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Percutaneous coronary intervention (PCI) is a frequently performed procedure that can have minor or major complications. One of the more serious complications of PCI is the development of coronary no-reflow. No-reflow signifies reduced or absent coronary flow in the distal coronary circulation in the absence of flow-limiting lesions. We present a case of a middle-aged man who presented as an outpatient for elective coronary angiography due to angina pectoris and a high-risk exercise stress test. Coronary angiography demonstrated significant single-vessel disease with lesions in the proximal and mid-segments of the left anterior descending (LAD) coronary artery. Successful placement of drug-eluting stents in the LAD was followed by a severe drop in blood pressure, worsening chest pain, and ST elevation on telemetry. Immediate angiography showed the development of no-reflow in both the LAD and left circumflex coronary arteries. Ionotropic and intravenous anti-platelet agents were administered with simultaneous placement of an intra-aortic balloon pump, restoring normal flow in both arteries. No-reflow occurs most commonly following PCI in certain lesion subsets, and it is usually seen only in the vessel in which the PCI was performed (culprit vessel). It is important to realize that this phenomenon can occur in other circumstances since immediate recognition and treatment can be lifesaving., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Hussain et al.)

Dilated cardiomyopathy (DCM) is a severe myocardial disease with diversified etiologies. Coxsackievirus serotype B (CV-B) is a known cause of infectious myocarditis that leads to DCM. The pathogenesis of CV-B myocarditis is complex and involves a combination of tissue destruction from viral proliferation and host immune response. Diagnosis is based on clinical findings and the presence of post-infection elevated titers of IgM antibodies to CV-B. Echocardiography is an important imaging modality that plays a key role in diagnosing DCM. Rare complications of coxsackievirus infection may include facial paralysis and chronic kidney disease with nephrotic syndrome. Here we present a rare case of a 29-year-old-male with recent Bell's palsy who presented with new-onset heart failure with left ventricular ejection fraction of 5% and focal segmental glomerulosclerosis nephrotic syndrome in the setting of elevated antibodies to CV-B., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Ahmed et al.)

High entropy alloys (HEAs) are a relatively new class of material that have shown the potential to exhibit excellent combinations of mechanical properties. Various microstructural modifications have been explored to further enhance their mechanical properties for use in demanding structural applications. The main focus of the present work is an investigation of the effect of adding varying amounts of hard ceramic material (WC) to a tough HEA matrix (CoCrFeNi) by arc melting under an argon atmosphere, including microstructural changes, and evaluation of the WC additions on mechanical properties. X-ray diffraction analysis of the HEA-WC composites showed the presence of both fcc and carbide phases. Scanning electron microscope investigations, including energy dispersive spectroscopy, reveal that chromium diffuses from the matrix and interacts with WC to form an alloyed carbide phase. The amount of alloyed carbide was found to increase with increasing amount of WC addition to the HEA matrix. Mechanical characterization revealed that hardness and yield strength of the HEA-WC composites increase with increasing amount of the carbide phase in the matrix. The hardness of HEA-20wt.% WC sample was found to be as high as 3.3 times (593 HV) the hardness of the base HEA (180 HV), while the yield strength increased from 278 MPa for the base HEA to 1098 MPa for the CoCrFeNi-20 wt.% WC composite. The investigated composites also showed excellent values of ductility (~ 50% strain for CoCrFeNi-10 wt% WC and ~ 20% strain for CoCrFeNi-20 wt% WC). It is therefore believed that ceramic-reinforced high entropy matrix composites have the potential to provide outstanding combinations of mechanical properties for demanding structural applications., (© 2022. The Author(s).)

White clover ( Trifolium repens ) is an allotetraploid pasture legume widely used in moist temperate climates, but its vulnerability to drought, grazing pressure and pests has restricted its wider use. A related species, Caucasian clover ( Trifolium ambiguum ), is a potential source of resistances to drought, cold, grazing pressure and pests that could potentially be transferred to white clover by interspecific hybridization. Although direct hybridization has been achieved with difficulty, the hybrids have not been easy to backcross for introgression breeding and no interspecific chromosome recombination has been demonstrated. The present work shows that interspecific recombination can be achieved by using Trifolium occidentale , one of the ancestral parents of T. repens , as a bridging species and that large white clover breeding populations carrying recombinant chromosomes can be generated. A 4 x hybrid between T. ambiguum and T. occidentale was crossed with T. repens and then backcrossed for two generations. Five backcross hybrid plants with phenotypes appearing to combine traits from the parent species were selected for FISH-GISH analyses. Recombinant chromosome segments from T. ambiguum were found in all five plants, suggesting that recombination frequencies were significant and sufficient for introgression breeding. Despite early chromosome imbalances, the backcross populations were fertile and produced large numbers of seeds. These hybrids represent a major new resource for the breeding of novel resilient forms of white clover., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ullah, Ansari, Verry, Hussain, Ellison, McManus and Williams.)

