We treated a patient with thoracic and abdominal aortic aneurysms, multiple stenoses of the cerebral arteries, and coronary artery stenosis. Total debranching thoracic endovascular aortic repair is useful for avoiding neurological complications in cases where cardiopulmonary bypass is difficult. Furthermore, it helps devise an intraoperative cervical branch reconstruction method.
We report the first case with central retinal artery occlusion (CRAO), which is a rare but ophthalmic emergency complication, in periprocedural periods of atrial fibrillation ablation. In this case, sudden visual loss occurred after the procedure and visual loss was persisted. Operators should know the incidence and management of CRAO.
Rationale, Aims & Objectives COVID-19 mandated a rapid and dramatic transformation of general practice. ‘Total Triage’ (TT), where all consultations should be triaged first, and ‘Remote-by-Default’ (RbD) consulting, where a clinician should consult remotely unless there is a “clinical exception”, were advised. It is unclear how these new ways of working were implemented in practice, and how they impacted vulnerable patients. We provide a first look at how these changes are impacting those with historic difficulties in accessing primary care under the traditional GP model. This service evaluation aimed to assess the impact of TT and RbD on vulnerable patients and identify mitigation strategies using a mixed methods service evaluation in Lewisham, London, an area of high deprivation. Method Three parallel datasets were collected and analysed: Semi-structured interviews with stakeholders working with vulnerable groups and qualitative data from forums with black and ethnic minority patients, a survey of General Practitioners exploring implementation of TT and RbD, and a mystery shopper exercise reviewing access and messaging of ten practices. Results Barriers to access for vulnerable patients included challenges navigating the new model, difficulty engaging with remote consultations and digital exclusion. There was wide variation in messaging regarding changes to services and the practical application of TT and RbD. Potential solutions included clearer practice guidance and patient messaging, more consistent implementation, and identification and recording of patient access needs, to enable better tailoring of care provision. Conclusion We identified perceived and actual barriers to accessing general practice for vulnerable patients following the rapid introduction of TT and RbD consulting in Lewisham. We recommend immediate steps that can be implemented at a local level to mitigate some of these impacts, and propose further work to gain better insights into the issues identified.
Background and aim: Mitral valve (MV) repair is a well-accepted surgical approach for infective endocarditis (IE). In our hospital, extensive MV reconstruction with fresh autologous pericardium (AP) and artificial chordae (AC) has been performed for patients with profoundly extensive and destructive IE in which valve reconstruction would be extremely challenging, especially in young patients to avoid mechanical valve replacement. Long-term outcome including the future performance of the newly created leaflet has not been established. Methods: Five patients (50 ± 30 years of age; 3 men, 2 women) underwent this procedure from January 2011 to December 2020. In all patients, preoperative cardiac function was good (left ventricular ejection fraction, 70% ± 5%). After complete debridement of the infective valve tissue, the MV was reconstructed with large, fresh, trimmed AP and AC. Results: The reconstructed leaflets were anterior in three patients and posterior in four, and AC were placed in four patients. All patients showed an uneventful postoperative course and were discharged to home 35 ± 5 days postoperatively after completion of intravenous antibiotic therapy. Pre-discharge echocardiography revealed no or trivial mitral regurgitation (MR) in all patients. The mean follow-up period was 7.2 (range, 1.3–9.5) years, and no patients developed recurrence of the IE. The latest echocardiography in four patients showed trivial/mild MR with good leaflet function. One patient developed recurrence of MR, 5 months postoperatively. Conclusions: The short- and long-term outcomes of this procedure were satisfactory. This procedure might be considered as an effective and valuable option, especially in young patients.
