A patient with internal carotid artery (ICA) rupture due to multiple irradiations underwent revascularization with high-flow bypass under the condition that endovascular treatment could not be performed. It was possible to safely remove necrotic tissues and reconstruct the skull base using trapping of the ruptured ICA.

Impact of Pre-ablation Weight Loss on the Success of Catheter Ablation for Atrial FibrillationAbdul Hafiz Al Tannir BS, Marwan M. Refaat MDDepartment of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, LebanonRunning Title: Pre-ablation Weight Loss and Success of AF AblationDisclosures: NoneFunding: NoneKeywords: Cardiac Arrhythmias, Cardiovascular Diseases, Heart Diseases, Weight Loss, Catheter Ablation, Atrial FibrillationWords: 621 (excluding references)Correspondence:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FRCPAssociate Professor of MedicineDirector, Cardiovascular Fellowship ProgramDepartment of Internal Medicine, Cardiovascular Medicine/Cardiac ElectrophysiologyDepartment of Biochemistry and Molecular GeneticsAmerican University of Beirut Faculty of Medicine and Medical CenterPO Box 11-0236, Riad El-Solh 1107 2020- Beirut, LebanonFax: +961-1-370814Clinic: +961-1-759616 or +961-1-355500 or +961-1-350000/+961-1-374374 Extension 5800Office: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)Email: [email protected] the United States, the prevalence of obese individuals has risen 3-fold since 1960, with 1 in every 3 persons being obese. The effect of weight changes on the progression on atrial fibrillation is well-established but the effect of pre-ablation weight loss on the recurrence of atrial fibrillation is not well-studied. Atrial fibrillation is the most frequently encountered cardiac arrhythmia [1]; it currently affects around 2.7 million people in the United States of America and is estimated that 6-12 million people will suffer from this condition by 2050 [2, 3]. Pulmonary vein isolation is the primary target for cardiac ablation; it can be achieved either by radiofrequency (RF) or cryoballoon ablation (CBA) [4, 5]. The FIRE and ICE trial conducted by Kuck et al showed that CBA therapy was associated with significantly fewer recurrence, rehospitalization, and cardioversion rates [6]. Several studies suggest the preferred use of CBA in treating atrial fibrillation in obese patients due to the increased surface area for ablation [4].Obesity has adverse effects on the structure and hemodynamics of the heart and it is a well-established risk factor for the development of atrial fibrillation [3]. A prospective cohort study performed by Pathak et al showed that progressive weight loss in obese and overweight patients resulted in dose-dependent effects on freedom from atrial fibrillation (FFAF) [7]. Similarly, Middeldrop et al, concluded that obesity is associated with the progression of the disease while weight loss is associated with reversal of the progression [8]. Limited data is available regarding the effect of weight loss on the recurrence of atrial fibrillation post-ablation. Current guidelines recommend lifestyle modifications, including a healthy diet and exercise, for overweight and obese patients before ablation [8, 9].The study of Peigh et al. is a retrospective cohort study from 2012-2017; 607 patients met the inclusion criteria. The aim of the study is to assess the impact of patient-directed weight loss 1 year before CBA on FFAP 15 months after ablation. The authors addressed an important topic that is poorly understood. Obese patients have a significantly lower FFAF rate 40-50% than the overall population 60-80%. The study selectively included patients undergoing CBA therapy. The follow-up time was 1-year post-ablation. The study concluded that, with the exception of non-obese patients with persistent atrial fibrillation, weight loss is associated with a significantly increased FFAF while weight gain led to a decrease in FFAF. A similar study assessed the impacted of physician-mediated risk control in patients undergoing RF ablation for atrial fibrillation [10]. A total of 149 patients were included in the prospective cohort study. The study showed a positive association between physician-directed weight loss (≥ 10%) and FFAF in symptomatic obese patients. The study performed by Peigh et al, included though a larger subject group (607) than LEGACY (141); however, the LEGACY is a prospective cohort study that is more suitable to monitor the fluctuation in patients’ variables before ablation.This study was well conducted but has the limitations of retrospective studies; a prospective cohort study would better monitor the variations in patients’ variables pre-ablation. In addition, as the authors stated, asymptomatic atrial fibrillation episodes may go unnoticed.Patients with atrial fibrillation, particularly those who are obese, should be advised to lose weight prior to catheter ablation. Lifestyle modifications should not be limited to patients undergoing ablation; the effect of weight loss on disease progression is well-established. Due to the overgrowing prevalence of atrial fibrillation and obesity worldwide, more studies are encouraged to better understand the ideal lifestyle management in patients. Larger prospective cohort studies should be conducted in order to validate the results. There is also an ongoing randomized clinical trial BAROS (Bariatric Atrial Return of Sinus Trial) [NCT 04050969] which will provide more data on this topic.