Background: Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms., Methods: This was a retrospective chart review of two cohorts. We identified ED charts from six-month periods prior to and after adoption of our HEART score-based protocol. Patients in whom an electrocardiogram and troponin were ordered were eligible for inclusion. We analyzed data for patients with typical symptoms (chest pain) and atypical symptoms both together and separately., Results: We identified 1546 charts in the pre-adoption cohort and 1623 in the post-adoption cohort that met criteria. We analyzed the first 900 charts in each group. Discharges from the ED increased (odds ratio [OR[1.56, P<.001), and admissions for cardiac workup decreased (OR 0.46, P <.001). ED length of stay was 17 minutes shorter (P = .01). Stress testing decreased (OR 0.47, P<.001). We estimate a cost savings for our hospital system of over $4.5 million annually. There was no significant difference in inpatient length of stay or catheterization rate. When analyzing typical and atypical patients separately, these results held true., Conclusion: After adoption of a HEART score-based protocol, discharges from the ED increased with a corresponding decrease in admissions for cardiac evaluations as well as cost. These effects were similar in patients presenting without chest pain but with presentations concerning for ACS.

This review was aimed to probe into factors that resulted in worsening of novel coronavirus disease 2019 (COVID-19) pandemic in New York City, USA. Extensive review of available information sources, such as scientific literature, COVID-19 data generating websites, expert opinions as well as government briefings and simultaneous measures, were carried out to fulfil the objectives of this paper. Data was arranged in tabular form. Gaps in responding to the pandemic were identified. There was lack of proactivity in measures taken by governments which is due to neo-liberal capitalism on one hand and lack of coordination among three tiers of government on the other. Cosmopolitan features of the city also made it prone to devastating spread of pandemic. Crowded mega cities with incompetent governments in implementing timely public health measures for prevention of spread of COVID-19 are at potential threat of high disease spread across the globe. Keywords: New York City, COVID-19 pandemic, Response gaps, Metropolitan.

Introduction Shortness of breath is a leading cause of intensive care unit (ICU) admissions and is multifactorial. Acute hypoxemic respiratory failure due to heart failure is one of the leading causes of ICU admissions. N-terminal pro-brain natriuretic peptide (NT-proBNP) is secreted by ventricles and carries a negative predictive value for heart failure (2). NT-proBNP can also be raised in sepsis (4). Changes in NT-proBNP strongly correlated with changes in C-reactive protein (CRP) and leukocytes levels (8). Objective This study was conducted to explore the diagnostic utility of NT-proBNP and CRP to diagnose heart failure in patients presenting with acute hypoxemic respiratory failure. Materials and methods After informed consent and approval from the institutional review board (IRB), patients of acute hypoxemic respiratory failure were included in the study. History and physical examination were done by a medical resident and recorded in the patients' files. Data were transferred to a structured proforma by the researcher. All tests were conducted within three hours of presentation. The diagnosis of heart failure was made by a panel of experts, including the consultant cardiologist and consultant intensivist in charge. The chest X-ray was reported by the radiologist. The cost of the test was afforded by the institution. Data were analyzed by SPSS version 15 (SPSS Inc., Chicago, Illinois). Analysis of variance (ANOVA), Pearson correlation and linear regression were applied to find out the relation between variables and significance. Results We studied 137 patients. Out of them, 72.9% were diagnosed as heart failure. Heart failure was more common in females (43.7%) as compared to males (29%). NT-proBNP was raised in 111 (81%) patients and out of them, 88 patients (79%) had heart failure. Sensitivity and specificity of NT-proBNP were found to be (95.56%) and (46.81%), respectively. Similarly, CRP was 90% sensitive and 25.53% specific for heart failure. The most common findings in chest X-rays of patients with heart failure were upper lobe diversion and enlarged cardiothoracic ratio (71%). Conclusion We concluded our study as NT-proBNP is a highly sensitive test to diagnose heart failure in settings of acute hypoxemic respiratory failure. CRP is also significantly raised in heart failure. Upper lobe diversion and an increased cardiothoracic ratio is a strong predictor of heart failure., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Abdullah et al.)

Background: Trifolium ambiguum occurs as a 2x, 4x, 6x polyploid series in W Asia. The 6x form is the most agronomically desirable, having strong rhizomatous spread and drought tolerance. These traits would be potentially very valuable if they could be transferred to white clover (T. repens) which is the most important agronomic clover species. However, to-date, no fertile interspecific hybrids with 6x T. ambiguum are available. Previously, 2x T. occidentale from W Europe has produced synthetic fertile hybrids with both 2x and 4x T. ambiguum and these were inter-fertile with white clover. Here we ask whether 2x T. occidentale can form fertile hybrids with 6x T. ambiguum and act as a genetic bridge to white clover and bring these species together as part of a common gene pool., Results: Ten verified F 1 (6x T. ambiguum x 2x T. occidentale) hybrids were produced by embryo rescue and seven were studied further. All four investigated for chromosome number were 2n = 4x = 32 and FISH confirmed the expected 21 T. ambiguum and 8 T. occidentale chromosomes. Hybrid fertility was extremely low but 2n female gametes functioned with white clover pollen to produce seeds. Derived plants were confirmed using FISH and were successfully backcrossed to white clover to produce partially fertile breeding populations., Conclusions: Although T. occidentale and 6x T. ambiguum are widely separated by geography and ecological adaptation they have maintained enough genomic affinity to produce partially fertile hybrids. Inter-fertility of the hybrids with allotetraploid T. repens showed that T. occidentale can provide a genetic bridge between 6x T. ambiguum and white clover to produce plants with new phenotypes combining the traits of all three species. Use of this information should enable potentially valuable stress tolerance traits from 6x T. ambiguum to be used in white clover breeding for the first time.

