Objective: This study aimed to develop deep learning (DL) models for differentiating between eosinophilic chronic rhinosinusitis (ECRS) and non-eosinophilic chronic rhinosinusitis (NECRS) on preoperative computed tomography (CT). Methods: A total of 878 chronic rhinosinusitis (CRS) patients undergoing nasal endoscopic surgery were included. Axial spiral CT images were pre-processed and used to build the dataset. Two semantic segmentation models based on U-net and Deeplabv3 were trained to segment sinus area in CT images. All patient images were segmented using the better-performing segmentation model and used for training and validation of the transferred efficientnet_b0, resnet50, inception_resnet_v2, and Xception neural networks. Additionally, we evaluated the performances of the models trained using each image and each patient as a unit. The precision of each model was assessed based on the receiver operating characteristic curve. Further, we analyzed the confusion matrix, accuracy, and interpretability of each model. Results: The Dice coefficients of U-net and Deeplabv3 were 0.953 and 0.961, respectively. The average area under the curve and mean accuracy values of the four networks were 0.848 and 0.762 for models trained using a single image as a unit, while the corresponding values for models trained using each patient as a unit were 0.853 and 0.893, respectively. The generated Grad-Cams showed good interpretability. Conclusion: Combining semantic segmentation with classification networks could effectively distinguish between patients with ECRS and NECRS based on preoperative sinus CT images. Furthermore, labeling each patient to build a dataset for classification may be more reliable than labeling each medical image.

Canopies shape net precipitation patterns, which are spatially heterogeneous and control soil moisture response to rainfall. The vast majority of studies on canopy water fluxes were conducted in forests, whereas grassland canopies are often assumed to be spatially homogeneous, therefore likely not inducing patches of heterogeneity at and below the soil surface. Yet, some studies on short-structured vegetation, such as grasslands, proposed the importance of canopy-induced heterogeneity for net precipitation, but systematic investigations on the effects on soil wetting patterns are missing. Therefore, in this study, we investigated soil moisture response to rainfall in a managed temperate grassland by exploring the individual impacts of spatially varying throughfall, vegetation height and antecedent soil moisture status on the soil wetting patterns. We applied linear mixed effects models to disentangle the role of grassland canopy versus abiotic drivers. The spatial average soil water response showed that less and less water was stored in the upper parts of the soil as the growing season progressed and the soils dried, indicating bypass flow. Spatial variation of grass height was a significant driver of soil wetting patterns along with precipitation and antecedent soil moisture status. Soil wetting was suppressed in locations with tall canopy, although surprisingly this was not directly related to throughfall patterns. Instead, our results suggest that seasonally drier conditions and grassland stemflow kick off preferential flow. Ultimately, our results confirm that spatial variation of the canopy affects soil moisture wetting patterns not only in forests and indicate a strong influence of preferential flow on soil water patterns.

Coxiellosis (Q-fever) caused by Coxiella burnetii is a cosmopolitan zoonosis that causes significant losses through abortions and stillbirths in small ruminants. A cross-sectional seroprevalence study was conducted in three agricultural zones of Borno State in the flocks of sheep and goats. Seven hundred sixty-eight small ruminants (384 sheep and goats each) of both sexes (282 males and 486 females) of different age groups from 90 flocks were randomly selected to collect sera and related epidemiological data information. A commercial indirect enzyme-linked immunosorbent assay (iELISA; I.D. Vet) was used to test the samples for the presence of both phases I and II antibodies to Coxiella burnetii infections. The seroprevalence in sheep and goats was 10.9% (44/384) and 12.0% (46/384). There was no statistically significant association in the two species of the animals tested and the infection rates of coxiellosis. Bivariate analysis showed that female animals of all species tested were more seropositive for antibodies to Coxiella burnetii than males. There was a statistically significant association between the sex of both sheep and goats tested and the infection rates of coxiellosis. Breed and age of sheep and goats were not statistically significant for seropositivity to Coxiella burnetii. The study indicates that seroprevalence of coxiellosis was high in the studied small ruminants’ population, particularly among female sheep and goats and can be considered a potential risk for both susceptible animals and humans in the study area.