Background: Despite major advances in basic and advanced life supports, patients who survived from out of hospital cardiac arrest (OHCA) has still poor prognosis. Several inflammatory parameters have been used to determine early and long-term prognosis in patients with OHCA. C-reactive protein-to-albumin ratio (CAR) is also a novel marker of systemic inflammation. To our knowledge, there is no study evaluating the clinical importance of CAR in OHCA patients. Aims: To evaluate the effect of CAR on mortality in patients with OHCA. Methods: A total of 102 patients with OHCA were included in this study. The study population were divided into two groups as survivor (n = 43) and non-survivor (n = 59) during follow-up. Complete blood cell counts, biochemical and blood gas analysis were recorded for all patients. Neutrophil to lymphocyte ratio (NLR) was calculated as the ratio of neutrophil to lymphocyte. CAR was calculated as the ratio of CRP to the albumin. Results: NLR (P=0.012), CAR (P<0.001) and serum lactate level (P =0.002) were significantly higher whereas lymphocyte (P=0.008) and serum albumin (P<0.001) were significantly lower in non-survivor group compared to survivor group. Multivariate logistic regression analysis showed that NLR (odds ratio [OR]: 1.044, 95% confidence interval [CI]: 1.044-1.437, P=0.013), CAR (OR: 1.971, 95% CI: 1.327-2.930, P=0.001), and lactate level (OR: 1.268, 95% CI: 1.095-1.469, P=0.002) were independent predictors of mortality. Conclusions: We have demonstrated for the first time that CAR was an independent predictor of in-hospital mortality in OHCA patients.
Introduction:To evaluate the efficacy, safety and postoperative outcomes of the BiVap saline vaporization and Twister™ Diode Laser systems with benign prostatic obstruction (BPO) in prostate volüm between 90-150 ml. Methods:In total, we included 131 patients treated with BiVap system (n=68) and Twister system (n=63). Postoperative complications including urinary tract infection, transient hematuria, severe dysuria and fever >38° C, urinary incontinence and urethral stricture were also noted. All patients were evaluated at the postoperative 1st, 3rd, 6th and 12th month and preoperative and postoperative values of IPSS score, QoL score, total PSA, IIEF 15, PVR, Qmax and Qave were compared. Statistical analyses were performed with SPSS version 18. A P-value<0.05 was considered significant. Results:Preoperative demographic characteristics were similar in the 2 groups. There was observed significant improvement for IPSS, Qmax, Qave, PVR, and QoL score by the postoperative first month compared to the preoperative values in both groups. Maximum improvement in the IPSS, Qmax, Qave, QoL score and PVR were achieved at postoperative 6, 3, 12, 3 and 12th months respectively in group 1. In group 2 maximum improvement in the IPSS, Qmax, Qave, QoL score and PVR were achieved at postoperative 6, 3, 6, 6 and 12th months, respectively. There was no significant difference between the two groups in terms of IPSS, Qmax, Qave, QoL score, PSA, PVR, IIEF-EF and IIEF-OS during the 1 year follow-up period postoperatively. Conclusions:BiVap and Twister systems are safe, effective, and useful technique, which can be used in the surgical treatment of BPO between 90-150ml.
Ovarian immature teratoma is a rare tumor during pregnancy. In this disease, the role of adjuvant chemotherapy for initial stage 1, grade 2 and 3 is essential in pregnancy. Two cases of ovarian immature teratoma grade 2 in pregnancy with two different managements and outcomes have been illustrated down below.
When formulating a hydrologic model, scientists rely on parameterizations of multiple processes based on field data, but literature review suggests that more frequently people select parameterizations that were included in pre-existing models rather than re-evaluating the underlying field experiments. Problems arise when limited field data exist, when “trusted” approaches do not get reevaluated, and when processes fundamentally change in different environments. The physics and dynamics of snow interception by conifers, including both loading and unloading of snow, is just such a case. The most commonly used interception parameterization is based on data from four trees from one site, but field study results are not directly transferable between environments. The process varies dramatically between locations with relatively warmer versus colder winters. Here, we combine a comprehensive literature review with a model to demonstrate essential improvements to model representations of snow interception. We recommend that, as a first and essential step, all models include increased loading due to increased adhesion and cohesion when temperatures rise from -3 and 0°C. The commonly used parameters of a fixed maximum value for loading and an e-folding time for unloading are not supported by observations or physical understanding and are not necessary to reproduce observations. In addition to unloading based on physical processes, such as wind or canopy warming, all models must represent melting of in-canopy snow so that it can be unloaded in liquid form. As a second step, we propose field experiments across climates and forest types to investigate: a) a representation of the force balance between adhesion and cohesion versus gravity for both interception efficiency and rates of unloading, b) wind effects during and between storms, and c) lubrication when snow melts. For greatest impact, this framework requires dedicated field measurements. These processes are essential for models to accurately represent the impacts of dynamically changing forest cover and snow cover on both global albedo and water supplies.
