Background: Covid-19 can have remarkable effects on pregnancy, and pregnant women with this infection are at higher risk for developing ketoacidosis. In this case report, we report a 35-year-old pregnant woman infected with Covid-19 with early manifestations of ketoacidosis during term pregnancy.

Dynamic digital radiography (DDR) is a motion-detective technique with high temporal resolution. Flexible laryngoscopy is a common modality for observation of the larynx, but it is aerosol generating. DDR is an easy and less risky screening test for diagnosis of recurrent laryngeal nerve paralysis during the COVID-19 pandemic.

In this paper, a deep dynamical analysis is made using tools from multidimensional real discrete dynamics of some derivative-free iterative methods with memory. They all have good qualitative properties, but one of them (due to Traub) shows the same behavior as Newton’s method on quadratic polynomials. Then, the same techniques are employed to analyze the performance of several multipoint schemes with memory, whose first step is Traub’s method, but their construction was made using different procedures. Therefore, their stability is analyzed, showing which is the best in terms of the wideness of basins of convergence or the existence of free critical points that would yield convergence towards different elements from the desired zeros of the nonlinear function. Therefore, the best stability properties are linked with the best estimations made in the iterative expressions rather than their simplicity. These results have been checked with a numerical and graphical comparison with many other known methods with and without memory, with different orders of convergence, with excellent performance.

A 60-year-old male presented with sudden onset chest pain and pulmonary oedema. Investigation confirmed torrential aortic regurgitation of a bicuspid valve. At surgery a ruptured chordae tendineae was identified which had been supporting the left-right cusp commissure with loss of attachment to the aortic wall. This case demonstrates that chordae tendineae may be present as a supporting structure of the aortic valve, and rupture can be a rare cause of torrential aortic regurgitation, similar in pathogenesis to how it may be associated with acute severe mitral regurgitation.

Background: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-maze procedure, which is currently the gold standard treatment for AF, data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. Objective: We conducted a systematic review to identify randomized controlled trials (RCT) and observational studies comparing the mid-term mortality and recurrence of atrial fibrillation (AF) after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. Methods: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. A meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. Results: Three RCTs and 3 observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that concomitant Cox-Maze procedure was associated with a higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimate pooled across the 3 RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (RR=1.58, 95%CI 0.91-2.73). In 2 out of 3 higher quality observational studies, 12-month AF recurrence was higher in PVI than in Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated survival benefit of Cox-Maze. Conclusions: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required in order to clarify benefits of concomitant Cox-Maze in AF patients during MV surgery.

The idea that populations are spatially structured has become a very powerful concept in ecology, raising interest in many research areas. However, despite dispersal being a core component of the concept, it typically does not consider the movement behavior underlying any dispersal. Using individual-based simulations in continuous space, we investigate the emergence of a spatially structured population in landscapes with spatially heterogeneous resource distribution and with organisms following simple area-concentrated search (ACS); individuals do not, however, perceive or respond to any habitat attributes per se but only to their foraging success. We investigated effects of different resource clustering pattern in landscapes (single large cluster vs. many small clusters) and different resource density on spatially structure of populations and movement between resource clusters of individuals. As results, we found that foraging success increased with increasing resource density and decreasing number of resource clusters. In a wide parameter space, the system exhibited attributes of a spatially structured populations with individuals concentrated in areas of high resource density, searching within areas of resources, and ‘dispersing’ in straight line between resource patches. ‘Emigration’ was more likely from patches that were small or of low quality (low resource density), but we observed an interaction effect between these two parameters. With the ACS implemented, individuals tended to move deeper into a resource cluster in scenarios with moderate resource density than in scenarios with high resource density. ‘Looping’ from patches was more likely if patches were large and of high quality. Our simulations demonstrate that spatial structure in populations may emerge if critical resources are heterogeneously distributed and if individuals follow simple movement rules (such as ACS). Neither the perception of habitat nor an explicit decision to emigrate from a patch on the side of acting individuals are necessary for the emergence of spatial structure.