Title:Letter to Editor:Re: Impact of analysis technique on our understanding of the natural history of labour

Using the Heisenberg uncertainty principle in a semi-classical formalism, it is shown that mass and nuclear structure can be accounted for by the configuration of electric charge under only the Coulomb potential. In this approach, mass is accounted for by the confinement of electric charge. Tri-polar Coulomb interactions are responsible for the stability of the proton and the neutron, and bipolar Coulomb interactions provide the required stability for the nuclei. Initial calculations from this model are consistent with known nuclear binding energies and configuration. In addition, this approach gives an ab-initio estimates for the radius and mass of the quarks, and the radius of the proton. The estimated value for the radius of the proton is 1 fm, in close agreement with the known value of 0.83-0.88 fm. There is only electric charge (charge). That is the main idea of this work. It is meant in the sense that the distribution of charge is enough to explain the observable universe. To establish this novel claim, it will be argued that gravitational interactions and the interaction of sub-atomic particle can be explained by relatively simple considerations of the confinement and configuration of positive and negative charge. In this work the angular, magnetic , and spin degrees of freedom will be ignored. This aspect is left for future studies. A semi-classical approximation will be used where quarks are assumed to be "particles" with sharp boundaries. As a side note it is mentioned that any measurement would occur over a finite time interval, hence, the measured charge density will be smooth. The results of both Special and General Relativity are assumed. [1] They include the relationships between mass and energy, between space/time/momentum/energy, and as a general theory for gravitational interaction between mass. However, as will be discussed below, it is proposed that mass comes about from the potential energy of confined charge. Historically, mass entered physics at a very early stage since it is one of the most easily experienced physical measurements. Having the entrenched position in classical physics it is understandable how the notion that mass results from the quantum confinement of charge [2] is conceptually challenging. Similarly, the first observations of nuclear interactions [3, 4] involved protons and neutrons confined to a nucleus tiny in comparison to the size of the electron orbitals. [4, 5] Hence, it was unclear how this positive charge is confined and the strong nuclear force was conjured for an apparently missing "strong" attraction to hold the protons and nucleus together. [5] However, with the establishment of the quark model of the nucleons [6-8] it is possible to understand nuclear stability as a quantum outcome of Coulomb interactions , without the need for any addition interactions. Possibly the most fundamental idea of quantum mechanics is the Heisenberg Uncertainly Relations (HUR): [9-11] ∆x ∆p ħ. (1) ∆t ∆E ħ. (2) These expressions describe the smallest possible quantum states, with x the position, p the momentum, t time, E the energy of a state, and ħ the Planck constant. While the HUR have been around for almost 100 years, they still conceal many exciting discoveries. It is guessed that we still do not understand the mathematics and physics prescribed by the HUR. Here, their implications for charge systems will be used. For one thing, the HUR imply that nothing can have zero momentum in the quantum world. The HUR also hints to a finite minimal quantum state. States as such will be refereed to here as Minimal Quantum States (MQS). For these states an equality will be assumed for the inequality in Eqs. 1 and 2. An MQS is a

The Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak from December 2019 causing millions of deaths all over the world and the lack of specific treatment for severe forms of coronavirus disease 2019 (COVID-19) has led to vaccines development in record time with emergency use authorization in several countries increasing the risk of vaccine safety issues. Recently, several cases of Thrombotic Thrombocytopenic Purpura (TTP) have been reported following COVID-19 vaccination. TTP represents a life-threatening consumptive coagulopathy requiring urgent diagnosis and prompt treatment. It is a rare disease characterized by thrombocytopenia, microangiopathic hemolytic anemia and ischemic end-organ lesions. It can be either congenital or acquired. Various events such viral infections, medication, pregnancy, malignancies, and vaccinations may cause TTP. Clinicians should consider this diagnosis when evaluating thrombocytopenia in the post-vaccine period. Here, we report two cases of acquired TTP following Sinopharm COVID-19 vaccine (BBIBP-CorV) and Sinovac COVID-19 vaccine (CoronaVac). Diagnosis was based on clinical presentation and confirmed with severe reduction in the activity of von Willebrand factor-cleaving protease ADAMTS-13 and the presence of inhibitory autoantibodies. The two patients were successfully treated with corticosteroids, plasma exchange therapy and rituximab in the acute phase. In the literature, the reported cases of TTP induced by COVID-19 vaccination occurred after Adenoviral Vector DNA- and SARS-CoV-2 mRNA-Based COVID-19 Vaccines. To the best of our knowledge, this is the first report of acquired TTP after inactivated virus COVID-19 vaccines. A short literature review regarding acquired TTP patients following COVID-19 vaccines is also included.

