Objectives: To characterize the incidence proportions and survival probability of patients with hypo-pharyngeal cancer and lung metastases. Design: Secondary data analysis Setting: The Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute. Participants: We identified 2814 adult patients diagnosed with hypo-pharyngeal cancer between 2010 and 2014 for whom the status of lung metastases was known. Patients with an unknown follow-up were excluded; leaving 2714 patients in this cohort. Main outcome measures: Multivariable logistic and Cox regression models were performed to identify the risk factors associated with the presence of lung metastases at diagnosis and five-year all-cause mortality respectively. Results: We identified 128 patients with lung metastases at the time of diagnosis of hypo-pharyngeal cancer, representing 4.7% of the entire cohort. Females were less likely to have lung metastases (15, 11.7%)(P=0.037). Incidences of lung metastases was higher among patients with histological grade III/IV (56, 43.8%)(P<0.001). Patients with lung metastases had a larger tumor size(49.9690.25mm, P <0.001). For each 10 mm increase in tumor size, the odds of having lung metastases increased by 6.6%. Patients with lung metastases had a shorter survival time(HR:3.05, 95% CI:2.17-4.28, P<0.001). For age, tumor size increase and black study subjects were also significantly associated with a shorter survival time. Conclusion: Our study provides insight into the epidemiology of lung metastases in patients with hypo-pharyngeal cancer. When the tumor is diagnosed, we should pay close attention to the sex, race, tumor size and histological grade in order to quickly detect the distant metastases.

The neonatal Fc receptor (FcRn) is an ubiquitously-expressed protein historically involved in IgG and albumin recycling. Recent data suggest an involvement in the pathophysiology of antibody-mediated autoimmune diseases. Among them, systemic lupus erythematosus (SLE) implies clinical and biological abnormalities of innate and adaptive circulating immune cells potentially involving newly described functions of FcRn. In this study, FcRn expression was measured by flow cytometry in leukocytes of 41 SLE patients with either active or inactive disease and 32 healthy donors. FcRn expression in B cells, natural killer cells, T cells of SLE patients was statistically lower as compared to healthy donors. Conversely, FcRn levels were statistically higher in non-classical monocyte subpopulation (CD14+CD16+ monocytes) of SLE patients vs. healthy donors. Non-classical monocytes are known to be involved in organ damage in SLE. Thus, the higher expression of FcRn in these cells could support the hypothesis of FcRn participation in the pathophysiology of SLE, especially in lupus nephritis.

The interface fracture toughness test of SnSb11Cu6/20steel is realized by three-point bending experimental technique, interfacial cracks are introduced through the overall bending of the composite panel, and the critical energy release rate of 12.07×103 J/m2 is obtained by calculating the energy released per unit area at the fracture interface. To characterize the stress state of the crack tip, the stress phase angle of the crack tip is calculated using finite element analysis(FEA). At the same time, five sets of FEA experiments are specifically set up to determine the magnitude of the effect of changes in the interface fracture critical load values on the critical energy release rate. The results show that the change in the critical load value affects the critical energy release rate by only 0.08%. And the characterization of the crack tip stress state reveals that the relative strength of the shear stress that drives the interfacial cracking is weaker than that of the positive stress after the crack propagates to a certain length under bending conditions, which also implies that the positive stress is the main reason that drives the interfacial crack to continue propagating when the composite layer is completely fractured.

In this paper, an approach for solving the Intuitionistic Fuzzy Multi-Objective Linear Fractional Programming Problem (IFMOLFPP) has been presented. The coefficients of objective functions, resources, and all the technological coefficients are taken to be a triangular intuitionistic fuzzy number (TIFN). In this paper, a component-wise optimization method has been adopted to handle the impreciseness. First, each intuitionistic fuzzy fractional objective is transformed into an equivalent crisp multiple fractional objectives, and then using the fuzzy programming approach, an optimal solution is obtained for every intuitionistic fuzzy fractional objective. Then, the optimal solution of each individual intuitionistic fuzzy fractional objective is used to transform it into a corresponding intuitionistic fuzzy linear objective and thus the original problem now transforms to Multi-Objective Intuitionistic fuzzy LPP which is further transformed into an Intuitionistic Fuzzy LPP with a single objective and the problem is then solved by using component-wise optimization and fuzzy goal programming approach. A numerical example is also presented to explain the methodology of the approach defined in this paper.

