Conjoined twins are a rare clinical event. There is limited evidence as to the optimal method of pregnancy termination, particularly in cases of advanced gestational age. We report a successful dilation and evacuation done for conjoined twins at 22 weeks of gestation.

Objective: There is currently no subjective, definitive evaluation method for therapeutic indication other than symptoms in aortic regurgitation. Energy loss, a novel parameter of cardiac workload, can be visualized and quantified using echocardiography vector flow mapping. The purpose of the present study was to evaluate whether energy loss in patients with chronic aortic regurgitation can quantify their subjective symptoms more clearly than other conventional metrics. Methods: We studied 15 patients undergoing elective aortic valve surgery for aortic regurgitation. We divided the patients into symptomatic and asymptomatic groups using their admission records. We analyzed the mean energy loss in one cardiac cycle using transesophageal echocardiography during the preoperative period. The relationships between symptoms, energy loss, and other conventional metrics were statistically analyzed. Results: There were seven and eight patients in the symptomatic and asymptomatic groups, respectively. The mean energy loss of one cardiac cycle was higher in the symptomatic group (121 [96 to 184]) than in the asymptomatic group (87 [80 to 103]) (p=0.040), whereas the diastolic diameter was higher in the asymptomatic group (65 [59 to 78]) than in the symptomatic group (57 [51 to 57]) (p=0.040). There was no significant difference between the symptomatic and asymptomatic groups in terms of other conventional metrics. Conclusions: An energy loss can quantify patients’ subjective symptoms more clearly than other conventional metrics. The small sample size is the primary limitation of our study, further studies assessing larger cohort of patients are warranted to validate our findings.

Ultrasound-guided Erector spinae planae block was practiced after induction of general anesthesia on a male heart patient to perform a nephrectomy, with the aim of an opioid-sparing approach. We founded an important hemodynamic instability 15 minutes after the execution of the block and we want to investigate the possible causes.

Percutaneous occlusion of the left atrial appendage is increasingly being used for stroke prevention in patients with non-valvular atrial fibrillation (AF) at high risk of complications from long term anticoagulation. We describe a case of left atrial appendage perforation after Watchman device deployment requiring emergency repair of the left atrium using sternotomy and cardiopulmonary bypass. Technical considerations for surgical decision making are discussed, in hemodynamically unstable patients as well as those at high risk for embolization.

The seismic impact of transcatheter interventions is rocking the spectrum of structural heart disease (SHD) treatment, with the compelling and attractive appeal of minimally invasive procedures and fast-track discharge. The trend is relentless and continual innovation comes to our doors nearly on a daily basis. Litwinowicz and colleagues describe their trailblazing experience in 223 consecutive patients in whom they performed left atrial appendage occlusion (LAAO) via the percutaneous route. All interventions were performed by surgeons, who had undergone pre-training in a simulation model. Soon thereafter, they were able to achieve outcomes that were comparable to those obtained by experienced interventional cardiologists. The unique surgeons’ training and skills in open-heart surgery make their contribution to perfection and safety of SHD treatment, which are potentially exceptional and distinctive. Extrapolating for the entire field of SHD, which is blossoming ahead, the message to be conveyed is that cardiac surgeons must be trained and embrace every aspect of SHD.

Purpose: To evaluate the awareness of the use of fluoroscopy in endourological procedures, as well as the theoretical and practical applications of preventive measures. Material and Method: Between May 2018 - April 2019, a 26-question survey prepared using Google Docs was sent to urologists via e-mail. Personal information, radiation training and behaviors related to radiation and fluoroscopy usage, and the use of protective equipment were queried. Results: A total of 226 participants fully completed and returned the email survey. Of the 226 participants 78 (34,5%) were academics, 44 (19,4%) were residents while 104 (46.1%) were experts. More than 60% of the participants stated that they participated in the operation requiring less than five fluoroscopy-use per week. The majority of operations requiring fluoroscopy consisted of endourological procedures. The lead apron was used by 93% of the participants, but the use of protective glasses and gloves was very low (3.5%). The majority of academicians, experts and residents did not use dosimeters (76.9%, 82,7 and 81,8%, respectively). More than 50% of the participants did not have literature information about the harmful effects of radiation due to the use of fluoroscopy. The most common complaints on the day of fluoroscopy were fatigue and headache. Conclusion: The lack of information regarding the radiation protection measures and harmful effects of radiation are common among urologists in Turkey. Therefore, systematic training programs on fluoroscopy use and radiation exposure should be provided during urology residency. Keywords: Urologist, fluoroscopy, radiation, radiation protection

