Objectives: evaluate the Surveillance Program of Gestational and Congenital Toxoplasmosis. Methods: 424 pregnant women were interviewed regarding their knowledge of prevention measures in 2019. Secondary prevention measures were assessed on the results of anti-Toxoplasma gondii serological tests were collected from pregnant women, from 2015 to 2018. the tertiary prevention measures, we screened the babies of mothers who had recent suspected infections of T. gondii to verify the referrals to the reference service. Results: 45.5% (192/424) reported that they had received guidance from health professionals; 35.4% (68/192) changed their risk habits. The variables of schooling and age, having received prior guidance from health professionals and feline possession, proved to be significant when associated with the notions of preventive measures. 90.2% (17,423 / 19,319) of pregnant women had undergone serological tests to detect anti-T. gondii antibodies but there was an excess in requests for tests and medication and only 40.6% (26/64) of the children were referred to the referral hospital. Conclusions: the Program presents positive results regarding the performance of serological screening in prenatal care; however, the dissemination of knowledge about the prevention of toxoplasmosis and the request for tests need to be improved.

Early improvement of smile esthetic is critical in patients with severely malformed front teeth particularly when it affects the patient's confidence. As illustrated in this report, correction of midline by moving a fused central incisor across the midpalatal suture was successfully performed to make an acceptable esthetic smile.

Reflections from the Book of the Dead: Weighing the Impact of Epicardial Fat on Atrial Fibrillation Vulnerability T. Jared Bunch MDDepartment of Medicine, School of Medicine, University of Utah, Salt Lake City, UtahAddress for correspondence: T. Jared Bunch, M.D.University of Utah School of Medicine Department of Internal Medicine Division of Cardiovascular Medicine 30 North 1900 East, Room 4A100 Salt Lake City, UT 84132 Phone: 801-213-2387 E-mail: [email protected]

BACKGROUND Although low voltage zones (LVZs) in the left atrium (LA) are seen as arrhythmogenic substrate in some patients with atrial fibrillation (AF), pathophysiologic factors responsible for LVZ formation remain unclear. OBJECTIVE To elucidate the anatomical relation between the LA and ascending aorta responsible for remodeling of the anterior LA wall. METHODS We assessed the relation between existence of LVZs on the anterior LA wall and measurements taken on 3-dimensional computed tomography images obtained from 102 patients who underwent AF ablation. RESULTS Twenty-nine patients (28%) had LVZs >1.0 cm2 on the LA wall at the LA-ascending aorta contact area (LVZ Group); no LVZs were seen in the other 73 patients (No LVZ Group). In the LVZ Group (vs. No LVZ Group), the aorta-LA angle was smaller (21.0±7.7° vs. 24.9±7.1°, P = 0.015), the aorta-left ventricle (LV) angle was greater (131.3±8.8° vs. 126.0±7.9°; P = 0.005), non-coronary cusp (NCC) diameter was greater (20.4±2.2 mm vs. 19.3±2.5 mm; P = 0.036), and the NCC was closer to the anterior LA wall (2.29±0.68 mm vs. 2.76±0.79 mm; P = 0.006). The aorta-LA angle correlated positively with patients’ body mass index (BMI) and negatively with body weight and BMI. CONCLUSION Deviation of the ascending aorta course and distention of the NCC appear to be related to the development of LA anterior wall LVZs at the LA-ascending aorta contact area. Mechanical pressure exerted by extracardiac structures on the LA along with limited thoracic space may contribute to the development of LVZs associated with AF.

