneum, and lacked nuclei. The CTCs of the filiform papillae consisted of a main core and slender accessory cores surrounding a concavity. Those in the apex linguae were similar in appearance and consisted of main and adjacent accessory cores. The fungiform papillae had a dome-like epithelial surface and their CTCs were columnar, with upper concavities and flanges. The simplified lingual morphology of the American mink, particularly in the filiform papillae in the apex linguae, may be influenced by its diet and semiaquatic lifestyle.

A fatal case of infantile malignant osteopetrosis complicated by pulmonary arterial hypertension after hematopoietic stem cell transplantation.

Infantile malignant osteopetrosis (IMO) is a rare and fatal autosomal recessive condition characterized by a generalized increased in bone density. Hematopoietic stem cell transplantation (HSCT) is the only effective and rational therapy with achieving long-term disease-free survival. However, complications with HSCT for IMO remain unclear. Here we describe a male infant with IMO, carrying two novel mutations in the T-cell immune regulator 1 (TCIRG1) gene. The TCIRG1 gene encodes the a3 subunit of vacuolar H(+)-ATPase that plays an essential role in the resorptive function of osteoclasts. Direct sequencing of all 20 exons of the TCIRG1 gene revealed a single nucleotide change in exon 11 (c1305 G > T), which causes the substitution of Asp (GAT) for Glu (GAG) at position 435, and a two-nucleotide deletion in exon 16 (c1952-1953 del CA), causing a frame-shift mutation. However, the functional consequence of each mutation remains to be determined. Allogeneic HSCT was performed in the patient at the age of nine months. Donor engraftment was achieved, and abnormal bone metabolism and extramedullary hematopoiesis were corrected. Graft-versus-host disease was mild (grade I). However, the patient died of complication of pulmonary arterial hypertension at seven months after the HSCT. Postmortem examination revealed prominent vascular wall thickening of the pulmonary artery and macrophage infiltration to alveoli. It should be noted that a patient with IMO has a risk for pulmonary arterial hypertension, and the evaluation of pulmonary arterial flow should be included in the assessment of each patient with IMO even after HSCT.

A fatal snakebite envenomation due to King cobra (Ophiophagus hannah) in the Eastern Visayas, Philippines.

This report details a documented case of fatal King cobra (Ophiophagus hannah) envenomation in the Philippines. A 46-year-old woman from a mountainous town in Leyte was bitten on her left thigh by a snake. Despite receiving prompt medical attention, including administration of fluids and oxygen, she went into arrest and succumbed within 2.5 hours of the bite. Inadequate pre-hospital care, including endotracheal intubation and assisted ventilation, highlights a notable gap in emergency medical services. Photographic evidence, verified by a herpetologist, confirmed the involvement of a King cobra, with venom presenting with a swift and lethal systemic effect that led to the patient's demise, despite minimal local manifestations. This incident accentuates the urgent need for accessible, effective antivenom and improved snakebite management protocols in the Philippines. It also calls for heightened awareness and preparedness among pre-hospital healthcare providers and the public, alongside advocating for more research into snakebite envenomation.

N-terminal pro-brain natriuretic peptide and risk of coronary artery lesions and resistance to intravenous immunoglobulin in Kawasaki disease.

OBJECTIVE: To determine whether the serum N-terminal pro-brain natriuretic peptide (NT-proBNP) can be a useful marker not only to identify the patients with Kawasaki disease (KD) who are at a higher risk of developing coronary artery lesions (CAL), and predict resistance to intravenous immunoglobulin (IVIG). STUDY DESIGN: We enrolled 80 patients with the acute phase of KD at a single center. The demographic, clinical, and laboratory data were prospectively collected. RESULTS: Nineteen of the 80 patients developed CAL, despite IVIG administration. They had a significantly higher serum NT-proBNP level in comparison with the patients without CAL. The NT-proBNP cut-off value of 1300 pg/mL yielded a sensitivity of 95% and a specificity of 85% for predicting CAL. However, 17 of the 80 patients were IVIG non-responders. They also had a significantly higher serum NT-proBNP level in comparison with the IVIG responders. The NT-proBNP cut-off value of 800 pg/mL yielded a sensitivity of 71% and a specificity of 62% for predicting IVIG non-responders. CONCLUSIONS: The serum NT-proBNP level is increased in children with KD with CAL and IVIG resistance. It may be useful to predict CAL and IVIG resistance in KD.