Lowering the Threshold for Left Bundle Branch Area PacingLukasz P. Cerbin, MD1 and Lohit Garg, MD11 Division of Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.Relevant Disclosures: NoneFunding: NoneCorresponding Author: Lohit Garg, MDDivision of Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus12401, E. 17th Ave, Aurora, Colorado-80045Email: [email protected] pacing remains the mainstay of therapy for conduction system disease and irreversible bradyarrhythmias. Due to known complications from chronic RV pacing and electromechanical dissociation1,2, there has been a growing interest in physiologic pacing. While cardiac resynchronization therapy (CRT) with LV pacing from a lead in the coronary sinus has been shown to ameliorate some of the morbidity from RV septal pacing3, activation is still via myocyte to myocyte conduction rather than engaging the specialized conduction system. Furthermore, LV lead placement can be challenging and response to CRT is heterogeneous and difficult to predict4. And finally, CRT’s role in patients with preserved LV systolic function has not been established.In this light, there has recently been a substantial growth in conduction system pacing directly engaging the native His-Purkinje conduction system. This began with a case series published in 2000 demonstrating selective his bundle capture and subsequent permanent His bundle pacing (HBP) lead placement in patients with heart failure and tachycardia induced cardiomyopathy secondary to atrial fibrillation5. Additional studies demonstrated the feasibility and clinical benefit of HBP as a strategy for CRT6,7. However, continued research revealed high capture thresholds and low R wave amplitudes, calling this technique into question8. Furthermore, HBP failed to demonstrate improved outcomes in patients with underlying LBBB, likely due to the presence of conduction disease distal to the site of capture9. Due to these concerns, the enthusiasm for HBP gradually waned, with a subsequent rise in interest in left bundle branch area pacing (LBBAP). This approach utilizes the same lead and implant technique to fix a lumenless pacing lead approximately 1.5 cm distal to the anatomical His bundle within the interventricular septum, directly engaging the left bundle.In this issue, Mehta et al. describe a single center’s experience of implantation of left bundle branch area pacing leads, complete with one year follow-up data. Their retrospective study included 65 patients over an 18 month period who received a 3830 Medtronic lead for LBBAP. Only patients with one year of follow up data were included. Importantly, they excluded 7 patients in whom LBBAP implant was unsuccessful, resulting in a reported implant success rate of 91.8%. The reported procedure time was 72.7 +/- 28.8 minutes. The mean QRS duration decreased significantly in patients with pre-existing LBBB, was unchanged in those with pre-existing RBBB, and increased significantly in patients without pre-exiting bundle branch block. At one year follow-up, they found a significantly higher capture threshold compared to threshold at implant (p<0.0001), although they noted that the absolute increase (0.2-0.3 V) was relatively modest. No short or long-term complications related to device implant were identified.This study underscores several important points regarding LBBAP. Firstly, procedural success is high, with the authors reporting an implant success rate of 91.8% in this study. Reasons for implant failure included unacceptably high pacing thresholds, inability to meet parameters used to ensure capture of the left bundle, and anatomic constraints in one patient that prohibited lead placement. This success rate is similar to that reported in other studies10. Other studies have found higher implant success rate with LBBAP as compared to HBP11. Secondly, this success rate is likely easily reproducible as the implant technique does not require additional or specialized training, only a long delivery sheath and some familiarity with the mechanism to fix the 3830 lead to the interventricular septum. With preliminary data suggesting improved outcomes compared to traditional RV septal pacing12and the relative ease of procedural proficiency, it would seem that this technique could rapidly become the gold standard for pacemaker implantation.While there is great enthusiasm for LBBAP, several key questions remain. Firstly, this study, along with a recent publication from the Geisinger-Rush Conduction System Pacing Registry12, are the first to publish one year data following LBBAP lead implant. While lead parameters were reported to be stable at one year in this study, longer term data are needed. Furthermore, in addition to data on long term lead parameters and clinical efficacy, long term safety outcomes will be important. Particularly, subclinical perforation of the helix into the LV may carry thrombotic risk and long term data on whether this increases stroke risk will be important13. One prior study found two cases of subclinical septal perforation occurring after LBBAP lead placement14. Another case report described a patient presenting with presyncope two weeks after device implant with perforation of the lead into the LV and associated lack of capture up to 3.5 V @ 0.4 ms (bipolar)15. The incidence and risk factors for these events has yet to be established and the associated morbidity, including stroke risk from thromboembolism, remains uncharacterized. Another question that needs to be addressed is that of extractability of LBBAP leads. While there have been few published reports of successful extraction of these leads16, these lumen-less leads represent unique challenges in terms of extraction tools and technique. More data is needed to characterize the approach and outcomes for extraction of LBBAP leads.Finally, the criteria for left bundle capture, as opposed to left septal pacing, has yet to be firmly established, with both being included in the catch-all term “left bundle branch area pacing.” A recent study by Wu et al. utilized temporary HBP leads and LV septal mapping with multielectrode catheters during LBBAP lead implant to identify markers of selective LBBP17. They identified several useful parameters, including paced RBBB pattern (100% sensitive), LBB potential on the lead electrogram, abrupt shortening of stim-LV activation time (LVAT) and certain stim-LVAT times (which varied based on the presence or absence of an underlying LBBB). Another study from the same group utilized a decapolar coronary sinus catheter to examine differences in LV activation time and depolarization with left bundle capture versus left septal pacing, finding that the a model combining the presence of a LBBB potential on the lead coupled with a validated stim-LVAT had excellent test characteristics (AUC = 0.985) to differentiate conduction system from septal pacing18. In the current study, the authors reported 67.7% of patients with selective left bundle capture and 32.3% with left septal pacing when applying this algorithm. A scientific consensus on how to identify left bundle capture is essential to both study the long term clinical benefits in patients undergoing LBBAP implantation as well as establishing criteria to guide implanting physicians attempting to achieve selective left bundle capture.In summary, left bundle branch area pacing remains an exciting and burgeoning area within cardiac electrophysiology. This study by Mehta et al. demonstrated stable and acceptable lead parameters one year after LBBAP implantation, adding evidence of the long term safety and efficacy of this technique. Several questions remain, including longer term efficacy, the incidence of subacute and chronic complications, the ability to extract these leads when indicated, and the effect of LBBAP clinical outcomes. Furthermore, rigorous definitions for left bundle capture and left septal pacing need to be agreed upon. However, if these data can be replicated on a larger scale and longer term data shows similar safety and efficacy, LBBAP may likely represent the gold standard for pacing for bradyarrhythmia indications in the near future.