Arbuscular mycorrhizal (AM) fungi are important in plant resistance against insects and disease. However, the effect of AM fungi in plants during simultaneous pathogen and insect attacks is unknown. Phoma medicaginis and pea aphid (Acyrthosiphon pisum) majorly limit alfalfa production worldwide. This study established an alfalfa (Medicago sativa)-AM fungus Rhizophagus intraradices-P. medicaginis-pea aphid system. RNA-seq analysis was done to determine the differentially expressed genes, plant defense, and signaling substances in different alfalfa treatments.Pea aphid increased P. medicaginis disease occurrence by 24.94%. The AM fungus decreased the disease index by 22.37% and enhanced alfalfa growth and development by increasing the plant total N and total P uptake. P. medicagonis induced plant CAT and POD activity by 292.93 and 63.46%, NO and trypsin inhibitor contents by 9.80 and 5.71%. However, aphids induced PPO activity, and AM fungi enhanced plant-defense enzyme activity against aphid infestation and subsequent P. medicaginis infection. Additionally, the AM fungus increased the SA and ABA content of plants exposed to pathogen- or aphid-stress. Abscisic acid and hormone binding GO terms were up-regulated in aphid-infested or pathogen-infected alfalfa. However, AM fungus down-regulated genes related to the KEGG pathway, ribosome, for resisting P. medicaginis and pea aphid attack. The MAPK signaling pathway-plant (map04016) was up-regulated in alfalfa against pea aphid or P. medicaginis.Moreover, the AM fungus enhanced aphid-induced plant defense and signaling and may defend alfalfa against subsequent disease and insect pest attacks.

Background: Inhaler technique (IT) knowledge among healthcare providers is poor. The aim was to improve PED healthcare providers’ IT technique by carrying out an education intervention, and sustain it for 6 months. Methods: open-label, quasi-experimental, prospective and unicentric study. Healthcare professionals working at the Pediatric Emergency Department (PED) were enrolled. The study was developed in three phases: baseline evaluation and education intervention (P1) and reevaluation 1 month (P2) and 6 months (P3) after the education intervention. Participants fulfilled an eight-question theoretical test. Practical skills were evaluated by demonstrating IT in all three phases. The education intervention consisted in a verbal explanation of IT followed by a demonstration of IT with metered-dose inhaler using a mannequin. Results: 84 healthcare providers (medical residents, nurses and nursing assistants) were involved. In the theoretical questionnaire, the mean score at baseline was 4.4/8 (SD 1.7) improving to 6.3/8 (SD 1.2) in P2 and 6.47/8 (SD 1.1) in P3. In the IT evaluation for children <7 years old, the score improved from 5.7/7 (SD1.3) to 6.5/7 in P2 and 6.7/7 in P3 (p<0.001). For children >7 years old, the mean score of IT at baseline was 3.1/10 (SD 4), which improved to 7.4/10 (SD3) and 8.2/10 in P2 and P3 respectively (p<0.001). Only laboral category influenced results at baseline. Conclusion: Healthcare providers’ theoretical knowledge and practical skills on IT are low. The education intervention performed is a useful strategy to ameliorate IT among healthcare providers.

Pleural drainage was differently performed in two similar neighboring hospitals (32.0 % vs. 58.2 %, p < 0.001), but the length of stay was shorter in the hospital using a more conservative approach (median 12 days vs. 18 days, p < 0.001). This result seemed unrelated to severity but associated with the shorter duration of intravenous treatment. This study adds to previous reports suggesting that pleural drainage is unnecessary in many cases; controlled studies are needed to determine which patients may actually benefit from its use.