A document by Özlem Güler. Click on the document to view its contents.

Background: The predictive value of preoperative pulmonary function testing (PFT) in left ventricular assist device (LVAD) patients remains unknown. This study evaluates the relationship between abnormal PFTs and postimplant outcomes in LVAD patients. Methods: LVAD implants from January 2004 to December 2018 at a single institution were included. Patients were stratified based on presence of abnormal preoperative PFTs, and the primary outcome was respiratory adverse events (AE). Secondary outcomes included one-year overall postimplant survival, and complications including bleeding, renal failure, thromboembolism, and device malfunction. Results: 333 patients underwent LVAD implant, 46.5% (n=155) with normal PFTs and 53.5% (n=178) with abnormal PFTs. Patients with abnormal PFTs were noted to have higher rates of respiratory AEs (25.9% vs 15.1%, p=0.049). In multivariable analysis, the impact of PFTs was most significant when FEV1/FVC ratio was <0.5 (HR 16.32, 95% CI 1.70, 156.78). The rates of other AEs including bleeding, renal failure, right heart failure, and device malfunction were similar. One-year overall postimplant survival was comparable between the groups (56.8% vs 68.8%, p=0.3183), though patients in the lowest strata of FEV1 (<60% predicted) and FEV1/FVC (<0.5) had elevated risk-adjusted hazards for mortality (HR 2.63 95% CI 1.51, 4.60 and HR 18.92, 95% CI 2.10, 170.40, respectively). Conclusions: The presence of abnormal preoperative PFTs is not prohibitory for LVAD implantation although it can be used for risk stratification for respiratory AEs and mortality, particularly in patients with severely reduced metrics. The importance of careful patient selection should be underscored in this higher risk patient subset.

Ehlers-Danlos syndrome (EDS) is a group of connective tissue disorders that can result in a range of complications during pregnancy. Pregnant EDS patients generally have a favourable outcome, but those with vascular EDS are more likely to suffer from severe maternal complications. Early diagnosis of EDS and subtype characterization can aid in pre-pregnancy counselling, planning of antenatal care, risk assessment of obstetric and neonatal complications, and influence both obstetric and anaesthetic management of these patients. This piece aims to outline the obstetric implications of classical, hypermobile, and vascular EDS, and review the current literature regarding their optimal obstetric management.

Background: Myasthenia gravis (MG) is an autoimmune disease which can affect reproductive-aged women and impact pregnancy outcomes. Objectives: To systematically review pregnancy outcomes for patients with MG. Search Strategy: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PubMed (Non-Medline records), Web of Science, and LILACS databases were systematically searched for pregnancies complicated by MG. Selection Criteria: Human studies of five or more subjects reporting outcomes of MG in pregnancy published in any language. Data Collection and Analysis: Following identification and review of relevant studies, data on study characteristics, MG subtypes, treatment, disease and pregnancy outcomes were extracted. Assessment of bias was performed using the National Institutes of Health Quality Assessment Tool for Case Series. In addition, cases of MG in pregnancy managed at our centre were identified and outcomes included in the analysis. Main Results: In total, 32 publications met inclusion criteria for systematic review, for a total of 33 unique data sets including 48 cases at our institution. In total, outcome data was available for 824 pregnancies complicated by MG. Overall risk of MG exacerbation was 33.8% with a 6.4% risk of myasthenic crisis in pregnancy and 8.2% postpartum. Spontaneous vaginal delivery occurred in 56.3% of pregnancies. The risk of transient neonatal myasthenia gravis (TNMG) was 13.0%. Conclusions: One third of pregnant MG patients will experience an exacerbation with 6.4% and 8.2% experiencing myasthenic crisis in pregnancy and postpartum respectively. More than half of MG patients had a spontaneous vaginal birth. The risk of TNMG is 13%

