Abstract Background: We aimed to use preoperative clinical data from paediatric patients with simple congenital heart disease to predict the risk of prolonged mechanical ventilation after surgery. Methods: The clinical data from paediatric patients with simple congenital heart disease who underwent anatomical correction under cardiopulmonary bypass in a single centre during a continuous period were retrospectively collected. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for prolonged mechanical ventilation (>24 h) after surgery, and a mathematical model was established. Then, using data from another centre, we adopted an ROC curve to verify the scalability of the model. Results: A total of 585 paediatric patients were eligible for inclusion in this study. Multivariate logistic regression analysis showed that weight (kg), the size of the ventricular septal defect, the size of the atrial septal defect and the shunt direction of the defect site were significantly correlated with prolonged mechanical ventilation (>24 h) after surgery. The risk prediction model was established and the area under the curve of the model was 0.853 (ROC curve). A set of data from another heart centre, with equivalent inclusion criteria, was used to validate the scalability of the model, and the area under the curve of the accepted validated data was 0.841 (ROC curve). Conclusions: The risk of prolonged mechanical ventilation (>24 h) after surgery in paediatric patients with simple congenital heart disease with anatomical correction assisted by cardiopulmonary bypass can be well predicted by using preoperative clinical data.

We report a case of superior vena cava obstruction of a 39 years old female patient with primary antiphospholipid syndrome presented with upper limb pain and swelling ,which improved on thrombolytic therapy ,we review patients with Antiphospholipid syndrome and management with thrombolytic therapy .

CONCEPTSTEMpreneurship is a three-phased STEM program that introduces students to basic STEM concepts through assembling STEM kits, then coming up with their own conceptual design through the engineering design process, then lastly exposure to entrepreneurship and teaching them how to enter their product design into the business marketplace. The culmination of STEMpreneurship is the "Shark Tank-like" competition where the students present their product design to would-be investors attempting to obtain funding for their design.Discalimer: This program can be lengthen and modified into a 6,8, or 12 week program.OVERALL PROGRAM OBJECTIVESStudents will learn the following science concepts by assembling STEM kits:Basic electric circuits;Solar Energy;Air propulsion;Structures; andWind Energy.Students will learn to design their own product through the engineering design process;Students will learn basic entrepreneurship and business skills;Students will use mathematics to develop their investor pitch to would-be investors;Students will learn to use technology to develop their product design and presentation;Students  will learn to collaborate in a team environment to develop the presentations to would-be investors.Students will learn to connect STEM concepts to real-world applications.LESSON 1: STEM CONCEPTSSuggested Time: 55 Minutes (Per STEM Kit)OVERVIEWStudents will learn various STEM concepts such as electric circuits, solar energy, air propulsion, structures, and wind energy by assembling STEM kits provided by AcaSTEMics, LLC. Each session is for one STEM kit. The following STEM kits correspond to the following STEM concept:1. Basic electric circuits - Table Top Lamp2. Solar Energy - Solar Fan3. Air Propulsion - Twin Engine Electric Plane4. Structures - Marshmallow Building5. Wind Energy - Wind TurbineThe LessonPART 1: STEM KIT ASSEMBLY (40 MINUTES, per kit)1. STEM Kits are distributed to the students.

We carefully read the recent paper by Hammond et al. (1) on the use of sutureless bioprosthetic valve for homograft failure in the setting of infective endocarditis (IE). This article is the latest demonstration that new sutureless and rapid deployment (RD) valve prostheses are safe and easy-to-use devices for surgical aortic valve replacement, and indicates their suitability for different scenarios and peculiar surgical situations as infective endocarditis (IE).

