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The quadricuspid aortic valve (QAV) is a rare congenital anomaly that typically is unrelated to other cardiac anomalies. It usually is discovered incidentally through imaging modalities such as echocardiogram or computed tomography angiogram, during surgery, or autopsy. Some patients with QAV develop aortic regurgitation and, rarely, other cardiovascular complications like aortic aneurysm. Due to its rarity, it is difficult to characterize these patients or standardize management. However, review of case reports can be very useful in rare medical conditions such as QAV. In this manuscript, in addition to presenting two cases of QAV, the authors reviewed 149 cases of QAV from 2010 to 2020 from published case studies and series in order to gain a better insight into the characteristics of the patient population with QAV and its management.

Background: Cosmetics have been a part of routine body care not only for the upper classes but also for the middle and lower classes since the dawn of civilization. Cosmetic formulations are in more demand as the public's interest in skin whitening grows. The contamination of cosmetics with heavy metals is a major concern as they containing heavy metals and pose a major risk to human health. This study looks in to the effects of Lead on human skin. Methods: in this cross-sectional study different products were examined. The matrices (scalp hair, blood, serum and nails) of reference and dermatitis cosmetic female patients (seborrhoeic dermatitis, rosacea, allergic contact dermatitis, and irritant contact dermatitis) and cosmetic samples were used in a 2:1 mixture of HNO3 (65%) and H2O2 (30%), and oxidation was performed using a microwave. The oxidized beauty and biological specimen underwent electrothermal atomic emission spectrophotometry after microwave-assisted acid digestion. The validity and precision of the methodology were verified using certified reference materials. Cosmetic products (lipstick, face powder, Eye Liner and Eye shadow) of different brands contain Pb concentrations in the ranges of 50.5–120 μg/g, 14.6–30.7 μg/g, 2.87–4.25 μg/g and 15.3–21.6 μg/g, respectively. Results: In the present study, cosmetic products (lipstick (N=15), face powder (N=13), eye liner (N=11), eye shadow (N=15) and female patients with dermatitis (N=252) residing in Hyderabad city, Sindh, Pakistan, was investigated. The outcome of this investigation showed significantly higher levels of Pb in biological samples (blood and scalp hair) of different types of female dermatitis patients than in reference subjects (p

Pulmonary artery aneurysm (PAA) is a rare disorder that may be classified as congenital, acquired, or idiopathic, in the case of unclear etiology. When associated with severe idiopathic pulmonary arterial hypertension, such a case of PAA may present to the operating room as an indication for lung transplantation. In this article, we present such a case of a patient with a giant main and right PAA that underwent a double lung transplant. We describe the pathophysiology and natural course of this PAA and discuss the role of intraoperative transesophageal echocardiography in the management of patients with this rare diagnosis.

Persistent left superior vena cava (PLSVC) is a rare abnormality with incidence reported as 0.3% to 0.5% in the general population and about 10 times higher in patients with congenital heart disease. The diagnosis of PLSVC in native or donor hearts of patients undergoing heart transplants has been reported in surgical journals. However, this rare finding has not been described in similar heart transplant settings in anesthesia literature. This case describes a 44-year-old male orthotopic heart transplant recipient who was incidentally diagnosed with PLSVC in his native heart on transesophageal echocardiogram after a central venous catheter placement. The particular position of the central venous catheter, in our case, raised the suspicion of PLSVC but needed further verification. With the help of images and videos, we demonstrate that transesophageal echocardiogram can be instrumental in diagnosing PLSVC. Furthermore, the case highlights the importance of effectively communicating with the surgeon about such a finding so that the surgical plan can be modified in a timely manner.

Impending paradoxical embolism is a rare but potentially life-threatening complication of venous thromboembolism that is usually associated with acute pulmonary embolism and a right to left atrial shunt. Patients may have associated right ventricular pressure or volume overload with subsequent failure. Transesophageal echocardiography is the preferred diagnostic test of choice in this patient group. Definitive management has yet to be clearly defined. However, emergent surgical removal of the entrapped intracardiac blood thrombus may be necessary. In this article, we review a case of impending paradoxical embolism managed surgically and describe the perioperative anesthetic considerations in this patient population, along with the role of intraoperative transesophageal echocardiography.