Key Message: The widely divergent species 4xTrifolium ambiguum and 2xT.occidentale are inter-fertile long after speciation (including polyploidisation) has occurred. Tri-species hybrids (T. repens × T. ambiguum × T. occidentale) have the potential to achieve introgression of stress resistant traits from both wild species into white clover. Trifolium ambiguum and T. occidentale are geographically, adaptionally and phenotypically contrasting species in the white clover section (Trifoliastrum) of the genus. T. ambiguum occurs as a high-altitude polyploid series (2x, 4x, 6x) in W Asia and NE Europe. T. occidentale is a diploid coastal species, occurring at sea level in W Europe. This study investigated hybridisation between 4xT. ambiguum and 2xT. occidentale and considered the significance of the hybrids for introgression breeding of white clover. Partially fertile F 1 hybrids between 4xT. ambiguum and 2x and 4xT. occidentale were generated by embryo rescue. Hybrid plant morphology and fertility varied widely and hybrids generally expressed traits from both species. Advanced generation (F 2 -F 5 ) 4x hybrids were highly fertile and constitute a new synthetic allotetraploid species. FISH analyses of 4x hybrids showed multivalent chromosome configurations with homoeologous associations between T. ambiguum and T. occidentale chromosomes. Crosses of the hybrids with T. repens produced fertile tri-species progeny. These very divergent species remain inter-fertile long after speciation (including polyploidisation) has occurred. Tri-species hybrids have the potential to achieve introgression of stress resistance traits from both wild species into white clover.

Objective The goal of the study was to determine the percentage of hyperchloremia in patients who died in medical intensive care unit (ICU) and thus emphasizing the need of avoiding chloride-rich solutions due to their deleterious effects. Study design We conducted a retrospective study of data from 206 patients who expired in medical ICU in one year from January 2017 to December 2017 in the department of critical care medicine at Shifa International Hospital, Islamabad. Material and methods The study included 206 patients: 93 (43.1%) men and 123 (56.9%) women, over the age of 18 years who expired in medical ICU in one year from January 2017 to December 2017. Patients included for the study were all those who expired with any diagnosis but those who remained admitted in ICU for at least 72 hours and received intravenous fluids. The serum chloride levels of the patients at the time of admission and at 72 hours of stay in ICU were collected. The patients who were having serum chloride levels of 107 milliequivalent per deciliter (meq/dl) or more were labeled as having hyperchloremia. The data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Crop., Armonk, NY, USA). The mean and standard deviations were calculated for continuous variables while frequency and percentages were calculated for qualitative variables. Results Among 206 patients who expired in our ICU, 109 (50.5%) patients had hyperchloremia at 72 hours of admission in ICU while 107 (49.5%) patients did not had hyperchloremia. Hyperchloremia was more frequent in patients with sepsis or septic shock. Conclusion Higher percentage (50.5%) of hyperchloremia at 72 hours of admission among patients (who expired in our medical ICU) indicates excessive use of chloride-rich intravenous fluids. This finding may have significant impact on mortality along with other contributing factors that lead to death of the patients. Keeping in view the findings of the study, chloride-rich solutions should be used carefully to counter the effects of hyperchloremia in patients requiring large volume fluid resuscitation in ICU. Fluids with lower content of chloride such as lactated ringer may be equally good in large volume fluid resuscitation with advantage of avoiding hyperchloremia., Competing Interests: The authors have declared that no competing interests exist.

Objective The goal of the study was to see if anti-ganglioside antibodies have a role in the diagnosis of Guillain-Barré syndrome (GBS). Study design Between May 2016 to October 2017, we conducted a prospective pilot study of 15 patients with a clinical diagnosis of GBS with equivocal cerebrospinal fluid (CSF) analysis and/or nerve conduction studies (NCS) . Materials and methods All adult patients (age >18 years) whose clinical diagnosis was GBS but diagnostic tests (either NCS or CSF analysis or both) were not suggestive of GBS were included in the study and were tested for anti-gangliosides antibodies. Data was entered in SPSS, version 21.0 (IBM, Armonk, New York) and analyzed. Results Of the 15 patients fulfilling the inclusion criteria, 60% had a normal CSF analysis while 40% had normal NCS. The percentages of different GBS variants observed in sampled patients were acute inflammatory demyelinating polyradiculopathy (AIDP) 40%, acute motor axonal neuropathy (AMAN) 40%, acute motor and sensory axonal neuropathy (AMSAN) 13.3%, and Miller Fisher syndrome 6.7%. However, the anti-ganglioside antibodies were negative in all patients. Conclusion Anti-gangliosides antibodies cannot be used as an alternative diagnostic investigation in GBS patients as our study failed to show positive results in different GBS variants., Competing Interests: The authors have declared that no competing interests exist.