Background and Objective: With improved survival in neonates with meconium aspiration syndrome (MAS), the focus is currently on mitigating the morbidities. The objective of this study was to predict factors determining prolonged hospital stay in neonates with MAS. Materials and methods: It was a retrospective cohort from five centres of south India between 2018 and 2020. Neonates ≥35 weeks of gestation admitted to NICU with the diagnosis of MAS and requiring oxygen beyond 24 hours of life were included in the study. The morbidities in the neonates with stay ≤7 days (short stay) were compared with >7 days (prolonged stay). Logistic regression by the backward stepwise method was used for predictive score creation. Results: Out of 347 neonates with MAS discharged home, 103 (29%) had a short stay and 244 (71%) had prolonged stay. The primary support beyond O2 (CPAP/MV) (42% vs 83%, p<0.001), FiO2 at 1hr>30% (45% vs 87%, p<0.001), HIE stage 2 or 3 (2% vs 27%, p<0.001), moderate-severe PPHN (3% vs 31%, p<0.001) were independent factors associated with prolonged stay on logistic regression. A prediction model was devised using weighted scores of these four associated morbidities. The clinical score thus developed had 83% sensitivity, 68% specificity for the prediction of prolonged stay [AUC- 82, 95% CI (78-87), p<0.001]. Conclusion: More than two-thirds of neonates with MAS had prolonged stay. The primary support beyond oxygen, Fio2 requirement >30%, Moderate to severe PPHN, HIE stage 2 or 3 were predictive of prolonged stay in neonates with MAS.

An 80-year-old man underwent catheter ablation for atrial tachycardia (AT), which developed after catheter ablation for atrial fibrillation. The AT was diagnosed as dual-loop tachycardia, which included peri-mitral and roof-dependent ATs. An ethanol infusion into the vein of Marshall resulted in left phrenic nerve paralysis. During the procedure, the phrenic nerve paralysis was completely relieved.

A 32-year-old primigravida woman had pregnancy complications from pre-existing MG and developed preeclampsia. Intravenous magnesium sulphate caused MG aggravation, which resolved upon ceasing treatment. Symptoms were milder upon repeated infusion at reduced dose. No myasthenic crisis occurred in the intrapartum or postpartum period after successful caesarean section.

Coronavirus disease-19 (COVID-19) is an emerging global pandemic. Since its emergence, the COVID-19-associated cutaneous manifestations have been increasingly reported, and they are extremely polymorphic.We report a case of acute generalized exanthematous pustulosis (AGEP) developed in a Tunisian adult, a few days after recovery from severe COVID-19 infection

There is still uncertainity about the use of CT-scan for LAAO device sizing. The main reason for this disappointing position is likely to relate to the scarcity of robust data, since there is still difference among institutions with regards how to perform measurement of the devices. Dallan et al. (1) report their own experience on the use of a novel computed tomography angiography-based (CTA) for sizing the Watchman Flex device for left atrial appendage occlusion (LAAO) . The authors through the TruPlan software package that a pre-procedural CTA sizing protocol can be applied successfully with ICE guidance and provide excellent procedural outcomes.The applied CTA protocol is safe and can provide high success rates with the WatchmanTM FLX device reducing the number of deployment attempts and reducing the risk of complications.