Catheter ablation in children has evolved to become a highly effective and safe therapy. Each iterative improvement in ablation technology provides another opportunity to investigate how much incremental benefit can be made without sacrificing safety. Contact force sensing catheters represent an example of such technology that has become commonplace in adult ablation. Its capability in predicting lesion size and collateral damage to critical structures has not been meticulously explored. Backhoff and colleagues describe an animal ablation model where they quantitate lesion characteristics at the atrium, atrioventricular groove, and ventricle using low and high contact force targets, with a specific focus on assessing for coronary arterial injury. In this controlled experiment, chronic lesion characteristics were widely variable (~0-8 mm diameter) yet there was a statistically significant (albeit small) increase in lesion diameter for high (vs low) contact force lesions delivered to the atrioventricular groove. The risk of chronic sub-clinical coronary artery injury was 1-2%.

Objective: To evaluate for cardiac involvement in recovered COVID-19 patients using cardiac magnetic resonance imaging (MRI). Methods: A total of 30 subjects recently recovered from COVID-19 and abnormal left ventricular global longitudinal strain were enrolled. Routine investigations, inflammatory markers and cardiac MRI were done at baseline with follow-up scan at 6 months in individuals with abnormal baseline scan. Additionally, 20 age-and sex-matched individuals were enrolled as healthy controls (HCs). Results: All 30 enrolled subjects were symptomatic during active COVID-19 disease and were categorized as mild: 11 (36.7%), moderate: 6 (20%) and severe: 13 (43.3%). Of the 30 patients, 16 (53.3%) had abnormal CMR findings. Myocardial edema was reported in 12 (40%) patients while 10 (33.3%) had LGE. No difference was observed in terms of conventional LV parameters however, COVID-19 recovered patients had significantly lower right ventricular (RV) ejection fraction, RV stroke volume and RV cardiac index compared to HCs. Follow-up scan was abnormal in 4/16 (25%) with LGE persisting in 3 patients. Myocardial T1 (1284 + 43.8 ms vs 1147.6 + 68.4 ms; P<0.0001) and T2 values (50.8+16.7 ms vs 42.6+3.6 ms; P=0.04) were significantly higher in post COVID-19 subjects compared to HCs. Similarly, T1 and T2 values of severe COVID-19 patients were significantly higher compared to mild and moderate cases. Conclusions: An abnormal CMR was seen in half of recovered patients with persistent abnormality in one-fourth at six months. Our study suggests a need for closer follow-up among recovered subjects in order to evaluate for long term cardiovascular sequalae.