Background The early detection of elevated intracranial pressure (ICP) can not only prevent mortality but also aid in more aggressive management. Brain computed tomography (CT) is a mainstay modality in detecting elevated ICP, but the feasibility of using brain CTs to detect elevated ICP in critically ill patients is limited, especially for patients who require high levels of inotropic support. The optic nerve sheath is a direct extension of the brain meninges. Therefore, the elevation of ICP is directly transmitted to the sheath. Measuring the optic nerve sheath diameter (ONSD) through ultrasound (US) is a bedside, noninvasive means to detect elevated ICP. The goal of this study was to assess the correlation of ONSD with elevated ICP as measured via US in an intensive care unit (ICU). Methods We conducted a six-month prospective, single-center, observational study of mass effect stroke patients aged 18 to 65 years who had a traumatic brain injury (TBI) and were admitted to the ICU. Patients with chronic hydrocephalus, extensive local orbit trauma, a pre-existing ocular disease affecting the optic nerve and/or orbital cavity, hyperthyroidism with exophthalmos, and facial trauma affecting the orbits and/or eyeballs were excluded. We measured the ONSD at the entry of optic nerve into the globe using two-dimensional (2D) US. Results One hundred patients were included in the study. Forty-nine patients had diffuse cerebral edema detected on CT scan correlating with increased ONSD notable via bedside US. The mean ONSD related to CT-detectable elevated ICP was 0.61 cm. The sensitivity for the ONSD cut-off value of ≥5.8 mm was 94% (95% confidence interval [CI], 84.05% to 98.79%), and the specificity was 96.08% (95% CI, 86.7% to 99.52%).The positive predictive value was 92.08% (95% CI, 86.28% to 98.96%), and the negative predictive value was 94.23% (95% CI, 84.47% to 98.00%). Conclusion The greatest accuracy in ONSD was found with a cut-off of >0.58 cm in patients with positive CT brain findings. Therefore, US can be used as an initial screening test when physicians suspect a patient has elevated ICP., Competing Interests: The authors have declared that no competing interests exist.

Background Acute kidney injury (AKI) is a frequently encountered clinical condition in hospitalized patients, particularly those admitted to intensive care units (ICU). AKI has its systemic sequelae and contributes to the morbidity of underlying diseases. Methods This descriptive case series aimed to determine the frequency of acute kidney injury in critically ill patients admitted to the ICU at Shifa International Hospital, Islamabad, according to the RIFLE (risk, injury, failure, loss, and end-stage) criteria. A total of 124 patients were enrolled in this study. RIFLE criteria were applied to determine the frequency of AKI in critically ill patients. Results The frequency of AKI was 68.55% and mortality was 18.55%. The severity of AKI was found to be significantly associated with mortality (p < 0.001). Conclusion AKI is very common in critically ill patients and contributes to the mortality and morbidity of the patients. Early identification of AKI can reduce mortality in critically ill patients., Competing Interests: The authors have declared that no competing interests exist.

Background A challenging task in the intensive care unit is weaning intubated patients from mechanical ventilation. The most commonly used weaning parameter, the rapid shallow breathing index (RSBI), gives thorough guidance on extubation timing with spontaneous breathing trials. Diaphragm plays vital role in tidal volume generation. The main objective of the study was to compare ultrasound-based diaphragmatic excursion (DE) with RSBI as weaning predictors. Methods We conducted an observational prospective cohort study on patients on mechanical ventilation. During a spontaneous breathing trial (SBT) we simultaneously evaluated right hemidiaphragm excursion by using M-mode ultrasonography as well as the RSBI. To be included, patients must have been on mechanical ventilation for longer than 48 hours, have no excessive tracheobronchial secretions, and their underlying critical illness (for which they were intubated) must be resolved. Patients younger than 14 years, patients with neuromuscular disorder, patients with pneumothorax, and patients with cervical spine injury were excluded from the study. We analyzed the data to determine the significance of DE and RSBI. Results A total of 90 patients were included in our study; 54 (60%) were men, and 36 (40%) were women. The average age of all the participants was 55 ± 16 years (range, 19 to 83 years). Sixty-two patients (68.9%) were successfully weaned. The mean DE was 1.44 ± 0.26 cm, and the mean RSBI was 56.88 ± 8.30 in all patients. Successful weaning patients had a mean DE of 1.51 ± 0.26 cm and a mean RSBI of 54.05 ± 7.00. The greater the DE value, the greater the weaning success rate, and the lesser the RSBI value, the greater the weaning success rate. The area under the receiver operator curve for DE and RSBI was 0.795 and 0.815, respectively (p < 0.0001). Conclusion RSBI is an optimized clinical predictor in classifying weaning outcomes for intubated patients, but DE is also helpful in extubation assurance and reintubation prevention., Competing Interests: The authors have declared that no competing interests exist.

