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Although widely studied experimentally in the 1990s, the structure and properties of low-dimensional or high-pressure phases of fullerenes have recently been re-examined. Remarkably, recent experiments have shown that transparent, nearly pure amorphous sp3-bonded carbon phases can be obtained by heating a C60 molecular crystal at a high pressure. With the additional aim of testing the ability of three classical carbon potentials reactive empirical bond order, environment-dependent interatomic potential, and reactive force-field to reproduce these results, we investigate the details of the structural transformations undergone by fullerene crystals over a wide range of pressures and temperatures. All the potentials tested show that the initial polymerization of fullerenes is accompanied by negative thermal expansion, albeit in slightly different ranges. However, more significant differences in structural and mechanical properties are observed in the amorphous phases, in particular the sp3 carbon fraction and the existence of layered amorphous carbon. Overall, these results indicate to which extent classical reactive potentials can be used to explore phase transitions over a wide range of pressures and temperatures., (© 2024 Author(s). Published under an exclusive license by AIP Publishing.) more...

Accurate air pollution prediction is vital for residents' well-being. This research introduces a secure air quality monitoring system using neural networks and blockchain for robust analysis, precise predictions, and early pollution detection. Blockchain guarantees data integrity, security, and transparency. Goals include real-time air quality data, secure blockchain recording, and enhanced safety through informed decisions. The research integrates blockchain and IoT for short- and long-term air quality monitoring, utilizing an optimized neural network. IoT sensors collect PM2.5, PM10, CO, NO2, and SO2, processed through noise removal and normalization, with feature extraction using N-tuple contrastive learning. Predictions utilize Graph attention-based deep Residual shrinkage Network and Bidirectional long short Term Memory (GRNBTM) categorized into five levels. An adaptive bowerbird algorithm optimizes parameters, reducing computational complexity. Blockchain integration ensures secure, tamper-proof data storage with a lightweight consensus-based algorithm. The GRNBTM model's air quality monitoring performance is extensively simulated and analyzed at 30-min, 2-h, 1-day, and 1-month intervals, demonstrating superior performance over existing techniques., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.) more...

Double-chambered left ventricle (DCLV) is a rare congenital cardiac lesion. It is usually an incidental finding in children and young adults. Diagnosis during fetal life is exceedingly rare. We report a case of DCLV diagnosed in the prenatal period associated with a ventricular septal defect (VSD). Transthoracic echocardiographic and magnetic resonance imaging confirmed the prenatal findings. At seven-month follow-up, the baby was asymptomatic. Transthoracic echocardiographic check-up revealed spontaneous closure of the VSD and stable aspect of the main left ventricle and the accessory chamber., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. more...

Introduction: Lightheadedness, syncope, dyspnea, chest pain, palpitation, loss of consciousness (LOC) or malaise are a frequent reason for consultation in school-age children (SAC). The yield of holter monitoring (HM) in the investigation of these symptoms in SAC is still controversial given the scarce studies., Aim: To determine the prevalence of baseline ECG abnormalities and those detected in HM in SAC, and to assess the predictive factors of abnormal HM test., Methods: We conducted a retrospective descriptive study in which we had included all the consecutive SAC (6 to 12 years) presenting: syncope or lightheadedness or palpitation, dyspnea, or chest pain, malaise, LOC and referred to our department for HM., Results: We included 366 children. Mean age was 9.7 ± 1.88 years. The major symptoms experienced by the patients were: palpitation (50.7%), chest pain (16.9%), lightheadedness (11.9%), syncope (6.9%), LOC (5.3%), ECG was abnormal in 8.7%. The two most common baseline ECG abnormalities were premature ventricular contractions (PVCs) (1.8%) and right bundle branch block (1.6%). HM was positive in 101 (26.6%) patients. The most common abnormalities in HM were vagal hypertonia in 61 patients (16.1%), PVCs in 29 patients (7.7%), Malignant abnormalities were encountered in 16 patients (13.9%) whereas benign abnormalities in 99 patients (86.1%). In the multivariate analysis: Age≥10 years, mean heart rate <94 beats per minute, the presence of syncope, LOC, malaise and the presence of PVCs in baseline ECG were identified as independent risk factors of abnormal holter., Conclusion: HM has an important diagnostic value in symptomatic SAC. It allows the identification of benign as well as malignant arrhythmias, which require urgent management. more...

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. It is generally diagnosed and surgically repaired early in life, with good overall outcomes., Case Presentation: We report the case of a patient incidentally diagnosed with paucisymptomatic TOF at the age of 56 years old, during investigations for carbon monoxide poisoning. The patient had a history of thyroidectomy, arterial hypertension, and four uncomplicated vaginal deliveries., Conclusions: This case shows us that some patients with TOF can reach older ages without surgical correction. Late surgical repair should be meticulously decided on a case basis., (© 2023. The Author(s).) more...

Ventricular dysfunction is the most frequent complication in adult patients post-Fontan completion. Through this work, we aim to evaluate ventricular systolic function by conventional echographic parameters and by global longitudinal strain (GLS) to determine the prediction of early ventricular systolic dysfunction. This is a prospective monocentric study enrolling 15 clinically stable adult Fontan patients with preserved ejection fraction (EF). Myocardial deformation study by GLS with speckle tracking technique in addition to a standard Doppler transthoracic echocardiography (TTE) was performed. Cardiac magnetic resonance imaging (CMR) was also performed. A comparison of echocardiographic and CMR parameters was made. In comparison to CMR-derived EF, we found a significant correlation with GLS and TTE-derived EF ( P =0.003 and 0.014). We divided our population into two groups based on the cut-off value of 50% of CMR derived EF. Comparison of GLS in both groups showed a significant correlation ( P =0.003). A cut-off value of -13.3% showed sensitivity of 67% and specificity of 100%. GLS has a moderate diagnostic value for systolic myocardial dysfunction in the population of adult patients with Fontan circulation., Competing Interests: All authors declare no competing interests. All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).) more...