The definite solution problems of three-interval composite nonlinear partial differential equations (PDE) under different conditions is studied in the paper. Then the definite solution problems are solved by Laplace transformation - similar constructing method - Stehfest numerical inversion equation (LT-SCM-SNI method). Firstly, the definite solution problems of three-interval composite nonlinear PDE is transformed into the boundary value problems of three-interval composite linear of ordinary differential equation (ODE) by linearization and Laplace transformation (LT). Secondly, the solution in Laplace space of the boundary value problems of three-interval composite linear of ODE is obtained through using the similar constructing method (SCM). The solution in real space of the definite solution problems of three-interval composite nonlinear PDE is obtained through using the Stehfest numerical inversion equation (SNI) and linearization equation. Finally, the nonlinear spherical seepage model of three-interval composite reservoir under infinite outer boundary conditions is solved through using the LT-SCM-SNI method. The influence of various parameters on dimensionless bottom-hole transient pressure is studied. The example shows the simplicity and practicability of the method presented in the paper.

In this paper, we investigate the existence and uniqueness of solutions and Ulam's type stabilities including the well-known Ulam-Hyers stability and the newly extended Ulam-Hyers' conformable exponential stability for two classes of fractional differential equations with the conformable fractional derivative and the time delay. The Banach contraction principle, the technique of Picard operator, the Gronwall integral inequalities and generalized iterated integral inequality in the sense of conformable fractional integral are the main tools for deriving our main results. Finally, several illustrative examples will be presented to demonstrate our work.

Aim: We aimed to evaluate the association of premature ejaculation with OSAS and to assess the effects of continuous positive airway pressure (CPAP) therapy on premature ejaculation. Methods: Sexually active men between the ages of 20-50 who were newly diagnosed with PE, and diagnosed with OSAS were included in the study. Arabic Premature Ejaculation Index (AIPE) and Intravaginal Ejection Delay Time (IELT) were questioned for the diagnosis of PE. Patients with OSAS who accepted to participate in the study were given one year CPAP treatment, and AIPE and IELT were questioned again, after the treatment. Results: Epworth score was significantly lower in the control group compared with the OSAS groups. In the beginning, IELT and AIPE scores were significantly higher in the control group compared with the OSAS groups. At the end of the treatment, in both OSAS groups, both sores improved. Conclusion: For the first time in literature we determined that the presence of OSAS was associated with significantly worse IELT and AIPE scores in males with PE, and the treatment of OSAS was related to the significant improvement in both scores, in the absence of any specific treatments for PE. -What’s already known? -The pathology of OSAS depends on repeated episodes of hypoxia during sleep that may result in cyclic changes in arterial oxygen saturation and increased production of reactive oxygen species. Higher prevalence of sexual dysfunction and erectile dysfunction was reported in OSAS patients. -What does this article add? -To the best of our knowledge first time in the literature we determined that the presence of OSAS was associated with significantly worse IELT and AIPE scores in males with PE, and the treatment of OSAS was related to the significant improvement in both scores, in the absence of any specific treatments for PE

Background: Management of refractory pain in pediatric sickle cell disease (SCD) and oncology is reliant on opioids though high opioid dosing increases side effects and tachyphylaxis. We introduced low dose ketamine infusion (LDKI) to our inpatient unit to determine if LDKI was safe and tolerable. We subsequently hypothesized that LDKI would improve pain scores but not decrease opioid utilization. Procedure: We retrospectively reviewed inpatients from LDKI initiation in March 2014 through October 2017, analyzing each patient’s first admission with LDKI. The day prior to LDKI initiation was compared with the day of LDKI initiation and two subsequent days in regard to cumulative daily opioid utilization, vital signs and pain scores. For patients with SCD, the LDKI admission was compared with up to three admissions in the prior year for a vaso-occlusive event. Results: Nineteen patients (12 oncology, 7 SCD) with a median age of 14.6 years received LDKI for a median of 6 days at a median initial dose of 0.06 mg/kg/h (1.1 mcg/kg/min). There was no change in pain scores, heart rate or opioid utilization when comparing the day prior to LDKI initiation with subsequent days. No patient discontinued LDKI due to intolerability. For patients with SCD, there was a median 32% reduction in cumulative pain scores when comparing the LDKI admission with prior admissions. Conclusions: LDKI is well tolerated and may be a viable option for refractory pediatric cancer- and sickle cell-related pain. Future study is required to further delineate appropriate dosing and patients most likely to benefit.

