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Despite inequitable access to telemedicine video visits for those lacking home-based broadband, and the ability of public libraries to address this gap, the adoption of telemedicine in public libraries has been slow. The purpose of this research is to describe the implementation experience of five libraries and library programs that were among the earliest adopters of telemedicine in public libraries. This research was guided by the Reach, Efficacy, Adoption, Implementation and Maintenance implementation framework. A range of models have been implemented, but the most successful models include partnership with health providers or a health system. Dissemination of early adopters’ experiences can aid other libraries to learn from their example, enabling more rapid uptake of this important programming.

Aflatun’s thoughts, as great Greek philosopher, are still counted as one of the best references in terms of political philosophy and are in practice in the world of politics. Aflatun owns a utopian state based on the foundation of justice and virtue. Aflatun’s state, ruled by philosopher-kings, is characterized by having particular thoughts about the system of education. Politics is vitally important within Aflatun’s philosophy. It is regarded as means of planning his utopian city. Aflatun believes that political systems can be classified, in accordance to their ruling type, into aristocracy, timocracy, oligarchy, democracy, monarchy and dictatorship. Among them, Aflatun believes that aristocracy is the best since it’s practiced by a philosopher-king. Aflatun in his ideal state refers to metaphysics as an important basic of his utopian city. Aflatun’s view is that the ideal state can only be cherished in the life of hereafter, though those in power may be able to find some sort of the ideal life in this world. The philosopher-kings, on the other hand, are able to practice such an ideal life in this world. In Aflatun’s view, any sort of change happening in the world from the perfection towards the imperfection and weakness. This is due to the unstable feature of the world that never stays constantly. Only God is characterized by stableness and mortality. Aflatun thinks that ‘ethics’ is one of the practical fields of philosophy which shows the will of any human being that depends on performing the duty of individuals in the society to establish social justice. Aflatun states that education refers to the right preparation of human beings to suit the world of justice. He sees the education as the highest virtue. Aflatun repeats that all the social city-state classes have to get the proper education formed in certain phases based on the age of the citizens.

An anomalous left circumflex artery branching off from the right coronary artery is one of the most common congenital coronary artery abnormalities. However, because the incidence of such atypical abnormalities is relatively rare, our clinical understanding of the nuances in patients with such abnormalities remains limited. We present a case of a 73-year-old male with coronary artery disease status-post stenting of an anomalous circumflex artery who subsequently underwent coronary artery bypass grafting and surgical aortic valve replacement with EKG changes post-operatively. He was emergently taken to the cardiac catheterization lab, where catheterization revealed total occlusion of the proximal circumflex artery, just distal to the previous stent. Acute inferior ST-elevation myocardial infarction was suspected to be secondary to intraoperative external manipulation at the site of occlusion in the retro-aortic segment of the vessel. Consequently, in patients with abnormal coronary artery anatomy, it is imperative to monitor for new EKG changes that may be indicative of new ischemia requiring further intervention.

Tomato is an important vegetable crop and cultivated all over the world. The production of tomato is reducing due to the attack of various insect pests such as Liriomyza trifolii. L. trifolii is a very destructive pest and can cause severe economic losses of tomato, Lycopersicon esculentum. Botanicals, Azadirachta indica, and Euclyptus camaldulensis were checked during 2017 under laboratory conditions to check them alone and combine toxicity against second instar larvae of tomato Liriomyza trifolii. Significant differences (P

Pulmonary artery intimal sarcomas (PAIS) are vascular sarcomas of mesenchymal origin and are exceedingly rare. Here, we detail a 57-year-old female who presents with worsening dyspnea and computed tomography scan findings consistent with a pulmonary embolus, however, upon examination in the operating room for emergent embolectomy, was found to have a PAIS. This case report highlights this rare illness and management decisions that can optimize care of these patients.

Ever since the adoption of the newest heart allocation system in the Fall of 2018, clinicians have grappled with the safest method of utilizing temporary mechanical circulatory support to get patients successfully to transplantation. In unique patients that do not have a durable left ventricular assist device as a therapeutic option and have not had a full work-up for transplantation consideration, the establishment of ambulatory extracorporeal membrane oxygenation is an attractive solution.