The antifungal mechanism of potato glycoalkaloids was studied using a sensitive species, Fusarium solani. The effects of potato glycoalkaloid extract on the ultrastructure, membrane permeability, and contents of reducing sugar, soluble sugar, soluble protein, and mycelial fat of F. solani were determined. Potato glycoalkaloids significantly affected F. solani mycelial morphology, resulting in bubbly mycelial cell walls, incomplete outer layer, discontinuous cell membrane, disorganized structures of mitochondria and other organelles, and visible leakage of cell contents. Investigation of material metabolism indicated that potato glycoalkaloids disrupted selective permeability of mycelial cell membranes; caused massive exudation of internal lipids, proteins, and carbohydrates; hindered hydrolysis of reducing sugar; affected nutrient absorption and utilization; and inhibited decomposition metabolism of mycelia. Thus, potato glycoalkaloids altered the morphology of fungal mycelia, destroyed cell membrane structure, increased mycelial cell membrane permeability, and caused cell contents leakage, resulting in effective inhibition of growth and metabolism of plant pathogenic fungi and so could decrease the occurrence of plant disease.

Right coronary artery (RCA) -left ventricular (LV) fistul with a giant right coronary artery aneurysm (CAA) is very rare. We reported a giant right CAA with the widest inner diameter of about 56.6 mm. Its terminal communicated with the LV with an inner diameter of about 22 mm. And the patient had the huge LV. We successfully operated the surgery by suturing the beginning of the coronary aneurysm and performing the coronary artery bypass grafting (CABG). RCA-LV fistul with a giant right CAA had some serious complications such as thrombosis, rupture and heart failure. Therefore, it is necessary to establish a positive and effective treatment strategy. Although our case is not unique, it represents a classic surgical treatment method.

Severe mitral annular calcification (MAC) may represent a challenging issue which can lead to poor outcomes and serious issues such as patient-prosthesis mismatch (PPM). The potential harmful effect of PPM must be prevented through the use of alternative techniques that allow mitral valve replacement with adequately sized bioprostheses in patients with MAC. PPM should be recognized as a contraindication for transcatheter valve-in-valve replacement as it leads to poor outcomes and early prosthetic degeneration.

Atmospheric CO2 levels influences plant growth and susceptibility to pathogens and pests but there is little information on the mechanisms involved. We therefore studied how elevated atmospheric CO2 concentrations (eCO2) effects shoot branching and the performance of the pea aphid on wild type peas and on mutants that are defective in either strigolactone (SL) synthesis or signalling. Shoot branching and dry biomass accumulation were increased under eCO2 conditions in all lines. However, eCO2 decreased shoot water content only in the wild type peas but not in the SL mutants. Growth under eCO2 decreased the levels of salicylic acid and increased jasmonic acid in the wild type peas, without any significant effect on aphid fecundity. However, aphid numbers were increased on the SL mutants under both ambient and eCO2 conditions. Of the shoot phytohormones measured in this study, only gibberellic acid (GA3) was decreased in the SL mutants, an effect that was exacerbated by eCO2. There was a negative correlation between aphid fecundity and shoot GA3 levels. Taken together, these studies provide confirm that eCO2 modifies the levels of defence hormones and provides the first evidence that SL and GA3 are important regulators of plant responses to phloem-feeding insects.