Title: Making the Cut for Generator ReplacementsAuthors: Venkatesh Ravi, MD1; Jeremiah Wasserlauf, MD, MS1;1: Section of electrophysiology, Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, USACorresponding author:Jeremiah Wasserlauf, MD, MSAssistant Professor of Medicine,Cardiac Electrophysiology, Department of Internal Medicine/Division of Cardiology,Rush University Medical Center.1717 W. Congress Parkway, Suite 345, Chicago, IL 60612Email: [email protected]: NoneDisclosure: Dr. Jeremiah Wasserlauf has received consulting fees from Stryker. No other conflicts of interest to disclose.EditorialCardiac implantable electronic devices (CIED) have become a common treatment modality for cardiac arrhythmia with over 300,000 new implants every year in the United States. A growing number of patients will require device replacement procedures throughout their lifetime.1 In a registry of 1744 patients undergoing CIED replacement procedures, lead damage or dislodgement requiring revision was found to occur in 1% of patients without previously planned addition of leads.2 The resulting lead addition and extraction procedures give rise to added procedural time, risk of complications, prolonged hospitalization, and increased health care costs.2 Polyurethane and copolymer insulation materials are more susceptible to thermal damage when compared to silicone.3,4 Avoidance of lead damage during CIED replacement procedures has been a topic of increasing investigation, with studies evaluating differences between electrosurgical modes, power settings, blade orientation, and equipment manufacturers. Operators have the option to choose between standard electrocautery with non-insulated blades, and cautery with insulated blades (PEAK PlasmaBlade, Medtronic Inc., Minneapolis, MN, or Photonblade, Stryker, Kalamazoo, MI).Electrocautery operates by generating a high current density which results in resistive heating and thereby cuts or coagulates tissue. PlasmaBlade uses a proprietary power output waveform to deliver energy along the exposed edge of a thin, insulated electrode powered by a proprietary electrosurgical generator. Photonblade is an alternative insulated electrocautery blade that is compatible with a standard electrosurgical generator. In a retrospective study by Kypta et al, PlasmaBlade was associated with a lesser risk of lead damage and shorter procedure duration and hospital stay when compared with electrocautery and scissors.3 In an ex vivo animal tissue model using Photonblade, coagulation mode during cautery was associated with more damage than cut, and this effect was greatest when contact occurred using the active edge as opposed to the insulated flat side of the cautery blade, and when the lead insulation consisted of polyurethane or copolymer. Visible lead damage was found to be more common with PlasmaBlade when compared to Photonblade. 4In this edition of the Journal of Cardiovascular Electrophysiology , Ananwattanasuk et al performed a retrospective analysis of traditional electrocautery vs PlasmaBlade on lead parameters and complications following CIED generator replacement procedures.5 The study included 410 consecutive patients (840 leads) who underwent CIED replacement using conventional electrocautery (EC group) and 410 patients (824 leads) who underwent CIED replacement using PlasmaBlade (PK group). The power settings for the PK group were 6 in CUT mode and 8 in COAG mode. In the EC group, power output was set to 40 Watts for both CUT and COAG mode. CUT mode was used for tissue dissection and COAG was only used for hemostasis. The two groups had similar device systems and baseline characteristics. In comparison to the PK group, the EC group had a slightly lower proportion of silicone leads (78% vs 83%, p < 0.01) and a slightly higher proportion of polyurethane leads (19% vs 13%, p < 0.01). The study found no statistically significant difference in lead damage requiring lead revision between the EC group and PK group (0.6% vs 0.4%, p=0.5). There was no difference in procedural complications between the two groups (2.2% vs 1.2%, p = 0.28). There was no difference in lead sensing. There was a higher number of patients with a decrease in lead impedance in the PK group compared to the EC group (61.5% vs 52.1%, p < 0.01), and perhaps unexpectedly, more patients with an increase in lead impedance in the EC group compared to the PK group (46.8% vs 34.2%, p<0.01).On average, the change in pacing impedance changed less than 10% in both groups. A majority of leads in both groups were comprised of silicone which may have been a primary contributor to the low rate of lead damage observed. These findings contrast with the older retrospective study that found a lower risk of lead damage with PlasmaBlade compared to a historical control group where titanium scissors were used with conventional electrocautery for hemostasis. The difference observed in the prior study between groups, and the overall higher rates of lead damage in that study may have been related to the use of scissors or perhaps a greater proportion of leads with non-silicone insulation (lead insulation material was not reported). The present study by Ananwattanasuk et al contributes to the literature with a larger cohort of patients and contemporary operative technique.It is never too late to scrutinize the benefit of tools that have added costs as our procedural techniques evolve. The authors should be commended for rigorously collecting not only clinical outcomes but also electrical device parameters to assess for subclinical lead damage. Although generator replacements are short and less complex when compared to other EP procedures, the total cost of generator replacement procedures is estimated at several billion dollars yearly in the US alone.6 Leadless pacemakers and the evolution of modular systems are attractive and may solve some problems related to lead damage during generator replacements, or perhaps one day eliminate generator replacements altogether. However, with the current number of CIEDs in operation and the aging population, a growing number of patients will continue to require generator replacement procedures over the next several decades. The overall safety of generator replacement procedures has improved though advances such as avoidance of routine capsulectomy, antibiotic-impregnated pouches for appropriate candidates, and prolonged replacement intervals due to improved battery longevity. Through an unremitting focus on safety and cost-effectiveness, we will stay on the cutting edge of straightforward and complex procedures in the EP lab.References1. Greenspon AJ, Patel JD, Lau E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol. 2011;58:1001-1006.2. Poole JE, Gleva MJ, Mela T, et al. Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry.Circulation. 2010;122:1553-1561.3. Kypta A, Blessberger H, Saleh K, et al. An electrical plasma surgery tool for device replacement–retrospective evaluation of complications and economic evaluation of costs and resource use. Pacing Clin Electrophysiol. 2015;38:28-34.4. Wasserlauf J, Esheim T, Jarett NM, et al. Avoiding damage to transvenous leads-A comparison of electrocautery techniques and two insulated electrocautery blades. Pacing Clin Electrophysiol.2018;41:1593-1599.5. Ananwattanasuk T, Jame S, Bogun F, et al. Journal of Cardiovascular Electrophysiology. 2021.6. Hauser RG. The growing mismatch between patient longevity and the service life of implantable cardioverter-defibrillators. J Am Coll Cardiol. 2005;45:2022-2025.