Bicuspid aortic valve (BAV) is a common congenital heart defect (population incidence, 1-2%) that frequently presents with ascending aortic aneurysm (AscAA)4. BAV/AscAA shows autosomal dominant inheritance with incomplete penetrance and male predominance. Causative gene mutations (for example, NOTCH1, SMAD6) are known for ≤1% of nonsyndromic BAV cases with and without AscAA, impeding mechanistic insight and development of therapeutic strategies. Here, we report the identification of variants in ROBO4 (which encodes a factor known to contribute to endothelial performance) that segregate with disease in two families. Targeted sequencing of ROBO4 showed enrichment for rare variants in BAV/AscAA probands compared with controls. Targeted silencing of ROBO4 or mutant ROBO4 expression in endothelial cell lines results in impaired barrier function and a synthetic repertoire suggestive of endothelial-to-mesenchymal transition. This is consistent with BAV/AscAA-associated findings in patients and in animal models deficient for ROBO4. These data identify a novel endothelial etiology for this common human disease phenotype. Bicuspid aortic valve (BAV) is a common congenital heart defect (population incidence, 1-2%) that frequently presents with ascending aortic aneurysm (AscAA)4. BAV/AscAA shows autosomal dominant inheritance with incomplete penetrance and male predominance. Causative gene mutations (for example, NOTCH1, SMAD6) are known for ≤1% of nonsyndromic BAV cases with and without AscAA, impeding mechanistic insight and development of therapeutic strategies. Here, we report the identification of variants in ROBO4 (which encodes a factor known to contribute to endothelial performance) that segregate with disease in two families. Targeted sequencing of ROBO4 showed enrichment for rare variants in BAV/AscAA probands compared with controls. Targeted silencing of ROBO4 or mutant ROBO4 expression in endothelial cell lines results in impaired barrier function and a synthetic repertoire suggestive of endothelial-to-mesenchymal transition. This is consistent with BAV/AscAA-associated findings in patients and in animal models deficient for ROBO4. These data identify a novel endothelial etiology for this common human disease phenotype.

To examine the impact of alvimopan on outcomes and costs in a rigorous enhanced recovery colorectal surgery protocol.Postoperative ileus remains a major source of morbidity and costs in colorectal surgery. Alvimopan has been shown to reduce incidence of postoperative ileus in enhanced recovery colorectal surgery; however, data are equivocal regarding its benefit in reducing length of stay and costs.Patients undergoing major elective enhanced recovery colorectal surgery were identified from a prospectively-collected database (2010-2013). Multivariable analyses were employed to compare outcomes and hospital costs among patients who had alvimopan versus no alvimopan by adjusting for demographic, clinical, and treatment characteristics.A total of 660 patients were included; 197 patients received alvimopan and 463 patients had no alvimopan. In unadjusted analysis, the alvimopan group had a faster return of bowel function, shorter length of stay, and lower rates of ileus, Foley re-insertion, and urinary tract infection (all P 0.01). After adjustment, alvimopan was associated with a faster return of bowel function by 0.6 day (P = 0.0006), and lower incidence of postoperative ileus (odds ratio 0.23, P = 0.0002). With adjustment, alvimopan was associated with a shorter length of stay by 1.6 days (P = 0.002), and a hospital cost savings of $1492 per patient (P = 0.01).Alvimopan administration as an element of enhanced recovery colorectal surgery is associated with faster return of bowel function, lower incidence of postoperative ileus, shorter hospitalization, and a significant cost savings. These results suggest that alvimopan is cost-effective in the setting of enhanced recovery colorectal surgery protocols, and should therefore be considered in these programs.

For the child born with a functionally univentricular heart, multi-stage surgical palliation culminating in the Fontan operation is now well established as the standard of care. Though this is an effective approach, there are several inherent disadvantages to the Fontan circulation: subnormal resting cardiac output, impaired exercise capacity, increased risk of thromboembolism, and increased risk of arrhythmia. Perhaps most importantly, the long-term deleterious effects of substantial systemic venous hypertension, which is necessary to "drive" blood through the pulmonary vascular bed, include progressive dysfunction of other organ systems, particularly renal, lymphatic, gastrointestinal, and hepatic systems. When such dysfunction is advanced, heart transplantation or even heart-liver transplantation may be a reasonable option. However, because the syndrome seems to be increasingly widespread and there is already a significant donor shortage, alternative solutions are required. Because many patients with "failing Fontan" physiology have preserved systemic ventricular function, application of a systemic ventricular assist device is unlikely to be effective. However, for such patients, a right-sided sub-pulmonary ventricular assist device is an intellectually appealing solution. Several such devices have been proposed or are in varying stages of evaluation. The lack of economic incentive for development of right-sided pumps may be partially ameliorated both by recognition of the size of the cohort of Fontan patients now surviving into adulthood as well as by the increasing recognition of important right-sided heart failure in adults with biventricular hearts supported only with durable left-sided ventricular assist devices.