Background: Hospitals have been identified as very high-risk places for COVID-19 transmission between health care workers and patients who do not have COVID-19. Health care workers are the most at-risk population to contract and transmit the infection, especially to already vulnerable patients who do not have COVID-19. In low-income countries, routine testing is not feasible due to the high cost of testing; therefore, presenting the risk of uncontrolled transmission within non-COVID-19 treatment wards. This challenge necessitated the development of an affordable intermediary screening tool that would enable early identification of potentially infected health care workers and for early real time DNA-polymerase chain reaction testing prioritization. This would limit the contact time of potentially infected health care workers with the patients but also enable efficient use of the limited testing kits., Objective: The aims of this study are to describe an early warning in-hospital mobile risk analysis app for screening COVID-19 and to determine the feasibility and user-friendliness of the app among health care workers., Methods: The primary result of this research project was the development of a mobile-based daily early warning system for in-hospital transmission of COVID-19. Overall, the Early Warning System for In-Hospital Transmission of COVID-19 (EWAS) mobile app was found to be feasible, with over 69% of the health care workers having logged more than 67% of the required times. Over 93% of the participants reported that the tool was easy to use., Results: The primary result of this research project was the development of a mobile-based daily early warning system for in-hospital transmission of COVID-19. Overall, the Early Warning System for In-Hospital Transmission of COVID-19 (EWAS) mobile app was found to be feasible, with 69% of the health care workers (69/100) having logged more than 67% of the required times. Of the 100 participants, 93 reported that the tool was easy to use., Conclusions: The EWAS mobile app is a feasible and user-friendly daily risk scoring tool for preventing in-hospital transmission of COVID-19. Although it was not designed to be a diagnostic tool but rather a screening tool, there is a need to evaluate its sensitivity in predicting persons likely to have contracted COVID-19., (©Ronald Mbiine, Cephas Nakanwagi, Herve Monka Lekuya, Joan Aine, Kawesi Hakim, Lilian Nabunya, Henry Tomusange. Originally published in JMIR Formative Research (https://formative.jmir.org), 17.12.2021.) more...

Insulator-based microfluidic devices are attractive for handling biological samples due to their simple fabrication, low-cost, and efficiency in particle manipulation. However, their widespread application is limited by the high operation voltages required to achieve particle trapping. We present a theoretical, numerical, and experimental study that demonstrates these voltages can be significantly reduced (to sub-100 V) in direct-current insulator-based electrokinetic (DC-iEK) devices for micron-sized particles. To achieve this, we introduce the concept of the amplification factor-the fold-increase in electric field magnitude due to the presence of an insulator constriction-and use it to compare the performance of different microchannel designs and to direct our design optimization process. To illustrate the effect of using constrictions with smooth and sharp features on the amplification factor, geometries with circular posts and semi-triangular posts were used. These were theoretically approximated in two different systems of coordinates (bipolar and elliptic), allowing us to provide, for the first time, explicit electric field amplification scaling laws. Finite element simulations were performed to approximate the 3D insulator geometries and provide a parametric study of the effect of changing different geometrical features. These simulations were used to predict particle trapping voltages for four different single-layer microfluidic devices using two particle suspensions (2 and 6.8 μm in size). The general agreement between our models demonstrates the feasibility of using the amplification factor, in combination with nonlinear electrokinetic theory, to meet the prerequisites for the development of portable DC-iEK microfluidic systems. more...

The manner of sample injection is critical in microscale electrokinetic (EK) separations, as the resolution of a separation greatly depends on sample quality and how the sample is introduced into the system. There is a significant wealth of knowledge on the development of EK injection methodologies that range from simple and straightforward approaches to sophisticated schemes. The present study focused on the development of optimized EK sample injection schemes for direct current insulator-based EK (DC-iEK) systems. These are microchannels that contain arrays of insulating structures; the presence of these structures creates a nonuniform electric field distribution when a potential is applied, resulting in enhanced nonlinear EK effects. Recently, it was reported that the nonlinear EK effect of electrophoresis of the second kind plays a major role in particle migration in DC-iEK systems. This study presents a methodology for designing EK sample injection schemes that consider the nonlinear EK effects exerted on the particles being injected. Mathematical modeling with COMSOL Multiphysics was employed to identify proper voltages to be used during the EK injection process. Then, a T-microchannel with insulating posts was employed to experimentally perform EK injection and separate a sample containing two types of similar polystyrene particles. The quality of the EK injections was assessed by comparing the resolution ( Rs ) and number of plates ( N ) of the experimental particle separations. The findings of this study establish the importance of considering nonlinear EK effects when planning for successful EK injection schemes. more...

Introduction: Hypernatremia is a commonly associated electrolyte disturbance in sepsis and septic shock patients in the ICU. The objective of this study was to identify the prognostic value of hypernatremia in sepsis and septic shock., Material and Methods: A prospective study conducted on sepsis and septic shock patients diagnosed prior to admission in the ICU in King Hamad University Hospital, Bahrain from January 1st 2017 to February 28th 2019. Data including age, sex, comorbidities, source of sepsis, sodium levels on days one, three, and seven. Data was correlated with the outcome (survival/death and the length of ICU stay)., Results: Patients included were 168, 110 survived, and 58 died. Hypernatraemia at day seven was associated with significantly higher mortality (P= 0.03). Hypernatraemia at Day1was associated with a significantly prolonged stay in the ICU (p= 0.039).Multivariate analysis to identify the independent predictors of mortality revealed that immunosuppression and hypernatraemia at Day7 proved to be independent predictors of mortality (P= 0.026 and 0.039 respectively)., Conclusion: Hypernatremia can be an independent predictor of poor outcome in septic and septic shock patients in the ICU., Competing Interests: Conflict of interest None to declare., (© 2020 Mohamed Shirazy, Islam Omar, Duaa Abduljabbar, Kamel Bousselmi, Maryam Alkhaja, Anis Chaari, Vipin Kauts, Karim Hakim, published by Sciendo.) more...