PurposeThe purpose of this paper is to explore the links between entrepreneurial behavior and success factors in a developing country context.Design/methodology/approachA case study approach was selected to analyze real‐life situations in order to gain an insight about entrepreneurial cognition and action related to success factors. Drawing from the behavioral theory of entrepreneurship, this paper presents a conceptual model which shows that entrepreneurial cognitions about success factors may lead toward entrepreneurial actions. The data were collected through face‐to‐face interviews. Three entrepreneurs were asked to outline responses to identified success factors such as start‐up planning, managing risk, learning, networking, managing human resource, and managing finances.FindingsThe results suggest that many behavioral patterns exhibited by the case study entrepreneurs were similar to entrepreneurs' behavior in more developed regions. The similarities include: preparation of business plan, ability cognition for start‐up planning, overconfidence and representativeness heuristics for managing risk, obtaining professional outsider assistance for learning, developing business relationships with suppliers for networking and favorable credit policies, and employing owner‐related and delaying‐payment methods of bootstrapping for managing finances.Originality/valueFor the first time in Pakistan this study explores entrepreneurial cognition and action in managing success factors. The findings of the research will potentially help practitioners and policy makers in nurturing entrepreneurial initiatives in a developing country context.

PurposeThis study aims to examine how the just‐in‐time (JIT) principles can be adopted for the air travel industry with specific emphasis on the management and operations of terminal buildings in airports.Design/methodology/approachThree methods were adopted for the empirical part of this study. These included the observational walk‐through, interviews and survey questionnaires conducted in the Changi International Airport in Singapore. The evaluation for JIT application, as part of a larger study, includes the points of arrival and departure, the check‐in hall, immigration area, transit mall, gate lounges, food and beverage outlets, retail shops as well as other management initiatives that strive for continuous improvement. This paper focuses only on the check‐in hall.FindingsJapanese businesses have been able to compete successfully in the world market in recent decades because of their total dedication to quality and productivity issues. This has been made possible in part by the guiding principles of the JIT concept which many Japanese businesses subscribed to. The JIT principles include waste elimination, pull production system, uninterrupted work flow, total quality control, top management commitment, employee involvement, long term working relationships with suppliers and continuous improvement. The JIT concept was specifically examined in this study in the context of the Changi International Airport through its planning processes and existing operations. The study was able to highlight the strengths as well as areas for potential improvements in the airport through the application of the seven JIT principles.Practical implicationsBeyond Japanese businesses, the JIT concept was also found to have benefited organizations in a wide range of industries including those relating to the built environment. The study covers major processes and procedures typical of the spatial management and operations of major airport terminal buildings which holds promising lessons for airport management worldwide.Originality/valueThe analysis shows significant potential in applying JIT principles for managing airport operations within the confines of the physical airport terminal buildings. It recommends that designers, project managers and asset managers should progress beyond the traditional “design follows functions” approach to adopt the more integrative “design follows JIT‐driven functions” approach.

Sex differences in morbidity and mortality associated with cardiovascular disease have been recognized by the medical community for decades. Investigation into the underlying biological basis of these differences was largely neglected by the scientific community until a report released by the Institute of Medicine in the United States in 2001 "Exploring the Biological Contributions to Human Health: Does Sex Matter?" Recommendations from this report included the need for more accurate use of the terms "sex" and "gender", better tools and resources to study the biological basis of sex differences, integration of findings from different levels of biological organization and continued synergy between basic and clinical researchers. Ten years after the Institute's report, this review evaluates some of the sex differences in cardiovascular disease, reviews new approaches to study sex differences and emphasizes areas where further research is required. In the era of personalized medicine, the study of the biological basis of sex differences promises to optimize preventive, diagnostic and therapeutic strategies for cardiovascular disease in men and women, but will require diligence by the scientific and medical communities to remember that sex does matter.