We describe four unrelated individuals with Loeys-Dietz syndrome (LDS) who presented with massive hemoptysis of unknown etiology. LDS is an autosomal dominant connective-tissue disorder characterized by altered cardiovascular, craniofacial, and skeletal development that is attributed to mutations in the TGFBR1, TGFBR2, SMAD3, or TGFB2 genes. Massive hemoptysis (MH) is a rare and often fatal pulmonary medical emergency. This is the first report of MH in individuals with LDS and establishes it as part of the LDS spectrum. It compels providers to educate their LDS patients on MH, although much investigation needs to be done to determine etiology and appropriate treatment for this newly described LDS feature.

Bicuspid aortic valve (BAV) is a common congenital heart defect (population incidence, 1-2%)

As the research increased in computer science highlight the scientists mind for the growing research world towards security. Researchers have done a lot of research work in network Security. Cybersecurity has progressively become a zone of alarm for officials, Government agencies and industries, including big commercialized infrastructure, are under attack daily. First signature-based intrusion detection systems were developed, and it detects only novel attacks. To detect strange attacks statistical IDS came into being recognized as anomaly-based IDS. It is not as much efficient as it detects all. In this, study the author focus on the efficiency of IDS using NSL-KDD99 dataset and support vector machine (SVM) technique to identify attacks. NSL-KDD dataset is used for the evaluation of these type of systems.

Background The optimal use of lumbar cerebrospinal fluid drainage for the prevention of spinal cord ischemia (SCI) with thoracic endovascular aortic repair (TEVAR) remains unclear. Here, we report our experience with selective preoperative lumbar drain placement with TEVAR. Methods Between May 2002 and January 12, 381 TEVAR procedures were performed at a single referral institution. Preoperative lumbar drains were placed selectively in patients considered high-risk for SCI due to planned long-segment aortic coverage with a history of prior aortic intervention or planned hybrid Crawford extent I to III thoracoabdominal aortic aneurysm repair. Results Preoperative lumbar drains were placed in 81 patients (21%); of these, drain placement in 38 (47%) was for procedures involving long-segment descending thoracic aortic coverage in the setting of prior descending thoracic or infrarenal aortic repair, and in 43 (53%) was for hybrid thoracoabdominal aortic aneurysm repair. SCI occurred in 12 patients (14.8%) who received a preoperative lumbar drain, transient in 6 (7.4%) and permanent in 6 (7.4%), whereas SCI occurred in 13 patients (4.3%) who did not receive a preoperative lumbar drain, 12 transient (4.0%) and 1 permanent (0.3%). A lumbar drain complication occurred in 9 drain patients (11.1%), although none resulted in permanent disability. Age, postoperative hypotension, and the number of endografts implanted were independently associated with SCI. Preoperative lumbar drain placement was not associated with reduced SCI. Conclusions Restricted use of preoperative lumbar drains for patients at high-risk of SCI undergoing TEVAR appears safe and leads to low rates of SCI in nondrained patients. However, the utility of preoperative lumbar drains in preventing SCI with TEVAR remains questionable and should be weighed against the risk of drain complications.

The light field describes light propagation in every direction through every point in space. Novel approaches allow an accurate and realistic capture of complex objects from dense light field sampling, including shape and surface properties. Industrial applications as well as captures for realistic content visualisations will be presented.