We aimed to infer the phylogenetic relationships of populations of Lobelia columnaris using chloroplast genomes and estimate the divergence time to reconstruct its historical colonization on the sky islands of Bioko and Cameroon. Specifically, we aim to answer the following questions: (1) What is the phylogenetic relationship among Bioko Island and Cameroon populations? (2) Are the older populations found on the older sky islands? (3) Does the colonization history reflect the age of the sky islands? We assembled novel plastomes from 20 individuals of L. columnaris from five mountain systems. The plastome data was explored with phylogenetic analyses using Maximum likelihood and Bayesian Inference. The complete plastome size varied from 164,609 bp to 165,368 bp. The populations of L. columnaris have a monophyletic origin, subdivided into three plastome-geographic clades. The plastid phylogenomic results and age of the sky islands indicate that L. columnaris colonized first along the Cameroon Volcanic Line’s young sky islands. The earliest divergent event (1.54 Ma) split the population in South Bioko from those on the mainland and North Bioko. The population of South Bioko was likely isolated during cold and dry conditions in forest refugia. Presumably, the colonization history occurred during the middle-late Pleistocene from South Bioko’s young sky island to North Bioko and the northern old sky islands in Cameroon. Furthermore, the central depression with lowland forest between North and South Bioko is a current geographic barrier that keeps separate the populations of Bioko from each other and the mainland populations. The Pleistocene climatic oscillations led to the divergence of the Cameroon and Bioko populations into three clades. L. columnaris colonized the older sky island in mainland Cameroon after establishing South Bioko’s younger sky islands. The biogeography history was an inverse progression concerning the age of the Afromontane sky islands.

Lobular breast cancer is rarely known to metastasise to the gastrointestinal tract. This article explores a case of a patient in remission from lobular breast cancer, who presented with bowel obstruction secondary to metastatic lobular cancer.

Hyperhemolysis syndrome (HS) should be considered in a multiply transfused thalassemia patient. HS in this patient was attributed to a combination of factors including multiple transfusions, presence of anti-Cw, macrophage hyperactivity, hypersplenism and suppression of erythropoiesis.

The concept of using a thermo-responsive p(NIPAM) polymer matrix for enzyme immobilization with lower critical solution temperature (LCST) value is rationalized by availability of the compartmental milieu to enzymes to operate within super porous 3-D matrix with special environmental conditions. Therefore, the enzyme immobilization within a support material will be carried out under the storage conditions of enzymes, generally ~-20 oC to afford unnecessarily loss of enzyme functionality in comparison to the other enzyme entrapment methods. Thus, here ɑ-Glucosidase as a model enzyme was entrapped within thermo-responsive super porous p(NIPAM) cryogels (ɑ-Glu@p(NIPAM) during the synthesis that uses cryogenic condition, ~-20 oC. The LSCT value for the prepared p(NIPAM) based cryogels were determined as 34.6±1.2 oC. The immobilization yield, immobilization efficiency, and activity recovery% values were calculated as 89.4±3.1, 66.2±3.3, and 74.0±3.3%, respectively at pH 6.8 and 37 oC for ɑ-Glu@p(NIPAM) cryogel system. Interestingly, the optimum working conditions were achieved as 25 oC and pH 6.8 with higher activity, 98.4±0.2% for the prepared ɑ-Glu@p(NIPAM) cryogel system. The operational and storage stability studies revealed that the prepared ɑ-Glu@p(NIPAM) cryogel system possessed much better operational and storage stability than free ɑ-Glu enzyme e.g., more than 50% activity after 10th usage and 10-day room temperature storage time. Moreover, the kinetic parameters such as Km and Vmax of free-Glu enzyme and ɑ-Glu@p(NIPAM) cryogel system were calculated by non-linear Michaelis-Menten equation.

Vehicle traffic induced soil compaction has negative effects on soil functions and ecosystems which may cause the degradation of farmland. This study investigated the magnitude and distribution of soil stress under the tracked and tired vehicles to explore the penitential of using rubber track instead of tire to reduce the subsoil compaction. The field experiment in this study included three replicates and was conducted on a sandy loam soil. Vertical and horizontal soil stress were measured under the centerlines of the rubber track and tire at a depth of 0.35m by using embedded transducers. The SoilFlex model was applied to simulate vertical and horizontal stress in the soil profile. Unevenly distributed vertical and horizontal stress were observed under the tire and rubber track. The vertical stress was characterized by one peak under the tire and several peaks under each of track wheels and rollers. The horizontal stress exhibited peaks before and after the tire and each of track wheels and rollers. The measured maximum stress was significantly higher under the tire than under the rubber track: that is, vertical and horizontal stress were approximately 3.4 and 2.0 times higher, respectively. This finding indicated that using rubber track maybe an effective method to reduce soil stress when compared with the tire, and was more effective in reducing the vertical stress than horizontal stress. Improving the uniformity of stress distribution under the track is the key to improve the ability of tracked vehicle to mitigate soil compaction.