Anthropogenic climate change has led to unprecedented shifts in temperature across many ecosystems. In a context of rapid environmental changes, acclimation is an important process as it may influence the capacity of organisms to survive under novel thermal conditions. Mechanisms of acclimation could involve upregulation of stress response genes involved in protein folding, DNA damage repair and the regulation of signal transduction genes, along with a simultaneous downregulation of genes involved in growth or cell cycle, in order to maintain cellular functions and equilibria. We transplanted Lobaria pulmonaria lichens originating from different forests to determine the relative effects of long-term acclimation and genetic factors on the variability in expression of mycobiont and photobiont genes. We found a strong response of mycobiont and photobiont to high temperatures, regardless of sample origin. The green-algal photobiont had an overall lower response than the mycobiont. The gene expression of both symbionts was also influenced by acclimation to transplantation sites and by genetic factors. Lobaria pulmonaria seems to have evolved powerful molecular pathways to deal with environmental fluctuations and stress and can acclimate to new habitats by transcriptomic convergence. Although L. pulmonaria has the molecular machinery to counteract short-term thermal stress, survival of lichens like L. pulmonaria depends mostly on their long-term positive carbon balance, which can be compromised by warmer temperatures and reduced precipitation, and both these outcomes have been predicted for Central Europe in connection with global climate change

Ventricular tachycardia (VT) normally occurs from an abnormal structural substrate. We report a case in which VT was caused by a large tumor in the interventricular septum. Surgical intervention was not an option due to the location of the tumor and its proximity to the coronary arteries. The patient underwent ablation and upgrade to CRT before ultimately receiving a heart transplant.

It is well known that the left internal mammary artery (LIMA) should be the first conduit of choice. Similarly, especially in patients younger than 70 years, other conduits should be search among arterial grafts such as right internal mammary artery (RIMA) or radial artery (RA). If the RA can be harvested in the meanwhile of LIMA harvesting without time consuming, it is well established that former one has to be grafted only on presence of a good run-off. One of the main criticisms moved to the use of RIMA are linked to technical difficulties in its harvesting it. Edgar Aranda-Michel and coworkers tried to answer to the age-old question is “RIMA has to be used in situ or free-graft?” In a retrospective study on 667 patients (442 had free RIMA and 245 had free RIMA) that were also matched through propensity analysis (202 patients per group), they did not find any differences between the two groups in the major outcomes, including heart failure specific readmissions. This finding is consistent with the literature, hence the take-home message is whatever happens, two mammary is better than one.

Telemedicine, telehealth and artificial intelligence in healthcare are becoming commonly utilized in various medical specialties. The article authored by Dr. Aminah Sallam and colleagues in the Journal provides data in support of the cardiac surgical patients, and the caring cardiac surgeons willingness to adopt telemedicine as a method of connectivity between patient and surgeon.

We describe two cases of microlaryngeal surgery under general anesthesia in severe obese elite vocal performers. Microlaryngeal surgery under general anesthesia is feasible in patients with severe obesity, provided that the anesthesiologist and nurse work together to perform preoperative simulations and take into consideration the position and anesthesia.

Background: There is limited data to inform minimum case requirements for training in robotically-assisted coronary artery bypass grafting (RA-CABG). Current recommendations rely on non-clinical endpoints and expert opinion. Objectives: To determine the minimum number of RA-CABG procedures required to achieve stable clinical outcomes. Methods: We included isolated RA-CABG in The Society of Thoracic Surgeons (STS) registry performed between 2014 and 2019 by surgeons without prior RA-CABG experience. Outcomes were approach conversion, reoperation, major morbidity or mortality, and procedural success. Case sequence number was used as a continuous variable in logistic regression with restricted cubic splines with fixed effects. Outcomes were compared between operations performed earlier versus later in case sequences using unadjusted and adjusted metrics. Results: There were 1195 cases performed by 114 surgeons. A visual inflection point occurs by a surgeon’s 10th procedure for approach conversion, major morbidity or mortality, and overall procedural success after which outcomes stabilize. There was a significant decrease in the rate of approach conversion (7.7% and 2.5%), reoperation (18.9% and 10.8%), and major morbidity or mortality (21.7% and 12.9%), as well as an increase in rate of procedural success (72.9% and 85.3%) with increasing experience between groups. In a multivariable logistic regression model case sequences of >10 was an independent predictor of decreased approach conversion (OR 0.27, 95% CI 0.09 to 0.84) and increased rate procedural success (OR 1.96, 95% CI 1.00 to 3.84).

Mosquito allergy can rarely give raise to severe clinical manifestations.Here we describe the case of a patient suffering from relapsing anaphylaxis after mosquito bites, who completely responded to off label therapy with anti-IgE monoclonal antibody.This is the first demonstration of the efficacy of omalizumab in such unusual life-threatening allergy.