Objective: Reports of prevalence and clinical significance of bicuspid aortic valve (BAV) disease are variable. We assessed our institutional echocardiography (ECHO) database to understand the reported prevalence of BAV and its potential association with thoracic aortic aneurysm disease (TAAD). Methods: All ECHOs of adult patients (>18 years) performed at a single institution between calendar year 2013 to 2018 were reviewed. BAV patients were categorized by age group (Young age:18-39 years; Middle age:40-65 years; Old age: >65years) to assess for aortic valvulopathy and TAAD. Logistic regression analysis was performed to understand association of BAV with TAAD. Results: Of 48,503 unique patient ECHOs, 245 (0.51%) described a diagnosis of BAV, with 93(40%) concomitant TAAD. Increased association with endocarditis (p=0.01) and severe aortic insufficiency (p=0.005) was seen in the Young group. Ascending aortic diameter was significantly higher in the Middle compared to the Young group (p<0.001), but similar to Old group. On multivariable regression, BSA(OR=7.31(2.27-23.57)) and age (OR=1.02(1.00-1.04)), but not BAV dysfunction (OR1.07(0.51-2.26)) were associated with TAAD. Conclusions: In this large cross-sectional ECHO study, reported BAV prevalence was 0.51%. We found high association of BAV with concomitant TAAD especially in patients greater than 40 years of age. This suggests that more frequent aortic surveillance may be warranted in the middle and old age BAV subjects.

In this study, cumulative and daily cases are estimated online using a discrete-time dynamic linear model (DLM) and Adaptive Kalman Filter (AKF) based on the total COVID-19 cases between Marc h-July 28, 2020 in USA-Florida, USA-Texas, USA-Arizona, USA-New York. Employing the data collected between Marc and July 28, 2020, it is showed that the discrete-time DLM in conjunction with AKF provides a good analysis tool for modeling the daily cases made using the in terms of mean square error (MSE) and . After estimating the number of cumulative cases, the daily case number estimate was calculated. After calculating the daily case number estimate, the reproduction number estimate was obtained. The method is online. Only the data on the last day is sufficient. The AKF has never been considered for such an application. To the best of our knowledge, the estimation of COVID-19 has not been studied with this method.

The present work aims to produce a composition of 5’-ribonucleotides using spent brewer’s yeast as cheap source of RNA and barley malt rootlets as cheap source of 5’-phosphodiesterase (5’-PDE). This strategy is very promising because both are residues of the brewing process and are closely linked in a cycle that until now is not yet commercially exploited due to lack of studies. The results of the present work showed that extraction of 5’-PDE was mainly influenced by the fineness of the rootlets and amount of extraction solvent (water). The main molecules formed during RNA hydrolysis were 5’-ribonucleotides, which represented 85.86% of the total hydrolyzed molecules. Finally, the results of the approach here proposed can generate a new perspective for the brewing industry in relation to the management of its wastes in order to generate from them products of high added value and with a wide range of applications.

Background: The COVID-19 pandemic has caused a global havoc with our limited understanding of the SARS-CoV-2, disease manifestations and management. Inadequacy of available data in pediatric patients coupled with evolving disease course makes it imperative to conduct a meta-analysis assessing the results of pediatric COVID-19 studies over the course of the pandemic. Methods: A random-effect meta-analysis was conducted using PRISMA guidelines. Two databases were screened for pediatric COVID-19 studies and selected articles reviewed for demographic, co-morbidities, clinical manifestations, laboratory and radiological evaluation, treatment and outcomes. Prevalence with mean and 95% confidence interval was calculated. Results: Out of 1703 articles, 37 articles comprising of 993 patients for a period of over six months and 72 variables were selected. This meta-analysis revealed that one-fourth of patients were asymptomatic (23.8%, 95% CI 17.6-31.2%) Fever (52.5%, 95% CI 45.7–59.1%) and cough (47.6%, 95% CI 41.2–54.0%) were the most common symptoms. The most frequently encountered white blood count abnormalities were neutropenia (16.6%, 95% CI 10.2-25.8%), lymphocytosis (15.3%, 95% CI 9.9–23.0%) and leukopenia (13.9%, 95% CI 10.1–18.8%). Ground glass opacities were the most common radiological finding of children with COVID-19 (35.9%, 95% CI 29.4-43%).  The hospitalization rate was 95.9% (95% CI 91.9-98.0%) of which 11.2% (95% CI 4.7-24.2) were ICU admissions, and 4.2% (95% CI 2.6-6.9%) died. Conclusion: Majority of pediatric patients are asymptomatic or have mild manifestations similar to other upper respiratory viruses. Serious disease and death occurred in 15.4%. More studies are needed from a wider geographic area as the pandemic continues.