A 72-year-old housewife presented with ischemic cerebrovascular stroke. Intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) followed by mechanical thrombectomy under general anesthesia were attempted. The patient developed stridor and tongue swelling, in addition to hypotension and bradycardia, 60 min after completion of the rt-PA infusion. The airway was intubated, and intramuscular adrenaline, together with intravenous hydrocortisone and diphenhydramine, were administered. On the second day, the tongue edema subsided, and the cuff leak test was negative. However, extubation was not attempted due to the development of brain edema. A tracheostomy was later performed, and the patient was weaned off mechanical ventilation. more...

Carbon-enriched rocky exoplanets have been proposed to occur around dwarf stars as well as binary stars, white dwarfs, and pulsars. However, the mineralogical make up of such planets is poorly constrained. We performed high-pressure high-temperature laboratory experiments ( P  = 1-2 GPa, T  = 1523-1823 K) on chemical mixtures representative of C-enriched rocky exoplanets based on calculations of protoplanetary disk compositions. These P-T conditions correspond to the deep interiors of Pluto- to Mars-sized planets and the upper mantles of larger planets. Our results show that these exoplanets, when fully differentiated, comprise a metallic core, a silicate mantle, and a graphite layer on top of the silicate mantle. Graphite is the dominant carbon-bearing phase at the conditions of our experiments with no traces of silicon carbide or carbonates. The silicate mineralogy comprises olivine, orthopyroxene, clinopyroxene, and spinel, which is similar to the mineralogy of the mantles of carbon-poor planets such as the Earth and largely unaffected by the amount of carbon. Metals are either two immiscible iron-rich alloys (S-rich and S-poor) or a single iron-rich alloy in the Fe-C-S system with immiscibility depending on the S/Fe ratio and core pressure. We show that, for our C-enriched compositions, the minimum carbon abundance needed for C-saturation is 0.05-0.7 wt% (molar C/O ∼0.002-0.03). Fully differentiated rocky exoplanets with C/O ratios more than that needed for C-saturation would contain graphite as an additional layer on top of the silicate mantle. For a thick enough graphite layer, diamonds would form at the bottom of this layer due to high pressures. We model the interior structure of Kepler-37b and show that a mere 10 wt% graphite layer would decrease its derived mass by 7%, which suggests that future space missions that determine both radius and mass of rocky exoplanets with insignificant gaseous envelopes could provide quantitative limits on their carbon content. Future observations of rocky exoplanets with graphite-rich surfaces would show low albedos due to the low reflectance of graphite. The absence of life-bearing elements other than carbon on the surface likely makes them uninhabitable. more...

Background: The outcome of Kawasaki disease (KD) depends on cardiovascular complications (CVCs)., Objectives: This study aimed to explore diagnostic features and CVCs in Tunisian patients with KD., Methods: In total, 33 Tunisian patients (age, 2.9 ± 2.2 years) fulfilling the diagnosis criteria of KD, were retrospectively reviewed. Nonparametric tests were used to compare the two groups with regards to coronary complications (CCs)., Results: Diagnosis of KD was established at day 11 ± 5.1 from the beginning of the fever. Apyrexia was obtained in an average of 29 h after completion of intravenous immunoglobulin. CVCs were identified in 52% of cases: CC in 15 patients (giant aneurysm >8 mm in five patients) and non-CCs in 6 patients (severe in three patients). CCs were more frequently associated with the male sex (p = 0.037), fever lasting >8 days (p = 0.028) and longer time to apyrexia (p = 0.031)., Conclusion: In Tunisia, better knowledge and monitoring of KD are warranted., (© The Author(s) [2018]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.) more...

A mother presented with a fetus at 22±1 weeks of gestation with a sustained supraventricular tachycardia  (SVT) at initially 186 beat per minute (bpm). The fetal M-mode echocardiography showed a 1/1 atrio ventricular ratio (with short atrioventricular (AV) interval and a long ventriculo-atrial (VA) interval, suggesting a Persistent junctional reciprocating tachycardia (PJRT) . Upon  initial present no signs of heart failure or hydrops  were noted and treament was initiated with amiodarone and  digoxin . Fetus heart rate slowed  .Postnatal electrocardiogram  Confirmed  the diagnosis of PJRT New born was put on amiodarone and proparonal). Sinus rhythm was rapidly achieved 9 days later .The patient doing well at  10 months of age with maintain of sinus rhythm. Conclusion: our case report illustrates  a particular  form of  JRT   diagnosed  prenatal PJRT  , characterized  by  a good clinical tolerance, its absence of evolution towards cardiomyopathy  and its rapid and unusual response to antiarrhythmics. more...

Background Glycogen storage disease type III (GSDIII), due to a deficiency of glycogen debrancher enzyme (GDE), is particularly frequent in Tunisia. Phenotypic particularities of Tunisian patients remain unknown. Our aim was to study complications of GSDIII in a Tunisian population and to explore factors interfering with its course. Methods A retrospective longitudinal study was conducted over 30 years (1986-2016) in the referral metabolic center in Tunisia. Results Fifty GSDIII patients (26 boys), followed for an average 6.75 years, were enrolled. At the last evaluation, the median age was 9.87 years and 24% of patients reached adulthood. Short stature persisted in eight patients and obesity in 19 patients. Lower frequency of hypertriglyceridemia (HTG) was associated with older patients (p<0.0001), higher protein diet (p=0.068) and lower caloric intake (p=0.025). Hepatic complications were rare. Cardiac involvement (CI) was frequent (91%) and occurred early at a median age of 2.6 years. Severe cardiomyopathy (50%) was related to lower doses of uncooked cornstarch (p=0.02). Neuromuscular involvement (NMI) was constant, leading to a functional discomfort in 64% of cases and was disabling in 34% of cases. Severe forms were related to lower caloric (p=0.005) and protein intake (p<0.015). Conclusions A low caloric, protein and uncooked cornstarch intake is associated with a more severe outcome in GSDIII Tunisian patients. Neuromuscular and CIs were particularly precocious and severe, even in childhood. Genetic and epigenetic factors deserve to be explored. more...

