Search

In this era of all-digitalization, there are so many advances in technology in various aspects of life, it cannot be denied that studying the Koran is very important especially for children at an early age so that they learn from childhood, of course exciting learning requires learning methods and media Learning the Qur'an by using the Learns Al-Quran with Marbel application will be able to improve cognitive development in children. Therefore, development is a way of working changes that occur in a gradual process through time to time, from a very easy reliability to becoming something difficult that is psychological. Development occurs because it starts from an early age until later in adulthood. Cognitive development is something that is very important to be learned and implemented by children because this cognitive development is a way for progress in children's thinking so that they can develop and working Optimally, with this application media, it will certainly help children in recognizing hijaiyah letters and learning the al-quran . The ongoing activities can certainly stimulate the cognitive aspects of children in learning the Koran which is fun. Cognitive in children is certainly the responsibility of all of us so that the generation of the Indonesian nation more advanced and intelligent, this study uses a qualitative descriptive method because in accordance with existing research, data collection and research was carried out on July 25, 2022, data analysis will be measured by the results of observations of children's cognitive development through the application media learns al-qur'an with marbel significant effect on the cognitive potential of children in learning the al-quran

The era of globalization requires humans to have more expertise to work and be competitive. These pressures lead to issues of productivity, efficiency, level of competition, which demand increased performance and quality. In addition to the problem of educated unemployment, it turns out there are still many schools or institutions that have not yet implemented life skills education, so graduates do not have more expertise to develop. Islamic Education Study Program Faculty of Islamic Religion Unsika which is one of the institutions of higher education is obliged to equip students with life skills education, so that graduates are able to compete in the global arena. Life skill education which is most followed by students is the education of reading the Qur'an, practice recitations, practice of worship, basic training of student leadership, and training of preacher and preacher cadres.

Javanmonkey (Trachypithecus auratus) an endemic primate of Java is vulnerable and listed in Appendix II of CITES. This study was done to observeits feeding behavior and food diversity.The results is expected to support its population in the wild from the destruction of habitat. It was conducted in March-April 2012 in Situ Sangiang Gunung Ciremai National Park, Majalengka, West Java Province. The method used is animal scan sampling was applied feeding behavior and purposive sampling to determine the vegetation diversity. Its feeding monkey between 07:00 to 11:00; 13:00 to 14:00; and 15:00 to 17:00 time in tree stratum(>15 meters), mostly on haripingku (Dysoxylum densiflorum). Other food plant shantap (Sterculia oblongata), kigambir (Uncaria gambir), nangsi (Villebrunea rubescens), kiara (Ficus globosa), hamirung (Vernonea arborea), mara (Macaranga tanarius), tisuk (Hibiscus macrophyllus), kiara koneng (Ficus annulata Bl.), mahoni (Swietenia mahagoni), saninten (Castanopsis argentea), and nunuk (* not identified). Key words : feeding behavior, Gunung Ciremai National Park, Javan monkey

Kapal jenis BulkCarrier menjadi fokus dalam SOLAS Chapter XII. Regulasi SOLAS menyangkut struktur ruang muat No.I yang menerangkan Transverse Bulkhead pada dua ruang muat terdepan dan konstuksi doble bottom pada ruang muat terdepan harus mempunyai kekuatan untuk menahan beban yang diakibatkan jika ruang muat No.1 termasuki air (Flooding). Penelitian dilakukan dengan metode elemen hingga dengan alat batntu program komputer berbasis metode elemen hingga. Konstruksi Transverse Bulkhead yang akan diteliti adalah konstruksi Transverse Bulkhead ruang muat no.1 pada 18500 DWT DCV yang saat ini sedang dibangun oleh salah satu galangan di Kota Semarang. Penelitian ini diawali dengan melakukan analisa MEH untuk mendapatkan nilai tegangan maksimum beserta letak terjadinya, lalu dilakukan Perhitungan Faktor Keamanan sehingga dapat ditentukan keamanan kontsruksi tersebut. Hasil penelitian telah menunjukkan tegangan maksimum terjadi pada bagian tengah Konstruksi Transverse Bulkhead dengan nilai 295.99 Mpa dan Faktor keamanan 0.695 yang memiliki arti bahwa konstruksi Bulkhead (khususnya pada bagian corrugated) tidak mampu menahan tegangan yang terjadi akibat pembebanan Kondisi Flooding pada ruang muat.

