Background Iron deficiency anemia (IDA) is detrimental to growth and neurodevelopmental outcomes in young children. IDA is primarily managed in the outpatient setting, though children with severe anemia may require admission. No prior studies of children with severe IDA admitted to US children’s hospitals exist. The objective is to describe characteristics of children requiring admission for IDA. Procedure Using the Pediatric Health Information system database, we identified children age 0-5 years admitted from 2004-2018 with a primary diagnosis of IDA. Patient characteristics were compared by chi-square test or t-test of means. Univariate logistic regression was used to identify factors associated with readmission. We also performed a retrospective review of primary care records. Results A total of 4963 unique patients were identified, with 5202 unique hospitalizations. The mean age at admission at index hospitalization was 1.5 years with no gender difference. A trend towards an increasing number of admissions was noted in recent years. The majority of the patients received blood transfusions (87.3%) and oral iron (61.4%), whereas only 4.9% of patients received intravenous iron. Overall, 13.1% of patients required ICU admission, which was more common in female patients and children of Black or Asian race. Factors associated with decreased odds of readmission included blood product transfusion and use of oral iron during the index hospitalization. Conclusions IDA is a preventable condition, with potential for detrimental long-term outcomes. Trends in the number of admissions over time are concerning in light of the substantial use of hospital resources.

von Willebrand disease is a hereditary disease associated with a tendency to bleed and it is important to reduce the possibility of bleeding in a procedure. This case describes the use of a hemostatic factor, Factor VIII concentrate (Confact F®), during a dental procedure involving teeth extraction and implant placement.

In this article, we aimed to elaborate a universal clinical multidisciplinary protocol in order to facilitate the management of the peg-shaped maxillary lateral incisors, via a case of two upper lateral incisors affected by microdontia. A meticulous clinical analysis, wax up and mock up are crucial to ensure optimal rehabilitation.

Evaluating the spatial and temporal model performance of distributed hydrological models is necessary to ensure that the simulated spatial and temporal patterns are meaningful. In recent years, spatial and temporal remote sensing data have been increasingly used for model performance evaluation. Previous studies, however, have focused on either the temporal or spatial model performance evaluation. In addition, temporal (or spatial) model performance evaluation is often done in a spatially (or temporally) lumped approach. Here, we evaluated (1) the temporal model performance evaluation in a spatially distributed approach (spatiotemporal) and (2) the spatial model performance in a temporally distributed approach (temporospatial) model performance evaluation. This study demonstrated that both spatiotemporal and temporospatial model performance evaluations are necessary since they provide different aspects of the model performance. For example, spatiotemporal model performance evaluation helps in detecting the areas with an issue in the simulated temporal patterns. However, temporospatial model performance evaluation helps in detecting the time with an issue in the simulated spatial patterns. The results also show that an increase in the spatiotemporal model performance will not necessarily lead to an increase in the temporospatial model performance and vice versa, depending on the evaluation statistics. Overall, this study has highlighted the necessity of a joint spatiotemporal and temporospatial model performance evaluation to understand/improve spatial and temporal model behavior/performance.

BACKGROUND: This study aims to determine nicotine dependence levels in pre and during pandemic and its correlations with COVID-19 phobia among healthy men during controlled social life: a sample of primary care population. METHODS: This cross-sectional study was conducted with 472 healthy men in Çorum, Black Sea Region, Turkey between February 2019 and October 2020. An online questionnaire was used to collect data including demographic profile, smoking behavior, intention to quit, Fagerström Nicotine Dependence test (FTND) pre and during COVID-19 pandemic and COVID-19 phobia scale. RESULTS: In this study, a percentage change of +6.2, +0.8, +1.9, -2.7, -5.1 was found in very low, low, medium, high and very high dependence categories respectively between pre-pandemic and during controlled social life in pandemic. A percentage change of +2.8 was seen in terms of intention to quit smoking. The mean score for COVID-19 phobia was 65.9 ± 15.8 and almost two-thirds of the participants (62%) had medium and high COVID-19 phobia. Men with high/very high dependence had significantly more COVID-19 phobia than the other two groups. There was a significant correlation between FTND scores and COVID-19 phobia. CONCLUSIONS: There were considerable changes in dependence levels and COVID-19 phobia was more common in high/very high dependence group. Controlled social life should be considered a golden opportunity for predicting levels of nicotine dependence and will bring benefit for lower smoking prevalence. COVID-19, Nicotine dependence, Phobia, men, Primary health care.