Objective The goal of this study was to determine the efficacy of early tracheostomy (i.e., ≤ 10 days of intubation) compared with a late tracheostomy (> 10 days of intubation) with regards to timing, frequency of ventilator-associated pneumonia (VAP), mortality rate, and hospital stay in patients who received decompressive craniectomy. Study design We conducted a retrospective study of data from 168 patients who underwent decompression in the department of critical care medicine at Shifa International Hospital, Islamabad, Pakistan, from January 2017 to December 2017. Materials and methods The study included men and women over the age of 18 years who had undergone tracheostomy following decompressive craniectomy in the intensive care unit as a result of stroke, traumatic brain injury, or acute severe injury. Data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, US). We also applied the Chi-square test, and p ≤ 0.05 was considered significant. Results Of 168 patient records reviewed, tracheostomy was performed in 48 patients (21 men, 27 women). In the 48 tracheostomy patients, 15 (31%) were early tracheostomies and 33 (69%) were late tracheostomies. The mean age of patients was 44 ± 11 years. Twenty-eight patients (58.3%) were in the younger age group (age 18 to 45 years) and 20 patients (41.7%) were in the older age group (age > 45 years). Patients who received an early tracheostomy spent significantly less time on a ventilator (≤ 12 days) than those patients receiving a late tracheostomy (> 12 days, p = 0.004). The early tracheostomy group also had a lower incidence rate of VAP than patients with a late tracheostomy (𝑥 2 = 7.855, p = 0.005). Patients who received an early tracheostomy had lower mortality rates than those who received late tracheostomies (𝑥 2 = 6.158, p = 0.013). Finally, the length of hospital stay was ≤ 15 days for patients who received early tracheostomies; most patients who received a late tracheostomy had a hospital stay of > 15 days (𝑥 2 =11.965, p = 0.001). Conclusions Performing a tracheostomy within 10 days of intubation following decompressive craniectomy significantly reduced ventilator time, mortality, the incidence of VAP, and length of hospital stay. Given the potential benefits of early tracheostomy in critical care patients following decompressive craniectomy, physicians should consider early tracheostomy in appropriate cases., Competing Interests: The authors have declared that no competing interests exist.

The complement system consists of a family of proteins that play a critical role in the innate immune system. Complement activation has been implicated in many chronic inflammatory diseases, including atherosclerosis. However, a number of experimental studies have highlighted a beneficial role of component C1q in early atherosclerosis and in diabetes mellitus (DM). Despite these data, there have been no studies that have specifically examined the utility of plasma complement C1q as a clinical biomarker in patients with known or suspected coronary artery disease. In this study, baseline plasma complement C1q levels were measured in 159 men with DM who were referred for coronary angiography and who were followed up prospectively for the development of all-cause mortality for 10 years. After adjustment for baseline clinical, angiographic, and laboratory parameters, reduced plasma complement C1q levels were an independent predictor of all-cause mortality at 10 years (hazard ratio 0.66, 95% confidence interval 0.52 to 0.84, p = 0.0006). In additional multivariate models that adjusted for a variety of biomarkers with established prognostic efficacy, complement C1q remained an independent predictor of all-cause mortality at 10 years. In conclusion, reduced levels of complement C1q are associated with an increased risk of all-cause mortality at 10 years in patients with DM referred for coronary angiography. Furthermore, this association is independent of a variety of clinical, angiographic, laboratory variables, including biomarkers with established prognostic efficacy in the prediction of adverse cardiovascular outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective The objective of this study is to find a correlation between internal jugular vein (IJV) and common carotid artery (CCA) diameter ratio and central venous pressure (CVP) measurement and find a cut-off value for the IJV/CCA ratio to predict low CVP i.e. < 10 cm H 2 0, for estimating the volume status in critically ill patients. Methods This prospective cross-sectional study was conducted at the critical care department of Shifa International Hospital, Islamabad, from July to December 2017. A sample of 49 patients ≥ 18 years with intrathoracic central venous catheters (CVCs) who underwent bedside sonographic assessments of IJV and CCA diameter were included in this study using convenient sampling. The IJV/CCA diameter ratio was calculated and correlated with CVP and the predictive value of the IJV/CCA diameter ratio to predict CVP < 10 cm H 2 O was explored by calculating the area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, and positive and negative predictive values. Results A total of 49 patients, 30 males (61.2%) and 19 females (38.8%) with a mean age of 56.00±16.11 years were included in the study. The mean CVP was 8.98±2.37cm H 2 O in ventilated (51%) and 10.7± 6.01 cm H 2 O in non-ventilated (49%) patients. The mean IJV/CCA diameter ratio was 1.60±0.55 at expiration and 1.41±0.56 at inspiration. There was a significant correlation between the IJV/CCA diameter ratio and CVP at expiration (r=0.401, p=0.004). The correlation between IJV/CCA and CVP was significant in non-ventilated patients at expiration (r=0.439, p=0.032). The area under the ROC curve for the IJV/CCA diameter ratio for predicting CVP < 10 cm H 2 O was 0.684 (p=0.028). The predictive value of the IJV/CCA diameter ratio for CVP < 10 cm H 2 0 at the cutoff value of < 2 was insignificant. A new cut-off < 1.75 was taken for the IJV/CCA diameter ratio from the coordinates of the ROC curve. The sensitivity, specificity, PPV, and NPV of an IJV/CCA diameter ratio of < 1.75 for predicting a CVP < 10 cm H 2 0 were 84.62%, 52.17%, 66.67%, and 75.00%, respectively. Conclusion The assessment of volume status by the IJV/CCA diameter ratio with a sonographic device may be a useful noninvasive alternative for a central venous catheterization with a cut-off < 1.75., Competing Interests: The authors have declared that no competing interests exist.