Effects of seed soaking with plant growth regulators (IAA, GA3, kinetin or prostart) on wheat (Triticum aestivum cv. Auqab-2000) emergence and seedling growth under normal (4 dS/cm) and saline (15 dS/cm) conditions were studied to determine their usefulness in increasing relative salt-tolerance. During emergence test, emergence percentage and mean emergence time (MET) were significantly affected by most of priming treatments, however, root and shoot length, fresh and dry weight of seedlings were significantly increased by 25 ppm kinetin followed by 1% prostart for 2 h treatments under both normal and saline conditions. All pre-sowing seed treatments decreased the electrolyte leakage of steep water as compared to that of non-primed seeds even after 12 h of soaking. Seed soaking with 25 ppm kinetin induced maximum decrease in electrolyte leakage while an increase in electrolyte leakage was observed by 25, 50 or 100 ppm IAA treatments. It is concluded that priming has reduced the severity of the effect of salinity but the amelioration was better due to 25 ppm kinetin and 1% prostart (2 h) treatments as these showed best results on seedling growth, fresh and dry weights under non-saline and saline conditions whereas seed soaking with IAA and GA3 were not effective in inducing salt tolerance under present experimental material and conditions.

Background: Tarsal tunnel syndrome, also known as posterior tibial neuralgia, is a compressive neuropathy of the posterior tibial nerve or one of its divisions (calcaneal, lateral plantar or medial plantar nerve) within the tarsal tunnel. This scoping review aims to systematically map and summarise current literature regarding the management of tarsal tunnel syndrome., Methods: PubMed, Embase, Emcare, Medline and Cinahl were searched using the terms 'tarsal tunnel', 'syndrome', 'entrapment', 'compression', 'posterior tibial', 'neuropathy' and 'neuralgia. Two stage title abstract screening was performed. Observational studies reporting the outcome of treatment of tarsal tunnel syndrome were included., Results: A total of 32 studies were included in the review. Excellent or good results are seen in 75.3 % of cases, with the remainder (24.7 %) achieving fair or poor outcomes. Factors which may influence outcome include patient age, symptom duration, aetiology, co-morbidities, pre-treatment symptom severity and nerve fibrosis., Conclusions: Although favourable outcomes are seen in the majority of cases, poor results are not uncommon. A range of prognostic factors are identified; however, firm conclusions cannot be drawn from the findings of individual low-quality studies. Further research in identifying prognostic factors may aid in clinical decision making and management of patient expectations., Level of Evidence: Level IV Scoping review., Competing Interests: Declarations of Interest: The senior author, Mr Maneesh Bhatia is a member of the scientific committee of the European Foot and Ankle Society and the educational committee of the British Foot and Ankle Society., (Crown Copyright © 2024 All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

In this study, we report on the enhancement of the electrochemical properties of MXene by intercalating C60 nanoparticles between its layers. The aim was to increase the interlayer spacing of MXene, which has a direct effect on capacitance by allowing the electrolyte flow in the electrode. To achieve this, various concentrations of Ti 3 SiC 2 (known as MXene) and C60 nanocomposites were prepared through a hydrothermal process under optimal conditions. The resulting composites were characterized by using X-ray diffraction, scanning electron microscopy, energy dispersive spectroscopy, Raman spectroscopy, and cyclic voltammetry. Electrodes were fabricated using different concentrations of MXene and C60 nanocomposites, and current-voltage ( I - V ) measurements were performed at various scan rates to analyze the capacitance of pseudo supercapacitors. The results showed the highest capacitance of 348 F g 1- for the nanocomposite with a composition of 90% MXene and 10% C60. We introduce MXene-C60 composites as promising electrode materials for supercapacitors and highlight their unique properties. Our work provides a new approach to designing high-performance electrode materials for supercapacitors, which can have significant implications for the development of efficient energy storage systems., Competing Interests: The authors declare no competing financial interest., (© 2023 The Authors. Published by American Chemical Society.)

