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Background Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation. Methods Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure. Results A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p p = 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001). Conclusion There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline. Trial registry number clinicaltrials.gov, NCT02697786 14.

Cardiac tumors are rare, and their treatment differs interindividually regarding the histopathological proprieties and the stage of disease. Authors present a case of symptomatic cardiac melanoma metastasis that expressed an ERBB2 (HER2) gene amplification in a course of the disease that has not yet been reported. The frail patient with a history of pulmonary and renal carcinoma, was admitted to the hospital due to a symptomatic left atrial tumor mass. The patient underwent a tumor-resecting cardiac surgery. At first mistaken for myxoma on echocardiography, the histopathological examination of the tumor revealed a melanoma of acral or mucosal origin. The melanoma metastasis was negative for common genetic mutations in BRAF, NRAS or KIT genes, and for the presence of NTRK genes fusions, but carried ERBB2 (HER2) gene amplification. The absence of standard gene mutations rendered it unresponsive to treatment with BRAF and MEK inhibitors. This molecular finding is rare in melanomas and represented a therapeutic target for off-label systemic treatment with drugs, primarily aimed at ERBB2 positive breast, gastric, and gastroesophageal junction cancers. A rare finding like this justifies molecular genetic analysis of unusual tumor specimen and guarantees optimal treatment for uncommon types of cardiac metastatic tumors.

Background Pocket-related complications following the implantation of cardiovascular implantable electronic devices primarily include pocket hematoma, infection, skin erosion or decubitus, device migration, and Twiddler's syndrome, with other pathologies such as nerve impairment or bone lesions being extremely rarely encountered. We report a case of a 20-year old asthenic, non-athlete female patient presenting with a device-generated fracture of the second rib several months after sub-muscular permanent pacemaker implantation due to repeated bilateral pre-pectoral pocket infections. Case presentation A 20-year old female patient was readmitted to our institution 9 months following sub-pectoral implantation of a permanent pacemaker, complaining of severe pocket-related pain, which arose spontaneously in the absence of direct trauma, intense physical activity or vigorous coughing, and was associated with normal day-to-day activity. To rule out a pacemaker re-infection, a native computed tomography and a positron emission tomography—computed tomography of the thorax were performed. Both modalities excluded an infection but showed a healing fracture and a focus of enhanced metabolic activity in the anterolateral part of the right second rib, indicating a non-traumatic or stress fracture of the bone. Consequently, a complete extraction of the pulse generator and both leads was performed and the smallest available single-chamber pulse generator with a single atrial electrode was implanted in the sub-fascial, pre-muscular pocket in the now recovered and uninfected left subclavicular region, alleviating patient’s severe pain symptoms and significantly enhancing her quality of life. Conclusions In the absence of direct trauma, intense physical activity or vigorous coughing, we assume that in this asthenic girl a normal day-to-day motion of the right shoulder has persistently forced the sub-muscularly placed pulse generator toward thoracic wall, putting increased repetitive pressure force on the underlying bones, finally causing a fatigue stress fracture of the second rib. In asthenic phenotype patients with small thorax and short subclavicular distance, a sub-muscular pacemaker implantation can potentially cause unique and unexpected pocket-related adverse events necessitating advanced diagnostics and timely treatment.

Poultry farming is an important sector of the Beninese agriculture. But this sector is facing economic difficulties. The aim of this study is to evaluate the effects of Moringa oleifera powder and soybean meal on zootechnical parameters in the ISA Brown pullet. For this purpose, the experiment was carried out on a total of 250 day-old chicks with an initial average weight of 40 ± 1 g. Among these chicks, 25 subjects were used for the digestibility test and the rest were grouped into cinq (05) batches of 45 chicks fed with different rations. The test lasted 56 days. The apparent digestibility of the dry matter varied significantly from 50.0 ± 9.18 to 50.42 ± 16.11 at the 5% threshold between the different batches. Feed consumption of chicks of the different experimental batches did not show any significant variation, while for the feed conversion rate, weight gain and average daily gain, most averages vary significantly between batches and weeks. It brings out that M. oleifera powder improves the feed conversion and growth rates of ISA Brown pullets fed with a feed containing M. oleifera powder at different incorporation rates. Key words: Moringa oleifera, soybean, ISA Brown laying hens, zootechnical parameters.

Surgical treatment of lesions of the facial nerve by an hypoglossal-facial anastomosis takes a long time to re-sprout of the nerve fibers to the facial muscles. The recovery time of facial function after surgical treatment of patients with paralysis of the facial nerve is long enough and can start from 6-8 months after surgery and last up to 2 years. Thus, all this time the mimic muscles are in a state of denervation. The purpose of this work was to determine the effect of electrical stimulation of facial muscles in patients with lesions of the facial nerve of different etiology after hypoglossal -facial anastomosis. Materials and methods: To evaluate the results of the use of early postoperative transcutaneus electrical stimulation, a low frequency FES was used, starting from the 2nd month after performing a XII-VII anastomosis. Assessment of the recovery of facial nerve function was performed 1 year after surgery. The study included 88 patients who underwent surgery to restore facial nerve function - hypoglossal -facial anastomosis. The survey was divided into 2 groups. The first (main) group consisted of 28 patients who underwent FES of facial muscles in the postoperative period, and the second group (comparison) consisted of 60 patients who underwent XII-VII anastomosis according to the following by the same method, but no further pharmacological or physiotherapeutic agents were used that could affect facial nerve regeneration. Results and discussion: According to this scale, the surveyed control group after 12 months. After the operation of XII-VII anastomosis according to the classical method, the following distribution was observed: The 1st degree of recovery of facial nerve function was not present in any of the patients, the 2nd degree had 2 (3.33%) patients, the thirds - 28 (46, 66%), IV - 20 (33,33%), V - 6 (10%) and VI - 4 (6,66%). In patients in the main group (where FES was used), distribution by degrees of recovery of facial nerve function on the House-Brackman scale after 12 months. after surgery it had the following character: II degree had 2 (6.45%) examined, III - 17 (54.83%), IV - 5 (22.58%), V - 2 (7.4%) and VI - 2 (7.4%). Conclusions: A statistically significant difference was observed in the postoperative period when comparing the mean M-responses of mimic muscles registered at different times after surgery in control subjects compared with patients in the main group in which FES was used. In addition, in the main group, a significantly larger number of patients reported a recovery of FN function to grade III-IV on the House-Brackman scale. Therefore, based on the results of the evaluation of the function of FN on the House-Brackman scale and electromyographic examination data in patients who underwent XII-VII anastomosis, it can be argued that with the use of FES in the postoperative period of recovery of facial nerve function is significantly faster and more complete in compared to the control group.