Objective To compare hospital-wide code rates and mortality before and after the implementation of a rapid response team (RRT). Study design A prospective cohort design with historical controls. Place of study This study was conducted at Shifa International Hospital, Islamabad, from January 21, 2016, to January 20, 2017. Materials and methods The triggers for the rapid response team (RRT) were displayed on each floor. The in-house staff was trained on when and how to activate the rapid response team (RRT). Data were collected on a specified data collection form. Mortality and hospital-wide code blue rates were calculated and compared with those from one year before the implementation of the rapid response team (RRT) (i.e., from January 21, 2015, to January 20, 2016). Results The total number of admissions during the study period was 40,177. In total, 796 RRTs were activated with a rate of activation of 19.81 per 1000 admissions. The most common activator for RRTs was an altered level of consciousness (24.12%), followed by tachycardia (19.22%), and tachypnea (14.45%). The total number of admissions one year before the implementation of the RRT was 39,460. The total number of mortality events before the implementation of the RRT was 1470 (3.725%) and after the implementation of the RRT was 1529 (3.805%), which was not significantly different (P = .576). The total number of code blues before the implementation of the RRT was 146 (0.369%) and after the implementation of RRT was 148 (0.368%), which was not significantly different (P = .929). Conclusion In this large single-institution study, rapid response team implementation was not associated with significant reductions in either hospital-wide code blue or mortality., Competing Interests: The authors have declared that no competing interests exist.

A high-performance metal oxide polymer magnetite/polyethylene glycol nanocomposite was prepared and coated in situ on the surface of the optical fiber by sol-gel technology. The magnetite nanoparticles as nanofillers were synthesized by a coprecipitation method and bonded with polyethylene glycol as a polymer. The chemically bonded coating was evaluated for the headspace solid-phase microextraction of some environmentally important volatile organic compounds from aqueous samples in combination with gas chromatography and mass spectrometry. The prepared fiber was characterized by scanning electron microscopy and Fourier transform infrared spectroscopy. The mass ratio of nanofiller and polymer on the coating extraction efficiency, morphology, and stability were investigated. The parameters affecting the extraction efficiency, including the extraction time and temperature, the ionic strength, desorption temperature, and time were optimized. The sol-gelized fiber showed excellent chemical stability and longer lifespan. It also exhibited high extraction efficiency compared to the two types of commercial fibers. For volatile organic compounds analysis, the new fiber showed low detection limits (0.008-0.063 ng/L) and wide linearity (0.001-450 × 10 4 ng/L) under the optimized conditions. The repeatability (interday and intraday) and reproducibility were 4.13-10.08 and 5.98-11.61%, and 7.35-14.79%, respectively (n = 5). For real sample analysis, three types of water samples (ground, surface, and tap water) were studied., (© 2017 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Objective: To identify the pattern of mortality in medical wards of a tertiary care hospital., Methods: This retrospective study was conducted at the Khan Research Laboratories Hospital, Islamabad, Pakistan, and comprised medical records of people who died during hospital stay between December 2013 and November 2014.SPSS 11 was used for data analysis., Results: Of the 3,228 admissions, 105(3.25%) patients expired. Of them, 41(39.04%) were men with a mean age of 55±13.48 years (range: 17-88 years) and 64±11.76 (60.9%) were women with a mean age of 61±15.5 years (range: 23-91 years). The mean length of time between admission and death was 6.58±3.7 days (range: 1-33 days). The causes of death were categorised as infectious in 37(35.23%) patients, cancer-related in 20(19.045%), pulmonary in 19(18.09%), cardiovascular in 18(17.14%), gastrointestinal and neurological in 13(12.38%) each, nephrology in 10(9.52%), autoimmune disorders in 6(5.71%) and miscellaneous in 9(8.57%). Complications of sepsis were the most common cause of death in 38(36.19%) cases., Conclusions: Sepsis, primarily from pneumonia, was the major cause of mortality.

Background: The unambiguous identification of individual chromosomes is a key part of the genomic characterization of any species. In this respect, the development and application of chromosome banding techniques has revolutionised mammalian and especially, human genomics. However, partly because of the traditional use of chromosome squash preparations, consistent fluorescence banding has rarely been achieved in plants. Here, successful fluorescence chromosome banding has been achieved for the first time in perennial ryegrass (Lolium perenne), a forage and turf grass with a large genome and a symmetrical karyotype with chromosomes that are difficult to distinguish., Results: Based on flame-dried chromosome preparations instead of squashes, a simple fluorescence Q-banding technique using quinacrine mustard, unambiguously identified each chromosome and enabled the development of a banded karyotype and ideogram of the species. This Q-banding technique was also shown to be compatible with sequential FISH mapping enabling labelled genes and molecular markers to be precisely assigned to specific cytogenetic bands. A technique for DAPI-banding, which gave a similar pattern to Q-banding, was also introduced. This was compatible with FISH mapping and was used to anchor a single copy gene from an earlier mapped linkage group of L. perenne, thus providing a step towards integration of the genetic and cytogenetic maps., Conclusions: By enabling the allocation of genes mapped by other methods to physically identified chromosome positions, this work will contribute to a better understanding of genomic structures and functions in grasses.