Background: Radiofrequency catheter ablation (RFA) for atrial fibrillation (AF) is being increasingly performed without fluoroscopy. This study aims to determine the safety of fluoroless RFA for patients with pre-existing cardiac implantable electronic devices (CIED)., Methods: This is a single-center, single-operator, retrospective, observational study of 225 consecutive fluoroless RFA procedures for AF from June 1, 2019 to June 1, 2022. All procedures were performed with intracardiac echocardiography (ICE) support. Patients with pre-existing CIED were extracted from the database. Each CIED was interrogated at the start and end of each procedure and at 30-day follow-up. Pre- and post-procedure CIED interrogations were compared for any change in device or lead parameters. Patients were tracked for any subsequent device malfunction., Results: Out of 225 fluoroless AF ablations, 25 (10.2%) had pre-existing CIED (14 dual-chamber pacemakers, three dual-chamber defibrillators, three single-chamber defibrillators, one single chamber pacemaker, and four biventricular devices). Mean patient age was 71 ± 6 years. The mean duration of indwelling CIED was 1804 ± 1645 days (range: 78-6267 days). One (4%) patient had lead-related fibrin on ICE imaging. There was no significant difference in lead(s) threshold, impedance, or sensing post procedure or at 30-day follow-up compared to pre procedure. None of the patients required lead revision. There were no intra- or post-op thromboembolic events or subsequent device infection. One patient underwent CIED extraction after 11 months for an unrelated secondary device infection., Conclusions: Radiofrequency catheter ablation for AF can be safely performed without fluoroscopy in patients with pre-existing CIED., (© 2023 Wiley Periodicals LLC.)

Introduction: The clinical benefit of curcumin, the active ingredient in turmeric, among women diagnosed with polycystic ovarian syndrome (PCOS) is unclear. In this systematic review, we aim to provide a brief review of the existing literature on the association between curcumin supplementation and PCOS., Evidence Acquisition: Published articles relevant to the topic was obtained through extensive search using relevant keywords such as "polycystic ovarian syndrome," "PCOS," "turmeric," and "curcumin." Inclusion criteria included studies that investigated PCOS and turmeric/curcumin, while studies that investigated the use of curcumin in other gynecological disorders, infertility, rodent studies, and non-RCTs were excluded., Evidence Synthesis: A total of 14 articles were found and only five studies were incorporated based on the exclusion criteria. The main findings were that curcumin supplementation aids in improvement of lipid and glycemic profiles, Body Mass Index (BMI) and lowers androgen levels associated with PCOS., Conclusions: We shed light on additional therapeutic management for PCOS other than the conventional treatment. Further studies are required with larger sample sizes and diverse patient population to derive definitive conclusions regarding benefits of curcumin supplementation in PCOS.

Introduction: Radiofrequency ablation (RFA) for atrial fibrillation (AF) has been associated with variable incidence (0.88%-10%) of pericarditis manifested as chest pain, possibly more prevalent with the advent of high-power short-duration (HPSD) ablation. This has led to the widespread use of colchicine in preventative protocols for postablation pericarditis. However, the efficacy of preventative colchicine has not been validated yet., Objective: To evaluate the efficacy of a routine postoperative colchicine regimen (0.6 mg twice a day for 14 days post-AF ablation) for prevention of postablation pericarditis in patients undergoing HPSD ablation., Method: We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for the prevention of postablation pericarditis. All ablations were performed with 50 watts. Patients were divided into colchicine and noncolchicine groups. We recorded incidence of postablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence, and cardioversion for AF within the first 30 days following ablation. We also recorded colchicine-related side effects and medication compliance., Results: Two hundred and ninety-four consecutive HPSD AF ablation patients were screened for the study. After implementing the prespecified exclusion criteria, a total of 205 patients were included in the final analysis, yielding 101 patients in the colchicine group and 104 patients in the noncolchicine group. Both groups were well-matched for demographic and procedural parameters. There was no significant difference in postablation chest pain (9.9% vs. 8.6%, p = .7), pericardial effusion (2.9% vs. 0.9%, p = .1), ER visits (11.9% vs. 12.5%, p = .2), 30-day hospitalization for AF recurrence (0.9% vs. 0.96%, p = .3), and 30-day need for cardioversion for AF (3.9% vs. 5.7%, p = .2). Fifteen (15) patients had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely. There were no major procedural complications in either group., Conclusion: In this single-operator retrospective analysis, prophylactic colchicine was not associated with significant reduction in the incidence of postablation chest pain, pericarditis, 30 day hospitalization, ER visits, or AF recurrence or need of cardioversion within first 30 days after HPSD ablation for AF. However, its usage was associated with significant diarrhea. This study concludes no additional advantage of prophylactic use of colchicine after HPSD AF ablation., (© 2023 Wiley Periodicals LLC.)