In this review of Low Energy Nuclear Astrophysics we review the nuclear energy and evolution of the sun. Then we review the estimate of dark matter from galaxy rotation. Next we discuss neutron star formation from the gravitational collapse of massive stars which produces neutron stars and their velocity. Then origin of supernovae, the estimate of dark energy from supernovae acceleration, and experiments related to low energy nuclear astrophysics are reviewed.

Background: Community pharmacy services have evolved to include medical and pharmaceutical interventions alongside dispensing. Whilst established pharmacogenomic (PGx) testing is available throughout the Netherlands, this is primarily based in hospital environments and for specialist medicines. Aim: The aim of this work was to describe how best to implement PGx services within community pharmacy, considering potential barriers and enablers to service delivery and how to address them. Method: The service was implemented across a selection of community pharmacies in the Netherlands. Data was captured on test outcomes and through a pharmacist survey. Results: Following testing, 17.8% of the clinical samples were recommended to avoid certain medication (based on their current medicines use), and 14.0% to have their dose adjusted. Pre-emptive analysis of genotyped patients showed that the majority (99.2%) had actionable variants. Pharmacists felt confident in their operational knowledge to deliver the service, but less so in applying that knowledge. Delivering the service was believed to improve relationships with other healthcare professionals. Conclusion: These results add to the evidence in understanding how PGx can be delivered effectively within the community pharmacy environment. Training pharmacists in how to respond to patient queries and make clinical recommendations may enhance service provision further.

The coronavirus outbreak has caused a devastating effect on people all around the world and has infected millions. The exponential escalation of the spread of the disease makes it emergent for appropriate screening methods to detect the disease and take steps in mitigating it. The conventional testing technique involves the use of Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR). Due to limited sensitivity it is more prone to providing high false negative rates. Also due to a high turnaround time (6-9 hours) and a high cost, an alternative approach for screening is called for. Chest radiographs are the most frequently used imaging procedures in radiology. They are cheaper compared to CT scans and are more readily available and accessible to the public. Application of advanced artificial intelligence (AI) techniques coupled with radiological imaging can be helpful for the accurate detection of this disease. In this paper 8 different architectures of CNN (EfficientNet, ResNet, DenseNet, VGG, Mobilenet) are compared regarding classification performance on the COVID-19 dataset. The proposed models are developed to provide accurate diagnostics for multiclass classification (Covid vs No Findings vs Pneumonia) and the best performing models are used to perform binary classification (Covid vs No Findings). Areas under the receiver operating characteristics curves (AUROC) between 0.9622 and 0.9987 could be achieved for multiclass classification while accuracy scores ranged from 90.32% to 94.93% achieving next to state-of-the-art results. A dataset was created as a mix of publicly available X-ray images from patients with confirmed COVID-19 disease, common bacterial pneumonia and healthy individuals.

The diploid Poropuntius huangchuchieni in the cyprinid family, which is widely distributed in the Mekong and Red River basins, is one of the most closely related diploid progenitor-like species of allotetraploid common carp, which was generated by merging of two diploid genomes during evolution. Therefore, the P. huangchuchieni genome is essential for polyploidy evolution studies in Cyprinidae. Here, we report a high-quality chromosome-level genome assembly of P. huangchuchieni by integrating Oxford Nanopore and Hi-C technology. The assembled genome size was 1021.38 Mb, 895.66 Mb of which was anchored onto 25 chromosomes with a N50 of 32.93 Mb. The genome contained 486.28 Mb repetitive elements and 24,099 protein-coding genes. Approximately 95.9% of the complete BUSCOs were detected, suggesting a high completeness of the genome. Evolutionary analysis revealed that P. huangchuchieni diverged from Cyprinus carpio at approximately 12 Mya. Genome comparison between P. huangchuchieni and the B subgenome of C. carpio provided insights into chromosomal rearrangements during the allotetraploid speciation. With the complete gene set, 17,474 orthologous genes were identified between P. huangchuchieni and C. carpio, providing a broad view of the gene component in the allotetraploid genome, which is critical for future genetic analyses. The high-quality genomic dataset created for P. huangchuchieni provides a diploid progenitor-like reference for the evolution and adaptation of allotetraploid carps.