Aim: North China leopard (Panthera pardus japonensis), is the most widespread subspecies of leopard and one of the rare and endangered species in China. It is currently confined to several isolated reserves, and little is known about its habitat network connectivity with land use changes. We proposed an approach for the evaluation of the impacts of land use changes on landscape connectivity for North China leopard. Location: The Great Taihang Region, in the north of China, covers the entire territory of Shanxi province, as well as some districts and counties in Beijing, Hebei and Henan provinces. Methods: We analysed multiple background layers affecting North China leopard movement patterns, including environmental and anthropogenic factors, and generated a landscape resistance surface. Then we used Circuit theory-based connectivity models to delineate pathways suitable for species movement, and evaluate the connectivity status of core areas and the impacts of land use changes on landscape connectivity. Results: We identified 33 least cos distance paths in 1990 and 34 paths in 2020, and four key barrier areas. The landscape connectivity has not been greatly improved with the land use changes, especially with the increase of forest land from 26.61 to 34.85%. Nevertheless, there is a decreasing trend on connectivity in some key movement barrier areas. Improving landscape connectivity at a broad spatial scale is as important as protecting the habitats (natural reserves) where the species lived. Main conclusions: Our study can serve as an example of how to explore the relationships between land use changes and landscape connectivity for species at broad spatial scales with limited movement patterns data. This information is proved to be critical for enhancing landscape connectivity for conservation concern of North China leopard and planning of natural reserves network.

Climate change is increasing aridity in grassland and desert habitats across the southwestern United States, reducing available resources and drastically changing the breeding habitat of many bird species. Increases in aridity reduce sound propagation distances, potentially impacting habitat soundscapes, and leading to a breakdown of the avian soundscapes in the form of loss of vocal culture, reduced mating opportunities, and local population extinctions. We developed an agent-based model to examine how changes in aridity will affect both sound propagation and the ability of territorial birds to audibly contact their neighbors. We simulated vocal signal attenuation under a variety of environmental scenarios for the south central semi-arid prairies of the United States, ranging from contemporary weather conditions to predicted extremes under climate change. We also simulated how changes in physiological conditions, mainly evaporative water loss (EWL), would affect singing behavior. Under extreme climate change conditions, we found significantly fewer individuals successfully contacted all adjacent neighbors than did individuals in either the contemporary or mean climate change conditions. We also found that at higher sound frequencies and higher EWL, fewer individuals were able to successfully contact all of their neighbors, particularly in the extreme and extreme climate change conditions. These results indicate that climate change-mediated aridification may disrupt the avian soundscape, such that vocal communication no longer effectively functions for mate attraction or territorial defense. As climate change progresses increased aridity in current grasslands may favor shifts toward low frequency songs, colonial resource use, and altered songbird community compositions.

Routine exome sequencing (ES) in individuals with neurodevelopmental disorders (NDD) remains inconclusive in >50%. Research analysis of unsolved cases can identify novel candidate genes but is time consuming, subjective, and hard to compare between labs. The field therefore needs automated and standardized assessment methods to prioritize candidates for matchmaking. We developed AutoCaSc (https://autocasc.uni-leipzig.de) based on our candidate scoring scheme (CaSc). We validated our approach using synthetic trios and real in-house trio ES data. AutoCaSc consistently (94.5%) scored variants in valid novel NDD genes in the top three ranks. In 93 real trio exomes, AutoCaSc identified most (97.5%) previously manually scored variants while evaluating additional highly scoring variants missed in manual evaluation. It identified candidate variants in previously undescribed NDD candidate genes ( CNTN2, DLGAP1, SMURF1, NRXN3, PRICKLE1). AutoCaSc enables anybody to quickly screen a variant for its plausibility in NDD. After contributing >40 descriptions of NDD associated genes, we provide usage recommendations based on our extensive experience. Our implementation is capable of pipeline integration and therefore allows screening of large cohorts for candidate genes. AutoCaSc empowers even small labs to a standardized matchmaking collaboration and to contribute to the ongoing identification of novel NDD entities.