Purpose: This systematic review aims to summarise the outcomes of gastrocnemius release in the management of Achilles Tendinopathy., Methods: A systematic review was performed according to PRISMA guidelines. A computer-based search was performed in PubMed, Embase, Cinahl, Scopus and ISI Web of Science. Two independent reviewers performed both title/abstract and full-text screening according to a-priori selection criteria. English-language original research studies reporting outcomes for gastrocnemius recession in patients with Achilles tendinopathy were included. Study quality and risk of bias were assessed using the MINORS criteria., Results: Of the 229 articles identified following database searching, nine studies describing 145 cases of gastrocnemius recession were included in the review. Clinically important differences were reported across a range of validated patient reported outcome scores including VISA-A, FFI, FAAM and VAS pain score. Outcomes appear to be superior in patients with noninsertional Achilles tendinopathy, however further research is required to confirm this. Studies also reported an increase in ankle dorsiflexion range of motion and a good rate of return to sport/work. The overall complication rate was 10/123 (8.1%), with sural nerve injury being the most common complication, occurring in 5/123 (4.1%) of cases., Conclusion: The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment., Level of Evidence: Level IV., (© 2022. The Author(s).)

Cross stimulation is defined as stimulation of one cardiac chamber when the stimulation of the other chamber is expected. We present a case of an eighty three year old patient with history of dual chamber pacemaker implantation with recent generator change which showed interesting ECG findings., (© 2022 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.)

Background: Arterial invasive monitoring is the most common method in the USA for hemodynamic monitoring during atrial fibrillation (AF) ablation. Although studies have shown favorable comparison between non-invasive and invasive hemodynamic monitoring (IHM) in non-cardiac procedures under general anesthesia, limited data is available for complex cardiac procedures such as AF ablation in the USA. With progressive improvement in AF ablation procedural safety, particularly with routine use of intracardiac echocardiography (ICE) to monitor for pericardial effusion, it is unclear if invasive hemodynamic monitoring provides any advantage over non-invasive methods. Therefore, the purpose of this study is to determine whether noninvasive hemodynamic monitoring is non-inferior to invasive hemodynamic monitoring during AF ablation under general anesthesia in patients without major cardiac structural abnormality., Methods: A multi-center retrospective data of AF ablation from July 2019 to December 2020 was extracted. A total of three hundred and sixty-two patients (362) were included, which were divided into group A (non-invasive hemodynamic monitoring) and group B (invasive hemodynamic monitoring). The primary outcome was to compare procedural safety between the two groups., Results: Out of 362 patients, 184 (51%) received non-invasive and 178 (49%) received invasive hemodynamic monitoring with similar baseline characteristics. There was no significant difference between the two groups in complication rates (groin hematoma, pericardial effusion, cardiac tamponade). Mean procedure time was longer in group B with 3.35% arterial site discomfort. Urgent arterial access was required in only 1 patient in group A., Conclusion: This retrospective multicenter study strongly suggests that catheter ablation for atrial fibrillation under general anesthesia can be safely performed with noninvasive hemodynamic monitoring without requiring arterial access, with potential benefit in procedural duration and cost., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