OBJECTIVES Extraction of cardiovascular implantable electronic devices in low-volume medical centres with limited clinical experience and an evolving lead extraction programme may be challenging. We aimed to evaluate the safety and efficacy of stepwise transvenous lead extraction (TLE) using a novel type of hand-powered rotational sheath as a first-line tool for extraction of chronically implanted devices in a single, low-volume centre. METHODS Sixty-seven consecutive patients undergoing a TLE procedure using the novel Evolution® RL rotational sheath as the first-line extraction tool between 2015 and 2019 at our institution were enrolled in the study. Their short-term and 30-day outcomes were observed. RESULTS Sixty-nine devices and 131 leads were explanted. Procedural and clinical success rates were 92.4% and 98.5%, respectively. Two procedures were classified as failures due to lead remnants >4 cm remaining in patients’ vascular systems. One major (1.5%) and 3 minor (4.4%) adverse events and no deaths were observed. CONCLUSIONS TLE procedures, performed in a stepwise manner, using the Evolution RL sheath as a first-line extraction device and conducted by an experienced, surgically well-trained operator, offer excellent results with clinical and procedural success rates comparable to those, achieved in dedicated, high-volume institutions. Opting for optimal lead extraction approach in low-volume centres or institutions with evolving TLE programmes, a stepwise extraction strategy using the Evolution RL sheath by skilled operator may provide the optimal scheme with an excellent ratio between clinical and/or procedural success and complications.

Aims We investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP). Methods and results Between June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock. Conclusions Our study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Aim To compare the spectra of pathogens causing febrile urinary tract infections (UTI) in children, treatment and antimicrobial susceptibility between 2004-2006 and 2007-2009. Methods UTI were identified from a cohort study of febrile children younger than 5 years presenting to a large tertiary children's hospital's emergency department with febrile illnesses. We compared pathogenic profiles, antibiotic choices and susceptibilities between 2004-2006 and 2007-2009 and tested for differences using χ2 and Fisher's exact tests. Antibiotic choice was compared with national therapeutic guideline recommendations for UTI in children (oral cotrimoxazole, cephalexin or amoxycillin-clavulanate or intravenous gentamicin plus ampicillin). Results There were 539 (2.71%) confirmed UTI from 19 889 febrile illnesses in 2004-2006 and 654 (2.99%) confirmed UTI from 21 846 febrile illnesses in 2007-2009. There was no difference in the frequency of the isolated pathogens by period: Escherichia coli (69.2 vs. 69.7%, P = 0.85), Proteus mirabilis (7.9 vs. 7.2%, P = 0.66) and Klebsiella species (6.2 vs. 4.7%, P = 0.25). National therapeutic guideline recommendations were followed in 277 of 539 (51.4%) versus 318 of 654 (48.6%) (P = 0.34). Oral antibiotics were given in 20.6 versus 18.9%. There was no difference in extended spectrum beta lactamase (1.5 vs. 1.7%, P = 0.82) or other antibiotic susceptibilities (e.g. E. coli: cotrimoxazole = 75.9 vs. 75.2%, P = 0.8). Conclusions Overall, approximately 3% of febrile illnesses were due to UTI, but we found no change in the spectrum of pathogens or antibiotic susceptibility patterns, including extended-spectrum beta-lactamase, with time. In both time periods, treatment followed therapeutic guidelines approximately half the time, and most pathogens were susceptible to oral antibiotics, but they were infrequently used.

Context/Objective: to investigate the usefulness of classical homeopathy for the prevention of recurrent urinary tract infections (UTI) in patients with spinal cord injury (SCI).Design: prospective...

Incineration is the key form of treatment for waste-to-energy. The existing incinerator developed is simple in design; it did not consist of a dustbin to store the waste. The waste disposed directly went through the heating chamber with no control technology i.e., the switch of chamber is controlled manually. This disadvantage is covered by our system as the switch is automatically controlled with the use of a controller. Arduino is used to control the sweeping of the valve. Programming is done with various condition to meet the requirement of the proposed work. The system is environmental friendly as it has a chimney with a filter installed in it. With the use of this system it is easier to dispose waste. It is portable as it is a wheel based incinerator. This portable wherein furnace and valve is automatically operated based on Arduino program. System is reliable and efficient as it is wheel based. The most attractive is it has inbuilt smart dustbin in it. About 65-80% of the energy content in the organic substances can be utilize to produce electricity.