Antigen-presenting cells in parotid glands contain cystatin D originating from acinar cells.

Cystatin D encoded by Cst5 is a salivary classified type II cystatin. We investigated the dynamism of cystatin D by examining the distribution of cystatin D protein and mRNA in rats, to identify novel functions. The simultaneous expression of Cst5 and cystatin D was observed in parotid glands, however in situ hybridization showed that only acinar cells produced cystatin D. Synthesized cystatin D was localized in small vesicles and secreted from the apical side to the saliva, and from the basolateral side to the extracellular region, a second secretory pathway for cystatin D. We also identified antigen-presenting cells in the parotid glands that contained cystatin D without the expression of Cst5, indicating the uptake of cystatin D from the extracellular region. Cystatin D was detected in blood serum and renal tubular cells with megalin, indicating the circulation of cystatin D through the body and uptake by renal tubular cells. Thus, the novel dynamism of cystatin D was shown and a function for cystatin D in the regulation of antigen-presenting cell activity was proposed.

Phase II study of concurrent chemoradiotherapy at the dose of 50.4 Gy with elective nodal irradiation for Stage II-III esophageal carcinoma.

OBJECTIVE: Definitive chemoradiotherapy is one of the curative options for resectable esophageal squamous cell carcinoma with organ preservation. We evaluated the efficacy and toxicity of radiotherapy at a dose of 50.4 Gy concurrent with chemotherapy for Stage II-III esophageal cancer. METHODS: Esophageal cancer patients with clinical Stage II-III (T1N1M0 or T2-3N0-1M0) were eligible. Radiotherapy was administered to a total dose of 50.4 Gy with elective nodal irradiation of 41.4 Gy. Concurrent chemotherapy comprised two courses of 5-fluorouracil (1000 mg/m(2)/day) on days 1-4 and 2-h infusion of cisplatin (75 mg/m(2)) on Day 1; this was repeated every 4 weeks. Two courses of 5-fluorouracil with cisplatin were added. RESULTS: Fifty-one patients were enrolled in the study from June 2006 to May 2008. The characteristics of the 51 patients enrolled were as follows: median age 64 years; male/female, 45/6; performance status 0/1, 32/19 patients; Stage IIA/IIB/III, 9/20/22 patients, respectively. A complete response was achieved in 36 patients (70.6%). The 1- and 3-year overall survival rate was 88.2 and 63.8%, respectively. The median 1- and 3-year progression-free survival rate was 66.7% (80% CI: 57-74%) and 56.6% (80% CI: 47.1-64.9%), respectively. Acute toxicities included Grade 3/4 anorexia (45%), esophagitis (35%) and febrile neutropenia (20%). Eight patients (15.6%) underwent salvage surgery due to residual or recurrent disease. There were no deaths related to salvage surgery. CONCLUSION: Chemoradiation therapy at a dose of 50.4 Gy with elective nodal irradiation is promising with a manageable tolerability profile in esophageal cancer patients.

A child with Epstein-Barr Virus-associated hemophagocytic lymphohistiocytosis complicated by coronary artery lesion mimicking Kawasaki disease.

There is considerable overlap between hemophagocytic lymphohistiocytosis (HLH) and Kawasaki disease (KD) in terms of aberrant immune response though the etiology of KD remains unknown. We present a case fulfilling the criteria of both HLH and KD complicated by coronary artery dilatation: HLH was confirmed to be triggered by Epstein-Barr virus. This case alarms us the possibility that even patients with HLH may be complicated by coronary artery lesion, which is one of the hallmarks of KD. We would like to draw attention that if features of KD become apparent in patients with HLH, echocardiographic examinations should be performed not to miss coronary artery lesion.