Objectives: To determine post-COVID-19 complications after recovery and investigate the reported cases of re-infection. Methods: The researchers systematically reviewed three databases: PubMed, Google Scholar, and Word Health Organization (WHO) COVID-19 database looking for studies reported post-COVID-19 complications and COVID-19 reinfection. The search was conducted between November 21, 2020 and January 14, 2021. Inclusion criteria were articles written in English and had primary data. The studies reported the complications of COVID-19 after full recovery were included. Case reports were only included in the COVID-19 reinfection section. Results: The review included 69 studies related to post-COVID-19 complications and 13 case studies related to COVID-19 reinfection. Thirty-six studies reported post-cure respiratory complications including dyspnea to residual pulmonary fibrosis. Cardiac symptoms were reported in nine studies including palpitation, chest pain and diastolic dysfunction. Neurological complications included post-traumatic stress syndrome (PTSD), anxiety, depression, memory issues, insomnia and sleeping disturbance, cognitive impairments, and stigma. Gastrointestinal symptoms included nausea, vomiting, diarrhoea, and acute liver injury. Physical decline was the most common symptom reported in the musculoskeletal complications. Thirteen cases COVID-19 reinfection from nine countries were reported. Four patients had severe symptoms in the second infection while the symptoms of nine patient ranged from mild to moderate. The time taken for the reinfection ranged from 26 days to 145 days. Conclusion: COVID-19 may cause several types of complications after recovery. Lung abnormalities, neurological complications, and exercise intolerance were frequently identified complications among COVID-19 survivors. Reinfection can occur among COVID-19 survivors. Thus, COVID-19 may need long-term follow-up and should take preventive measures to prevent the reinfection.

Within this study, four thermal ring-opening reactions, Reactions (1-4), were selected in order to investigate the phenomenon of torquoselectivity as well as predicting non-competitive or competitive reactions in QTAIM and stress tensor frameworks rather than using conventional methods. The theoretical analysis for these reactions exhibits differently for non-competitive and competitive reactions as well as for the conrotatory preferences either TSOC or TSIC directions by presenting degeneracy or non-degeneracy in their results. The concordant results of stress tensor and QTAIM scalar and vectors with experimental results provide a better understanding of all reactions mechanism. Examination the (rb), ε, H(rb), ℙσ, 3, BPL, and H indicate that Reaction 1 is a competitive and Reactions (2-4) are non-competitive reactions with TSOC, TSOC, and TSIC preference directions respectively.

In the case of a suspicious mole on the skin, the question always arises as to whether it is benign or malignant. Is it a harmless mole, a capillary malformation or a basal cell carcinoma, squamous cell carcinoma or even a melanoma? Often the nevus can be assessed just by a close examination of the lesion and a few questions about its origin. However, every dermatologist knows all too well the problem that very different lesions can look extremely similar to the naked eye and even on dermatoscopy. Therefore, the question arises: how should dermatology deal with and communicate in such cases? This article identifies ways forward in this difficult situation, which occurs tens of thousands of times a day around the globe.

Aims Mycophenolic acid (MPA) is typically used for anti-neutrophilic cytoplasmic antibody associated nephritis (AAN) but with large individual variability of pharmacokinetics. This study aims to investigate clinical factors impacting MPA disposal so as to simulate dosage regimen in pediatric AAN. Methods We conducted a retrospective study in 25 children with AAN treated with MPA. A population pharmacokinetic model was developed to explore the effects of demographics and biochemical covariates on MPA. Monte Carlo simulations were performed to optimize dosage regimens. Results A total of 391 MPA concentrations from 25 patients were analyzed. MPA pharmacokinetics best fitted a two-compartment model with first-order absorption and linear elimination. The pharmacokinetic parameters for Ka, CL, Vc, Vp, and Q were 0.45 h-1, 9.86 L/h, 19.69 L, 408.32 L and 23.01 L/h, respectively. Dosage form significantly affected drug absorption. CL significantly decreased with increasing cystatin C, while with decreasing myeloperoxidase. Cystatin C was superior to serum creatinine in predicting CL of MPA. A dose of 650 mg/m2 was required to achieve the target exposure in children with normal renal function and no inflammation. Dose of MPA in patients with renal failure was almost 1/3 that of normal kidney function. The combined effects of myeloperoxidase and renal function resulted in a 6-fold range in MPA dose. Conclusions Myeloperoxidase was not only a biomarker of AAN, but also an inflammatory factor to impact drug CL. The influence of renal function and underlying diseases on drug metabolism should be fully considered in personalized medication for AAN children.