Background. Heart failure (HF) is characterized by unfavorable prognosis. Disease trajectory of HF, however, may vary, and risk assessment of patients remains elusive. In our study, we sought to determine the prognostic impact of endocan—a novel biomarker of endothelial dysfunction and low-grade inflammation—in patients with heart failure. Methods. In outpatients with chronic HF, baseline values of endocan were determined and clinical follow-up for a minimum of 18 months obtained. A multivariate Cox proportional hazard model was built for HF-related death or hospitalization requiring inotropic support. Results. A total of 120 patients (mean age 71 years, 64% male, mean LVEF 36%) were included. During a mean follow-up of 656±109 days, 50 patients (41.6%) experienced an event. On Cox multivariate analysis, endocan values emerged as an independent predictor of HF prognosis (HR, 1.471 CI 95% 1.183-1.829, p=0.001, for each 1 ng/mL increase) even after adjustment for age, gender, HF etiology, LVEF, NYHA class, NT-proBNP, and exercise tolerance. Conclusions. Endocan is an independent predictor of HF-related events in chronic HF individuals and represents a promising tool for risk assessment of HF patients.

Despite the rise of deep learning in numerous areas of computer vision and image processing, iris recognition has not benefited considerably from these trends so far. Most of the existing research on deep iris recognition is focused on new models for generating discriminative and robust iris representations and relies on methodologies akin to traditional iris recognition pipelines. Hence, the proposed models do not approach iris recognition in an end-to-end manner, but rather use standard heuristic iris segmentation (and unwrapping) techniques to produce normalized inputs for the deep learning models. However, because deep learning is able to model very complex data distributions and nonlinear data changes, an obvious question arises. How important is the use of traditional segmentation methods in a deep learning setting? To answer this question, we present in this paper an empirical analysis of the impact of iris segmentation on the performance of deep learning models using a simple two stage pipeline consisting of a segmentation and a recognition step. We evaluate how the accuracy of segmentation influences recognition performance but also examine if segmentation is needed at all. We use the CASIA Thousand and SBVPI datasets for the experiments and report several interesting findings., 6 pages, 3 figures, 3 tables, submitted to IWBF 2019

Background. Galectin-3 plasma levels (gal-3) were shown to correlate with the scar burden in chronic heart failure (CHF) setting. As scar burden predicts response to stem cell therapy, we sought to explore a correlation between gal-3 and response to CD34+ cell transplantation in patients with CHF. Methods. We performed a post hoc analysis of patients, enrolled in 2 prospective trials investigating the clinical effects of CD34+ cell therapy in patients with ischemic cardiomyopathy (ICMP) and nonischemic dilated cardiomyopathy (DCMP). CD34+ cells were mobilized by G-CSF, collected via apheresis, and injected transendocardially using NOGA system. Patients were followed for 3 months and demographic, echocardiographic, and biochemical parameters and gal-3 were analyzed at baseline and at follow-up. Response to cell therapy was defined as an LVEF increase of ≥5%. Results. 61 patients were included in the analysis. The mean age of patients was 52 years and 83% were male. DCMP and ICMP were present in 69% and 31% of patients, respectively. The average serum creatinine was 86±23 μmol/L, NT-proBNP 1132 (IQR 350-2279) pg/mL, and LVEF 30±6%. Gal-3 at baseline and at 3 months did not differ significantly (13.4±5.5 ng/mL vs. 13.1±5.8 ng/mL; p=0.72), and there were no differences in baseline gal-3 with respect to heart failure etiology (15.1±7.2 ng/mL in ICMP vs. 12.7±4.3 ng/mL in DCMP; p=0.12). Comparing responders (N=49) to nonresponders (N=18), we found no differences in baseline gal-3 (13.6±5.7 ng/mL vs. 13.2±4.9 ng/mL; p=0.80). However, responders had significantly lower gal-3 at 3-month follow-up (12.1±4.0 ng/mL vs. 15.7±8.4 ng/mL; p<0.05). Also, responders demonstrated a significant decrease in gal-3 over 3 months, while in nonresponders, an increase in gal-3 occurred (−1.5±5.4 ng/mL vs. +2.7±4.3 ng/mL; p=0.01). Conclusions. In patients with chronic heart failure undergoing CD34+ cell therapy, a decrease in galectin-3 plasma levels is associated with beneficial response to this treatment modality. Further prospective data is warranted to confirm our findings and to deepen our understanding of the role of gal-3 in the field of stem cell therapy.

Pelaporan estimasi laju filtrasi glomerulus (eLFG) pada setiap hasil pemeriksaan kreatinin dianjurkan, walaupun saat ini tidak semua laboratorium mencantumkan pada hasil pemeriksaan. Modification of Diet in Renal Disease ( MDRD) merupakan formula yang digunakan untuk mengestimasi laju filtrasi glomerulus menggunakan kreatinin serum. Cystatin C serum merupakan pemeriksaan yang relatif baru dan petanda yang baik untuk menilai fungsi ginjal. Penelitian ini bertujuan mengetahui korelasi antara MDRD dan cystatin C serum. Penelitian ini menggunakan data sekunder dari 260 subjek penelitian usia 40–70 tahun yang memeriksakan kreatinin serum dan cystatin C serum selama periode Januari 2013–September 2014 di laboratorium klinik swasta di Jakarta Barat dengan desain potong lintang. Hasil penelitian menunjukkan bahwa usia rata-rata subjek 55,7+7,8 tahun. Kadar cystatin C serum rata-rata 0,99 + 0,6 mg/L, MDRD 80,24±28,1 mL/min/1,73m2. Terdapat korelasi negatif antara MDRD dan cystatin C serum dengan r=-0,767, p=0,001 (uji Pearson). Disimpulkan bahwa semakin tinggi nilai MDRD, nilai cystatin C serum semakin rendah. MDRD dapat digunakan sebagai alternatif uji fungsi ginjal bila pemeriksaan cystatin C serum tidak tersedia. [ MKB . 2016;48(3):129–34] Kata kunci: Cystatin C, eLFG, kreatinin, MDRD Correlation between Modification of Diet in Renal Disease (MDRD) and Serum Cystatin C in 40–70 Years Old Reporting of the estimated glomerular filtration rate (GFR) in every creatinine test is suggested, despite the fact that every laboratory reports it in their result. Modification of Diet in Renal Disease (MDRD) is a formula that is used to estimate the GFR using serum creatinine. Serum cystatin C is a relatively new test and superior for assessing kidney functions. The purpose of this study was to show the correlation between MDRD and serum cystatin C. A cross-sectional study was conducted using secondary data from 260 subjects, aged 40–70 years old to assess serum creatinine and serum cystatin C at a private laboratory in West Jakarta, during the period of January 2013–September 2014. The result of the study showed that the mean age of subjects was 55.7 + 7.8 years old, the mean serum cystatin C level was 0.99 + 0.6 mg/L, and the mean MDRD was 80.24±28.1 mL/min/1.73 m 2 . Pearson correlation analysis showed a negative correlation between MDRD and serum cystatin C with r = -0.767 and p =0.001. In conclusion, higher MDRD presents lower cystatin C serum; hence, MDRD can be used as an alternative renal function test when serum cystatin C is not available. [ MKB. 2016;48(3):129–34]