Dr. Rahul George Muthalaly MBBS, MPH1,2, Dr. Roy M John MBBS, PhD, FRCP3Monash Heart, Monash Health, Melbourne VICVictorian Heart Institute, Monash University, Melbourne VICStanford University, Palo Alto, CA 94304 USACorresponding Author:Dr. Rahul G MuthalalyPh: +61397847777Rahul.muthalaly@gmail.comContact information for all other authors:Royjohn@stanford.eduWord Count: 1238 wordsFunding: NoneConflict of Interest: NoneAblation for atrial fibrillation (AF) is an established therapy that continues to grow in scope and indication(1). The benefits of AF ablation are well recognized in heart failure and symptomatic paroxysmal AF. Additionally, the recent EAST-AFNET4 trial demonstrated benefit for an early AF rhythm control strategy even in asymptomatic patients (2). This change in paradigm from rate and rhythm control equivalence may be partially related to the increasing use of AF ablation for rhythm control. As ablation therapy continues to proliferate, questions of how to optimise procedural outcomes at a health service level arise. A key component of this optimisation is defining predictors of outcomes related to ablation procedures.One such predictor is procedural case volume. Studies outside of AF ablation have demonstrated complex relationships between institutional size, procedural volume, case difficulty and outcomes. Published data on transcatheter aortic valve replacement (TAVR) for example, suggest a durable link between hospital case volume and mortality even after adjusting for institutional learning curves and known risk factors for poor outcomes (3). These insights have relevance for AF ablation for which there is wide-ranging procedural variation across factors such as lesion sets and type of ablation energy. The relationship between AF ablation volume and outcomes have been explored in previous studies(4, 5). Tonchev and colleagues, in a meta-analysis, demonstrated a significantly lower risk of complications in centres performing >100 procedures per year (OR 0.62, 95%CI 0.53 to 0.73) (4). This carried over to mortality, which was significantly lower in high volume centres (OR 0.33, 95% CI 0.26-0.43). Ablation efficacy was also greater in higher volume centres. Importantly, the majority of procedures included in this meta-analysis of real-world data were undertaken in low volume centres (70.9% in centres with <100 procedures/year) alerting to the reality that high-volume centers are not readily available to most patients.The influence of energy types (cryoballoon ablation versus catheter based radiofrequency ablation) on the relationship between procedural volume and outcomes is less well defined. This is of relevance as cryoablation appears to have a gentler learning curve than radiofrequency ablation for centres that are newly introducing AF ablation(6). In this issue of the journal , Kanaoka and colleagues present data on the relationship between procedural volume, energy type and acute procedural outcomes based on analysis of the Japanese National Database of Insurance Claims and Specific Health Check-ups. The authors identified 270,116 patients from this database undergoing first-time AF ablation with cryoablation or radiofrequency energy. A small subset of patients who underwent hot balloon and laser ablation were excluded as the numbers were too low. Complications were identified using administrative coding for the most common diagnoses associated with ablation risks. Ablation success could only be defined using coding for repeat AF ablation or initiation of anti-arrhythmic drug within 1 year.The authors split hospitals into quartiles using case volume resulting in groups with medians of 69 (very low), 157 (low), 252 (high) and 469 (very high) procedures per year. They found that the relative risk of peri-procedural complications was approximately 10-20% lower in all other groups when compared with the very low procedural volume hospitals. Cubic spline plots demonstrated a plateau effect, with no further reduction in complications when hospitals approach 150-200 cases per year. Similarly, when considering AF recurrence assessed by repeat ablation or initiation of anti-arrhythmic drugs up to 1 year, there was approximately a 10% relative risk reduction in the low, high and very high-volume hospitals when compared to very low-volume centres. Of note, there appeared to be a similar plateau volume of approximately 150-200 cases per year above which the benefit attenuated. The relationship between procedural volume and outcomes was however, only seen with RF ablation. Among the more than 56,000 cryoablation cases, there were no significant differences in complications or recurrence in the low, high or very high procedural volume hospitals when compared with the very low volume hospitals. Of note, there was a similar burden of AF related comorbidities in the radiofrequency and cryoablation populations.These results of Kanoaka and colleagues add further evidence to the notion that, when it comes to AF ablation, there appears to be a threshold of hospital procedural volume above which the risk of complications and recurrence decreases. The finding of a threshold in the range of 150-200 procedures per year, is in keeping with previous work suggesting benefits in excess of 100 