Peripheral arterial disease is a common but underdiagnosed and undertreated disorder with substantial morbidity and mortality. The pathophysiology of peripheral arterial disease and the risk factors for developing it are similar to those for atherosclerotic disease occurring at other sites. Peripheral arterial disease can be diagnosed accurately with simple, noninvasive, office-based tests that measure the severity of the disease and provide valuable prognostic information. Optimal medical therapy includes a supervised exercise program, tobacco cessation, and modification of treatable risk factors. Cilostazol can improve pain-free and peak walking distances in patients with intermittent claudication. As a general rule, patients with lifestyle-limiting claudication who do not respond to medical management or those with critical limb ischemia should be referred to a vascular specialist for consideration of revascularization.

PurposeThis paper seeks to present research into the development of a theoretical model for making more informed decisions for the management of variations in building projects. Primarily, the study proposes six principles of effective variation management, which would be helpful for building professionals in assessing and taking proactive measures for reducing the adverse impact of variations.Design/methodology/approachBased on the principles of effective variation management, a theoretical framework for management of variation orders was developed. The stages presented in the theoretical framework were grouped into three main phases – screening, choice of promising alternatives, and dominance building. Based on the theoretical framework, a model for management of variations was developed.FindingsThe theoretical model presents a structured format for management of variation orders. The model will enable the project team to take advantage of beneficial variations when the opportunity arises without an inordinate fear of the negative impacts. By having a systematic way to manage variations, the efficiency of project work and the likelihood of project success should increase.Originality/valueThe study would assist building professionals in developing an effective variation management system. The model emphasized sharing the lessons learned from existing projects with project teams of future projects. The lessons learned should be identified throughout the project life cycle and communicated to current and future project participants. The system would be helpful for them to take proactive measures for reducing variation orders. Hence, the study is valuable for all professionals involved with building projects.

This paper describes the development of the knowledge-based decision support system (KBDSS) for management of variation orders for institutional buildings in Singapore. The KBDSS consists of two main components, i.e., a knowledge-base and a decision support shell for selecting appropriate controls. The database is developed by collecting data from the source documents of 79 institutional building projects, questionnaire survey, literature review and in-depth interviews with the professionals who were involved in these projects. The knowledge-base was developed through initial sieving and organization of the data from the database. The decision support shell provided decision support through a structured process consisting of building the hierarchy between the main criteria and the suggested controls, rating the controls, and analyzing the controls for selection through multiple analytical techniques. The KBDSS is capable of displaying variations and their relevant details, a variety of filtered knowledge, and various analyses of the available knowledge. This would eventually lead the decision maker to the suggested controls for variations and assist in selecting the most appropriate controls. The KBDSS is able to assist project managers by providing accurate and timely information for decision making, and a user-friendly system for analyzing and selecting the controls for variation orders for institutional buildings.

The study identifies the causes of variations in institutional building projects in Singapore. To achieve the study objectives, a questionnaire survey and interviews were carried out to collect information on potential causes of variations. Responses from 28 professionals with a government agency from the client's side were analyzed. The results suggest that the errors and omissions in design, change in specifications by owner, design discrepancies, change in specifications by consultant and lack of coordination were considered as the most important causes of variations in institutional building projects. Recommendations were suggested based on the findings of the research and literature review. The involvement of professionals during the design phase, thorough detailing of design, involvement of owner during the design phase and approval of the design by government bodies before the inception of construction activities were suggested for controlling the most important causes of variation orders for insti...

The study identifies the causes of inconsistencies between the design and construction of large building projects. To achieve the study objectives, a questionnaire survey was carried out to collect information on potential causes of inconsistencies at the project design and construction interface. Responses from 27 contractors were analyzed. The results suggest that the involvement of designer as consultant, communication gap between constructor and designer, insufficient working drawing details, lack of coordination between parties, lack of human resources in design firm, lack of designer's knowledge of available materials and equipment, and incomplete plans and specifications were considered as the most important causes of the project design and construction interface inconsistencies. On the other hand, project management as a professional service, weather conditions, nationalities of participants, involvement of the contractor in design conceptual phase, unforeseen problems, involvement of the contractor in design development phase, and government regulations were the least important causes of inconsistencies between professionals at the project design and construction interface in large building projects.