Context: In patients with neurogenic lower urinary tract dysfunction due to Spinal Cord Injury (SCI), recurrent Urinary Tract Infections (UTI), is a frequently encountered clinical problem. Often, conventional preventive measures are not successful. Aims: To treat the patients of SCI suffering from recurrent UTI with classical homoeopathy as add-on to standard urologic care. Materials and Methods: After exclusion of morphological abnormalities and initiation of a standard regime for prophylaxis, all patients with a neurogenic lower urinary tract dysfunction due to SCI, with more than three symptomatic UTI/year, were offered additional homoeopathic care. Symptoms were fever, incontinence, increased spasticity, decreased bladder capacity or pain/decreased general health combined with significant bacteriuria. Descriptive statistics was used for analysis. Results: Eight patients were followed up for a median period of 15 months. Five patients remained free of UTI, whereas UTI frequency was reduced in three patients. Conclusion: Our initial experience with homoeopathic prevention of UTI as add on to standard urologic prophylactic measures is encouraging. For an evidence-based evaluation of this concept, prospective studies are required. Keys for the positive outcome of this case series are co-operation of well-qualified partners, mutual respect and the motivation to co-operate closely.

Iris segmentation is an important research topic that received significant attention from the research community over the years. Traditional iris segmentation techniques have typically been focused on hand-crafted procedures that, nonetheless, achieved remarkable segmentation performance even with images captured in difficult settings. With the success of deep-learning models, researchers are increasingly looking towards convolutional neural networks (CNNs) to further improve on the accuracy of existing iris segmentation techniques and several CNN-based techniques have already been presented recently in the literature. In this paper we also consider deep-learning models for iris segmentation and present an iris segmentation approach based on the popular U-Net architecture. Our model is trainable end-to-end and, hence, avoids the need for hand designing the segmentation procedure. We evaluate the model on the CASIA dataset and report encouraging results in comparison to existing techniques used in this area.

Swallow syncope is a rare dysautonomic syndrome characterized by temporary loss of consciousness upon swallowing solid foods or liquids, displaying primarily in individuals with an underlying structural or functional esophageal or cardiac pathology. However, the evidence also suggests that isolated vagal dysfunction or abnormal reactions of esophageal mechanoreceptors after mechanical irritation, demyelination, or trauma can potentially evoke a cardioinhibitory response or vasodepression upon swallowing. We present a case of a 49-year-old otherwise healthy female patient who developed swallow syncope two weeks after whiplash neck injury acquired in a rear-end collision. After no evident anatomical and/or functional cardiac or esophageal pathology was diagnosed using several diagnostic procedures, the final diagnosis was confirmed by a provocative tilt-table test while ingesting solid food. Subsequently, a dual-chamber pacemaker was implanted, relieving the patient from troublesome symptoms. Abnormal reactions of esophageal mechanoreceptors to stimuli associated with food ingestion and/or dysfunction of afferent and efferent vagal fibers due to stretch injury and related neck trauma (acquired during the car accident) may be the leading pathophysiological mechanisms of swallow syncope in our patient.

Cardiac perforation after an ICD implantation is a rare complication, with a reported incidence between 0.6-5.2%. Its manifestation might be acute, subacute, or delayed, with an acute perforation occurring within the first 24 hours after implantation, frequently accompanied by severe clinical signs, while subacute and delayed perforations have a more benign progression. Here, we report a case of a 69-year old patient with an acute right ventricular perforation by a defibrillator lead migrating all the way through the pericardium and thoracic wall into the left breast, with an unusually mild and benign clinical course, delaying prompt diagnosis and postponing subsequent surgical treatment. Heart perforation with a defibrillator electrode is a rare but dangerous complication, which may lead to pacing failure, cardiac tamponade, cardiogenic shock, and even death. Even with a benign clinical course, one must think of cardiac wall perforation at any time after device implantation, and a contrast enhanced computer tomography (CTA) must be performed if perforation is suspected. At re-implantation, the lead should be located at a different anatomical position within the RV, preferably at the interventricular septal site, and manipulation of the injury site within the RV avoided.