Invasive fungal infections are a leading cause of mortality among immunocompromised individuals. Treatment is notoriously difficult with the limited armamentarium of antifungal drugs, whose efficacy is compromised by host toxicity, a limited activity spectrum, or the emergence of drug resistance. We previously established that the molecular chaperone Hsp90 enables the emergence and maintenance of fungal drug resistance. For the most prevalent fungal pathogen of humans, Candida albicans , Hsp90 mediates resistance to azoles, which inhibit ergosterol biosynthesis and are the most widely deployed antifungals in the clinic. For the emerging opportunistic pathogen Aspergillus terreus , Hsp90 is required for basal resistance to echinocandins, which inhibit β(1, 3)-glucan synthesis and are the only new class of antifungals to reach the clinic in decades. Here, we explore the therapeutic potential of Hsp90 inhibitors in fungal disease using a tractable host-model system, larvae of the greater wax moth Galleria mellonella , and a murine model of disseminated disease. Combination therapy with Hsp90 inhibitors that are well tolerated in humans and an azole rescued larvae from lethal C. albicans infections. Combination therapy with an Hsp90 inhibitor and an echinocandin rescued larvae from infections with the most lethal mold, Aspergillus fumigatus . In a murine model of disseminated candidiasis, genetic compromise of C. albicans HSP90 expression enhanced the therapeutic efficacy of an azole. Thus, harnessing Hsp90 provides a much-needed strategy for improving the treatment of fungal disease because it enhances the efficacy of existing antifungals, blocks the emergence of drug resistance, and exerts broad-spectrum activity against diverse fungal pathogens.

understanding the biology of early-stage breast cancers, including DCIS and tailoring both local and systemic treatment to the molecular, histologic, and morphologic features that drive tumor behavior. HER2, a transmembrane receptor with tyrosine kinase activity, is overexpressed at the mRNA and/or protein level in approximately 20 % of early-stage breast cancer. Before the widespread use of HER2-targeted therapy, primarily with the monoclonal antibody trastuzumab, overexpression of HER2 was clearly associated with high recurrence rates and increased mortality. 2 The HER2-positive subtype confers a high risk of local failure independent of whether patients were treated with breast-conserving therapy (BCT) or mastectomy. An extensive analysis of 10-year local recurrence-free survival (LRFS) showed that the HER2 subtype had a LRFS of 83 % after mastectomy and 79 % after BCT compared with 92 % for both mastectomy and BCT in the Luminal A subtype. 3 Important to note, however, is that this study reported on patients diagnosed from 1986 to 1992, before use of trastuzumab. In the preceding article, Dr. Tot examined 203 consecutive cases of newly diagnosed invasive breast carcinomas measuring \10 mm in size during the period 2007–2013 at a single institution, including 23 cases of HER2-positive disease. A validation cohort of 80 cases from 1996 to 1998 also was analyzed. In both sets of samples, HER2-positive breast cancers were found to be more often associated with a higher component of diffuse DCIS around the invasive tumor (p \ 0.0001), more likely to be of higher grade (p = 0.0004), and have lymphovascular invasion (p = 0.0026) compared with tumors lacking HER2 overexpression. Although no multivariable analysis or recurrence data were provided, the author postulates a causal role of extensive DCIS for HER2positive breast cancer recurrence. The presence of an extensive intraductal component (EIC) has been recognized to be associated with a higher local recurrence rate following BCT, long before genomic subtyping of tumors. 4,5 However, the impact of EIC on local outcomes has been shown to be largely abrogated when free margins are achieved and when adjusted for age at diagnosis. 5–7 In the recently published ASCO/ASTRO guidelines, an extensive meta-analysis failed to support that larger margins were indicated for any tumor phenotype, including the HER2-positive subtype. 8 Moreover, HER2-positive breast cancers are biologically more aggressive independent of EIC, as is well demonstrated in Dr. Tot’s own data. In the absence of outcomes in Dr. Tot’s study, it is difficult to recommend any change in surgical treatment based on these observations alone, but an awareness of the association of HER2-positive disease with extensive involvement should highlight the importance of careful preoperative evaluation in order to accurately determine disease extent. Concurrent with recent efforts to decrease surgical morbidity, there has been an emerging recognition of the importance of systemic treatments to improve locoregional control. HER2-positive disease has been a true success of targeted therapy, with trastuzumab improving cancer mortality in HER2-overexpressing tumors by 33 %. 9 Moreover, local recurrence has also been shown to be