Mini-commentary on BJOG-20-1640.R2: Aetiologic testing compared with syndromic management for sexually transmitted infections in Human Immunodeficiency Virus-infected pregnant women in South Africa: a non-randomised prospective cohort study

We present the mathematical analysis of the Isolation Random Forest Method (IRF Method) for anomaly detection, introduced in {\sc F.~T. Liu, K.~M. Ting, Z.-H. Zhou:}, {\it Isolation-based anomaly detection}, TKDD 6 (2012) 3:1–3:39. We prove that the IRF space can be endowed with a probability induced by the Isolation Tree algorithm (iTree). In this setting, the convergence of the IRF method is proved, using the Law of Large Numbers. A couple of counterexamples are presented to show that the method is inconclusive and no certificate of quality can be given, when using it as a means to detect anomalies. Hence, an alternative version of the method is proposed whose mathematical foundation is fully justified. Furthermore, a criterion for choosing the number of sampled trees needed to guarantee confidence intervals of the numerical results is presented. Finally, numerical experiments are presented to compare the performance of the classic method with the proposed one.

With the emergence of the acquired immunodeficiency syndrome, we witnessed a higher incidence of disseminated and extrapulmonary tuberculosis. It poses a significant diagnostic challenge for the physicians; therefore, a high index of suspicion should be maintained. Here we present a case of isolated chest wall tuberculosis in an immunocompetent patient.

Emphysematous cholecystitis is caused by gas-forming micro-organisms, primarily in patients with immunosuppression and diabetes mellitus. It leads to a signature radiological finding with air in gall bladder wall as described in this report. Clinicians should be aware of this critical differential diagnosis.

Background: Previous studies suggest that wide area circumferential pulmonary vein ablation (WACA) is more effective than segmental pulmonary vein ablation (SPVA) for pulmonary vein isolation (PVI) for treatment of atrial fibrillation. Whether this is true in patients (pts) with very short duration paroxysmal atrial fibrillation (PAF) is unknown. Objective: To compare WACA to SPVA in pts with PAF lasting <48 hours. Methods: One hundred pts with PAF <48 hours were randomized to either WACA vs SPVA (45 and 53 pts respectively, with 2 withdrawals), and followed up for 24 months with 14-day ECGs every 6 months. Results: Among 97 pts at an average of 22.1±4.8 months followup, 26 (57.8%) remained free of any atrial arrhythmias after WACA versus 29 (55.86%) after SPVA (p=0.64). Sixteen pts (35.6%) had recurrent PAF after WACA versus 20 pts (38.5%) after SPVA (p=0.79). Seven pts (15.6%) had atrial flutter after WACA versus 5 pts (9.64%) after SPVA (p=0.376) and 1 pt (2.2%) had atrial tachycardia after WACA vs 1 pt (1.9%) after SPVA (p=0.918). Total procedure time was lower for SPVA vs WACA (242.9 vs 271.1 minutes, p= 0.047), and fluoroscopy time similar for WACA vs SPVA (50.8 vs 53.4 minutes, p=0.555). Conclusions: As an initial ablation approach in pts with PAF <48 hours, SPVA was similarly effective to WACA with respect to arrhythmia recurrence, supporting the central role of the pulmonary veins for maintaining AF in these pts. Future therapies using alternative ablation energies may incorporate these insights to reduce risk to gastroesophageal structures.

Complete transposition of the great arteries is incompatible with life without corrective surgery in the neonatal period. Even in the presence of large intracardiac shunts, a case of un-operated d-TGA that survived to late adulthood is thought-provoking. We described a case of un-operated d-TGA presenting at 46 years of age who had large secundum type ASD, pulmonary hypertension, pulmonary artery aneurysm, situs inversus, mirror image dextrocardia and abnormal origin of the coronary artery. The management of an un-operated case of d-TGA surviving to late adulthood has made it important to share case-based experiences as there are no evidence-based data.