BackgroundThe multifractal approach of HRV analysis offers new insight into the mechanisms of autonomic modulation of the diseased hearts and has a potential to depict subtle changes in cardiac autonomic nervous control not revealed by conventional linear and non-linear analyses in various conditions like heart failure or stable angina pectoris. The aim of this study was to employ the multifractality approach in cardiac surgery patients and evaluate the multifractality before and after beating-heart myocardial revascularization (off-pump CABG). MethodsTwenty-four hour Holter recordings were performed pre- and postoperatively in 60 patients undergoing off-pump CABG. Selected conventional time- and frequency-domain linear HRV indices were calculated from the 24h and 5min ECG segments, and preselected multifractal parameters ?(q=2), ?(q=3), h_top and Δh were determined for daytime (12:00-18:00) and nighttime (00:00-06:00) periods of the ECG recordings using Ivanov?s method. Mean differences over time were tested using paired-samples t-test and exact Wilcoxon matched-pairs test. The results are reported as mean?SD and median with interquartile range. A p value of

Rezidivierende symptomatische Harnweginfekte (HWI) bei Querschnittsgelahmten sind ein haufiges klinisches Problem. Eine effektive Prophylaxe ist oft nicht moglich. Wir prasentieren die Fallberichte von 5 Patienten mit rezidivierenden HWI, die additiv homoopathisch behandelt wurden. Unter dieser Therapie waren 3 Patienten infektfrei, bei 2 Patienten war die HWI-Frequenz rucklaufig. Unsere ersten Erfahrungen mit einer homoopathisch unterstutzten HWI-Prophylaxe sind ermutigend. Um die Effektivitat dieses Konzepts evidenzbasiert zu evaluieren, sind prospektive Studien erforderlich.

This paper proposes new regulation for nuclear power reactors aimed at increasing their safety. We begin by describing how limited liability leads to risk-loving behaviour in nuclear power companies and unsafe nuclear power reactors. By reviewing current regulatory regimes, we show that this issue is not being sufficiently addressed today. Therefore, we evaluate five regulatory instruments: (1) safety regulation, (2) minimum equity requirements, (3) mandatory insurance, (4) risk-sharing pools, and (5) catastrophe bonds. We conclude that any of these instruments either cannot be recommended in its pure form or is infeasible in reality. We therefore propose a new approach that, in its core, consists of a two-stage procedure. In the first stage, capital markets assess the risk stemming from each nuclear reactor via catastrophe bonds. In the second step, the regulator uses this private risk assessment and intervenes by charging an actuarially fair premium in the form of a Pigouvian risk tax. Society ultimately acts as an explicit insurer for nuclear risk and is, on average, fairly compensated for the risk it is taking over.

Left ventricular noncompaction cardiomyopathy (LVNC) is a rare hereditary cardiomyopathy characterized by the formation of an outer compacted and inner noncompacted layer of the myocardium. The latter is characterized by prominent trabeculations and deep intertrabecular recesses and is functionally inferior to the compacted myocardium. As there is no specific treatment for patients with LVNC who develop heart failure, the management of these patients is limited and many patients progress to advanced stages of the disease. For LVNC patients with advanced heart failure, the data regarding the use of mechanical circulatory support are scarce. We report a case of a 29-year-old patient with LVNC and advanced refractory heart failure, who was successfully bridged to heart transplantation using a long-term continuous-flow left ventricular assist device.

Introduction: The underlying mechanisms of CD34+ cell therapy in patients with non-ischemic dilated cardiomyopathy (DCM) remain poorly defined Hypothesis: We sought to evaluate the effects of CD34+ cell therapy on extracellular matrix. Methods: We performed a cohort analysis of 23 consecutive patients with DCM who underwent transendocardial CD34+ cell transplantation between January and December 2013. All patients received 5-day stimulation with G-CSF; CD34+ cells were selected with apheresis and injected transendocardially guided by electroantomical mapping. Patients were followed for 6 months and good clinical response was defined as an increase of left ventricular ejection fraction (LVEF) ≥5%. Extracellular matrix turnover was evaluated by measuring changes in galectin-3 serum levels. Results: Within 6 months after cell therapy galectin-3 levels decreased in 9 (39%) patients (Group A) and increased in 14 (61%, Group B). The two groups did not differ with regards to gender (male: 100% in Group A vs. 78% in Group B; P=0.15), age (51±10 years vs. 52±11 years; P=0.79), serum creatinine (86±22 μmol/L vs. 82±17 μmol/L, P=0.62), bilirubine (20±11 μmol/L vs. 17±9 μmol/L, P=0.51), or NT-proBNP levels (1465±1448 pg/mL vs. 1380±1626 pg/mL, P=0.72). Baseline LVEF (28±9% vs. 33±7%, P=0.10) and left ventricular end-diastolic diameter (7.1±0.8 cm vs. 6.5±0.7 cm, P=0.22) were also comparable in the two groups. Both groups received comparable doses of CD34+ cells (84±51 million cells in Group A vs. 132±96 million cells in Group B, P=0.21). At 6 months LVEF increased significantly more in Group A than in Group B (9.2±5.1% vs. 3.4±5.2%, P=0.01) and the same was true for 6-minute walk test distance (83±47 m vs. 37±27 m, P=0.03). NT-proBNP decreased in Group A (-356±684 pg/mL), but not in Group B (+449±1040 pg/mL, P=0.07) and overall clinical response was significantly better in Group A than in Group B (responders: 88% vs. 33%, P=0.008). Conclusions: In non-ischemic DCM, clinical response to CD34+ cell therapy appears to correlate with changes in galectin-3 serum levels. This suggests that the effects of CD34+ cell therapy may be partially mediated through remodelling of the extracellular matrix.