Letter to the Editor, BJOG Exchange

Background: The sustainability of the results of mitraclip procedures is a source of concern. Aims: To investigate risk factors of severe mitral regurgitation (MR) recurrence after Mitraclip in primary MR. Methods and results: Eighty-three patients undergoing successful Mitraclip procedures were retrospectively included. Valve anatomy and Mitraclips placement were comprehensively analyzed by post-processing 3D echocardiographic acquisition. The primary composite endpoint was the recurrence of severe MR. Mean age was 83±7 years-old, 37 (44%) were female. Median follow-up was 381 days (IQR 195-717) and 17 (20%) patients reached the primary endpoint. Main causes of recurrence of severe MR were relapse of a prolapse (64%) and single leaflet detachment (23%). Posterior coaptation line length (HR 1.06 95%CI 1.01-1.12 p=0.02), poor imaging quality (HR 3.84, 95%CI1.12-13.19; p=0.03), and inter-clip distance (HR 1.60, 95%CI 1.27-2.02; p<0.01) were associated with the occurrence of the primary endpoint. Conclusions: Recurrence of severe MR after a MitraClip procedure for primary MR is common and results from a complex interplay between anatomical (tissue excess) and procedural criteria (quality of ultrasound guidance and MitraClips spacing).

The first-order relativistic corrections to the non-relativistic energies of hydrogen-like atom embedded in plasma screening environments are calculated in the framework of direct perturbation theory by using the generalized pseudospectral method. The standard Debye-Hückel potential, exponential cosine screened Coulomb potential, and Hulthén potential are employed to model different screening conditions and their effects on the eigenenergies of hydrogen-like atoms are investigated. The relativistic corrections which include the relativistic mass correction, Darwin term, and the spin-orbit coupling term for both the ground and excited states are reported as functions of screening parameters. Comparison with previous theoretical predictions shows that both the relativistic mass correction and spin-orbit coupling obtained in this work are in good agreement with previous estimations, while significant discrepancy and even opposite trend is found for the Darwin term. The overall relativistic-corrected system energies predicted in this work, however, are in good agreement with the fully relativistic calculations available in the literature. We finally present the scaling law of the first-order relativistic corrections and discuss the validity of the direct perturbation theory with respect to both the nuclear charge and the screening parameter.