Introduction: Axillary lymph node biopsy in an irradiated or previously operated axilla can be technically challenging. Radio-labeled seed localized (RSL) biopsy is an emerging modality for localizing tissue of interest that is not amenable to wire localization. Case Report: A 60 year old female with history of breast cancer presented ten months after her initial resection with a new chest wall mass and an enlarged right axillary lymph node situated posterior and superior to the axillary vein. Given its location, wire localization was not possible and on the other hand operating without localization was too risky. We elected to place a 125I labeled titanium seed in the lymph node which greatly facilitated this otherwise difficult dissection and safely delivered the specimen needed for diagnostic purposes. Discussion: With the advancement of imaging technology, surgeons are able to safely and accurately recover diagnostic tissue specimen from extremely challenging anatomic spaces. Radio-labeled seed localization is another step in furthering surgical capabilities in this regard. RSL provides several advantages over wire localization: placement in lesions located deep in body cavities, seed placement can be scheduled a day prior to surgery thus making it more easier on patients, and no risk of cutting or dislodging the wire. Clinical practice points: The use of radio-labeled seed localized (RSL) breast biopsy is growing in popularity and is replacing wire localized breast biopsy. We present a case of a radioactive seed localized axillary lymph node resection that was not amenable to wire localization. Radioactive seed allowed precise localization of the node in a difficult anatomic location, thus facilitating successful resection of the node. Seed localization is a versatile approach for localizing lesions of interest and holds promise for not only breast surgery, but also for marking nodes or lesions of interest that are located deep in the abdominal or thoracic cavity.

Angiotensin II (AngII) mediates progression of aortic aneurysm, but the relative contribution of its type 1 (AT1) and type 2 (AT2) receptors remains unknown. We show that loss of AT2 expression accelerates the aberrant growth and rupture of the aorta in a mouse model of Marfan syndrome (MFS). The selective AT1 receptor blocker (ARB) losartan abrogated aneurysm progression in the mice; full protection required intact AT2 signaling. The angiotensin-converting enzyme inhibitor (ACEi) enalapril, which limits signaling through both receptors, was less effective. Both drugs attenuated canonical transforming growth factor–β (TGFβ) signaling in the aorta, but losartan uniquely inhibited TGFβ-mediated activation of extracellular signal–regulated kinase (ERK), by allowing continued signaling through AT2. These data highlight the protective nature of AT2 signaling and potentially inform the choice of therapies in MFS and related disorders.

Purpose: The purpose of the study is to explore the challenges that are faced by born global SMEs and how they overcome these challenges. Method: For literature review and secondary research, data and information has been gathered from disciplines of international entrepreneurship. Primary research has been done on four born global firms; two from Sweden and two from Pakistan. Qualitative research and analysis has been used in the study. Originality: This study contributes to literature by covering some missing portions in born global discipline. In this research, effort is made to compile various challenges that are faced by born global firms, through literature review. The report further has focused on overcoming these challenges by gathering information through primary research. Conclusion: The research has concluded that there are certain challenges that are faced by born global firms in their international business development. These challenges are internal as well as external. Despite these challenges and problems, born global firms are able to achieve their position in international market by overcoming these challenges through building networks and competency alliances with partners situated internationally.

The widespread use of Internet and other communication technologies has bring along the ease to reproduce, disclose, and distribute digital content. In addition to getting the benefits of information exchange, the digital community is confronted with authentication, forgery, and copyright protection issues. The amount of textual information on Internet is increasing besides images, audios, and videos. Therefore, copyright protection of plain text is the most important issue. In this paper, we propose a zero text watermarking algorithm based on occurrence frequency of non-vowel ASCII characters and words for copyright protection of plain text documents. The embedding algorithm incorporates occurrences of non-vowel ASCII characters in text partitions to form a key based on the watermark. The extraction algorithm extracts the watermark from the noisy text to identify original copyright owner. Experimental results prove the effectiveness of the proposed algorithm on text encountering dispersed insertion and deletion attacks occurring randomly.

Candidemia is the fourth most common bloodstream infection, with Candida albicans being the most common causative species. Success in reducing the associated morbidity and mortality has been limited by the inadequacy and time delay of currently available diagnostic modalities. Focusing on host response to infection, we used a murine model to develop a blood gene expression signature that accurately classified mice with candidemia and distinguished candidemia from Staphylococcus aureus bacteremia. Validation of the signature was achieved in an independent cohort of mice. Genes represented in the signature have known associations with host defense against Candida and other microorganisms. Our results demonstrate a temporal pattern of host molecular responses that distinguish candidemia from S. aureus-induced bacteremia and establish a novel paradigm for infectious disease diagnosis.