A comparative study of the synthesis of TiO 2 nanorods on fluorine-doped tin oxide (FTO) glass, Si, SiO 2 , Si/Ta, Si/TiN, Si/TiN/Ti and Si/HFO 2 substrates by hydrothermal reaction is presented. Detailed analysis on the growth of TiO 2 on pre-annealed Si/TiN/Ti and HfO 2 (HFO) surfaces is also given. For Si/TiN/Ti, a pre-annealing procedure led to the transformation of Ti to a TiO 2 layer which acts as a seed for aligned growth of TiO 2 nanorods. In contrast, Si/HFO does not provide a nucleation site for the formation of aligned nanorods. Various samples were prepared by varying the synthesis conditions, i.e. pre- and post-annealing temperatures and hydrothermal reaction time to figure out the optimum conditions which lead to unidirectional and highly aligned nanorods. X-ray diffraction, scanning electron microscopy, ultraviolet-visible spectroscopy and Raman spectroscopy were used to study structural, morphological and optical properties of synthesized samples. It is found that TiO 2 nanorods exhibit a rutile phase on the Si/Ti/TiN and Si/HFO substrates, but highly oriented vertical growth of nanorods has been observed only on pre-annealed Si/TiN/Ti substrates. On the other hand, TiO 2 nanorods form dandelion-like structures on Si/HFO substrates. Growth of vertically oriented TiO 2 nanorods on Si/TiN/Ti is attributed to the TiO 2 seed layer which forms after the process of pre-annealing of substrates at a suitable temperature. Variation in hydrothermal reaction time and post-annealing temperature brings further improvement in crystallinity and morphology of nanorods. This work shows that the pre-annealed Si/TiN/Ti substrate is the optimal choice to achieve vertically oriented, highly aligned TiO 2 nanorods.

Background: Osteochondral lesions of the talus are common, particularly after trauma. Arthroscopic bone marrow stimulation has emerged as the first-choice surgical treatment for small primary lesions less than 100 mm2. Individual studies on the topic are small and heterogeneous, and they have differed in their main findings; for this reason, systematically reviewing the available evidence seems important., Questions/purposes: In this systematic review, we asked: (1) What patient-reported outcomes and pain scores have been observed after arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus? (2) What complications were reported? (3) What demographic and clinical factors were reported to be associated with better patient-reported outcome scores?, Methods: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using Embase, EmCare, PubMed, CINAHL, and Scopus (databases last searched June 23, 2021). A two-stage title/abstract and full-text screening process was performed independently by two reviewers. Randomized control trials, cohort studies, and observational studies published in English that evaluated the outcome of arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus were included. Case reports, review articles, commentaries, abstracts, and letters to the editor were excluded. A total of 12 articles (10 case series and two retrospective comparative studies) involving 446 patients were included. Of these, 111 patients with a mean age of 33 years (range 20 to 49) received arthroscopic bone marrow stimulation for a secondary osteochondral lesion of the talus. The Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess the methodologic quality of included studies. The MINORS is a numerical score ranging from 0 to 16 for studies with no comparison group and 0 to 24 for comparative studies, with higher quality studies receiving higher scores. Of the 10 noncomparative case series, the highest score was 10 of 16, with a median (range) score of 7.5 (4 to 10), while the two comparative studies scored 22 of 24 and 19 of 24, respectively., Results: Studies varied widely in terms of patient-reported outcome measures such as the American Orthopaedic Foot and Ankle Society score (AOFAS), with inconsistent reporting across studies regarding whether or how much patients improved; there was variation in some effect sizes with regard to improvement seeming close to or below the minimum clinically important difference (MCID). Although no perioperative complications were reported in any included studies, 34% (26 of 77, in seven studies that reported on this endpoint) of patients who underwent a revision procedure. One study found a negative association between lesion size and AOFAS and VAS score. No other studies reported on factors associated with patient-reported outcome scores, and most studies were far too small to explore relationships of this sort., Conclusion: We found that arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus yielded inconsistent and often small improvements in patient-reported outcomes, with approximately one in three patients undergoing a revision procedure. Reported outcomes likely represent a best-case scenario, inflated by low-level study designs and major sources of bias that are known to make treatment effects seem larger than they are. Therefore, the use of arthroscopic bone marrow stimulation in such patients cannot be recommended, unless we are able to refine selection criteria to effectively identify patients who show a substantial clinical benefit., Level of Evidence: Level IV, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population., (© 2022 Marshfield Clinic Health System.)