Value management (VM) in construction is urgently required due to the escalating complexity of building projects. Building projects are complex because they involve many human and non-human factors and variables. VM, if implemented during the early stages, can save costs while maintaining or even improving the performance and quality of construction projects. The integration of project knowledge and experience at the design phase provides the best opportunity to improve overall project performance. This study presents a knowledge-based decision support system (KBDSS) to assist effective implementation of VM for controlling variations in educational building projects. The KBDSS consists of two main components, namely a knowledge base and a controls selection shell, and is developed by collecting data from the source documents of 80 educational projects, a questionnaire survey, and interviews in Singapore.The system provides an excellent opportunity for the project team to learn from past experience...

This study identifies major findings based on data collected from the source documents of 79 institutional building projects, and how these have implications for future policy. The study presents a Knowledge-Based Decision Support System (KBDSS), based on data collected from these 79 institutional buildings, for making timely and more informed decisions on the management of variations. To achieve the study's objectives, an in-depth study of source documents and a questionnaire survey were utilized. In-depth interviews with 62 professionals involved in these projects were analyzed. The KBDSS consists of two main components, a knowledge-base and a decision support shell for selecting appropriate controls. The KBDSS is able to assist project managers by providing accurate and timely information for decision-making, and a user-friendly system for analyzing and selecting the controls for variation orders regarding institutional buildings. The developed system and the findings of this study should be of interest to all building professionals.

PurposeTo provide an in‐depth analysis of the potential effects of variations in institutional building projects, which would be helpful for building professionals in assessing and taking proactive measures for reducing the adverse impact of variations.Design/methodology/approachTo achieve the study objectives, a questionnaire survey was carried out to collect information on potential effects of variations. Responses from 28 professionals working for a developer organization (a government agency) were analyzed. Furthermore, 26 face‐to‐face interviews using the questionnaires were also analyzed.FindingsThe results suggest that the most frequent effects of variations were increase in project costs, additional payments for contractor, progress affected but without any delay, completion schedule delay, increase in overhead expenses and rework and demolition. Recommendations were suggested based on the findings of the research and literature review.Research limitations/implicationsThis paper presented only the developers' view of the effects of variation orders on institutional building projects in Singapore. Further works can be extended to survey the consultants and the contractors who have carried out these projects.Practical implicationsThe study will benefit the professionals involved with institutional building projects. The professionals would learn about the downstream effects that may assist in the valuable evaluation of variation orders.Originality/valueThis is a timely study as the program of rebuilding and improving existing institutional buildings is currently underway in Singapore. A clearer view of the effects of variations on the projects will enable the project team to take advantage of beneficial variations. Furthermore, the findings can be used by future researchers to carry out studies on the management of variation orders in various other types of projects.

Variations are common in all types of construction projects. The construction process is influenced by highly changing variables and unpredictable factors that can arise from different sources. The study identifies the causes of variations in institutional building projects in Singapore. To achieve the study objectives, a questionnaire survey was carried out to collect information on potential causes of variations. Through the literature review, the 53 causes of variation orders were identified. These provided the basis for the formulation of the questionnaire. Responses from 33 design consultants, who were involved in the institutional projects in Singapore, were analysed. The survey results suggest that a change in plans or scope by the owner, unforeseen problems, defective workmanship, change in specifications by the owner and safety considerations were the most important causes of variation orders for institutional buildings in Singapore. Recommendations were suggested based on the findings o...

The study identifies the nature and frequency of occurrence of variations orders for educational buildingprojects in Singapore. To achieve the study objectives, an in-depth study of source documents of seventynine educational building projects was carried out for data collection. In-depth interviews with 28 professionals from the developer organisation (a governmental agency), were analyzed. The results indicate that the total number of variations in upgrading projects was almost twice, in absolute terms, the total number of variations in new projects. Though, in the relative terms, the average number of variations in upgrading projects was almost 21% more than in new projects. Furthermore, in the new projects, architectural variations were 65.29% of the total numbers of variations, 20.37% were mechanical and electrical variations, and civil and structural variations were 11.83%. In the upgrading projects, architectural variations were 59.20% of the total numbers of variations, 25.19% were mechani...