We extend the well-known Halanay inequality to the fractional order case in presence of distributed delays and delays of neutral type (in the fractional derivative). Both the discrete and distributed neutral delays are investigated. It is proved that solutions decay toward zero in a Mittag-Leffler manner under some rather general conditions. Some large classes of kernels and examples satisfying our assumptions are provided. We apply our findings to prove Mittag-Leffler stability for solutions of fractional neutral network systems of Cohen-Grossberg type.
Introduction: Ultra-high-density mapping for ventricular tachycardia (VT) is increasingly used. However, manual annotation of local abnormal ventricular activities (LAVAs) is challenging in this setting. Therefore, we assessed the accuracy of the automatic annotation of LAVAs with the Lumipoint algorithm of the Rhythmia system (Boston Scientific). Methods and Results: One hundred consecutive patients undergoing catheter ablation of scar-related VT were studied. Areas with LAVAs and ablation sites were manually annotated during the procedure and compared with automatically annotated areas using the Lumipoint features for detecting late potentials (LP), fragmented potentials (FP), and double potentials (DP). The accuracy of each automatic annotation feature was assessed by re-evaluating local potentials within automatically annotated areas. Automatically annotated areas matched with manually annotated areas in 64 cases (64%), identified an area with LAVAs missed during manual annotation in 15 cases (15%), and did not highlight areas identified with manual annotation in 18 cases (18%). Automatic FP annotation accurately detected LAVAs regardless of the cardiac rhythm or scar location; automatic LP annotation accurately detected LAVAs in sinus rhythm, but was affected by the scar location during ventricular pacing; automatic DP annotation was not affected by the mapping rhythm, but its accuracy was suboptimal when the scar was located on the right ventricle or epicardium. Conclusion: The Lumipoint algorithm was as/more accurate than manual annotation in 79% of patients. FP annotation detected LAVAs most accurately regardless of mapping rhythm and scar location. The accuracy of LP and DP annotations varied depending on mapping rhythm or scar location.
While several researchers have suggested that evolution should be explored from the initial years of schooling, little information is available on effective resources to enhance elementary school students’ level of understanding of evolution by natural selection (LUENS). For the present study, we designed, implemented and evaluated an educational activity planned for fourth graders to explore concepts and conceptual fields that were historically important for the discovery of natural selection. Observation field notes and students’ productions were used to analyse how the students explored the proposed activity. Additionally, an evaluation framework consisting of a test, the evaluation criteria and the scoring process was applied in two fourth-grade classes to estimate elementary school students’ LUENS before and after engaging in the activity. Our results suggest that our activity allowed students to effectively link all of the key concepts in the classroom and produced a significant increase in their LUENS. These results indicate that our activity had a positive impact on students’ understanding of natural selection. They also reveal that additional activities and minor fine-tuning of the present activity are required to further support students’ learning about the concept of differential reproduction. We also observed a low level of teleological predictions for both pre- and post-tests.
The purpose of this paper is to analyze a new kind of Hadamard fractional boundary value problem combining integral boundary condition and multipoint fractional integral boundary condition on an infinite interval. By the help of the Bai-Ge's fixed point theorem, multiplicity results of positive solutions are derived for the Hadamard fractional boundary value problem. In the end, to illustrative the main result, an example is also presented.
Interstitial pneumonia with autoimmune features is a concept to identify patients with idiopathic interstitial pneumonia and features suggestive of a connective tissue disease. There is no specific treatment which consists mainly of corticosteroids and immunossupressive agents. Rituximab is an effective rescue therapy for refractory interstitial lung disease.