A polyvinylimidazole/sol-gel composite is proposed as a novel solid-phase microextraction fiber to extract five halobenzenes from the headspace of aqueous solutions in combination with gas chromatography with mass spectrometry. The prepared fiber was characterized by scanning electron microscopy and Fourier transform infrared spectroscopy. The obtained results showed that porous polyvinylimidazole/sol-gel composite was chemically deposited on fused silica fiber. The effect of important extraction parameters including extraction temperature, extraction time, and salt content were investigated. The optimum conditions were as follows: extraction temperature 25°C, extraction time 20 min, and salt concentration 30 w/v%. Detection limits and relative standard deviations of the developed method for halogenated benzenes were below 0.1 pg/mL and 15%, respectively. Repeatability of the proposed method, explained by relative standard deviation, varied between 5.48 and 9.15% (n = 5). The limits of detection (S/N = 3) ranged between 0.01 and 0.10 ng/L using gas chromatography with mass spectrometry with selected ion monitoring mode. For real sample analysis, three types of water samples with different matrices (ground, surface, and tap water) were studied. The optimized procedure was applied to extraction and method validation of halogenated benzenes in spiked water samples., (© 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: White clover (Trifolium repens) is a ubiquitous weed of the temperate world that through use of improved cultivars has also become the most important legume of grazed pastures world-wide. It has long been suspected to be allotetraploid, but the diploid ancestral species have remained elusive. Putative diploid ancestors were indicated by DNA sequence phylogeny to be T. pallescens and T. occidentale. Here, we use further DNA evidence as well as a combination of molecular cytogenetics (FISH and GISH) and experimental hybridization to test the hypothesis that white clover originated as a hybrid between T. pallescens and T. occidentale., Results: T. pallescens plants were identified with chloroplast trnL intron DNA sequences identical to those of white clover. Similarly, T. occidentale plants with nuclear ITS sequences identical to white clover were also identified. Reciprocal GISH experiments, alternately using labeled genomic DNA probes from each of the putative ancestral species on the same white clover cells, showed that half of the chromosomes hybridized with each probe. F1 hybrids were generated by embryo rescue and these showed strong interspecific chromosome pairing and produced a significant frequency of unreduced gametes, indicating the likely mode of polyploidization. The F1 hybrids are inter-fertile with white clover and function as synthetic white clovers, a valuable new resource for the re-incorporation of ancestral genomes into modern white clover for future plant breeding., Conclusions: Evidence from DNA sequence analyses, molecular cytogenetics, interspecific hybridization and breeding experiments supports the hypothesis that a diploid alpine species (T. pallescens) hybridized with a diploid coastal species (T. occidentale) to generate tetraploid T. repens. The coming together of these two narrowly adapted species (one alpine and the other maritime), along with allotetraploidy, has led to a transgressive hybrid with a broad adaptive range.

The study was aimed to investigate microencapsulation of theophylline using different ratios of eudragit S 100 as wall material by the emulsion solvent evaporation technique. The release profiles, effect of stirring speed and different pH of dissolution medium on release profiles and stability were also studied. Various formulations of microcapsules were compressed in to tablets. In vitro dissolution studies indicated that the rate of drug release was reduced with an increase in the amount of Eudragit S 100. Moreover, the release data of various formulations were fitted to Zero order, First order, Higuchi, Hixson Crowell and Korsmeyer Peppas kinetic models. It was observed that the release of drug from all the formulations followed Higuchi's kinetic model as its value of coefficient of determination is greater than that of others. The release profiles of the test formulation in distilled water and various pH media were compared and decreased release rate was seen at lower pH i.e. pH 1.0. Slight or no change was apparent in the release rate at higher stirring speed compared to lower stirring speed. No significant changes were also observed in the drug release profiles of test tablets stored at different temperatures. Test tablet (F2) was found to produce similar and sustainable release rate compared to commercial product, Quibron-T/SR tablet on the basis of their T(70%). Similarly, f(2) values of reference versus F2 is 66.98 which show less difference between these two as compared to the comparison of reference with F1 and F3.

Background and Aims: DNA sequence similarities and hybridization patterns in Trifolium (clovers) section Trifoliastrum suggest that rapid radiation from a common ancestral source led to this complex of diverse species distributed across Europe, western Asia and North Africa. Two of the most geographically and ecologically divergent of these species are the rhizomatous T. ambiguum from high altitudes in eastern Europe and western Asia and the stoloniferous T. occidentale from sea level in western Europe. Attempts were made to hybridize these species to ascertain whether, despite this separation, gene flow could be achieved, indicating the retention of the genetic factors necessary for hybridization., Methods: Three F(1) hybrids formed after embryo rescue were described, characterized by conventional and molecular cytogenetics, subjected to fertility tests and progeny generations were developed., Results and Conclusions: Partially fertile hybrids between Trifolium ambiguum and T. occidentale were obtained for the first time. The F(1) hybrids produced seeds after open-pollination, and also produced triploid progeny in backcrosses to T. occidentale from the functioning of unreduced gametes in the hybrids. These plants were fertile and produced progeny with T. occidentale and with T. repens. Meiotic chromosome pairing in the F(1) showed six to eight bivalents per pollen mother cell, indicating pairing between the parental genomes. A chromosome-doubled form of one hybrid, produced using colchicine, showed some multivalents, indicative of interspecific chromosome pairing. The hybrid plants were robust and combined phenotypic characteristics of both species, having stolons, thick roots and a few rhizomes. Results show that despite separation by the entire breadth of Europe, the speciation process is incomplete, and these taxa have partially retained most of the genetic compatibilities needed for hybridization (possibly except for endosperm development, which was not tested). The fertile progeny populations could lead to new clover breeding strategies based on new hybrid forms.