Steroid pulse therapy for children with intravenous immunoglobulin therapy-resistant Kawasaki disease: a prospective study.

Patients with Kawasaki disease (KD) who did not respond to the initial IVIG are known to have higher risk for developing coronary arterial lesions (CALs). Our aim is to clarify whether patients with initial IVIG resistant KD may benefit from methylprednisolone pulse therapy (MPT) in comparison with re- treatment of IVIG (2nd IVIG). A total of 237 patients (median age: 2 years 2 months; range 1 months-10 years) with KD were initially treated with IVIG (2 g/kg). Among them, 41 patients (22 %) were assessed as IVIG resistance: these patients were allocated to either group A receiving MPT (n = 14) or group B receiving the 2nd IVIG (n = 27). Patients with resistant to the additional therapy (MPT or 2nd IVIG) were received second IVIG (group A) or MPT (group B). Changes in leukocyte count, C-reactive protein and albumin before and after an additional therapy were significantly greater in group A than those in group B. However, the prevalence of CALs did not differ between the groups (36 % in group A and 26 % in group B, p > 0.05). There was no significant difference in the medical cost between the groups (median cost: 92,032 JPY in group A and 97,331 JPY in group B). MPT does not reduce the risk of development to CAL and does not seem to be beneficial as single agent therapy for IVIG resistant KD.

The red ruffed lemur, Varecia rubra (É. Geoffroy Saint-Hilaire, 1812): a comparative morphology investigation of lingual papillae and connective tissue cores.

The morphology of the lingual papillae (filiform, foliate, fungiform, and vallate papillae) and the underlying connective tissue core of the red ruffed lemur (Varecia rubra) of a strepsirrhines species were studied using light and scanning electron microscopy. The filiform papillae distributed at the root of the tongue were larger than the structures distributed at the body and apex. Six to eight vallate papillae were arranged in a Y-shape at the border between the lingual body and the lingual root. Foliate papillae were observed at the posterior lateral border of the tongue. Scanning electron microscopy revealed a primary process and numerous auxiliary processes in the epithelial layer of filiform papillae. After epithelial removal, the connective tissue core of the filiform papilla showed several protrusions surrounding an oval-shaped depression that extended slightly posteriorly, and a large, maple-shaped filiform papilla was seen in the posterior portion of the tongue. The connective tissue cores of the fungiform papillae exhibited a longitudinally ridged cylindrical structure. The connective tissue core of the foliate papillae had numerous tubular projections arranged along a groove with a salivary gland conduit at the base. As a Lemuridae species, the appearance of the fungiform and filiform papillae of the red ruffed lemur is similar to that reported in previous studies of the ring-tailed lemur, with some differences, especially in the filiform papillary connective tissue core at the base and tongue body border. These findings suggest the taxonomic and phylogenetic origins of the lemurs as well as the influence of dietary diversity.

Barriers to the hospital treatment among Bede snake charmers in Bangladesh with special reference to venomous snakebite.

Snakebite envenoming is a potentially life-threatening global public health issue with Bangladesh having one of the highest rates of snakebite cases. The Bede, a nomadic ethnic group in Bangladesh, traditionally engages in snake-related business such as snake charming. The Bede relies on their own ethnomedicinal practitioners for snakebite treatment while there is a lack of concrete evidence on the effectiveness of such ethnomedicinal treatment. To identify the barriers to the utilization of biomedical treatment for snakebite we conducted interviews with 38 Bede snake charmers, who have experienced snakebite, and six family members of those who died of snakebite. Our results show that four critical barriers, Accessibility, Affordability, Availability, and Acceptability (4As), prevented some of the Bede from seeking biomedical treatment. Moreover, we found that a few Bede died of a snakebite every year. There are survivors of snakebite who were able to receive biomedical treatment by overcoming all of the 4As. Our results provide insights into the current state of snakebite treatment in Bangladesh and can inform the development of more effective and accessible treatment options for those affected. Partnership between the public sector and the Bede community has the potential to make a significant impact in reducing snakebite morbidity and mortality in Bangladesh.