Methods: This is a retrospective study including 47 patients with isthmic coarctation (CoA) diagnosed in ante et postnatal périod, hospitalized in pediatric cardiology departement of la Rabta Hospital-Tunisia during the period from 2000 to 2017., Results: They were 36 girls and 11 boys with an average age of 14 days. The diagnosis of CoA was suspected during the anténatalperiod in eight cases. In postnatal period heart failure was observed in (38.5%), abolition of femoral pulse (74%), a tension asymetry was found in all patients. Antenatal echocardiography suspected indicators of fetal coarctation especially ventriculo-arterial asymmetryechocardiography confirmed the diagnosis of CoA ,The ejection fraction was impaired in 31% of the cases.The abnormalities associated with coarctation were dominated by the patent ductus arteriosus (68%), atrial septal defect (55.5%), aortic hypoplasia, bicuspidia in respectively in 34% and 31% coarctation syndrome in (23.4%). Prostaglandin wasneccessary in (89.3%). forty two patients were operated with good immédiaterésults. the early postoperative mortality was 12.5%. In the long term, we deplored two late deaths, six cases of recoarctation with a follow-up of 14 months treated by percutaneous angioplasty with a result considered good in all cases., Conclusion: Coarctation of the aorta in neonates is a special form of aorticcoarctaion that differs from the child and adult forms in clinical, echocardiographic, and therapeutic characteristics . His clinical diagnosis must be early, if possible in antenatal , to asssure optimal management. more...

Learning Objectives: After studying this article, the participant should be able to: 1. Understand how to determine nipple-areola complex positioning on the reconstructed breast. 2. Understand the multitude of local flap and distant graft options for nipple-areola complex reconstruction. 3. Draw at least three fundamental nipple-areola complex reconstruction patterns. 4. Understand the forces that are responsible for flattening of the reconstructed papule. 5. Understand the current techniques used in secondary nipple-areola complex reconstructions., Summary: Nipple-areola complex reconstruction and tattooing represent the final two stages of breast reconstruction. Nipple-areola complex reconstruction is typically accomplished with the use of local flaps, local flaps with augmentation grafts, or a combination thereof. Regardless of the technique used, however, all nipple-areola complex reconstructions lose a degree of projection over time. Options for secondary reconstruction include the use of local tissue flaps alone or in combination with acellular biological matrices. more...

A 04-year-old boy was referred to our institution with severe, progressive heart failure of 4-months duration associated with a persistent wide QRS tachycardia with left bundle branch block and severe left ventricular dysfunction. Because of incessant wide QRS tachycardia refractory to antiarrhythmic drugs, he was referred for electrophysiological study. The ECG was suggestive of VT arising from the right ventricle near the His area. Electrophysiological study revealed that origin of tachycardia was septum of the right ventricle, near His bundle, however the procedure was not successful and an inadvertent complete atrioventricular conduction block occurred. The same ventricular tachycardia recurred. A second procedure was performed with a retrograd aortic approach to map the left side of the interventricular septum. The earliest endocardial site for ablation was localized in the anterobasal region of left ventricle near His bundle. In this location, one radiofrequency pulse interrupted VT and rendered it not inducible. The echocardiographic evaluation showed partial reversal of left ventricular function in the first 3 months. The diagnosis was idiopathic parahisian left ventricular tachycardia leading to a tachycardia mediated cardiomyopathy, an extremely rare clinical picture in children., (Copyright © 2017 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.) more...

Asymptomatic candiduria is a common finding in hospitalized patients. Its management modalities are still a matter of debate. Urinary catheter should be removed or replaced in all cases. In the current meta-analysis, we aimed to compare 2 different strategies in term of candida clearance from the urinary tract: Systemic fluconazole versus conservative management. A systematic search was performed in Pubmed, Web of science, and Cochrane Library database by 2 investigators. Three studies were included (421 patients). Data were extracted and the quality of each study was assessed. Systemic fluconazole was associated with a significantly higher short-term clearance of the funguria after 14 days of treatment [odds ratio = 0.43; confidence interval (CI) 95% (0.26-0.65)]. No significant heterogeneity was found among the included studies (Q statistic test = 0.38; I = 0). In conclusion, fluconazole significantly hasten short-term candida clearance from the urinary tract. more...

Sepsis and septic shock are life threatening condition associated with high mortality rate in critically-ill patients. This high mortality is mainly related to the inadequacy between oxygen delivery and cellular demand leading to the onset of multiorgan dysfunction. Whether this multiorgan failure affect the pancreas is not fully investigated. In fact, pancreatic injury may occur because of ischemia, overwhelming inflammatory response, oxidative stress, cellular apoptosis and/or metabolic derangement. Increased serum amylase and/or lipase levels are common in patients with septic shock. However, imaging test rarely reveal significant pancreatic damage. Whether pancreatic dysfunction does affect the prognosis of patients with septic shock or not is still a matter of debate. In fact, only few studies with limited sample size assessed the clinical relevance of the pancreatic injury in this group of patients. In this review, we aimed to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. Our main finding is that pancreatic injury does not significantly affect the outcome in septic shock patients. Hence, increased serum pancreatic enzymes without clinical features of acute pancreatitis do not require further imaging investigations and specific therapeutic intervention. more...