Objectives To estimate the prevalence of latent iron deficiency (LID) among pregnant women, assess LID in relation to parity, age, education, and household income, and to determine correlations between LID and red cell indices, red cell distribution width (RDW), and red cell morphology. Design Cross-sectional design Setting North Colombo Teaching Hospital, Sri Lanka. Sample Participants comprised 355 pregnant women with normal haemoglobin levels seeking antenatal care within < 20 weeks of gestation. Method Data were obtained from interviews and antenatal records. Participant full blood count (FBC), serum ferritin levels, and blood films were analysed. Main Outcome Measures Prevalence of LID, demographic data (age, parity, period of gestation, gap between pregnancies, income, and education), and blood film morphology. Results LID prevalence was 54%. Statistical significance for the gap between pregnancies being < 2 years was observed but not for participant’s age, parity, income, and education. Blood film morphology depicted statistically significant presence of hypochromic microcytic red cells and pencil cells. RDW was significant in indicating the presence of LID. Among those with LID, 25% had ferritin level in the iron deficiency range. Conclusions LID is highly prevalent in early pregnancy and 25% of participants had ferritin levels in the iron deficiency range. Presence of raised RDW, hypochromic microcytic red cells, pencil cells, and <2 years’ gap between pregnancies were indicators of LID. To identify pregnant women with LID, blood film, haemoglobin, and RDW could be recommended as basic tests, and ferritin test as an affirmative one.

The larva of Taeniidae species can infect a wide range of mammals, causing major public health and food safety hazards worldwide. The Qinghai-Tibet Plateau (QTP), a biodiversity hotspot, is home to many species of rodents, which act as the critical intermediate hosts of many Taeniidae species. In this study, we identified two new larvae of Taenia spp., named as T. caixuepengi and T. tianguangfui, collected from the plateau pika (Ochotona curzoniae) and the Qinghai vole (Neodon fuscus), respectively in QTP, and their mitochondrial genomes were sequenced and annotated. Phylogenetic trees based on the mitochondrial genome showed that T. caixuepengi has the closest genetic relationship with T. pisiformis, while T. tianguangfui was contained in a monophyletic group with T. crassiceps, T. twitchelli and T. martis. Biogeographic scenarios analysis based on split time speculated that the speciation of T. caixuepengi (~5.49 Mya) is due to host switching caused by the evolution of its intermediate host. Although the reason for T. tianguangfui (~13.11 Mya) speciation is not clear, the analysis suggests that it should be infective to a variety of other rodents following the evolutionary divergence time of its intermediate host and the range of intermediate hosts of its genetically close species. This study confirms the species diversity of Taeniidae in the QTP, and speculates that the uplift of the QTP has not only a profound impact on the biodiversity of plants and animals, but also that of parasites.

Mining activities that shape geographical patterns of biodiversity in individual regions are increasingly understood, but the complex interactions on broad scales and in changing environments are still unclear. In this study, we developed a series of empirical models that simulate the changes in biodiversity and ecosystem functions in mine-affected regions along elevation gradients (1500-3600 m a.s.l) in the metal-rich Qilian Mountains (~800 km) on the northeastern Tibetan Plateau (China). Our results confirmed the crucial role of potentially toxic elements (PTEs) dispersal, topography, and climatic heterogeneity in the diversification of plant community composition. On average, 54% of the changes in ecosystem functions were explained by the interactions among topography, climate, and PTEs. However, merely 30% of the changes were correlated with a single driver. Plant species composition (explained variables = 94.8%) changed more in lowland than in highland areas. The changes in species composition (explained variables = 94.8%) in the PTE-polluted habitats located in the warm low-elevation deserts and grasslands were greater than those occurring in the alpine deserts and grasslands. The ecosystem functions (soil characteristics, nutrient migration, and plant biomass) experienced greater changes in the humid low-elevation grasslands and alpine deserts. The effect of topography (i.e., slope and aspect) was less important than that of climatic heterogeneity (MAT, win10, and ET0) in predicting ecosystem functions of PTE-polluted habitats. Our results suggest that the processes driven by climate or other factors can result in high-altitude PTE-affected habitat expansions or contractions.