Although inflammatory bowel disease (IBD) is generally considered a disease of young adults, it can occur in elderly individuals. The clinical features and treatment considerations in older patients are similar to those in younger patients, with some notable exceptions, which are reviewed in this article. Consideration of appropriate differential diagnoses is critical in older IBD patients to achieve the correct diagnosis and appropriate therapy. The risks associated with use of some IBD medications may be increased in older patients, but so is the risk of under-treated IBD and surgery. Therefore, in older IBD patients, as in younger patients, a thorough understanding of the indications, contraindications, and potential adverse effects of the various medications used to treat the condition is essential.

An anonymous survey of 1143 employees in 17 nursing facilities assessed knowledge of, attitudes about, self-perceived compliance with, and barriers to implementing the 2002 Centers for Disease Control and Prevention hand hygiene guidelines. Overall, employees reported positive attitudes toward the guidelines but differed with regard to knowledge, compliance, and perceived barriers. These findings provide guidance for practice improvement programs in long-term care settings.

A 14 years female of Afghan origin reported with maxillofacial and tibia growths causing progressive deformities since nine months, both were giant cell tumours on histopathology. Serum calcium was normal, but the parathyroid hormone was exaggerated (678 pg/ml). Ultrasound indicated and Tc-99m Setamibi scan confirmed a left lower parathyroid lesion. A 4cm length mass was identified, removed and proved to be a parathyroid adenoma. Two weeks later a subtotal maxillectomy and six weeks later anterior wedge osteotomy of the tibia were carried out. Serum parathyroid hormone level normalized.

The predominant root-knot nematode in New Zealand pastures is Meloidogyne trifoliophila, and a recurrent selection program in Trifolium repens has developed resistance to this species. No data are available, however, on the mechanisms of resistance in T. repens or resistant genotypes of T. semipilosum. The development of M. trifoliophila in roots of T. repens and T. semipilosum was examined weekly after a 2-day inoculation with eggs. More second-stage juveniles (J2) were found in two resistant genotypes of T. repens than in two susceptible ones 1 week after inoculation. J2 did not develop further in resistant genotypes, but in susceptible plants development proceeded to the adult stage, visible at 4 weeks after inoculation. The mode of action of resistance to M. trifoliophila in T. repens and in T. semipilosum was compared after a 24-hour inoculation with J2. Numbers of J2 per root tip ranged from 0 to 12 with a median of one for each species. At 24 hours after inoculation (HAI), similar numbers of J2 were seen in the cortex oriented toward the root tip in both resistant and susceptible genotypes of both plant species. At 48 HAI, accumulations of J2 were seen in the meristem in both resistant and susceptible genotypes of both plant species. At 72 HAI, differences in nematode responses were evident between resistant and susceptible genotypes of both plant species; in susceptible roots, J2 heads were embedded in the developing stele. At this time, a browning reaction in resistant genotypes of both plant species indicated a hypersensitive response, and differences in the reaction were recorded between T. repens and T. semipilosum. More study is needed to determine whether the resistance reaction in T. semipilosum is suitable for introgression or insertion into T. repens.

Objective: To share experience of live donor nephrectomy (including intraoperative variables, morbidity and ethical aspects) and to give an overview of surgical technique being practiced., Design: A department-based prospective study., Place and Duration of Study: Department of Urology and Kidney Transplantation, Lahore General Hospital, Lahore, (September 1998 to March 2002). SUBJECTS AND METHODS During the study period, 58 patients had undergone live donor nephrectomy through 11th rib bed flank incision. Evaluation of donors comprised of counseling, history taking, physical examination and laboratory testing and radiological studies to document bilaterally functioning kidneys. Medical ailments, immunological incompatibility and inability to make a valid consent were contraindications for kidney donation., Results: Majority of the donors (58.5%) were 31-50 years old and 70.6% were first degree relatives. Left sided kidney was taken in 96.5% cases. Mean operative time was 145 minutes. Mean renal warm ischemia time from cross clamping of renal vessels to cold perfusion on the bench was 1.5 minutes per operation. Operative complications encountered were injury to lumbar veins in 5.1 % cases, slipping of satinsky clamp on vena cava stump in 1.7 % and accidental pleural damage in 5.1 % cases. Postoperative morbid complications found were urinary retention in 6.4% cases, epididymo-orchitis in 1.7 %, prolonged lymph drain in 3.4%, stitch infection in 1.7 % and prolonged wound discomfort in 5.1 % patients., Conclusions: Open live donor nephrectomy appears to be safe procedure for harvesting kidney. Related or emotionally related donors must be the choice in all cases. Non-related donors may be entertained in selected cases despite the probability of organ vending in our society.