procedures per year(5). Additionally, the present study sheds new light on the effect of ablation type on this relationship. In keeping with the recognition that cryoablation appears to offer an easier learning curve, the effect of procedural volume on both safety and efficacy outcomes was eliminated when considering only cryoablation cases.Limitations of the study have to be recognized. The study is observational, retrospective and derived from a national database. These factors admit the potential for unmeasured confounders and imperfect assessment of outcomes. The definition of ablation success was based on coding for repeat ablation or use of antiarrhythmic drugs within the first year. This definition, although pragmatic, does not account for recurrence occurring outside of 1 year or recurrence that did not result in repeat ablation or anti-arrhythmic drug therapy. Furthermore, complications were defined using administrative coding. Notably, this coding was not able to identify phrenic nerve injury, which occurs in approximately 5-6% of patients undergoing cryoablation(7). In addition, significant differences existed between the RF and cryoablation groups. There was a greater proportion of paroxysmal AF in the cryoablation compared to RF group (74% versus 46%). Because RF ablation allows for more flexibility in ablation lesion set, this energy form tends to be used in those with more advanced atrial remodelling. Hence, it is very likely that the RF group comprised a more complex patient group with a greater dependence on operator experience and case volume. The observed differences in learning curve between the two energy sources may have been less striking or even absent, had the groups been matched. The study however, has the advantage of the use of a database that covers of 98% of the Japanese population and magnitude of case volume included, allow for valuable insights.Abundant work has now demonstrated that hospital procedural volume is a key component of optimising outcomes from any complex interventional procedure(3, 5). The improved outcomes observed as a result of hospital procedural volume are likely due to a wide-range of additional factors that include appropriate patient selection, an experienced electrophysiology laboratory team and standardized, guideline-directed pre- and post-procedural management(8). The Heart Rhythm Society’s 2020 AF Centres of Excellence whitepaper outlines the rationale and guidance for key components of an AF Centre of Excellence(8). However, as the increasing benefit of AF ablation creates an increasing demand for the procedure, a balance must be struck between having very few centres of excellence and abundant centres with limited experience. In this context, the results of the current study by Kanoaka and colleagues are valuable and raises the possibility of a two-tiered approach. That of lower volume centres providing less complex procedures such as cryoablation for simpler cases of AF and higher volume ‘Centres of Excellence’ providing advanced ablation procedures for more complex AF cases. Such a division of labor may strike the balance between ablation availability and optimal outcomes. This differentiation, based on the characteristics of procedure offered and type of patients treated, will likely achieve greater importance as future technologies such as pulsed field ablation emerge and promise faster, safer and easier ablation strategies for AF(9).References1. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. European Heart Journal. 2020;42(5):373-498.2. Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. New England Journal of Medicine. 2020;383(14):1305-16.3. Vemulapalli S, Carroll JD, Mack MJ, Li Z, Dai D, Kosinski AS, et al. Procedural Volume and Outcomes for Transcatheter Aortic-Valve Replacement. New England Journal of Medicine. 2019;380(26):2541-50.4. Cheung JW, Yeo I, Cheng EP, Ip JE, Thomas G, Liu CF, et al. Inpatient hospital procedural volume and outcomes following catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2020;31(8):1908-19.5. Tonchev IR, Nam MCY, Gorelik A, Kumar S, Haqqani H, Sanders P, et al. Relationship between procedural volume and complication rates for catheter ablation of atrial fibrillation: a systematic review and meta-analysis. Europace. 2021;23(7):1024-32.6. Velagic V, Prepolec I, Pasara V, Puljevic M, Puljevic D, Planinc I, et al. Learning curves in atrial fibrillation ablation – A comparison between second generation cryoballoon and contact force sensing radiofrequency catheters. Indian Pacing and Electrophysiology Journal. 2020;20(6):273-80.7. Heeger C-H, Sohns C, Pott A, Metzner A, Inaba O, Straube F, et al. Phrenic Nerve Injury During Cryoballoon-Based Pulmonary Vein Isolation: Results of the Worldwide YETI Registry. Circulation: Arrhythmia and Electrophysiology. 2022;15(1):e010516.8. Piccini JP, Sr., Allred J, Bunch TJ, Deering TF, Di Biase L, Hussein AA, et al. Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective. Heart Rhythm. 2020;17(10):1804-32.9. Reddy VY, Dukkipati SR, Neuzil P, Anic A, Petru J, Funasako M, et al. Pulsed Field Ablation of Paroxysmal Atrial Fibrillation: 1-Year Outcomes of IMPULSE, PEFCAT, and PEFCAT II. JACC: Clinical Electrophysiology. 2021;7(5):614-27.