Effective knowledge exchange between farmers and other stakeholders, such as agricultural extensionists and soil scientists, is essential for increasing opportunities for sustainable soil fertility management. To achieve this, it is necessary to understand local farmers' conceptualisation of soil fertility. This study visualizes farmers' perceptions of soil fertility as mental models, in order to explore the expansion of their soil knowledge and the extent of their comprehension of the relationship between soil properties that are seen and measured and soil processes. Aggregated mental models of fertile and low fertility soils were created from data collected from 59 farmer interviews at two villages in Kitui County, Kenya. The share of respondents of each concept were shown to analyse the knowledge gaps among farmers and between villages. The mental models revealed that farmers recognize the important roles of soil texture, water availability and farm management in soil fertility. Their knowledge related to their lived experience of the actual productivity of soils, which resulted in a strongly different perspective of fertile and low fertility soil. The differences of perception between the villages were also recognized as the result of differences in land availability. Although the farmers who mentioned soil processes were very few, farmers had the potential to integrate further soil scientific knowledge. Consequently, using the mental model approach to visualize farmers' perceptions produced benefits by clarifying understanding of farmers' knowledge and identifying gaps where soil science and extension work could help to expand farmers' knowledge.

In case of valvular infective endocarditis, the infection is mainly localized on the flow side of the valves or at damaged valvular endothelium. We describe a rare case of an aortic valvular inefctive endocarditis with an aortic-valve vegetation situated on the aortic side of the valve. We believe this is the first description of this unusual localization of vegetations in a native aortic valve.

Abstract Background: The aim of this study was to evaluate the potential effect of 6-minute walking distance (6MWD) on exercise tolerance in patients with pulmonary hypertension (PH). To clarify whether 6WMD and right ventricle (RV) function measured by three-dimensional echocardiography (3D-echo) could result in better correlation with exercise capacity. Methods: 72 consecutive patients underwent right heart catheterization (RHC) and diagnosed with PH. Associations between 6WMD and measures of RV function were evaluated using the Pearson correlation coefficient. Receiver operating characteristic (ROC) curve analysis was applied to evaluate the clinical prognosis of patients. Results: RHC-derived parameters were significantly correlated with 6MWD: (RPVR = -0.719, RPAPs = -0.501, RPAPd = -0.404, and RPAPm = -0.468, all P <0.001). Meanwhile, 6MWD was positively correlated with CO (R = 0.54, P <0.001). Good correlations between 6MWD with 3D-echo parameters were shown as follows: R3D-RVEDV = -0.584, R3D-RVESV = -0.598, R3D-RVEF = 0.554, R3D-RV mass = -0.507, all P <0.001. The predictive value from 6MWD was not much inferior to the predictive values of PVR (AUC6MWD = 0.779 vs. AUCPVR = 0.875, both P <0.0001). Conclusions: 6MWD has a significant correlation with hemodynamic parameters obtained by RHC. And RV function obtained by 3D-echo result in better correlation with exercise capacity. 3D-echo might be candidate for RHC to assess right heart function in patients with PH.

Plants transitioned from an aquatic to a terrestrial lifestyle during their evolution. On land, fluctuations on water availability in the environment became one of the major problems they encountered. The appearance of morpho-physiological adaptations to cope with and tolerate water loss from the cells was undeniably useful to survive on dry land. Some of these adaptations, such as carbon concentrating mechanisms (CCMs), desiccation tolerance (DT) and root impermeabilization, appeared in multiple plant lineages. Despite being crucial for evolution on land, it has been unclear how these adaptations convergently evolved in the various plant lineages. Recent advances on whole genome and transcriptome sequencing are revealing that co-option of genes and gene regulatory networks (GRNs) is a common feature underlying the convergent evolution of these adaptations. In this review we address how the study of CCMs and DT have provided insight into convergent evolution of GRNs underlying plant adaptation to dry environments, and how these insights could be applied to currently emerging understanding of evolution of root impermeabilization through different barrier cell types. We discuss examples of co-option, conservation, and innovation of genes and GRNs at the cell, tissue and organ levels revealed by recent phylogenomic (comparative genomic) and comparative transcriptomic studies.