BACKGROUND: De-novo ventricular arrhythmias are potentially life-threatening complications after beating-heart revascularization (off-pump CABG). Whether pulmonary hypertension can influence initiation of ventricular arrhythmias through increased sympathetic activity is controversial. In order to determine the influence of pulmonary hypertension on its relative contribution to ventricular arrhythmia, we first had to define the role of cardiac autonomic modulation in patients with pulmonary normotension. We aimed to observe how parameters of linear and nonlinear heart rate variability are changed pre- and postoperatively in patients with pulmonary normotension undergoing off-pump CABG. METHODS: Fifteen-minute ECG recordings were collected before and after off-pump CABG in 54 patients with multivessel coronary artery disease and pulmonary normotension to determine linear (TP, HF, LF, LF:HF ratio) and nonlinear detrended fluctuation analysis (α1, α2) and fractal dimension (average, high and low) parameters of heart rate variability. Arrhythmia was monitored preoperatively in 24-hour Holter recordings and postoperatively by continuous monitoring and clinical assessment. RESULTS: Deterioration from simple (Lown I–II) to complex (Lown III–V) ventricular arrhythmia was observed in 19 patients, and improvement from complex to simple arrhythmia in five patients (P = 0.022). Patients with postoperative deterioration of ventricular arrhythmia had preoperatively significantly lower values of TP, HF and LF (P = 0.024–0.043) and postoperatively significantly higher values on the low fractal dimension index (P = 0.031) than patients with postoperative improvement of arrhythmia. CONCLUSION: Patients experiencing postoperative deterioration of ventricular arrhythmia already have impaired autonomic regulation before surgery. Higher postoperative values on the low fractal dimension index indicate that sympathetic predominance with or without concomitant vagal withdrawal is the underlying neurogenic mechanism contributing to ventricular arrhythmia.

BACKGROUND Advanced nonlinear methods of measuring heart rate variability (HRV) derived from the mathematics of complex dynamics and fractal geometry have provided new insights into the abnormalities of heart rate behavior in various pathologic conditions. These methods have provided additional prognostic information compared with traditional HRV measures and clearly have complemented the conventional linear methods. Knowledge about the behavior of complex cardiac dynamics indices after different cardiac procedures is very limited, however. We aimed to clarify how nonlinear heart rate dynamics are affected by beating-heart revascularization (off-pump coronary artery bypass graft [CABG] surgery) within the first week after the procedure. METHODS Included in the study were 66 patients who had isolated stable multivessel coronary artery disease and were in normal sinus rhythm. The patients were on chronic beta-blocker therapy and were scheduled for off-pump CABG. We performed 15-minute high-resolution electrocardiographic recordings preoperatively and on the third and seventh postoperative days to assess linear and nonlinear heart rate dynamics. Frequency-domain measurements, detrended fluctuation analysis (DFA) with short-term ( 11 beats, alpha2) correlation properties of RR-intervals, and fractal dimension (FD) measurements (average, high, and low) were made. Arrhythmia was monitored preoperatively with 24-hour Holter recordings, postoperatively by continuous monitoring for the first 4 days after the procedure, and subsequently by clinical monitoring; 24-hour Holter recordings were obtained again on the seventh postoperative day. We used the paired-samples Student t test, the Mann-Whitney U test, and the Fisher exact test for statistical analyses. Differences in arrhythmia occurrence before and after the procedure were tested with the Wilcoxon signed rank test and the McNemar test. A P level < .05 was considered statistically significant. RESULTS Values for all frequency-domain parameters decreased significantly after off-pump CABG (P< .001). Values for the alpha1 and high FD parameters decreased significantly after the procedure (P= .028 and .001, respectively), whereas alpha2 increased significantly (P= .023). DFA alpha1 was significantly lower in patients with postoperative atrial fibrillation than in patients remaining in sinus rhythm (mean +/- SD, 0.79+/-0.32 versus 1.13+/-0.45 [P= .003] on the third postoperative day; 0.89+/-0.31 versus 1.22+/-0.34 [P< .001] on the seventh postoperative day), whereas low and average FDs were significantly higher (1.84+/-0.16 versus 1.68+/-0.19 [P= .003] on the third postoperative day and 1.77+/-0.18 versus 1.66+/-0.17 [P= .01] on the seventh postoperative day for the low FD; 1.83+/-0.09 versus 1.76+/-0.10 [P= .011] on the third postoperative day and 1.80+/-0.11 versus 1.73+/-0.10 [P= .014] on the seventh postoperative day for the average FD). The low FD was significantly higher on the third postoperative day in patients with postoperative deterioration of ventricular ectopy than in patients with improved ventricular ectopy (1.74+/-0.17 versus 1.48+/-0.08, [P= .03]). CONCLUSION The decreases in alpha1, average FD, and high FD indicate that a profound decay of cardiac complexity and fractal correlation can be observed after off-pump CABG. Furthermore, a more extensive impairment of nonlinear indices was observed in patients who developed postoperative arrhythmias than in those who remained in stable sinus rhythm. Our findings suggest that the postoperative hyperadrenergic setting acts as a preliminary condition in which both reduced and enhanced vagal activity may predispose patients to arrhythmia, indicating that postoperative rhythm disturbances are an end point associated with divergent autonomic substrates.

Non-linear analyses of heart rate dynamics reveal subtle changes not evident from conventional heart rate variability measures. Traditionally, the information was inferred from 24-hour ECG recordings, making it less suitable for clinical application. Moreover, only few studies have attempted to evaluate the reliability of non-linear analyses in relation to varying proportion of artifacts in tracings. In 67 patients revascularized with beating-heart technique, fractal dimension and detrended fluctuation analyses were obtained from 24-hour Holter and 15-minute high-resolution ECG recordings pre and postoperatively. We found strong correlations of non-linear indices between 24-hour and 15-minute recordings (0.54-0.77, p

International audience; With progress in microelectronics the component density on a device increases drastically. As a consequence the power density reaches levels that challenge device reliability. New heat dissipation strategies are needed to efficiently drain heat. Thermal Interface Materials (TIMs) are usually used to transfer heat across interfaces, for example between a device and its packaging. Vertically Aligned Carbon Nanotubes (VACNTs) can be used to play this role. Indeed, carbon nanotubes are among the best thermal conductors (∼3.000 W/mK) and in the form of VACNT mats, show interesting mechanical properties. On one side, VACNTs are in contact with their growth substrate and there is a low thermal resistance. On the other side, good contact must be created between the opposite substrate and the VACNTs in order to decrease the contact thermal resistance. A thin-film deposition of an amorphous material can be used to play this role. This paper reports a chemically enhanced carbon nanotube based TIM with creation of chemical bonds between the polymer and VACNTs. We show that these covalent bonds enhance the thermal transfer from VACNTs to a copper substrate and can dramatically decrease local resistances. Implementation processes and thermal characterizations of TIMs are studied and reported.