Understanding how urbanization alters functional interactions among pollinators and plants is critically important given increasing anthropogenic land use and declines in pollinator populations. Pollinators often exhibit short-term specialization, and visit plants of the same species during one foraging trip. This facilitates plant receipt of conspecific pollen -- pollen on a pollinator that is the same species as the plant on which the pollinator was foraging. Conspecific pollen receipt facilitates plant reproductive success and is thus important to plant and pollinator persistence. We investigated how urbanization affects short term specialization of insect pollinators by examining pollen loads on insects' bodies and identifying the number and species of pollen grains on insects caught in urban habitat fragments and natural areas. We then assessed possible drivers of differences between urban and natural areas, including frequency dependence in foraging, species richness and diversity of the plant and pollinator communities, floral abundance, and the presence of invasive plant species. Pollinators were more specialized in urban fragments than in natural areas, despite no differences in the species richness of plant communities across site types. These differences were likely driven by higher specialization of common pollinators, which were more abundant in urban sites. Pollinators were also more specialized when foraging on invasive plants across sites, and floral abundance of invasive plants was higher in urban sites. Our findings reveal strong effects of urbanization on pollinator fidelity to individual plant species and have implications for the maintenance of plant species diversity in small habitat fragments. The higher fidelity of pollinators to invasive plants suggests that native species may receive fewer visits by pollinators. Therefore, native plant species diversity may decline in urban sites without continued augmentation of urban flora or removal of invasive species.

High rates of erosion and runoff production on road infrastructure have been documented, indicating that unpaved roads might be significant sources of sediment in catchments. In this paper, the production of surface sediments from unpaved rural roads at different scales is assessed. The study took place in northeastern Brazil, in a semiarid area of the Caatinga biome, vulnerable to desertification. Sediment production data from road surface segments were monitored for two years (2013-2014) under conditions of natural precipitation. By using hydrosedimentological modeling and Geographic Information System (GIS), the sediment budget was calculated at the meso-scale basin (aprox. 930 km²), in order to identify the relative contribution of roads to the sediment balance. Universal Soil Loss Equation (USLE) associated with Maner’s sediment delivery ratio (SDR) equation, proved to be an adequate approach for predicting sediment yield on the road segment scale; the best results were obtained for the road without traffic, due to the non-interference in this segment of external factors, such as traffic and maintenance activities, not explicitly considered in the model formulation. The modeling procedure showed that the roads, which occupy only 0.7% of the catchment surface, were responsible for approximately 7% of soil loss in the area. Furthermore, sediment connectivity might be enhanced by roads, which cross the river network and, therefore, deliver more directly the sediment generated at hillslopes. This is particularly important in the studied environment, where sediment connectivity is low due to limited runoff and the existence of a dense network of surface water reservoir

Dominant and non-dominant plants could be subject to different biotic and abiotic influences, partially because dominant plants modify the environment where non-dominant plants grow, causing an interaction asymmetry. Among other possibilities, if dominant plants compete strongly, they should deplete most resources forcing non-dominant plants into a more constrained niche space. Conversely, if dominant plants are constrained by the environment, they might not fully deplete available resources but instead ameliorate some of the environmental constraints limiting non-dominants. Hence, the nature of the interactions between the non-dominants could be modified by dominant species. However, when plant competition and environmental constraints have similar effects on dominant and non-dominant species no difference is expected. By estimating phylogenetic dispersion in 78 grasslands across five continents, we found that dominant species were clustered (underdispersed), suggesting dominant species are likely organized by environmental filtering, and that non-dominant species were either randomly assembled or overdispersed. Traits showed similar trends, but insufficient data prevented further analyses. Furthermore, several lineages scattered in the phylogeny had more non-dominant species, suggesting that traits related to non-dominants are phylogenetically conserved and have evolved multiple times. We found some environmental drivers of the dominant—non-dominant disparity. Our results indicate that assembly patterns for dominants and non-dominants are different, consistent with asymmetries in assembly mechanisms. Among the different mechanisms we evaluated, the results suggest two complementary hypotheses seldom explored: (1) Non-dominant species include lineages adapted to thrive in the environment generated by the dominant species. (2) Even when dominant species reduce resources to non-dominant ones, dominant species could have a stronger effect on—at least—some non-dominants by ameliorating the impact of the environment on them, than by depleting resources and increasing the environmental stress to those non-dominants. The results show that the dominant–non-dominant asymmetry has ecological and evolutionary consequences fundamental to understand plant communities.