1. IntroductionTropical mountainous ecosystems are recognized as providers of valuable ecological and hydrological services (Viviroli et al, 2007). In Central America, the Páramo, a high‐elevation tropical grassland ecosystem, extends over ~ 200 km2 in Costa Rica and Panama, with ~50% of this area located within the Chirripó National Park between 3,100 and 3,820 m asl (-83.49°, 9.46°). Vegetation mostly consists of 0.5 to 2.5 m tall bamboo dominated (Chusquea subtessellata ) grasslands, covering up to 60% of the total Páramo area in Costa Rica (Fig.1a). The climate is controlled by the northeast trade winds, the latitudinal migration of the Intertropical Convergence Zone (ITCZ), cold continental outbreaks (i.e., northerly winds), and the seasonal influence of Caribbean cyclones. These circulation patterns produce two rainfall maxima on the Pacific slope, one in June and one in September, which are interrupted by a relative minimum between July-August, known as the Mid-Summer Drought, due to intensification of trade winds over the Caribbean Sea (Magaña et al., 1999; Waylen, 1996). The wettest season extends from May to November (contributing up to 89% of the annual precipitation), whereas the driest season is from December to April (Fig. 2a; Esquivel-Hernández et al., 2018). The surface water system of Chirripó is characterized by a lake district which comprises approximately 30 lakes of glacial origin and streams flowing down the Caribbean and Pacific slopes (Fig 1b). Lake catchments are characterized by steep slopes that promote rapid hydrological responses such as fast water‐level changes. Input of water to these glacial lakes is mostly controlled by the seasonal inputs of rainfall, which mix up with stream and subsurface waters. In April 2015, the Chirripó Hydrological Research Site (CHRS) was installed with the goal of advancing the understanding of the hydrological functioning in the Central American Páramo using environmental tracers (i.e., water stable isotopes) in combination with hydrometric data. A detailed map of CHRS is available in Esquivel-Hernández et al. (2019).

Background Hypothyroxinemia, i.e. Low free T4 with normal TSH level, which overlaps, to a great extent, with the laboratory criteria of central hypothyroidism, could be easily neglected, if attention is paid only to patients with elevated TSH. We aimed to assess the association between mirtazapine use and hypothyroxinemia in patients affected by major depressive disorder. Methods We conducted a retrospective cohort study in the Second Affiliated Hospital of Xinxiang Medical University between January 2016 and December 2018. Patients affected by major depression disorder and admitted to the hospital for treatment during the study period and had thyroid tests at admission and after treatment were included. Patients with abnormal thyroid function at baseline or received mood stabilizers or quetiapine during hospitalization were excluded. Mirtazapine use was the exposure measure, and hypothyroxinemia was as the primary outcome of this study. Log-binomial model was used to estimate the association between mirtazapine use and hypothyroxinemia, after adjusting for potential confounding factors. Results A total of 220 eligible patients were included in the final analysis. Of them, 88 used mirtazapine. The incidence of hypothyroxinemia in patients who used mirtazapine was higher (37.5%) than those patients who did not use (19.7%). The relative risk of developing hypothyroxinemia was 1.64 (95% confidence interval: 1.31-1.78) for mirtazapine use, after adjusting for confounding factors. Conclusion Mirtazapine use was associated with the risk of developing hypothyroxinemia. Clinicians should be aware that hypothyroxinemia may be neglected in patients treated by mirtazapine due to attention paid only to those with elevated TSH.

A 61-year-old female with 50000 ventricular premature contractions and reduced left ventricular ejection fraction of 35% referred to our center. Although the origin was considered to be originated from the junction between the left and right coronary cusp, a single radiofrequency application above the aortic sinus cusp could eliminate it.