Interpretation and evaluation of images obtained by different contrast-enhanced diagnostic tools in patients on extracorporeal membrane oxygenation (ECMO) support can be extremely challenging due to profound pump-related alterations in haemodynamics and contrast media enhancement patterns. We present a case of a 65-year old patient on veno-arterial ECMO with a pseudo-filling defect of the arterial system on contrast-enhanced computed tomography scan, resembling aortic dissection.

Objective Elective minilaparotomy abdominal aortic aneurysm (AAA) repair is associated with a significant number of complications involving respiratory, cardiovascular, gastrointestinal, and central nervous systems, with mortality ranging up to 5%. In our study, we tested the hypothesis that intra- and postoperative intravenous restrictive fluid regimen reduces postoperative morbidity and mortality, and improves the outcome of minilaparotomy AAA repair. Methods From March 2009 to July 2013, 60 patients operated due to AAA were included in a prospective randomized controlled trial (RCT). About the administration of fluid during the operation and in the early postoperative period, all the patients were randomized into two groups: the group of standard fluid administration (S-group, 30 patients) and the group of reduced fluid administration (R-group, 30 patients). The verification of the treatment success was measured by the length of intensive care unit (ICU) stay, duration of hospitalization after the procedure, as well as the number and type of postoperative complications and mortality. This prospective RCT was registered in a publicly accessible database ClinicalTrials.gov with unique Identifier ID: NTC01939652. Results Total fluid administration and administration of blood products were significantly lower in R-group as compared with S-group (2,445.5 mL vs. 3308.7 mL, p = 0.004). Though the number of nonlethal complications was significantly lower in R-group (2 vs. 9 patients, p = 0.042), the difference in lethal complications remained nonsignificant (0 vs. 1 patient, p = ns). The average ICU stay (1.2 vs. 1.97 days, p = 0.003) and duration of postoperative hospital stay (4.33 vs. 6.20 days, p = 0.035 for R-group and S-group, respectively) were found to be significantly shorter in R-group. Conclusion Intra- and postoperative restrictive intravenous fluid regimen in patients undergoing minilaparotomy AAA repair significantly reduces postoperative morbidity, and shortens ICU and overall hospital stay. Even though incidence of lethal complication was lower in R-group, the difference did not reach statistical significance. Therefore, we may assume that this study was probably underpowered to estimate the differences in mortality between R- and S-groups. Further multicentric, sufficiently powered RCTs are needed to confirm these findings and to clarify effect of restrictive fluid management on mortality.

The Gun (Elevation) Stabilization Bump Course (GSBC) of the Aberdeen Proving Ground (APG) is a special road test track which is used for quality testing of the line-of-sight (LOS) stabilized devices which are mounted into military vehicles. There are optical devices, antennas and guns which are components of the fire control systems for example. The methodology for the quality testing of the LOS stabilized devices using the design of the GSBC is the basic standard for appropriate devices testing in all NATO countries. We present a simulation model of the vehicle passing the GSBC in our contribution. The Matlab model generates vibrations of suspended parts of the vehicle. These vibrations can be used as the inputs in simulators of the suspended parts movement or as the input in simulation models of the servos of the LOS stabilized devices. The spectral parameters of these vibrations are estimated, too.

Background: Patients with neurogenic bladder dysfunction are prone to various urologic disorders which sometimes cannot be appropriately treated. Especially recurrent urinary tract infections (UTI) in patients with spinal cord injury are a frequent clinical problem. Often, conventional preventive measures are not successful. We present our initial results of collaboration between homeopaths and urologists in these patients. Materials and Methods: after exclusion of morphologic abnormalities and initiation of a standard regime for prophylaxis, all patients with a neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) with more than 3 symptomatic UTI/year were offered additional homeopathic care (classical homeopathy with an individualized approach). UTI symptoms were fever, incontinence, increased spasticity, decreased bladder capacity or pain/decreased general health combined with significant bacteriuria. Results: Five of seven patients opted for homeopathic treatment. The bacterial strains detected in urinalysis were E. coli, proteus mirabilis and Klebsiella pneumonia, respectively. Morphologic and functional reasons for recurrent UTI were excluded by sonography, cystoscopy and urodynamics. After treatment, with a median follow-up of 15 months, 3 of these patients remained free of UTI, whereas UTI frequency was reduced in the other 2 patients. In three patients, standard prophylactic treatment could be reduced. No side effects were encountered. Conclusion: Our initial experience with homeopathic prevention of UTI is encouraging. Keys for a fruitful cooperation are well-qualified partners, mutual respect and the motivation to cooperate closely. For an evidence-based evaluation of this concept, prospective studies are required.

s S61 and at one year follow-up was 5.78 L/min vs. 6.38 vs. 5.88 (p= 0.063), respectively. Despite body size mismatch, recipient-to-donor LVEDD ratio was similar between groups (1.66 in-range vs. 1.86 undersized vs. 1.70 oversized, p= 0.057). Conclusion: We did not detect any difference in outcomes of patients transplanted with undersized or oversized donors. LVEDD was similar between the groups, despite the body size mismatch. Matching recipients and donors by LVEDD may allow expansion of the donor pool for OHT, and reduce OHT wait time.