In this study, it was investigated to increase the lipid yield of the microalgae Schizochytrium sp., by applying different cell disruption methods. Therefore, acid treatment with HCl, osmotic shock, enzyme applications and ultrasonic homogenizer were tried in this algae species combined with the Bligh and Dyer and Soxhlet methods as an alternative to classical lipid extraction methods. As a result of the study, the highest lipid value (21.72 ± 0.74%) was obtained in enzyme application with Bligh and Dyer method (BDE). The cell disruption processes increased the lipid yield compared to the control groups. The highest PUFA DHA was found in the range of 4.58 ± 2.44-19.25 ± 0.09%, and the highest value was observed in the BDE group. Highest SFA was palmitic acid. Effective results were observed in the Bligh and Dyer applied groups in terms of both total lipid and total fatty acids. In cell disruption methods, particularly in enzyme and HCl extraction, good results were obtained in terms of fatty acids. The highest total fatty acids and the highest lipid content were detected in the Bligh and Dyer enzyme (BDE). Enzyme applications are also advantageous because of being environmentally friendly. Lipid health indices such as n-6/n-3, PUFA/SFA, Atherogenicity index (AI), Thrombogenicity index (TI) and hypocholesterolemic/hypercholesterolemic ratios (HH) were almost favorable. With this study, an appropriate lipid extraction methods were determined to provide an economical and environmental friendly suggestion for future studies to be used in areas such as food, feed and cosmetics.

Abstract Objectives: This study aimed to evaluate the clinical utility of serum leukocyte counts (SLCs) for initial antibiotic use in Chinese women with mastitis who presented to the emergency department. Materials and Methods: Electronic medical records of breastfeeding women with mastitis were reviewed. Patients were divided into two groups according to the level of SLCs: slight elevated leukocyte counts (SELC, 1.0-1.5*10^9 cells/L); marked elevated leukocyte counts (MELC, >1.5*10^9 cells/L ). Treatment outcomes including rates of treatment failure and breast abscess formation were compared. Results: The rates of treatment failure and breast abscess were 12.7% and 7.1% in overall population and 7.7% and 6.4% in MELC group, respectively. In SELC group, treatment failures were observed in 29.7% and 6.4% patients without or with antibiotics, and the difference was significant (OR=4.207, 95% CI 1.318- 13.424); breast abscess was observed in 12.5% and 2.1% patients, and the difference was not significant (OR=6.571, 95% CI 0.793-54.481). Mean time to normal appearance of the breast or normal temperature was shorter in patients with antibiotics (3.8 ± 1.7 and 4.3 ± 2.1 days) than in patients without antibiotic use (2.5 ± 1.1 and 3.0 ± 1.3 days), p<0.001. Conclusion: Our study found that there were better clinical outcomes in patients with SELC or MELC when antibiotic was initially administrated compared to those without antibiotics, whicha indicates that SLC is an easy and practical reference index for gudiing antibiotic use, and patients who have an elevated SLC should be treated with antibiotic. Key Words: mastitis, antibiotic, serum leukocyte count

Introduction: Global medical advances within healthcare have subsequently led to the widespread introduction of biological products such as grafts, haemostats, and sealants. Although these products have been used for many decades, this subject is frequently not discussed during the consent process and remains an area of contention. Methods: A nationwide confidential online survey was distributed to UK-based junior registrars (ST3-5), senior registrars (ST6-8), post-CCT fellows, specialist associates/staff grade doctors and consultants working in general/vascular surgery, neurosurgery, otolaryngology, oral & maxillofacial surgery and plastic surgery. Results: Data was collected from a total of 308 survey respondents. Biological derivatives were correctly identified in surgical products by only 25% of survey respondents, only 19% stated that they regularly consent for use of these products. Our results demonstrate that most participants in this study do not routinely consent (81%) to the intra-operative use of biological materials. An overwhelming 74% of participants agreed that further education on the intra-operative use of biological materials would be valuable. Discussion: This study highlights deficiencies in knowledge that results in potential ethical compromise of the consenting process for surgical procedures. A solution to this would be for clinicians to increase their awareness via educational platforms and to incorporate an additional statement on the consent form which addresses the potential intraoperative use of biological products and what their derivatives may be. Conclusion: Modernising the current consent process to reflect the development and use of surgical biological products will help to ensure improved patient satisfaction, fewer future legal implications as well as a better surgeon-patient relationship.