Ventral hernia repair (VHR) for large abdominal wall defects is challenging. Prior research established that the use of mesh is superior to suture closure alone and that component separation is an effective technique to combat loss of abdominal domain. Studies comparing component separation technique (CST) outcomes utilizing synthetic versus biologic mesh are limited. A retrospective review was conducted of 72 consecutive patients who underwent VHR with CST between 2006 and 2010 at our institution. Surgeon preference and the presence of contamination guided whether synthetic mesh (27 patients) or biologic mesh (45 patients) was used. Mean follow-up interval for all comers was 13.9 months and similar in both groups (P > 0.05). Degree of contamination and severity of premorbid medical conditions were significantly higher in the biologic mesh group, as reflected in the higher Ventral Hernia Working Group (VHWG) score (2.04 versus 2.86). Clinical outcomes, as measured by both minor and major complication rates and recurrence rates, were not significantly different. Minor complication rates were 26% in the synthetic group and 37% in the biologic group and major complication rates 15% in the synthetic group and 22% in the biologic group. There was 1 recurrence (4%) in the synthetic mesh group versus 5 (11%) in the biologic mesh group. Multivariable analysis for major complications revealed no significant difference for either synthetic or biologic mesh while controlling for other variables. Subset analysis of uncontaminated cases revealed recurrence rates of 4% in the synthetic mesh group and 6% in the biologic mesh group. VHR using CST and either synthetic mesh or biologic mesh resulted in low recurrence rates with similar overall complication profiles, despite the higher average VHWG grading score in the biologic mesh group. Our results support the VHWG recommendation for biologic mesh utilization in higher VHWG grade patients. In VHWG grade 2 patients, our clinical outcomes were similar, supporting the use of either type of mesh. more...

Acute respiratory distress syndrome (ARDS) is a life threatening complication of H1N1 pneumonia. According to the Berlin conference guidelines, severe ARDS requires management with early invasive mechanical ventilation. Whether noninvasive positive pressure ventilation (NIPPV) should be attempted in patients with H1N1 pneumonia is still a matter of debate. We report the case of one patient with severe ARDS without other organ failure. The patient was managed successfully using NIPPV. Endotracheal intubation was avoided and the patient was discharged from the intensive care unit (ICU) after 10 days with a successful outcome. NIPPV can be useful in patients with isolated severe H1N1 ARDS provided early improvement of the oxygenation parameters is achieved. Patients with multiple organ failure or with persistent severe hypoxemia under noninvasive ventilation should be electively intubated and started on invasive mechanical ventilation. more...

Kawasaki disease (KD) is a common acute vasculitis in pediatric population that usually involves small- and middle-sized arteries, commonly coronary arteries. Although the incidence and natural course of coronary aneurysms after KD are well documented in studies, related reports on peripheral arterial and aortic aneurysms are scarce. We report the occurrence of a giant aortic aneurysm involving the horizontal part of aortic arch in a 28-month-old boy diagnosed with KD. This complication was managed by steroids therapy in the beginning. Because of mechanical complication and potential risk of rupture, surgery was undertaken. more...

Background: Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications., Methods: All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables., Results: There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups., Conclusions: Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest., Clinical Question/level of Evidence: Therapeutic, III. more...

Background: The Cook-Swartz Doppler has long been a trusted tool for close monitoring of blood flow after microvascular reconstruction; however, device implantation requires additional operating time. Synovis Life Technologies, Inc. received FDA approval in 2010 for the Flow Coupler, which combines an end-to-end anastomotic coupler with a removable 20 MHz Doppler, allowing both procedures to be performed simultaneously. However, its short history of widespread use necessitates further evaluation in the clinical setting. The authors studied the Synovis Flow Coupler in comparison to the more well-established Cook-Swartz Doppler for effectiveness and reliability in detection of vascular compromise., Methods: The authors reviewed 220 free flap breast reconstructions in 150 patients over a three-year period in which either the Cook-Swartz Doppler or the Synovis Flow Coupler was implanted to monitor blood flow. Outcomes measured include false-positive or false-negative rates (FPR, FNR); rates of OR take-back and salvage; and flap survival., Results: FPR was 1.0% for the Cook-Swartz Doppler and 1.9% for the Synovis Flow Coupler (p>0.05). FNR was 0.0% for both groups. Take-back rates were 10.1% for the Cook-Swartz, and 4.5% for Synovis (p>0.05). Flap failure rates were 1.8% and 0.9% for the Cook-Swartz and Synovis devices, respectively (p>0.05)., Conclusions: Our study reveals no statistically significant differences in outcomes for free flap breast reconstruction where either the Cook-Swartz Doppler or the Synovis Flow Coupler was used to monitor blood flow to the perforator flap., Level of Evidence: III., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.) more...

Background: Prosthetic reconstruction using human acellular dermis (ADM) is a common practice in breast reconstruction. AlloDerm and FlexHD are two different forms of ADM, each with unique characteristics. No studies have directly compared the postoperative complications of these 2 products., Methods: The outcomes of 547 consecutive implant-based breast reconstructions were reviewed., Results: Reconstruction was performed in 382 consecutive women (547 total breasts), employing mostly immediate reconstruction (81%). Mean follow-up was 6.4 months. Among immediate reconstructions, 165 used AlloDerm and 97 used FlexHD. Complications were similar by univariate analysis. In multivariate analysis, smoking and higher initial implant fill were risk factors for delayed healing. The use of FlexHD, single-stage reconstruction, and smoking were independent risk factors for implant loss., Conclusions: There is no significant difference in the complication rates between AlloDerm and FlexHD in immediate breast reconstruction. Multivariate analysis suggests that FlexHD may be a risk factor for implant loss. more...