Title pageTitle : Letter to the Editor: What are the factors affecting the progression of kidney failure mortality and morbidity after cardiac surgery in patients with chronic kidney disease”.Article type: Letter to the editorCorrespondence: 1. Hafsa ArifContact: +923092446917 Email : Hafsaarif1708@gmail.comInstitution: Jinnah Sindh medical university.Address: R141 salman garden malir, karachi.

Background: We aimed to determine the relationship between HbA1c levels and the development of postoperative atrial fibrillation (PoAF) . Methods: 288 patients diagnosed with diabet and undergoing on-pump coronary bypass were included in the study. Those with serum HbA1c levels between 5.5-7.0% were defined as Group 1, those with serum HbA1c levels between 7.1-8.9% were defined as group 2, while those with serum HbA1c levels 9.0% and above formed Group 3. Data between groups were compared. The predictive values of the independent variables for the development of PoAF were measured. Results: We did not found difference between groups in terms of development PoAF (p=0.170). Presence of hypertension was determined as an independent predictor for the development of PoAF (p=0.003) but not HbA1c levels (p=0.134). There was 50.5% sensitivity and 61.1% specificity for HbA1c values of 9.06% and above to predict PoAF (AUC: 0.571, p=0.049) Conclusions: HbA1c levels were not an independent predictor of PoAF development. However, we think that high HbA1c levels may be a risk factor for the development of PoAF.

Background: Unplanned 30-days readmission post cardiac surgery impose higher risk for complications, increased cost and unfavorable event both for the care provider and the patient. This study is to determine the unplanned readmission rate, determinants and most common events within thirty days post cardiac surgery . Recommendations to prevent or minimize these complications are included. Method : Sitting and design: A retrospective record review was conducted among all the adult patients who underwent open heart surgery between January 2020 and December 2021at King Abdulaziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia. methods and material: Using Google Forms, we manually collected data from hospital records. statistical analysis used: binomial logistic regression model (using the backward stepwise method). Regression outcomes were expressed as odds ratios (ORs) and 95%CIs. A p value of < 0.05 indicated statistical significance. Results: Among 400 patients who underwent cardiac surgery, 343 patients were included in the study, 53 unplanned readmission, rate of 16.3% (95%CI, 12.8 to 20.6%). The most frequently reported reasons for readmission were sternal wound infections (7.3%), pleural effusion (2.0%) and heart failure (1.7%). Female gender, high post operative LDH and urea are the most important risk factors. Conclusion: Discharge planning, patient education, and cardiac surgery nurse home visit constitute the most important factors to minimize 30 days of unplanned readmission.

Title Page:Title: Letter to the Editor: Intraoperative renal hypoxia and risk of cardiac surgery-associated acute kidney injuryArticle Type: Letter to the EditorCorrespondence: 1. Roomi RajaContact No: +92-3342946940. Email: Romirajagoindani@Yahoo.ComInstitute: Ziauddin University KarachiAddress: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton KarachiORCID: 0000-0001-9104-3644Co-Authors: 2. Muhammad fahad AminContact No: +92-3408056755. Email: fahad.a.maya@gmail.comInstitute: Ziauddin university karachiAddress: 128/2 14th street off khayaban e muhafiz phase 6 defence housing authority karachiORCID: 0000-0003-1861-5313Co-Authors: 3. Satesh KumarContact No: +92-3325252902. Email: Kewlanisatish@Gmail.ComInstitute: Shaheed Mohtarma Benazir Bhutto Medical College Liyari, KarachiAddress: Parsa Citi Garden East, KarachiORCID: 0000-0001-7975-6297Word Count: 302

Type A dissection complicated by cerebral malperfusion and coma may pose decision-making challenges. We describe the case of a patient who presented coma in the context of acute type A aortic dissection, without cardiac tamponade. Brain MRI was performed 4 hours after the onset of symptoms to evaluate the brain perfusion and viability. We discuss the potential role of the currently available emergency brain MRI as an additional tool in the workup of aortic dissection, and its potential to discriminate between irreversible brain injury and brain viability.