Purpose: A ganglion cyst is a benign soft tissue swelling filled with hyaluronic acid and other mucopolysaccharides. Whilst they most commonly present in the wrist region, their occurrence in the foot and ankle is not rare. This scoping review aims to systematically map and summarise current evidence regarding the management of ganglia of the foot and ankle, whilst identifying areas for further research., Methods: This scoping review follows the frameworks of Arksey and O'Malley, Levac and Peters. A comprehensive search strategy was used to identify relevant articles, before a two-stage screening process was performed independently by two reviewers., Results: A total of 2286 unique articles were identified, of which 12 were included in the review. A variety of conservative and surgical treatment strategies are reported, showing good outcomes. An overall pooled recurrence rate of 29.5% was seen across 8 studies. Aspiration alone showed the highest recurrence rate (78.1%), followed by aspiration and steroid injection (62%), steroid injection alone (37.5%) and surgical excision (17.6%). The pooled complication rate across six studies was 21/261 (8.0%), with the most common complication being paraesthesia, reported in 14/261 (5.4%) patients., Conclusions: There is a lack of high-quality research currently regarding the treatment of foot and ankle ganglia. Limited evidence suggests that there could potentially be associations between time to treatment, ganglion location and extent of surgical resection and recurrence rate. However, further research is required before any definitive conclusions can be drawn., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background Myocardial infarction is a life-threatening event, and timely intervention is essential to improve patient outcomes and mortality. Previous studies have shown that the time to thrombolysis should be less than 30 minutes of the patient's arrival at the emergency room. Pain-to-needle time is a time from onset of chest pain to the initiation of thrombolysis, and door-to-needle time is a time between arrival to the emergency room to initiation of thrombolytic treatment. Ideally, the target for door-to-needle time should be less than 30 minutes; however, it is unclear if the door-to-needle time has a significant impact on patients presenting later than three hours from the onset of pain. As many of the previous studies were conducted in first-world countries, with established emergency medical services (EMS) systems and pre-hospital ST-elevation myocardial infarction (STEMI) triages and protocols, the data is not completely generalizable to developing countries. We, therefore, looked for the impact of the shorter and longer door-to-needle times on patient outcomes who presented to the emergency room (ER) with delayed pain-to-needle times (more than three hours of pain onset).  Objective To determine the impact of delayed pain-to-needle time (PNT) with variable door-to-needle time (DNT) on in-hospital complications (post-infarct angina, heart failure, left ventricular dysfunction, and death) in patients with ST-elevation myocardial infarction (STEMI) who underwent thrombolysis. Methods and results A total of 300 STEMI patients who underwent thrombolysis within 12 hours of symptoms onset were included, which were divided into two groups based on PNT. These groups were further divided into subgroups based on DNT. The primary outcome was in-hospital complications between the two groups and between subgroups within each group. The pain-to-needle time was ≤3 hours in 73 (24.3%) patients and >3 hours in 227 (75.7%) patients. In-hospital complications were higher in group II with PNT >3 hours (p <0.05). On subgroup analysis, in-hospital complications were higher with longer door-to-needle time in group II (p<0.05); however, there was no difference in complications among group I. Conclusion Our study is consistent with the fact that shorter door-to-needle time, even in patients with delayed PNT (>3 hours), has a significant impact on in-hospital complications with no difference in mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Iqbal et al.)

Background Acute heart failure (AHF) can be life-threatening if not treated promptly and can significantly increase the number of annual emergency department (ED) encounters in the United States. Achieving adequate and prompt euvolemic state in AHF patients using intravenous (IV) diuretics is the cornerstone of treatment, which not only reduces in-hospital stay and mortality but also decreases healthcare expenditures. Surprisingly, the door to diuretic (D2D) time in AHF patients has always been a debatable issue among physicians worldwide, and so far, there are no set guidelines. This study examines a large cohort of AHF patients to determine the association between diuretics use within 90 minutes of ED admission and hospital length of stay (LOS) and patient mortality.  Methods Retrospective institutional data of AHF patients receiving IV diuretics following ED admission were extracted from 2016 to 2017. A total of 7,751 patients treated for AHF exacerbation were included, which were further divided into two groups based on the timing of diuretics administration (<90 minutes vs. ≥90 minutes). The primary outcomes were LOS between the two groups and hospital mortality. The standard statistical methodology was used for data analysis. Results  A total of 7,751 AHF cases receiving IV diuretics were identified. Almost 1,432 patients (18.5%) received IV diuretics within 90 minutes of ER admission (group 1) while 6,319 patients (81.5%) patients received IV diuretics after 90 minutes (group 2). Furthermore, among group 1 patients, average LOS was noted to be associated with shorter hospitalization (average of 1.423 days less as compared to group 2 patients (confidence interval (CI) =1.02-1.82; p<0.05). Finally, after controlling for other mortality risk factors, patients in group 2 were 1.435 times more likely to have died compared to patients in group 1 (CI=1.03-1.98; p<0.05). Conclusions  D2D time in AHF patients has always been a crucial judgmental decision. The current study successfully demonstrated the relation between IV diuretics administration within 90 minutes of ED admission, favorable clinical outcomes, and decreased mortality rates. More adequately powered studies are needed to validate the results of our current study further., Competing Interests: The abstract was published in JACC annual scientific conference abstract March 04, 2019 and was cited in the text of this article, (Copyright © 2021, Iqbal et al.)