A 56-year-old woman was found to have retroperitoneal hemorrhage secondary to isolated posterior inferior pancreaticoduodenal artery (PIPDA) dissection. She had chronic abdominal pain and celiac artery stenosis, suggesting that PIPDA dissection was associated with celiac artery compression syndrome (CACS). Clinicians may consider CACS as the cause of visceral dissection.
Background and purpose: Regulator of G-protein signal 4 (RGS4) is a signal transduction protein that accelerates intrinsic GTPase activity of Gαi/o and Gαq subunits, suppressing GPCR signaling. Here we investigate whether RGS4 modulates nociceptin/orphanin FQ opioid (NOP) receptor signaling and whether this modulation has relevance for L-Dopa induced dyskinesia. Experimental approach: HEK293T cells transfected with NOP, NOP/RGS4 or NOP/RGS19 were challenged with N/OFQ and the small molecule NOP agonist AT-403, using D1-stimulated cAMP levels as a readout. Primary rat striatal neurons and adult mouse striatal slices were challenged with N/OFQ or AT-403 in the presence of the RGS4 inhibitor, CCG-203920, and D1-stimulated cAMP or pERK responses were monitored. In vivo, CCG-203920 was co-administered with AT-403 and levodopa to 6-hydroxydopamine hemilesioned rats, and dyskinetic movements, striatal biochemical correlates of dyskinesia (pERK and pGluR1 levels) and striatal RGS4 levels were measured. Key results: RGS4 expression reduced NOFQ and AT-403 potency and efficacy in HEK293T cells. CCG-203920 increased N/OFQ potency in primary rat striatal neurons, and potentiated AT-403 response in mouse striatal slices. CCG-203920 enhanced AT-403 mediated inhibition of dyskinesia and its biochemical correlates, without compromising its motor-improving effects. Unilateral dopamine depletion caused bilateral reduction of RGS4 levels which was reversed by levodopa. Levodopa acutely upregulated RGS4 in the lesioned striatum. Conclusions and Implications: RGS4 physiologically inhibits NOP receptor signaling and an RGS4 inhibitor enhances NOP responses. Furthermore, an RGS4 inhibitor improved the antidyskinetic potential of NOP receptor agonists, mitigating the effects of upregulation of striatal RGS4 levels occurring during dyskinesia expression.
Purpose: To investigate the quality of life (QoL) in patients with end-stage renal disease who underwent open or robot-assisted renal transplantation (ORT and RART). Materials and Methods: Patients who underwent ORT and RART at Bakirkoy Sadi Konuk Training and Research Hospital between June 2016 and December 2018 constituted the target population of this study. The patient group was divided into two groups as per the surgical technique (i.e., open vs. robot-assisted). Demographic data, preoperative and postoperative data of all patients were collected prospectively. The QoL of the patients was assessed preoperatively and on the postoperative 30th day. Results: 67 patients who underwent ORT and 60 patients who underwent RART were included. The mean patient age and BMI were calculated as 40,9 ± 11,6 years and 24,4 ± 2,9 kg/m2, respectively. While mean total ischemia time was shorter in the ‘open’ group, incision length, duration of surgical drainage and hospital stay were shorter in the ‘robot-assisted’ group. The physical component scores of the QoL questionnaire revealed that postoperative impairment of quality of life was more significant in the ORT than the RART. Conclusion: Patients who underwent RART have a higher QoL than the patients who were treated with ORT as per their self-reported QoL scores in the early postoperative period. Keywords: End-stage renal disease; Open renal transplantation; Robot-assisted renal transplantation; Quality of life
It was recently reported that due to the COVID-19 pandemic, in the European winter 2020-2021, bronchiolitis had practically disappeared. But early reports from the southern hemisphere (Australia) raised concerns about a late spring / summer peak. After a full winter season and now ending the summer, we report that there was no peak of common respiratory viruses in late spring / summer in South America.