OBJECTIVES: To evaluate the use of CABG utilising an isolated pedicled Right Internal Thoracic Artery (RITA) or Left Internal Thoracic Artery (LITA) or the Pure Internal Thoracic Artery (PITA) technique to treat anomalous aortic origin of coronary artery (AAOCA). METHODS: A retrospective review of all patients at our institution over an 8-year period (2013-2021) who underwent surgery for AAOCA was performed. Data assessed included patient demographics, initial presentation, morphology of coronary anomaly, surgical procedure, cross-clamp time, cardiopulmonary bypass time and long-term outcome. RESULTS: 14 patients underwent surgery which included 11 males (78.5%) with a median logistic EuroSCORE of 1.605 (IQR 1.34). Median age was 62.5 years (IQR 48.75). Presentation was angina (7 patients), acute coronary syndrome (5 patients), incidental findings in aortic valve pathology (2 patients). AAOCA morphology varied: RCA from left coronary sinus (6), RCA from left main stem (3), left coronary artery from the right coronary sinus (1), left main stem arising from right coronary sinus (2) and circumflex artery arising from the right coronary sinus (2). Seven patients had co-existing flow-limiting coronary artery disease. CABG was performed using either a pedicled skeletonized RITA, LITA or PITA technique. There was no perioperative mortality. Overall median follow-up time was 43 months. One patient presented with recurrent angina secondary to graft failure at 2 years and there were 2 non-cardiac related deaths at 4 and 35 months. CONCLUSION: The use of internal thoracic artery grafts can provide a durable treatment option in patients with anomalous coronary arteries. The potential risk of graft failure in patients with no flow limiting disease should be very carefully considered. However, a proposed benefit of this technique is the use of a pedicle flow to increase the long-term patency. More consistent results are obtained when ischaemia can be demonstrated preoperatively.

Erythroid sarcoma is very rare form of pure erythroid leukemia with undetermined biological features. Here, we present an infant with a multifocal erythroid sarcoma, diagnosed because the tumor cells were positive for glycophorin A. After acute myeloid leukemia-oriented chemotherapy and surgical resection followed by cord blood transplantation, he has successfully maintained complete remission without any late effects. Total transcriptome analysis of the tumor identified a novel fusion gene, RCC1-LCK, and high LCK expression levels, suggesting that LCK overexpression was involved in leukemogenesis in this case.

Purpose: Primary germ cell tumors (GCTs) are the most common central nervous system (CNS) neoplasm in patients with Down syndrome (DS). However, a standard-of-care has not been established due to a paucity of data. Methods: A retrospective multi-institutional analysis was conducted, in addition to a comprehensive review of the literature. Results: Ten patients from six institutions (five USA, one Brazil) were identified, in addition to 31 patients in the literature from 1975 to 2021. Of the 41 total patients (mean age 9.9 years; 61% male), 16 (39%) had non-germinomatous germ cell tumors (NGGCTs), 16 (39%) had pure germinomas and eight (19.5%) had teratomas. Basal ganglia was the most common tumor location (n=13; 31.7%), followed by posterior fossa (n=7; 17%). Nine patients (22%) experienced disease relapse or progression, of which four died from tumor progression (one germinoma, three teratomas). Sixteen patients (39%) experienced treatment-related complications, of which eight (50%) died (five germinomas, three NGGCTs). Of the germinoma patients, two died from chemotherapy-related sepsis, one from post-surgery cardiopulmonary failure, one from pneumonia and one from Moyamoya following radiation-therapy (RT). Of the NGGCT patients, one died from chemotherapy-related sepsis, one from post-surgical infection and one from pneumonia following surgery/chemotherapy/RT. Three-year overall survival was 66% for all histological types – 62% germinomas, 79% for NGGCTs, and 53% for teratomas. Conclusion: Patients with DS treated for CNS GCTs are at an increased risk of treatment-related adverse events. A different therapeutic approach may need to be considered to mitigate treatment-related complications and long-term neurocognitive sequelae.

In this article, the generalized (3+1)-dimensional Korteweg-de Vries-Zakharov-Kuznetsov equation is investigated, which describes the influence of magnetic fields on weak ion-acoustic waves in plasma made up of cool and hot electrons and may be regarded as a nonlinear complicated physical model. To find out some new traveling waves solutions and other exact solutions, the improved $F$-expansion approach and the $\exp(-\phi (\zeta))$-expansion approach is applied to above mentioned nonlinear higher dimensional model. Several solutions have been found, including dark soliton, periodic type solitons, bell shaped solitons, single bell shaped solitons. We also show a graphical representation of a number of exact solutions to the equation, together with a description of their behaviour. The proposed techniques can also be used to solve a range of nonlinear evolution problems in mathematical physics and plasma physics.