Background: The negative effects of varicocele and smoking on infertility are known. In our study, we aimed to evaluate the effect of smoking on the healing process after varicocelectomy. Methods and Materials: 378 male patients who have undergone varicocelectomy operation were included in the study. Patients were divided into three groups as non-smokers, patients who smoke less than 10 cigarettes per day and patients who smoke 10 or more cigarettes per day. Semen analysis of the patients before varicocelectomy operation and three months after varicocelectomy operation were evaluated and semen volume, sperm concentration and sperm motility were evaluated according to WHO (World Health Organizations) guidelines. NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) program was used for statistical analysis. Results: Patient age changed between 16 and 52 and the mean age is 27,20±6,74. When cigarette usage was evaluated, it was determined that 52,82% of patients (n=220) were non-smokers, 13,8% of patients (n=52) smoke less than 10 cigarettes per day and 28,0% of patients (n=106) smoke 10 or more cigarettes per day Improvement in sperm concentration and motility rates after varicocelectomy was determined to be lower in 10 or more cigarette smoking group compared to other groups. Conclusions: It is shown that cigarettes play a negative role in recovery process after varicocelectomy operation. Knowing that smoking negatively affects the success of the operation may contribute to patients’ quitting smoking.

1 Vegetation attributes derived from species and plant functional types (PFTs) directly or indirectly drive the carbon (C) cycle in peatlands. However, anthropogenic-based disturbances may alter petland soil-plant interactions and their ability to sequester carbon. Likewise, it is unclear how the soil-plant linkages among different soil C decomposition-based pools and plant attributes vary under disturbance conditions. 2 We aimed to assess how anthropogenic disturbances affect the relationships between aboveground vegetation attributes and belowground C pools in a peatland located in Northern Patagonia, Chile. We further evaluated if attributes derived from PFTs are better suited to predict soil C pools than attributes derived from species. We used structural equation modeling and regression analyses to explore these differences. 3 We found that undisturbed peatland has more soil-plant significant relationships between soil C pools and vegetation attributes, yielding higher predictive accuracies than disturbed areas. The species-based attributes yielded consistently better results predicting soil C pools than PFT-based attributes. However, PFT-based information showed significant interactions with the highly-decomposed C pools in the undisturbed peatland. Likewise, plant height and diversity were only significant with C pools in the undisturbed peatland. 4 We observed that water-logged plant communities have different soil-plant interactions than dryer communities. These differences were observed in both areas but were higher in the disturbed peatland, making it impossible to find meaningful soil-plant relationships across vegetation types and taxa. 5 Our results highlight the importance of accounting for disturbance or management when linking vegetation attributes to soil C pools in peatlands. This implies that up-to-date extensive monitoring of peatland disturbances is needed to accurately monitor soil C attributes at the regional level using vegetation as proxies. We also need to aggregate species into specific plant functional types that hold these soil-plant interactions across landscapes, regions, and disturbances to generalize the soil-plant relationships accurately.

The decline of coral reefs has fueled interest in determining whether mesophotic reefs can shield against disturbances and help replenish deteriorated shallower reefs. In this study, we characterized spatial (horizontal and vertical) and seasonal patterns of diversity in coral recruits from Dabaisha and Guiwan reefs at Ludao, Taiwan. Concrete blocks supporting terra cotta tiles were placed at shallow (15m) and mesophotic (40m) depths, during 2016-2018. Half of the tiles were retrieved and replaced biannually over three 6-month surveys (short-term); the remainder retrieved at the end of the 18-month (long-term) survey. 451 recruits were located using fluorescent censusing and identified by DNA barcoding. Barcoding the mitochondrial cytochrome oxidase I (COI) gene resulted in 17 molecular operational taxonomic units (MOTUs). To obtain taxonomic resolution beyond the generic level, Pocillopora were phylotyped using the mitochondrial open reading frame (ORF), resolving eight MOTUs. Acropora, Isopora or Montipora recruits were identified by the nuclear PaxC intron, yielding ten MOTUs. Overall, 35 MOTUs were generated and were comprised primarily of Pocillopora, and in fewer numbers, Acropora, Isopora, Pavona, Montipora, Stylophora, among others. 40% of MOTUs recruited solely within mesophotic reefs while 20% were shared by both depth zones. MOTUs recruiting across a broad depth distribution appear consistent with the hypothesis of mesophotic reefs acting as a refuge for shallow water coral reefs. In contrast, Acropora and Isopora MOTUs were structured across depth zones representing an exception to this hypothesis. This research provides an imperative assessment of coral recruitment in understudied mesophotic reefs and imparts insight into the refuge hypothesis.