Costello syndrome is a rare syndrome associated with de novo mutations in the HRAS gene. It is mostly revealed during in the first months of life by growth retardation, facial dysmorphic features, skin and cardiac abnormalities and subsequent cognitive deficit of varying severity. We report a case of Costello syndrome in a 3-month-old infant. The initial cardiac investigations were normal except frequent premature atrial complexes. After few months, worsening arrhythmia with bursts of ventricular tachycardia were noted as well as the secondary progressive obstructive left ventricular hypertrophic cardiomyopathy (HCM). Cardiac involvement is determinant for the prognosis of Costello syndrome. It frequently consists of hypertrophic cardiomyopathy (one third of patients), with involvement of the left ventricle in half of the cases. It is often asymmetrical and associated with obstruction of the outflow recalling family hypertrophic cardiomyopathy. The natural history of HCM in Costello syndrome and its management remains poorly known because of paucity of reported cases. Progression of the HCM can be very rapid like the reported case. On the other hand, the spontaneous regression of the HCM in some patients has been reported. In addition, cardiac threatening arrhythmias may be noted. So that, cardiac assessment and monitoring with regular echocardiography and electrocardiogram follow up is mandatory. more...

Interruption of the aortic arch is a rare congenital disease. It is defined by the complete interruption between the ascending and descending aorta. A patent ductus arteriosus is necessary to maintain flow from the pulmonary to the descending aorta. Its closure leads to a cardiovascular collapse and this malformation is therefore duct-dependent. However, in rare cases, survival remains possible even after ductus arteriosus closure. We report such a case., (Copyright © 2014. Published by Elsevier SAS.) more...

Orthotopic heart transplantation (HTX) is nowadays the worldwide accepted gold standard for the treatment of terminal heart failure. The main indications for HTX are non-ischemic dilatative (54%) and ischemic (37%) heart failure. In the acute phase after HTX the survival rate is approximately 90%. Good short and long-term results with survival rates ranging from 81% after 1 year to more than 50% after 11 years demonstrate that there is currently no real treatment alternative to HTX for treatment of end-stage heart failure. In the case of irreversible pulmonary hypertension in combination with end-stage heart failure or complex congenital heart syndromes, a combined heart and lung transplantation (HLTX) is necessary. Compared with HTX the short-term survival of HLTX is reduced, mostly for technical reasons. Improved long-term results after HTX and HLTX are a result of highly specialized transplantation units and effective immunosuppression. However, a major problem is the shortage of organ donors in Germany and the resulting long waiting times for patients with frequently occurring blood groups of up to 10 months for transplantation. The consequence of the latter is the ever increasing number of implanted cardiac assist devices in patients not only as a bridge to transplant but also as destination therapy. more...

Background: Patients with a single ventricle represent a rare abnormality found in 1% of patients with congenital heart disease, often discovered during childhood. Without pulmonary stenosis, the disease can progress to fixed pulmonary hypertension. Both pregnancy and delivery are risky events capable of increasing the right-to-left shunt. Pregnancy is contraindicated., Case: We report the case of a 27-year-old woman with a single ventricle without pulmonary protection and fixed pulmonary hypertension at 60 mmHg, discovered during a pregnancy. The delivery was obtained by cesarean section with epidural anesthesia and the patient was perioperatively treated with nitric oxide. Though contraindicated, pregnancy and delivery were successfully achieved in this patient., Comment: Patients with single ventricle and Eisenmenger syndrome rarely reach adult life. Pregnancy with this condition is exceptional and fundamentally perturbs hemodynamic stability. In spite of the development of anesthesia and resuscitation and the description of some cases in literature, pregnancy with Eisenmenger syndrome is contraindicated. more...

Ebstein's disease with functional pulmonary atresia is a severe neonatal presentation of Ebstein's anomaly where the therapeutic management is typically based on the prescription of prostaglandins. The circular shunt is a serious "hemodynamic" complication which is often undiagnosed leading to the discontinuation of prostaglandins. We report a severe neonatal form of Ebstein's anomaly with hemodynamic deterioration relatted to a circular shunt. The diagnosis of Ebstein's anomaly with functional pulmonary atresia was made prenatally at 36 weeks of pregnancy. The patient was born at 38 weeks of gestation by caesarean section. Postnatal ultrasound confirmed the diagnosis. Treatment with prostaglandins was originally created to maintain the vital ductus arteriosus patent. Despite this treatment, hemodynamic deterioration was observed. Ultrasound monitoring showed pictures for a circular shunt. Indeed, blood coming into the pulmonary artery by the wide ductus arteriosus, was "drawn" to the right ventricle and the right atrium due to tricuspid regurgitation and from there to the left heart via the fossa ovalis shunting right to left, when it was ejected into the aorta and the ductus arteriosus. Before this circular shunt, treatment with prostaglandin was discontinued and treatment to reduce pulmonary resistance was described. However, the patient died prior to initiation of treatment. The neonatal form of Ebstein's anomaly is a severe form that can be complicated by a circular shunt. This hemodynamic phenomenon encourages early closure of the ductus arteriosus against indicating the prescription of prostaglandins. more...