Introduction: Brugada phenocopies (BrPs) are clinical entities that differ in etiology from true congenital Brugada syndrome (BrS) but have identical electrocardiographic (ECG) patterns. Methods: Our Manuscript reports a interesting case of BrP in a young man with heroin overdose who developed Acute Kidney Failure secondary to rhabdomyolysis. His initial ECG showed Brugada type 1 pattern with elevation “Coved-Type” of the ST segment in V1 and V2. The Brugada ECG pattern resolved upon hemodialysis treatment. Provocative testing using sodium channel blockers was performed, and failed to reproduce a BrS ECG pattern, confirming the diagnosis of Brugada’s phenocopy. Conclusion: Several clinical conditions can imitate a true Brugada Syndrome and Brugada Phenocopies are a part of those conditions. A systematic approach and a prompt recognition of this clinical and electrocardiographic entity may avoid diagnostic errors and may promote the initiation of appropriate treatments.

Background Coronavirus disease-2019 (COVID-19) has infected over 20 million people globally. The first confirmed case in the United Arab Emirates (UAE)  was reported on 29th  January 2020. To date there is no published data about COVID-19 infection among children in the  Arabian region. Objective To describe the epidemiologic, clinical and laboratory characteristics of children hospitalized with COVID-19 infection in Dubai, UAE Methods A cross-sectional multicentre study of children with confirmed COVID-19 infection admitted between March 1st and June 15th, 2020  to three large hospitals in Dubai, UAE. Their demographics, clinical characteristics and inpatient hospital course were investigated. Results 111 children were included in our study and represented 22 nationalities. Fifty-nine (53.2%) were boys. The mean age was 7 years, with 15.3% younger than 1 year. At presentation 43 (38.7%) were asymptomatic, 68 (61.2%) had mild or moderate symptoms and none had severe symptoms. Fever, cough and rhinorrhoea were common presenting symptoms and resolved by day 5 of hospitalization. Most of our patients had no abnormality on chest x-ray. The most common laboratory abnormalities on admission included variations in neutrophil count (24.7%), aspartate transaminase (22.5%), alkaline phosphatase (36.7%) and lactate dehydrogenase (42.5%). COVID-19 PCR turned negative at a median of 10 days after first positive. There was no significant difference to time of negative PCR between symptomatic and asymptomatic children. Conclusion A large percentage of children with COVID19 experience no symptoms, and severe disease is uncommon in the UAE. Ongoing surveillance and contact tracing will be important to contain future outbreaks.

The aim of this study was to evaluate whether high-frequency chest wall oscillation (HFCWO) could improve the symptoms of children with Mycoplasma pneumoniae pneumonia.We recruited 157 children with M. pneumoniae pneumonia between February 2017 and December 2018. We collated clinical data for each subject and then randomly divided the subjects into a control group (n=82) and an HFCWO group (n=75). Subjects in the control group were given azithromycin, budesonide, ipratropium bromide, and salbutamol. The HFCWO group received all of the treatments given to the control group but also received HFCWO. A range of tests were carried out on each group before treatment and 7 days after treatment, including chest X-ray, routine blood tests, C-reactive protein (CRP) levels, and lung function; we also recorded the duration of fever and cough. Treatment efficacy (based on upper respiratory tract symptoms) was better in the HFCWO group than in the control group (P=0.03). Levels of CRP were significantly lower in the HFCWO group. Patients in the HFCWO group also had shorter durations of fever and cough, and shorter stays in hospital (P<0.05). Treatment costs were also significantly lower in the HFCWO group(P<0.05).Relative to predicted values, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF), were all significantly improved in the HFCWO group(P<0.05). In conclusion, the combination of adjuvant treatment with HFCWO will be of significant benefit to children with M. pneumoniae pneumonia. This treatment combination improves clinical symptoms, reduces the length of hospital stay, and reduces costs.