In this case report, a medical sales representative consumed 250 mg of Baclofen out of curiosity. Baclofen has life-threatening complications like seizures, respiratory depression and coma. A majority of patients recover on symptomatic treatment. Baclofen has a great potential for abuse and overdose; therefore, its use must be strictly monitored

Inguinal hernia may contain the bladder as one of its contents, while bilateral inguinal bladder herniation is rare. Urinary obstruction and obesity are associated with increased abdominal pressure and are risk factors of bladder herniation. Clinicians should be aware of the bladder hernia in elderly with chronic dysuria and obesity.

In this article, the author provides synopses of the factors that have finally propelled healthcare education and practice to join, at times reluctantly, the overarching digital transformative process that has been swept other industries over the last few decades. The key contributors and driving forces that have energized the entry of healthcare education and practices are mentioned. The roles of major universities, large technology companies and the expanding roles of Artificial Intelligence and Machine Learning are described. The projected future developments are predicted to continue to be substantial, sweeping and forcing changes that are unprecedented. Thus, academicians and practitioners should be alerted to what the rapidly changing landscape is likely to become and accordingly take steps to manage and preserve their roles or risk be left behind or worse be forced out.

In naturally competent bacteria, DNA transformation through horizontal gene transfer is an evolutionary mechanism to receive extracellular DNA. Bacteria need to maintain a state of competence to accept foreign DNA and this is an energy-driven phenomenon that is tightly controlled. In Streptococcus, competence development is a complex process that is not fully understood. In this study, we used Streptococcus mutans, an oral bacterium, to determine how cell density affects competence development. We found that in S. mutans the transformation efficiency is maximum when the transforming DNA was added at low cell density and incubated for 2.5 h before selecting for transformants. We also found that S. mutans cells remain competent until the mid-logarithmic phase, after which the competence decreases drastically. Surprisingly, we observed that individual components of Clp proteolytic complexes differentially regulate competence. If the transformation is carried out at the early growth phase, both ClpP protease and ClpX ATPase are needed for competence. In contrast, we found that both ClpC and ClpE negatively affect competence. We also found that if the transformation is carried out at the mid-logarithmic growth phase ClpX is still required for competence but ClpP negatively affects competence. While the exact reason for this differential effect of ClpP and ClpX on transformation is currently unknown, we found that both ClpC and ClpE have a negative effect on transformation, which was not reported before.

Subsurface chlorophyll maxima layers (SCML) are ubiquitous features of stratified aquatic systems. Availability of the micronutrient iron is known to influence marine SCML, but iron has not been explored in detail as a factor in the development of freshwater SCML. This study investigates the relationship between dissolved iron and the SCML within the dimictic, ferruginous lake Grosses Heiliges Meer in northern Germany. The occurrence of the SCML under non-ferruginous conditions in the spring and ferruginous conditions in the fall are context to explore temporal changes in the phytoplankton community and indicators of primary productivity. Results indicate that despite more abundant chlorophyll in the spring, the SCML sits below a likely primary productivity maximum within the epilimnion, inferred based on co-located dissolved oxygen, δ13CDIC, and pH maxima. The peak amount of chlorophyll in the SCML is lower in the fall than in the spring, but in the fall the SCML is co-located with elevated dissolved iron concentrations and a local δ13CDIC maximum. Cyanobacteria and Chlorophyta have elevated abundances within the SCML in the fall. Further investigation of the relationship of iron to primary productivity within ferruginous SCML may help to understand the environmental controls on primary productivity in past ferruginous oceans.

Phenotypic plasticity in reproductive behaviour can be a strong driver of individual fitness. For example, in species with high intra-sexual competition, changes in socio-sexual context can trigger quick adaptive plastic responses in males. In particular, a recent study in the vinegar fly (Drosophila melanogaster) shows that males respond adaptively to perception of female cues in a way that increases their reproductive success, but we ignore the underlying mechanisms of this phenomenon. Here, we aimed to fill this gap by investigating the short-term effects of female perception on male pre- and post-copulatory components of reproductive success: a) mating success, b) mating latency and duration, c) sperm competitiveness, and d) ejaculate effects on female receptivity and oviposition rate. We found that brief sexual perception increased mating duration, but had no effect on the main pre- or post-copulatory fitness proxies. These results tie up with previous findings to suggest that male adaptive responses to sexual perception are not due to a short-term advantage, but rather to fitness benefits that play out across the entire male lifespan.