IImmunodeficiency and hyperinflammation characterize COVID-19 associated states; thus, repurposing of multiple cytokine and/or anti-cytokine drugs currently being used in other therapeutic areas has been suggested as a potential therapeutic strategy in COVID-19 patients. Clinical trials involving these drugs target the most frequent and life-threatening peripheral consequences of the disease, mainly focusing on lung, heart, and coagulation functions; however, a growing number of reports describe a wide range of COVID-associated neurological manifestations (altogether defined as neuro-COVID) including anosmia, seizures, confusion, stroke, encephalopathy, and paralysis. Notably, the underlying pathophysiological mechanisms for neuro-COVID may also include dysregulation of cytokines/chemokines, deficiencies in the innate immune response, and autoimmunity. This suggests that therapeutic attempts with drugs targeting cytokine-mediated inflammation in peripheral organs could also positively affect neuro-COVID manifestations. As a matter of fact, some of these drugs have also been scrutinized for their potential efficacy in treating neuroinflammatory diseases such as optic neuromyelitis, epilepsy, stroke, and traumatic brain injury, among others. On the other hand, anti-cytokine drugs, by impairing relevant physiological activities exerted by these mediators in the CNS, may also be endowed with significant neurological risk. Therefore, the primary aim of the present manuscript is to review the available preclinical and clinical data regarding the neurological effects of the drugs targeting cytokine-mediated inflammation, in order to raise awareness about their potentially beneficial or detrimental neurological consequences when used to treat COVID-19 patients.

Background and Purpose Osteoarthritis (OA) is a leading cause of disability and bears a large socioeconomic cost, but we lack an effective disease-modifying therapy. There is great need to identify novel target molecules in OA pathogenesis. Here, by asking why old cartilage appears to be more sensitive to OA pathogenic factors, we identified the importance and underlying mechanism of K-7174 as a blocker of the Zmiz1-GATA axis in age-related OA pathogenesis. Experimental Approach As a novel transcriptional regulator in OA pathogenesis, Zmiz1 was isolated as an up-regulated gene from aged cartilage, using microarray and Ingenuity Pathway Analysis (IPA). Infection and intra-articular injection of Ad-Zmiz1 were performed in vitro and in vivo. Cartilage-specific Col2a1-Zmiz1 TG mice with or without DMM (destabilization of the medial meniscus) surgery were evaluated by measurement of OA manifestations. To identify a specific Zmiz1-related transcription factor and a potential inhibitor, we performed transcription factor, in silico binding, and inhibition assays. Key Results The transcriptional regulator, Zmiz1, is up-regulated in old mouse cartilage and highly expressed in damaged cartilage of OA patients and DMM mice. Col2a1-Zmiz1 TG mice and DMM-induced Col2a1-Zmiz1 TG mice showed more severe cartilage destruction. Overexpression of Zmiz1 induced cartilage destruction by up-regulating Mmps and Cox2 through activation of the Zmiz1-GATA axis. Finally, we demonstrate that K-7174 interfered with the activation of the Zmiz1-GATA axis to crucially protect against OA pathogenesis and promote ECM synthesis. Conclusion and Implications The K-7174-mediated blockade of the Zmiz1-GATA axis could be a useful therapeutic strategy for blocking OA pathogenesis.

Background: Recent studies have confirmed that microRNA-223 may participate in high-on clopidogrel treatment platelet reactivity. Clopidogrel requires hepatic enzyme metabolic activation to produce its metabolite with pharmacological activity, as a result, there are few researches about platelet reactivity. The aim of the current study is to explore the possible regulatory mechanism between microRNA-223 and platelet reactivity after clopidogrel treatment. Methods: In this study, we established an experimental model of MEG-01 cells treated with clopidogrel and human liver microsomes incubation system, so that the effects of clopidogrel active metabolites on megakaryocytes and platelets can be simulated. The relation of microRNA-223, C/EBP α and P2Y12 was further investigated by both cell experiments and clinical studies. Results: The ratio of platelet P2Y12 expression before and after treatment was significantly higher in Low Responders group (1.14604 vs 0.77097, p=0.031). After treatment at 200 ul/2 ml for 3 and 5 consecutive days, miR-223 expression in MEG-01 cells decreased by 47.3% and 32%, respectively (p < 0.05). P2Y12 mRNA expression was 193.4% higher after 3 consecutive days (p < 0.001), and significantly lower after 5 consecutive days than that in the negative control group (p < 0.05). P2Y12 and C/EBP α protein expression were significantly lower after 5 consecutive days (p < 0.01). Conclusions: A negative feedback loop was carried out by clopidogrel active metabolite to recede its inhibition of P2Y12 signal pathway through P2Y12-PI3K/Akt-C/EBP α-miR-223 pathway, which may be excessively activated and play a role in the occurrence of high-on clopidogrel treatment platelet reactivity.