In this article, we report a 34-year-old man who presented with progressive hip pain and osteolytic bone lesions . Primary workup included Core needle biopsies manifested as osteomyelitis; however as no sign of remission was observed, an open biopsy considered which revealed primary bone lymphoma.

Colony is the basic geometric construction of coral reef. However, both the forming regulations of colony and reef are still obscure. In this study, we reconstructed 21 important samples by high-resolution micro-computed tomography to investigate coral growth pattern and parameter. Our skeleton and canal reconstructions revealed characteristics of different coral species and we further visualized the growth axes and growth rings to reveal coral growth directions. We drew a skeleton gray-scale map and calculated coral skeleton void ratios to reveal skeletal diversity, devising a method to quantify coral growth. On the bases of the 3D reconstructions and growth parameters, we investigated growth strategies of different coral species. This work extends the knowledge of how reef-building corals grow their colonies, giving a hint on reef forming regulation. The data of this paper contain large amount of coral growth information, and can be used in further research on reef forming patterns under different conditions. The method used in this study can also be applied in animals with porous skeletons.

Similar to most countries, the Brazilian water resources management considers topographically delineated catchment as a territorial unit for policy implementation. Yet, previous studies have shown that catchments are not hydrologically isolated, and topographic limits often neglect the groundwater boundaries. Thus, studies on effective catchment area are promising for shedding light on inter-catchment groundwater flow. Here, we investigated the deviation between the topographic and effective areas across Brazil. We applied the Effective Catchment Area index (ECI) to 733 Brazilian catchments and identified the most influencing attributes on the ECI by using Principal Component and Random Forest Analyses (PCA and RFA, respectively). Further analysis of consistency was carried out by contrasting the ECI values against the expected range of the Budyko curve considering both topographic and effective catchment areas (classic and adjusted framework). Considering the studied catchments, 15% and 16% of their effective areas were respectively smaller than half (strong losing water condition) and larger than double (strong gaining water condition) of their corresponding topographic areas. The aridity index was the main driving factor and negatively correlated with ECI followed by mean slope, precipitation seasonality, and mean elevation. In general, the more arid biomes in Brazil — the Cerrado and Caatinga — are prone to have smaller effective areas while larger effective areas were mostly found in the Atlantic Forest biome, a humid tropical region with a higher mean elevation. We highlight the potential of adopting a pooling of catchments based on their interconnectivity to minimize management costs while maximizing synergies and lessening trade-offs of water transfer processes. Our results contribute to a better country-scale understanding of hydrological connectivity among catchments and highlight the need to consider the effective catchment area to overcome water-food-energy security challenges on multiple scales.

A document by Ian Dickie, written on Authorea.

Introduction: Human atria comprise distinct epicardial layers, which can bypass endocardial layers and lead to downstream centrifugal propagation at the “epi-endo” connection. We sought to characterize anatomical substrates, electrophysiological properties, and ablation outcomes of “pseudo-focal” atrial tachycardias (ATs), defined as macroreentrant ATs mimicking focal ATs. Methods and Results: We retrospectively analyzed ATs showing centrifugal propagation with post-pacing intervals (PPIs) after entrainment pacing suggestive of a macroreentry. A total of 26 patients had pseudo-focal ATs consisting of 15 perimitral, 7 roof-dependent, and 5 cavotricuspid isthmus (CTI)-dependent flutters. A low-voltage area was consistently found at the collision site and co-localized with epicardial layers like the: (1) coronary sinus-great cardiac vein bundle (22%); (2) vein of Marshall bundle (15%); (3) Bachmann bundle (22%); (4) septopulmonary bundle (15%); (5) fossa ovalis (7%); and (6) low right atrium (19%). The mean missing tachycardia cycle length (TCL) was 67 ± 29 ms (22%) on the endocardial activation map. PPI was 9 [0-15] ms and 10 [0-20] ms longer than TCL at the breakthrough site and the opposite site, respectively. While feasible in 25 pseudo-focal ATs (93%), termination was better achieved by blocking the anatomical isthmus than ablating the breakthrough site [24/26 (92%) vs. 1/6 (17%); p < 0.001]. Conclusion: Perimitral, roof-dependent, and CTI-dependent flutters with centrifugal propagation are favored by a low-voltage area located at well-identified epicardial bundles. Comprehensive entrainment pacing maneuvers are crucial to distinguish pseudo-focal ATs from true focal ATs. Blocking the anatomical isthmus is a better therapeutic option than ablating the breakthrough site.