In wireless networked iterative learning control systems, the controller is separated from the plant, and additive noises, random delays and data dropouts arise in both sensor-to-controller and controller-to-actuator channels. In order to guarantee the convergence performance of such systems with the effect of these uncertainties, an input filter is designed based on a proportional iterative learning controller, so that updated inputs can be filtered at the actuator side. Specifically, two data transmission processes are first developed to describe the mix of those uncertainties in both channels by Bernoulli and Gaussian distributed variables with known distributions. Based on state augmentation, the two data transmission processes are further combined with the iterative learning process of controllers to build a unified filtering model. According to this unified model, an optimal filter is designed via the projection theory and implemented at the actuator side to filter the updated inputs in iteration domain. Moreover, the convergence performance of the filtering error covariance matrix is proved theoretically. Finally, some numerical results are given to illustrate the effectiveness of the proposed method.

Background. Acute mesenteric ischemia (AMI) after cardiac surgery is a rare but serious complication associated to high mortality. The time of onset is the key point to correctly evaluate the clinical scenarios. Methods. Data from adult patients who underwent laparotomy for AMI after elective or urgent cardiac surgery were reviewed (January 2005 - December 2019) to report their anatomoclinical features in relationship to time of onset. Early events (within 48 hours) were allocated to Group 1, whereas late onsets were allocated to Group 2. Results. The incidence of risk factors for non occlusive mesenteric ischemia was higher in Group 1 (chronic renal failure 80% vs 38.8%, P <0.05, use of inotropes 60% vs 5.5%, P <0.01, early oligo-anuria requiring CRRT 80% vs 16.6%, P <0.01, prolonged ventilation 46.6% vs 5.5%, P <0.05), where a significative occurrence of postoperative de novo atrial fibrillation was noted in Group 2 (55% vs 5.5%, P <0.01). The number of patients who required bowel resection was proportionally higher in the Group 2 Conclusions. Two well distincted categories of AMI after cardiac surgery can be classified. The first consists of patients with well-known risk factors developing ischemia as a result of severe visceral hypoperfusion The second consists of patients with low comorbidity who experience late AMI as a consequence of“trigger events”, mainly de novo atrial fibrillation. This classification may be useful to better alert the medical staff to the possibility of bowel ischemia at any time after cardiac surgery, promoting early diagnosis and treatment.

Background and purpose: Bradykinin [BK-(1-9)] is an endogenous nonapeptide involved in multiple physiological and pathological processes. A long-held belief is that peptide fragments of BK-(1-9) are biologically inactive. Here, we have tested the biological activities of BK-(1-9) and two major peptide fragments in human and animal systems. Experimental Approach: Levels of BK peptides in male Wistar rat plasma were quantified by mass spectrometric methods. Nitric oxide was quantified in human, mouse and rat cells, and loaded with DAF-FM. We used aortic rings from adult male Wistar rats to test vascular reactivity. Changes in blood pressure and heart rate were measured in conscious adult male Wistar rats. Key results: Plasma levels of BK-(1-7) and BK-(1-5) in rats were increased following infusion of BK-(1-9). All tested peptides induced NO production in all cell types tested. However, unlike BK-(1-9), NO production elicited by BK-(1-7) or BK-(1-5) was not inhibited by B1 or B2 receptor antagonists. BK-(1-7) or BK-(1-5) also induced concentration-dependent vasorelaxation of aortic rings, without involving B1 or B2 receptors. In vivo, either intravenous or intra-arterial administration of BK-(1-7) or BK-(1-5) induced similar hypotension response. Conclusions and implications: BK-(1-7) and BK-(1-5) are endogenous peptides present in plasma. They are formed, at least partially, through the BK-(1-9) proteolysis. BK-related peptide fragments show biological activity, not mediated by B1 or B2 receptors. These BK-fragments could constitute new, active components of the kallikrein-kinin system.

Background: Ventricular Septal Rupture (VSR) is a rare but challenging complication after myocardial infarction (MI). In the presence of acute MI, volume and pressure overload lead to acute heart decompensation. The present study was designed to evaluate the early surgical outcome of VSR for over 18 years. Method: This multicenter study was done during 2000-2018, in which 99 patients with post-MI VSR were included. Results: The patients (n=11) presenting hemodynamic deterioration at the time of hospital admission, died before any attempt for surgery. A consecutive series of 88 patients with surgical repair of VSR was evaluated. The mean interval from MI to VSR diagnosis was 7.5±7.2 days and from admission to the operation was 5±5 days. VSR location did not influence the outcome (p=0.1). The concomitant coronary bypass was done for all patients; two-vessel disease was more prevalent (39%). Only 25 patients survived and left the hospital (13 patients died in the operating room due to the failure of pump weaning and 50 patients in the ICU due to low cardiac output). Predictors of poor prognosis included low ejection fraction (p=0.01), prolonged pump time (p=0.01), and operation in the second half of this period (p=002). Conclusion: Despite the improvement in perioperative management and cardiac surgery techniques, the perioperative mortality rate of VSR has remained high where the assist device is not accessible. We suggest VSR repair limited to certain centers with adequate experiences because of the low average annual number.