The study focuses on the causes of discrepancies at the design and construction interface in large building projects. To achieve the study objectives, a questionnaire survey was carried out to collect information on potential causes of discrepancies at the project design and construction interface. Responses from 48 consultants and contractors were analyzed. The results suggest that the lack of coordination, insufficient working drawing details, involvement of designer as consultant, involvement of contractor as consultant and participants' honest wrong beliefs were considered as the most important causes of discrepancies at the project design and construction interface. On the other hand, project management as a professional service, the nationality of the professional firms and involvement of the contractor in design phases were least important causes of discrepancies between professionals at the project design and construction interface in large building projects.

A 66-year-old white man presented to the emergency department with a 4-day history of progressive dyspnea, cough, and hemoptysis. The patient was known to have mitral valve prolapse confirmed by transthoracic echocardiogram, performed 9 months before his present admission. The transthoracic echocardiogram had shown a myxomatous mitral valve with prolapse of the P2 scallop and severe eccentric mitral regurgitation (MR) that was anteriorly directed. The mitral regurgitant fraction using the volumetric method was 69%. The left ventricular (LV) end diastolic dimension was 4.8 cm, and the LV end systolic dimension was 3.3 cm, both within normal limits. The LV systolic function was normal with ejection fraction (modified Simpson’s rule) of 58%. The right ventricular dimensions were normal (apical 4-chamber view: long axis, 7.2 cm; midshort axis, 2.2 cm; inflow short axis, 2.5 cm). The right ventricular systolic function was normal. The peak pulmonary artery systolic pressure was 30 mm Hg, with estimated right atrial pressure of 5 mm Hg. The patient had a transrectal prostate biopsy done to rule out carcinoma a few weeks before his presentation to the emergency department. On examination, he was hypotensive (blood pressure, 96/61 mm Hg), tachycardic (heart rate, 122 beats per minute), and in respiratory distress (36 breaths per minute with oxygen saturation of 86% on room air and 98% on facemask). Cardiovascular examination was remarkable for grade 5 of 6, holosystolic murmur along the left sternal border, and the presence of significant bibasilar rales. There were numerous palpable petechial lesions on the skin (Figure 1). After admission to the coronary care unit, the …

Enterocolic lymphocytic phlebitis (ELP) is a recently described disease characterized by phlebitis in the wall and mesentery of the colon and small bowel. Unlike other systemic or localized vasculitic diseases that can have similar gastrointestinal manifestations, there is no involvement of the arterial system or evidence of systemic vasculitis. The lymphocytic phlebitis affects not only the grossly involved intestinal segment but also the apparently healthy bowel. The diagnosis of ELP is histologic, and other systemic vasculitis must be ruled out. Surgical resection of the bowel not only provides the diagnostic tissue but also leads to resolution of the symptoms. In the literature, ELP has most commonly been reported to present as an acute abdomen. We describe a case of ELP presenting as a large abdominal mass, without evidence of an acute abdomen. This mass was actually diffusely thickened colonic serosa, caused by extensive organizing fat necrosis and marked edema of the serosa and bowel wall.