Glucagon-like peptide- 1 receptor analogs (GLP-1RAs) are incretin mimetics with potent glucose-dependent insulinotropic action that translates to glycemic control in people with type- -2 diabetes mellitus (T2DM). These agents potentially have the ability to stimulate proliferation or prevent apoptosis of pancreatic β-cells, induce weight-loss and provide vascular benefits in patients with T2DM. Newer GLP-1RA, semaglutide has shown a robust reduction in HbA1c up to 1.5 - 1.8%. However, individual differences exist between the different GLP-1RAs, in terms of efficacy, pharmacokinetics, tolerability, and vascular protection. The potential of vascular protection offered by newer anti-diabetic agents has generated a lot of excitement in the field of diabetes, and to a large extent, is now driving treatment decisions. So far, six cardiovascular outcome trials of GLP-1 RAs have been published, analyzing lixisenatide (ELIXA), liraglutide (LEADER), semaglutide (SUSTAIN-6), long-acting exenatide (EXSCEL), dulaglutide (REWIND), and oral semaglutide (PIONEER 6) with a follow-up duration of 2-4 years. LEADER, REWIND and SUSTAIN-6 trials have demonstrated a reduction in rates of major adverse cardiovascular events with active GLP-1 RA treatment, but ELIXA, PIONEER 6 and EXSCEL, have been neutral. In this review, we discuss the available evidence from randomized controlled trials (RCTs) analyzing the cardiovascular effects of various GLP-1 RAs with the aim of comparing individual drugs. We have also summarized the general aspects of GLP-1RAs that can be applied in clinical practice., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: The FOXG1 gene plays a vital role in mammalian brain differentiation and development. Intra- and intergenic mutations resulting in loss of function or altered expression of the FOXG1 gene cause FOXG1 syndrome. The hallmarks of this syndrome are severe developmental delay with absent verbal language, post-natal growth restriction, post-natal microcephaly, and a recognizable movement disorder characterized by chorea and dystonia., Case Presentation: Here we describe a case of a 7-year-old male patient found to have a de novo balanced translocation between chromosome 3 at band 3q14.1 and chromosome 14 at band 14q12 via G-banding chromosome and Fluorescence In Situ Hybridization (FISH) analyses. This rearrangement disrupts the proximity of FOXG1 to a previously described smallest region of deletion overlap (SRO), likely resulting in haploinsufficiency., Conclusions: This case adds to the growing body of literature implicating chromosomal structural variants in the manifestation of this disorder and highlights the vital role of cis-acting regulatory elements in the normal expression of this gene. Finally, we propose a protocol for reflex FISH analysis to improve diagnostic efficiency for patients with suspected FOXG1 syndrome.