Introduction: The respective roles of hypocalcemia and intracerebral calcifications in the occurrence of various neurological manifestations in hypoparathyroidism is not entirely clear. Nevertheless, therapeutic and prognostic implications are important., Objectives: We analyze the neurological clinical aspects observed in hypoparathyroidism and correlate them to the biological calcium abnormality and radiological CT scan findings. We also compare these results with data reported in the idiopathic form of striatopallidodentate calcinosis., Patients: The neurological clinical, CT scan findings and outcome have been retrospectively studied in patients recruited during 13 years (2000-2012) for neurological features associated with hypoparathyroidism or pseudohypoparathyroidism., Results: Twelve patients with primary hypoparathyroidism (n=5), secondary to thyroidectomy (n=4) and pseudohypoparathyroidism (n=3) were studied. The sex-ratio was 1 and mean age was 39 years. All patients had a tetany, 60% had epilepsy, associated in one patient with "benign" intracranial hypertension; 50% had behavioral changes. Response to calcium therapy was excellent for all these events. Moderate cognitive deficit was noted in three patients (25%), parkinsonism in two patients and hyperkinetic movement disorders in one other. These events were not responsive to calcium therapy and were more common in cases of extensive brain calcifications and in patients who had pseudohypoparathroidism., Comments: This study suggests that, in patients with hypoparathyroidism, epilepsy and psychiatric disorders are induced by hypocalcemia and reversible after its correction. Cognitive and extrapyramidal impairment seem to be related to the progressive extension of intracerebral calcification, particularly in patients with a late diagnosis. In patients with pseudohypoparathyroidism, this finding is different because of the contribution of other factors, specific to this disease., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.) more...

Background: CT angiography has become the gold-standard imaging modality prior to DIEP flap breast reconstructions. Recent studies show excellent correlation between CTA and operative perforator location, but not their clinical significance. This study seeks to specifically evaluate the clinical utility of CTA in DIEP free flaps., Methods: Preoperative CT angiography of the deep inferior epigastric system was obtained in 52 sequential DIEP free flaps involving 37 patients with dominant perforators marked by radiologist. Planned and used perforators were documented by the surgeon before and after the operation., Results: A total of 62 out of 76 planned perforators were ultimately used (82%). Of those not used, 71% were abandoned due to inadequacy of preoperative CT. An additional 38 perforators were used that were not part of the initial preoperative plan, 60% of which were added due to inadequacy of the preoperative CT for planning. In total 23/52 flaps (44%) involved intraoperative changes due to features not appreciated on preoperative CT., Conclusion: CTA mapping of perforators prior to DIEP flap surgery increases surgeon confidence and reduces operative time; however, there are still a significant number of changes made based on clinical judgment. This study highlights the importance of surgeon review of CTA images. Caution is warranted in reliance on CTA mapping, and significant perforators should not be sacrificed until the anticipated perforator(s) have been exposed and evaluated., Level of Evidence: Level 3., (Published by Elsevier Ltd.) more...

Background: This study aimed to assess if clampless off-pump coronary artery bypass grafting (CABG) decreases risk-adjusted mortality, stroke rate, and morbidity in unselected patients in comparison to conventional CABG., Methods and Results: Between July 2009 and November 2010, data of 1282 consecutive patients undergoing isolated CABG were prospectively recorded. In 30.8% (n=395), clampless off-pump revascularization was used, either with the PAS-Port automated central venous anastomosis system (n=310) or as total arterial revascularization without central anastomoses (n=85). Propensity score (PS) matching was performed based on 15 preoperative risk variables to correct for selection bias. In-hospital mortality and stroke rate as primary end point, as well as major complications and follow-up outcome of clampless off-pump (lessOPCAB) and conventional CABG (cCABG) were compared in 394 matched patient pairs (total: 788 patients). The clampless off-pump technique decreased the in-hospital rate of death (odds ratio, 0.25; 95% confidence interval, 0.05-1.18, P=0.080) and stroke (odds ratio, 0.36; 95% confidence interval, 0.13-0.99, P=0.048) significantly. Complications such as low cardiac output syndrome, prolonged ventilation and rethoracotomy were also reduced by lessOPCAB. Over a 2-year follow-up period overall survival, cerebrovascular and major adverse event rate were significantly lower in the lessOPCAB group, while the repeat revascularization rate was comparable., Conclusions: In a retrospective PS-matched analysis, clampless off-pump CABG lowers mortality, stroke rate and other morbidity in an unselected group of patients with coronary artery disease. more...

Background: Infection rates for breast surgery are 3 to 15 percent, higher than average for a clean surgical procedure. Preoperative and postoperative antibiotics have lowered infection rates in other surgical groups, yet there is no consensus on postoperative prophylactic antibiotic use in microsurgical breast reconstruction., Methods: A retrospective review of consecutive patients who underwent autologous breast reconstruction between 2006 and 2009 was performed. Specific risk factors for autologous reconstruction were reviewed, including medical comorbidities, irradiation, and chemotherapy history. Data were collected on type and duration of prophylactic antibiotics. A prospective cohort of patients who received only 24 hours of postoperative antibiotics was identified. The incidence of surgical-site infections was measured using Centers for Disease Control and Prevention criteria., Results: A total of 256 patients with 360 microvascular breast reconstructions who received both preoperative and postoperative prophylactic antibiotics were analyzed. The overall surgical-site infection rate was 17.2 percent (44 of 256 patients). Surgical-site infection was correlated with increased age, tobacco use, and prior radiation. Duration of postoperative antibiotic use did not differ in those patients who developed surgical-site infections (6.2 versus 7.7 days; p = 0.19). Eighty-two patients (32 percent) received only 24 hours of postoperative antibiotics, while 174 (68 percent) received more than 24 hours of antibiotics for a median duration of 10 days. There was no difference in the overall surgical-site infection rate in those who received more than 24 hours of antibiotics (19.5 versus 15.5 percent; p = 0.47)., Conclusion: There was no reduction in the overall surgical-site infection rate among autologous breast reconstruction patients who received postoperative antibiotic prophylaxis for more than 24 hours., Clinical Question/level of Evidence: Therapeutic, III. more...