Automatic identification of VT substrate in the era of ultra-high-density mapping: Do Humans or Machines emerge victorious?Richard G. Bennett, BSc, MBChB,a Timothy G. Campbell, BSc,a Saurabh Kumar, BSc(Med)/MBBS, PhDaaDepartment of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia.Correspondence: Associate Professor Saurabh Kumar, Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Darcy Road, Westmead, New South Wales, Australia, 2145. Phone +612 8890 8140; Fax: +612 8890 8323; email: [email protected]: Timothy Campbell has received speakers’ honoraria for Biosense Webster, Inc. in the last 12 monthsFunding: Dr Saurabh Kumar is supported by the NSW Early-mid Career FellowshipKeywords: Ventricular tachycardia, local abnormal ventricular activities, electroanatomic mapping, catheter ablation, structural heart disease

Background: 64 million pharmacy filled multicompartment medication compliance aids (MCAs) are dispensed by pharmacies in England each year as a method to improve medication adherence. Despite the widespread use of MCAs and evidence that their use may be associated with harm there is no national consensus regarding MCA provision by acute hospital Trusts in England. Aim: To determine current practice for initiation and supply of MCAs in acute hospital Trusts in England and the potential consequences for patients and hospitals. Methods: A 26 item survey was distributed to all acute hospital Trusts in England. The questionnaire covered policy, initiation, supply and review of MCAs; alternatives offered; and pharmacy staffing and capacity related to MCAs. Results: 72 out of 138 (52%) Trusts responded to the survey. 60/70 (86%) had a policy for the provision of MCAs. 33/55 (60%) that supplied MCAs on discharge supplied a different prescription length for MCA vs. non-MCA prescriptions. 49/55 (89%) Trusts provided only one brand of MCA. 47/55 (85%) MCA-supplying Trusts identified frequent difficulties with MCAs and 13/55 (24%) reported employing staff specifically to complete MCAs. 30/35 (86%) MCA-initiating Trusts had an assessment process for initiation, with care agency request as the most common reason. Conclusion: There is a lack of a national approach to MCA provision and initiation by acute hospital Trusts in England. This leads to significant variation in care and has the potential to put MCA users at an increased risk of medication related harm.

ST-segment changes may provide a clue to the presence of pneumopericardium accompanying SPM. These EKG changes associated with SPM are rare. The management in SPM with concurrent pneumopericardium is mainly supportive. We describe two SP cases with concomitant pneumopericardium that presented with a deceptive clinical spectrum, closely mimicking acute pericarditis.

We report a case of a 52-year old patient complaining of palpitations and syncope. His heart rate trends from his Apple Watch SE suggested two types of tachycardia, and we successfully performed ablation for both of them in a single session. Our case demonstrates the cardiological potential of smart watches.

Objective: To evaluate group differences in social adjustment in survivors of pediatric ALL compared to survivor siblings, and controls; identify disease-related predictors of social adjustment in survivors; and explore whether executive functioning explained differences in social adjustment across groups and between disease-related predictors. Methods: Survivors of pediatric ALL (n=38, average age at diagnosis=4.27 years [SD=1.97]; average time off treatment=4.83 years [SD=1.52]), one sibling (if available, n=20), and one parent from each family were recruited from a long-term survivor clinic. Healthy age- and sex-matched controls (n=38) and one parent from each family were recruited from the community. Parents completed the Behavioral Assessment System for Children, Parent Rating Scale (BASC-3) Social Withdrawal subscale as a measure of social adjustment and the Behavior Rating Inventory of Executive Functions (BRIEF-2) as a measure of executive function for each of their children. Results: Parents reported that survivors had significantly worse social adjustment compared to controls (b=6.34, p=.004), but not survivor siblings. Among survivors, greater time off treatment (b=2.06, p=.058) and poorer executive functioning (b=0.42, p=.006) were associated with worse social adjustment. Executive function did not mediate differences in social withdrawal between survivors and controls or the relationship between time off treatment and social withdrawal among survivors. Conclusions: Survivors of pediatric ALL presenting to follow-up programs should be screened for difficulties with social adjustment. Future research should examine treatment- and non-treatment-related factors contributing to poorer social outcomes.

The advanced use of a pH-responsive biomaterial-based injectable liquid implant for effective chemotherapeutic delivery in glioblastoma multiforme brain (GBM) tumour treatment is presented. As an implant, we proposed a water-in-oil-in-water multiple emulsion with encapsulated doxorubicin. The effectiveness of the proposed therapy was evaluated by comparing the cancer cell viability achieved in classical therapy (chemotherapeutic solution). The experimental study included doxorubicin release rates and consumption for two emulsions differing in drop sizes and structures in the presence of GBM-cells (LN229, U87 MG), and a cell viability. The results showed that the multiple emulsion implant was significantly more effective than classical therapy when considering the reduction in cancer cell viability: 85% for the emulsion-implant, and only 43% for the classical therapy. A diffusion-reaction model was adapted to predict doxorubicin release kinetics and elimination by glioblastoma cells. CFD simulations confirmed that the drug release kinetics depends on multiple emulsion structures and drop sizes.