Objectives This study sought to compare survival of patients with poorly compressible arteries (PCA) to those with a normal ankle-brachial index (ABI) and those with peripheral arterial disease (PAD). Background Limited data are available regarding survival in patients with PCA identified in the clinical setting by noninvasive lower extremity arterial evaluation. Methods We conducted a historical cohort study of consecutive patients who underwent outpatient, noninvasive lower extremity arterial evaluation at the Mayo Clinic, Rochester, Minnesota, from January 1998 through December 2007, and who were followed for a mean duration of 5.8 ± 3.1 years. An ABI 1.00 to 1.30 was considered normal, PAD was defined as a resting or post-exercise ABI ≤0.90, and PCA defined as an ABI ≥1.4 and/or an ankle systolic blood pressure >255 mm Hg. Patients were followed for all-cause mortality through September 30, 2009. Results Of 16,493 individuals (mean age 67.8 ± 13.0 years, 59% male); 29% had normal ABI, 54% had PAD, and 17% had PCA. During follow-up (mean duration 5.8 ± 3.1 years), 4,365 patients (26%) died. The percent alive at the end of the study period was 88%, 70%, and 60% for normal ABI, PAD, and PCA, respectively. After adjustment for age, sex, cardiovascular risk factors, comorbid conditions, and medication use, the hazard ratios (95% confidence intervals) of death associated with PCA were 2.0 (1.8 to 2.2) and 1.3 (1.2 to 1.4) compared with the normal ABI and PAD groups, respectively. Conclusions Patients identified by noninvasive vascular testing to have poorly compressible leg arteries have poor survival, worse than those with a normal ABI or those with PAD.

The competence of a construction program in the core area of construction project management is in imparting to its students the necessary expertise in order to practice professionally in the construction industry. The study identifies the competencies for baccalaureate level construction education in Alberta, Canada. To achieve the study objectives, a questionnaire survey was carried out to collect information on industry's perspective on construction professional competences. Responses from 32 construction industry professionals were analyzed. The results suggest that the construction acumen, project management and leadership, business acumen, professionalism, and communications were considered as the most important (top five) and desirable competencies for baccalaureate level construction education. Other important competencies include building techniques, international project management, research, cost management, conflict resolution, ability to learn, contracts management, risk management, teamwork, and technological competency, procurement management. It is recommended that the breadth and depth of the core's syllabi ensures sufficient coverage of fundamental and extended topics on construction project management. Construction programs should help to equip our students better to participate in the local and global construction industries that await them. The findings from this study would also be valuable for all academicians and researchers involved in the area of academic development in general.

Sex differences in morbidity and mortality associated with cardiovascular disease have been recognized by the medical com006Dunity for decades. Investigation into the underlying biological basis of these differences was largely neglected by the scientific community until a report released by the Institute of Medicine in the United States in 2001 “Exploring the Biological Contributions to Human Health: Does Sex Matter?” Recommendations from this report included the need for more accurate use of the terms “sex” and “gender”, better tools and resources to study the biological basis of sex differences, integration of findings from different levels of biological organization and continued synergy between basic and clinical researchers. Ten years after the Institute’s report, this review evaluates some of the sex differences in cardiovascular disease, reviews new approaches to study sex differences and emphasizes areas where further research is required. In the era of personalized medicine, the study of the biological basis of sex differences promises to optimize preventive, diagnostic and therapeutic strategies for cardiovascular disease in men and women, but will require diligence by the scientific and medical communities to remember that sex does matter.

Objective We investigated whether markers of inflammation—white blood cell (WBC) count, C-reactive protein (CRP), and lipoprotein-associated phospholipase A2—are associated with mortality in patients referred for noninvasive lower-extremity arterial evaluation. Methods Participants (n = 242, mean age 68 years, 54% men) were followed for a median of 71 months. Ankle-brachial index (ABI), WBC count, plasma CRP, and lipoprotein-associated phospholipase A2 were measured at the start of the study. Factors associated with all-cause mortality were identified using Cox proportional hazards. Results During the follow-up period, 56 patients (25%) died. Factors associated with higher mortality were greater age, history of coronary artery disease/cerebrovascular disease, lower ABI, higher serum creatinine, and higher WBC count/plasma CRP. In stepwise multivariable regression analysis, ABI, serum creatinine, WBC count, and CRP were associated significantly with mortality. Patients in the top tertile of WBC count and CRP level had a relative risk of mortality of 3.37 (confidence interval [CI], 1.56-7.27) and 2.12 (CI, 0.97-4.62), respectively. However, only the WBC count contributed incrementally to prediction of mortality. Inferences were similar when analyses were limited to patients with peripheral arterial disease (ABI Conclusion WBC count, but not plasma CRP level, provides incremental information about the risk of death in patients referred for lower-extremity arterial evaluation and in the subset of these patients with peripheral arterial disease.