We present a case of a young woman with a mangled leg, that could be salvaged with a combination of negative pressure wound therapy, Matriderm® augmented split-skin grafting, and maggot biodebridement. The aim of this case report is to outline alternative treatment options in severe soft tissue injuries.

Pembrolizumab is considered to be an effective therapy for patients with microsatellite instability (MSI)-high cancer. Here, we report a case of MSI-high cholangiocarcinoma effectively treated with pembrolizumab. MSI status should be actively evaluated in patients with cholangiocarcinoma.

ALS is a fatal untreatable disease involving degeneration of motor neurons. Μultiple causative genes encoding proteins with versatile functions have been identified indicating that diverse biological pathways lead to ALS. Gene and stem cell-based therapies are not expected to enter clinical practice anytime soon. Thus, chemical entities represent a promising choice to delay ALS progression, attenuate symptoms and/or increase life expectancy. Various compounds proved effective in transgenic models overexpressing distinct ALS causative genes but showed no efficacy in clinical trials. Notably, while animal models provide a uniform genetic background for preclinical testing, ALS patients are not stratified, and the distinct genetic forms of ALS are treated as a unique group which could explain the discrepancy between treating genetically homogeneous mice and quite heterogeneous patient cohorts. We suggest that chemical entity-genotype correlation should be exploited to guide patient stratification for therapy.

Rationale: Methicillin resistant Staphylococcus aureus (MRSA) is prevalent and consequential in cystic fibrosis (CF). Whole genome sequencing (WGS) could reveal genomic differences in MRSA associated with poorer outcomes or detect MRSA transmission. Objectives: To identify MRSA genes associated with low lung function and identify potential MRSA transmission in CF. Methods: We collected 97 MRSA isolates from 74 individuals with CF from 2017 and performed short-read WGS. We determined sequence type (ST) and the phylogenetic relationship between isolates. We aligned accessory genes from 25 reference genomes to genome assemblies. We classified the MRSA by accessory gene content and correlated the accessory genome to clinical outcomes. Results: The most prevalent ST were ST5 (N=55), ST105 (N=14), and ST8 (N=14). Closely related MRSA strains were shared by family members with CF, but rarely between unrelated individuals. Three distinct clusters of MRSA were identified by accessory genome content. The first included ST5 and ST105 strains and was common among older patients with lower FEV1. The second cluster included ST8, which was generally identified in younger patients. Sputum density of MRSA and Pseudomonas aeruginosa was higher in cultures from patients with ST5/ST105 compared to patients with ST8 at similar ages. Conclusions: In this CF cohort, we identified MRSA subtypes that predominate at different ages and differ by accessory gene content. ST5 and ST105 represented the most prevalent cluster of MRSA. ST8 MRSA was more common in younger patients and thus has the potential to rise in prevalence as these patients age.

Current climate change is disrupting biotic interactions and eroding biodiversity worldwide. However, species sensitive to drought, high temperatures and climate variability might persist in microclimatic refuges, such as leaf shelters built by arthropods. We conducted a distributed experiment across an 11,790 km latitudinal gradient to explore how the importance of leaf shelters for terrestrial arthropods changes with latitude, elevation and underlying climate. Our analyses revealed leaf shelters to be key facilitative elements for the diversity of arthropods. Predator diversity and overall biomass within shelters increased with local drought and temperature variability, regardless of latitude and elevation. In contrast, shelter usage by herbivores increased with abundance of predators on those same plants and in wetter climates. Projected increase in climatic variability and drought in certain geographic regions is therefore likely to enhance the importance of biotic refuges, especially for predators, in mitigating the impact of climate change on species persistence.