A document by Joana Loureiro. Click on the document to view its contents.

Many hospitals will continue to see a surge in COVID-19 cases and halt of elective cases, while others pass the surge and begin to restart elective surgeries. Regardless of the phase each hospital encounters, the safety of both patients and staff must be taken into account.1,2 This case report describes a patient who underwent urgent coronary artery bypass grafting (CABG) at the beginning of the COVID-19 surge. The initial postoperative course was uneventful and the patient was discharged on postoperative day 4. The patient presented nearly two weeks later with a subsequent severe COVID-19 infection complicated by STEMI and stroke. This case not only demonstrates the risks and potential complications of caring for cardiac surgery patients during the COVID-19 pandemic, it is the only known reported case of a patient developing severe COVID-19 infection after a CABG resulting in STEMI and stroke due to hypercoagulable state associated with COVID-19.

We present prolonged viral shedding in an immunocompromised HIV patient with a literature review of risk factors for prolonged viral shedding and its implications for isolation strategies. We explore the role of PCR-CT-value (cycle threshold) as an instrument for guiding isolation policies and the impact of HIV on Covid-19.

Congenital absence of one pulmonary valve cusp with normal morphology of the other two cusps is a very rare finding. In this unusual case we present the first images of 3-dimensional pulmonary valve reconstruction as a useful tool for preoperative evaluation of pulmonary valve anatomy.

Objective: Post-infarction ventricular septal defect (PIVSD) is a severe complication of acute myocardial infarction. Transcatheter closure (TCC) perform an alternative option to the surgical repair. This study was undertaken to examine the published literature to give the objective evidence of TCC using a meta-analysis. Methods: We searched for significant medical and publishers’ databases. Two reviewers checked the quality of studies and extracted data. Eligible studies included single-arm studies and comparative studies. Weighted mean, pooled event rates, efficacy outcomes and odds ratios(OR) for immediate shunt reduction(ISR), presence of cardiogenic shock (CS), New York Heart Association ( NYHA) class IV, time from AMI to ventricular septal defect(VSD), time to VSD closure was estimated. Results: 27 single arm articles (462 patients) were included. The pooled event rate was 89.7% (95%CI: 0.772-1.021) for successful device implantation, 80.9% (95%CI: 0.645-0.972) for ISR, 31.5% (95%CI of 0.149-0.482) for 30-day mortality, 25.3% (95%CI: 0.072-0.434) for 30-day mortality of primary closure at acute phase. CS (OR=3.607, 95%CI: 2.301-5.653), NYHA class IV (OR=6.491, 95%CI: 1.444-29.188) and time to VSD closure are risk predictor for TCC. There is no correlation between the defect size (OR=2.592, 95%CI: 0.380-17.661) and mortality. Conclusion: TCC should be a relatively safe and low invasive method for PIVSD, with an excellent successful device implantation rate and acceptable low 30-day mortality. The procedure appears promising, but its safety and efficacy could only be demonstrated by randomized controlled trials. Therefore, they are needed more investigations to determine whether the acute phase or chronic phase to practice the procedure.

Transcatheter aortic valve replacement (TAVR) has become the procedure of choice for patients deemed high-risk or inoperable for surgical aortic valve replacement. For patients with inadequate iliofemoral access, the risk of vascular injury is extremely high and alternative techniques have been utilized and include the transapical, transaortic and transsubclavian or transaxillary (TAx) routes. Alternative approaches often require open surgical exposure under general anesthesia. Herein, we describe a unique TAx TAVR with a balloon-expandable Edwards SAPIEN 3 device in a 77 year-old male patient with the history of coronary artery and ilio-femoral bypass surgery, permanent pacemaker implantation at the left pectoral fossa and left subclavian artery stent.