This study aimed to describe the results of learning through the use of media folder. The subject of research grade II SDN 009 Tanjung Palas. Improved learning outcomes in terms of four categories of goods, namely absorption, the effectiveness of learning, mastery learning completeness students both individually and classical completeness and accuracy of the results of learning. The instrument used for data collection is an oral test and a written test in the form of worksheets performed after the learning process. Results Shows absorption learning outcomes on average 83% is considered very good, very effective learning effectiveness categorized with an average of 70. While the completeness of student learning outcomes Presented complete 100%. In addition, increase the thoroughness of students in each cycle, the first cycle (58.82%), the second cycle (70.59%), the third cycle (88.24%). Based on these results it can be concluded that through active learning model of revisiting the difficulty can improve students' mathematics learning outcomes.

In this paper, an approach to multivariable combustion control design within the Individual Channel Design (ICD) framework for analysis and control design is presented. ICD is a framework which involves an interplay between customer specification, uncertain plant characteristics, and the multivariable feed-back design itself. Established multivariable methods and process engineering knowledge can be incorporated or evaluated within the ICD framework. The combustion control has been designed and evaluated with a computer simulation of both a linearized model and a nonlinear model of the closed-loop system. The ICD multivariable framework shows in a highly transparent manner, by way of simple graphical frequency response indicators, what the main possibilities and difficulties posed by a combustion process for multivariable control are, and how much trade-off between control specifications is possible. Solutions are also presented for problems such as: integrity of closed-loop control, balance of input-output channels, simple and transparent controller structure, and robustness.

The incidence of cardiac rupture complicating myocardial infarction has declined since the introduction of thrombolytic therapy. Despite the advances in the management of myocardial infarction, cardiac rupture remains an important cause of death among infarction-related fatalities. We discuss a patient who presented to our hospital with myocardial infarction and who subsequently developed a complex ventricular septal rupture, for which surgical repair was not feasible. Implantation of a CardioWest Total Artificial Heart (SynCardia Systems) allowed for immediate hemodynamic stabilization and served as a bridge to transplantation.

In this chapter, advantages of credit insurance v. self-insurance and other virtually equivalent substitutes and/or complementary financial instruments are listed and analyzed, for example, invoice discounting and factoring, letter of credit, bank guarantees, and so on. As a conclusion, it is clearly stated and argued that credit insurance of short-term trade receivables with its supplementary services is advanced, rather flexible, discreet, efficacious, price competitive, and oftentimes superior financial instrument of protection against nonpayment risks of private and/or public buyers suitable for credit risk portfolio management of many exporters and other business operators.

To get efficacious protection, credit insurance contract with whole turnover coverage or its variants should be carefully stipulated and periodically adjusted to changed circumstances. On the other hand, credit insurance policy management is labor intensive and requires due care of the policyholder and day-to-day activities during the policy period. In this chapter, procedures to obtain and manage credit insurance policy are described starting from different types of policies and request for insurance, setting of buyers’ revolving credit insurance limits, and described main content and legal characteristics of embraced credit insurance contract. The chapter continues with the description of the insured’s obligations such as reporting and notifications, prohibited underdeclaration, overloading and other prevention and loss minimization measures, alterations of insurance limits, insurance declarations, payment of insurance premium, reports on payment delays, debt collection activities, request for claims payment as well as claims handling, and subsequent recoveries of the claims paid, if any.

Credit insurance functions with powerful elements of risk management are presented in this chapter, for example, the most important active function is the risk transfer and insurer’s “financial guarantee” for indemnification for the loss incurred due to insolvency or protracted default of the buyers as well as its preventive and curative functions. With the latter auxiliary services offered within serviced credit insurance (credit information, risk monitoring, debt collection and recoveries, etc.), insured companies, in addition to achieved cash flow and balance sheet protection, prevent loss-causing events, minimize their harmful consequences, and can outsource some credit risk management activities cost-effectively. On the other hand, credit insured companies may safely extend supplier credits to their buyers on competitive terms and create potential for increased sales/exports and growth. And lastly, credit insurance—especially by assignment of insurance policy rights—also enhances external financing by commercial banks, factoring companies and other credit institutions.

Background: Virtually many patients with spinal cord injury (SCI) suffer from neurogenic lower urinary tract dysfunction (NLUTD). Although the most severe consequence of NLUTD, damage of renal function, can be treated effectively today, urinary tract infections (UTI) are the most common urologic problems in SCI patients. They severely impair the quality of life, and no evidence-based prophylaxis exists. The goal of this study is to assess the usefulness of adjunctive homeopathic treatment for the reduction of UTI in patients with SCI. Methods/Design: A prospective randomized controlled trial is designed to assess whether adjunctive treatment with classical homeopathy leads to a relevant reduction of the rate of UTI in patients with SCI. In addition, it will be assessed if homeopathic treatment will significantly improve patient satisfaction and quality of life. Fifty patients with SCI and recurrent (3 or more) UTI per year will be recruited from the patients of the neuro-urology of the Swiss paraplegic Centre in Nottwil, Switzerland. All patients will be randomly allocated into two groups: patients in the homeopathy group (n = 25) will receive standard of-care prophylaxis combined with homeopathic treatment; the control group (n = 25) will receive standard of-care prophylaxis alone. Standard of-care prophylaxis consists of cranberry products and urine acidification. Homeopathic treatment consists of a homeopathic medication; the remedy is chosen individually based on the homeopathic case taking. Patients do not routinely present to the homeopaths during the study, but can contact them if a UTI occurs during the course of the study. Primary outcome are the UTI rate, and secondary outcomes are quality of life and satisfaction with the treatment over a follow-up period of 1 year. Discussion: There is a high demand for effective UTI prophylaxis in patients with SCI, because UTI are associated with an increased morbidity and even mortality. The results of the study will significantly add to our knowledge not only about UTI prevention, but the clinical value of homeopathy. Trial registration: ClinicalTrials.gov identifier: NCT01477502, registered on 17 November 2011. Ethics: The "Ethikkommission Nordwest- und Zentralschweiz (EKNZ): PB_2016-00054" approved this study protocol. Informed consent: Patients will sign an informed consent prior to participation in the study.