Several studies have attempted to understand the origin and evolution of single exon genes (SEGs) in eukaryotic organisms including fishes, but few have examined the functional and evolutionary relationships between SEG and multiple exon gene (MEG) orthologs, in particular the conservation of promoter regions. Given that SEGs originate via the reverse transcription of mRNA from a “parental” MEG, such comparisons may enable identifying evolutionarily-related SEG/MEG orthologs, which might fulfill equivalent physiological functions. Here, the relationship of SEG proportion with MEG count, gene density, intron count and chromosome size was assessed for the genome of sea bass, Dicentrarchus labrax. Then, SEGs with an MEG parent were identified, and promoter sequences of SEG/MEG orthologs compared, to identify highly conserved functional motifs. The results revealed a total proportion of 1585 (8.3%) SEGs evenly distributed in the sea bass genome, which was correlated with MEG count but not with gene density. These results suggest that SEGs are continuously and independently generated after species divergence over evolutionary time, as is evident from the significant proportion of SEGs with an MEG parent. Functional annotation showed that the majority of SEGs are functional, as is evident from their expression in RNA-seq data used to support homology-based genome annotation. Differences in 5’UTR and 3’UTR lengths between SEG/MEG orthologs observed in this study may contribute to gene expression divergence between them, and therefore lead to the emergence of new SEG functions. The comparison of nonsynonymous to synonymous changes (Ka/Ks) between SEG/MEG parents showed that 74 of them are under positive selection (Ka/Ks > 1; P = 0.0447). An additional fifteen of SEGs with a MEG parent have a common promoter, which implies that they are under the influence of common regulatory networks and may be involved in equivalent functions.

Studying soil water dynamics and water balance on coral islands is important to utilize and manage the limited freshwater resources of these islands. In this study, we investigated the soil water dynamics of Zhaoshu Island, Xisha Archipelago, using observed data and the Richards equation and analyzed the water balance of this island from October 2018 to September 2019. The precipitation, the water change values in the entire flow domain (△Volume), the bottom boundary flux (vBot), transpiration (Er), and evaporation (Es) during the entire observed year were 913 mm, 10 mm, 349 mm, 203 mm, and 351 mm, respectively. Precipitation is the only source of the freshwater, while approximately 38% of the precipitation infiltrated into the groundwater, 22% of the precipitation was taken up by vegetation, and 39% of the precipitation evaporated from the land surface. From November 2018 to April 2019 (dry season), there was a dry soil layer at depths between 40 cm and 160 cm in the soil profile. Evapotranspiration (ETa) was only 44 mm/month, which was 94% greater than the amount of precipitation, and approximately 14 mm/month of water was taken up from the groundwater by plants. However, in wet season, infiltration dominated the processes of soil water movement. Approximately 56% of the precipitation infiltrated into the groundwater and 37% of the precipitation was consumed by ETa. This study can help us to better understand the process of water movement on coral islands and provide references for further management to protect coral island ecology.

In this paper, we developed a meshless collocation method by using barycentric rational interpolation basis function based on the Chebyshev to deduce the scheme for solving the Helmholtz equation defined in arbitrary domain with complex boundary shapes. Firstly, the spatial variables and their partial derivatives are treated by interpolation basis functions, and the collocation method for solving second order differential equations is established. Then the differential matrix is used to simplify the differential equations on a given test node. Finally, numerical experiments based on three kinds of test nodes show that the proposed method can be used to calculate not only the high wave numbers problems, but also the variable wave numbers problems. Moreover, the algorithm has the advantages of high calculation accuracy, good numerical stability and the less CPU time consuming.