Aims: To optimize the dosing regimen in patients with severe renal impairment based on population pharmacokinetic/pharmacodynamic (PPK/PD) analysis. Methods: The pharmacokinetics and safety of nemonoxacin was evaluated in a single-dose, open-label, nonrandomized, parallel-group study after single oral dose of 0.5 g nemonoxacin capsule in 10 patients with severe renal impairment and 10 healthy controls. Both blood and urine samples were collected within 48 hours after admission and determined the concentrations. A PPK model was built using nonlinear mixed effects modelling. The probability of target attainment (PTA) and the cumulative fraction of response (CFR) against S. Pneumoniae and S. aureus was calculated by Monte Carlo simulation. Results: The data best fitted to a two-compartment model, from which the PPK parameters were estimated, including clearance (8.55 L/h), central compartment volume (80.8 L), and peripheral compartment volume (50.6 L). The accumulative urinary excretion was 23.4±6.5% in severe renal impairment patients and 66.1±16.8% in healthy controls. PPK/PD modeling and simulation of 4 dosage regimens found that nemonoxacin 0.5 g q48h was the optimal dosing regimen in severe renal impairment patients, evidenced by higher PTA (92.7%) and CFR (>99%) at nemonoxacin MIC ≤ 1 mg/L against S. pneumoniae and S. aureus. The alternative regimens (0.25 g q24h; loading dose 0.5 g on Day 1 followed by 0.25 g q24h) were insufficient to cover the pathogens even if MIC ≤ 0.5 mg/L. Conclusion: An extended dosing interval (0.5 g q48h) may be appropriate for optimal efficacy of nemonoxacin in case of severe renal impairment.

Lymphangiomas of the tongue are very rare tumors usually diagnosed in infancy and early childhood. Children with Lymphangiomas of the tongue may require multidisciplinary care and a close collaboration between physician and dentist to be able to eradicate any sources of dental infections before undertaking medical treatment.

We present a unique Richter's transformation case in CNS with identical to CLL clonal origin in a patient treated with Venetoclax. With our case we make implications on whether Venetoclax penetrates the blood-brain barrier and we address the debating issue of the appropriate Venetoclax dose in case of drug-drug interactions.

A 68-year-old male presented with a difficult airway secondary to a firm mass at the base of the tongue on intubation for an emergency general surgical procedure. Further workup confirmed a lingual thyroid with previous upper airway obstruction requiring a temporary tracheostomy. The mass was excised using transoral robotic surgery.

Thrombosis within the microvasculature and medium to large vessels is a serious and common complication among critically ill individuals with COVID-19. While children are markedly less likely to develop severe disease than adults, they remain at risk for thrombosis during acute infection and with the post-acute inflammatory illness termed multisystem inflammatory syndrome in children. Significant knowledge deficits in understanding COVID-19 associated coagulopathy and thrombotic risk pose clinical challenges for pediatric providers who must incorporate expert opinion and personal experience to manage individual patients. We discuss clinical scenarios to provide framework for characterizing thrombosis risk and thromboprophylaxis in children with COVID-19.

Background The role of percutaneous repair of functional mitral regurgitation (MR) is evolving. Left ventricle remodeling is known to be different between men and women; however, outcomes following percutaneous repair of functional MR have not considered the impact of sex. Methods Between 2012 and 2018, 175 patients underwent percutaneous repair of functional MR with the Mitra Clip NT/NTR (Abbott, Irvine CA) at our institution. Patients were assessed in a dedicated clinic with a follow-up that averaged 0.7±1.2 years and extended to 5.7 years. Results Men had a larger body surface area than women (p<0.001), whereas women were more likely than men to have diabetes preoperatively (p=0.02). There were no deaths or instances of single leaflet detachment. Immediate post-procedure MR was <2+ in 158 (90%) with a mean trans-mitral valve repair gradient of 3.4±1.0 and 3.5±2.1 mm Hg, respectively for women and men (p=0.8). One- and 2-year freedom from MR >3+ was 86.0±3.5% and 77.6±5.1%, respectively. After adjusting for differences between male and female patients, women were more likely to have recurrent MR >3+ (hazard ratio 4.7, 95% confidence interval 1.2-18.4, p=0.03). Upon adjusted analysis, there was also no association between gender and survival (p=0.2). One- and 2- year survival was 69.8±4.3% and 54.3±5.5%, respectively. Conclusion Women are more likely to have recurrent severe MR after percutaneous repair of functional MR. The mechanism for this remains undetermined.

Hepatorenal syndrome is a rare life-threatening complication of acetaminophen toxicity. It is not responsive to fluid therapy and need performing an emergent liver transplantation. Here, we introduce a 24-year-old woman with a history of chronic high doses of acetaminophen consumption, presenting with nausea, vomiting, lethargy, oliguria, and severe metabolic acidosis.