Ischemia is a common underlying factor in a number of pathologic conditions ranging from cardiac dysfunction to delayed wound healing. Previous efforts have shown the resulting hypoxia activates the hypoxia inducible factor, a transcription factor with signaling effects through an intranuclear hypoxia response element (HRE). We hypothesized that ischemic conditions should activate these hypoxic signaling pathways in a measurable manner. We tested our hypothesis using variations of an established rabbit ear ischemic wound model and an HRE-luciferase-reporter gene construct. This plasmid construct was transfected into the ears of young, female New Zealand White rabbits, harvested at day 7 and processed to yield a reactive solution. Luminometry was used to quantify luciferase expression in each solution as a marker for HRE activation in each wound. Quantitative readings of hypoxic signaling as measured by luminescence yielded profound and statistically significant differences between the various ischemic models. Our results suggest that the biologic systems for hypoxic signaling can be used to detect local ischemia. HRE-luciferase transfection is an effective tool for quantifying the degree of tissue hypoxia. The caudal ischemic rabbit ear model showed significantly higher levels of hypoxia. Use of a validated model that produces sufficient tissue levels of hypoxia is recommended for meaningful study of ischemic wound healing. more...

Introduction: Combined medullar sclerosis, together with peripheral sensory neuropathies, is the most common neurological manifestation observed in cobalamin deficiency. Biermer's disease is the predominant cause. Other clinical and etiological aspects are nevertheless frequent, although underestimated., Methods: This retrospective study included patients with neurological symptoms and cobalamin (B12 vitamin) deficiency confirmed by laboratory tests collected over a period of 11 years., Results: Twenty-seven cases were analyzed. Mean age was 47 years and there were 11 women and 16 men. Distribution of the neurological syndromes was: combined medullar sclerosis in 18 patients (67%), sensory neuropathies in 30% of cases and sensory-motor neuropathies in 15%. One patient had fronto-subcortical dementia with good improvement after vitamin replacement. In addition, autonomic dysfunction was noted in six patients (orthostatic symptomatic hypotension and/or urinary dysfunction and/or erectile failure). Dysautonomia revealed cobalamin deficiency in three patients with a good and fast response to the cobalamin therapy in all cases. Biermer's disease was diagnosed in 17 patients (63%) and a likely syndrome of nondissociation of cobalamin in two patients. One patient had Crohn's disease and no etiology was found in seven patients. In five patients (19%), nitrous oxide undoubtedly induced decompensation of latent cobalamin deficiency; four after a general anesthesia and one by chronic professional exposure. Outcome was very good in 46% of patients after vitamin replacement, particularly if treatment was started rapidly., Discussion: The findings in this series highlight the frequency of autonomic dysfunction sometimes revealing cobalamin deficiency with a fast and good response to vitamin replacement and the frequency of neurological disorders following decompensation triggered by general anesthesia using nitrous oxide in patients with latent cobalamin deficiency. more...

Introduction: Neurological manifestations in Gougerot-Sjogren syndrome (GSS) are valued differently. This is essentially the achievement of the peripheral nervous system., Methods: We report 9 cases of neurological manifestation revealing primitive Gougerot-Sjogren syndrome collected over a period of 8 years (1997-2004). GSS diagnosis was retained according to Americano-European group criteria consensus revised on 2002., Results: All our patients were female with an average age of 43 years. Peripheral nervous system manifestation occurred in 78% (Truncal Neuropathy in 44%, anterior horn involvement in 2 cases). Central nervous system involvement was observed in 55.6% (chronic myelopathy and aseptic meningoencephalitis)., Discussion and Conclusions: The analysis of neurological manifestations in GSS encounters three difficulties: the lack in homogeneity of diagnostic criteria (which makes it difficult to compare the frequency of neurological complications in different series), the limited number of large series, and the cases with neurological manifestations revealing this syndrome. more...

Background: The common arterial trunk is a heart disease in witch a unique arterial trunk, with a unique ventriculo-arterial valve, exits from the ventricular mass and supply directly the coronary, the aortic and also the pulmonary arterial circulations. Its anatomic repair is now possible but necessitates the use of conduit in pulmonary position., Aim: To evaluate the incidence and the causes of late reinterventions after repair of common arterial trunk., Methods: We retrospectively study the outcome of 17 patients who underwent repair of common arterial trunk between January 1983 and December 2006. The 15 early survivors were followed during a median period of 7 years (range 10 months and 13 years)., Results: Nine reinterventions were necessary in 8 patients. Only one conduit reintervention was necessary in the 8 patients. Freedom from conduit reintervention was 73% at 5 years and 33% at 10 years. Three reinterventions were performed in 2 patients for severe truncal valve incompetence, including repair in 2 cases and replacement in one case. Freedom from truncal valve reintervention was 67% at 10 years., Conclusion: Late reinterventions are inevitable after repair of common arterial trunk. The most common reasons are conduit stenosis and truncal valve incompetence. more...

Background: Patients who undergo pelvic floor resection as treatment for recurrent cancer following radiation therapy have increased rates of complications, particularly if permanent prosthetic mesh is used for reconstruction. Human acellular dermal matrix (HADM), commonly used for reconstruction in other torso locations, is associated with lower rates of complications (including infection, adhesions and cutaneous exposure) than synthetic mesh. We describe an effective technique to reconstruct the pelvic floor and perineum with HADM and thigh-based flaps following pelvic exenteration and radical vulvectomy., Case: A 75-year-old woman underwent radical resection of the pelvic floor and perineum to treat recurrent vulvar squamous cell carcinoma and osteoradionecrosis. The pelvic floor and perineal soft tissue defect were reconstructed with HADM (AlloDerm; LifeCell Corporation, Branchburg, NJ) and bilateral, thigh-based tissue flaps, respectively. Despite a large resection, previous irradiation therapy and bacterial contamination the wounds healed without complications., Conclusion: Reconstruction of pelvic floor defects using HADM is an option when wound conditions are unfavorable for the use of permanent prosthetic meshes. more...