Objective: To describe a case of Graves disease (GD) and coexistent pancytopenia associated with autoimmune vitamin B 12 deficiency. While thyrotoxicosis and antithyroid drugs can cause pancytopenia, other autoimmune conditions such as vitamin B 12 deficiency can occur, leading to severe anemia and pancytopenia., Methods: A 19-year-old female with GD treated with methimazole presented with thyrotoxicosis and evidence of pancytopenia. Diagnostic studies included a complete blood cell count, peripheral blood smears, thyroid function tests, and a bone marrow biopsy., Results: White blood cells were 2.4 × 10 9 cells/L (reference range [RR] is 3.4 to 9.6 × 10 9 cells/L), hemoglobin was 7.9 g/dL (RR is 11.6 to 15.0 g/dL), neutrophil count was 1.2 × 10 9 cells/L, and platelets were 84 × 10 9 cells/L (RR is 157 to 371 × 10 9 cells/L). Thyroid-stimulating hormone was <0.01 mIU/L (RR is 0.50 to 4.30 mIU/L), free thyroxine was 3.7 ng/dL (RR is 1.0 to 1.6 ng/dL), and total triiodothyronine was 221 ng/dL (RR is 91 to 218 ng/dL). Due to suspicion for drug-induced pancytopenia, methimazole was discontinued. Three days later, she was hospitalized for a syncopal episode with a further decline in hemoglobin to 6.7 g/dL, neutrophils to 0.68 × 10 9 cells/L, and platelets to 69 × 10 9 cells/L. Bone marrow biopsy findings showing marrow hypercellularity and hypersegmented neutrophils suggested vitamin B 12 deficiency. Vitamin B 12 was <70 ng/L (RR is 180 to 914 ng/L). Intramuscular vitamin B 12 injections were initiated, and pancytopenia resolved within 1 month., Conclusion: Although rarely described in the literature, autoimmune vitamin B 12 deficiency can be missed as an underlying etiology for pancytopenia in patients with GD. The clinical picture can be further confounded when these patients are treated with antithyroid drugs known to cause bone marrow suppression., Competing Interests: DISCLOSURE The authors have no multiplicity of interest to disclose., (Copyright © 2020 AACE.)

Background/introduction: Mycoplasma pneumonia affects 1% of the population in the United States. The majority of patients infected with Mycoplasma experience upper respiratory tract infection symptoms, and about 10% of patients infected with Mycoplasma develop pneumonia. A rare complication is a pulmonary embolism (PE), which may be life-threatening if not diagnosed early and treated promptly. Our case explores the presentation of Mycoplasma pneumonia complicated by acute saddle PE, an association only reported in the form of case reports globally., Case Presentation: A 75-year-old previously healthy female presented to the emergency department with shortness of breath. The patient was found to be in acute hypoxic respiratory failure secondary to community acquired pneumonia and antibiotics were started. During hospitalization, her respiratory failure worsened and had to be escalated to a non-rebreather mask. Repeat chest X-ray showed a possible developing infiltrate on the left side. Antibiotic coverage was escalated and broadened. Serology was positive for mycoplasma pneumoniae. Telemetry monitoring showed non-sustained episodes of Atrial Fibrillation and Electrocardiogram showed the presence of new-onset SIQIIITIII. Computer Tomography Angiography of the chest showed acute saddle PE. The patient was subsequently upgraded to the ICU, where she was intubated and started on catheter-directed thrombolysis to decrease clot burden., Conclusion: To our knowledge, this is the first case of acute saddle PE in a live patient with mycoplasma pneumonia. This entity is important in order to ensure early diagnosis of PE in association with mycoplasma pneumonia and the initiation of early treatment to improve patient outcomes., Competing Interests: Regarding the publication being submitted, Acute Saddle Pulmonary Embolism: A Rare Complication of Mycoplasma Pneumonia, this is to disclose that the following authors do not have any conflict of interest to disclose. This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.Farrah Chilet, MDArshad Muhammad Iqbal, MDNikolay Mitzov, MDSalman Muddassir, MD, FACPEddib Abdulmagid, MD, (© 2020 Published by Elsevier Ltd.)

Adverse childhood experiences (ACE) have been associated with a greater prevalence of risky behaviors and chronic health conditions, such as diabetes in adulthood. While adolescents with risk taking behaviors experience worsening of diabetic metabolic control, it is yet to be determined whether glycemic management in children and adolescents is negatively and independently influenced by ACEs. This study examines the relationship between ACEs in children and adolescents with type 1 diabetes (T1DM) and glycemic control, BMI and lipids. For such children, we hypothesized that hemoglobin A1c (HbA1c) is positively correlated with ACE scores. Parents of children (age 2-18 years) with T1DM completed a validated ACE questionnaire. The associations between parent and child ACE score and HbA1c, lipids and BMI z-scores were assessed using linear regression. The prevalence of any ACE was 27.9% among children and 49.0% among parents. HbA1c was significantly higher in children who had exposure to three or more ACEs (β:0.63 (4.5 mmol/mol); p = 0.02), in those who had a parent exposed to four or more ACEs (β:0.87 (7.2 mmol/mol); p = 0.03), in children who had exposure to household incarceration (β:0.62 (4.4 mmol/mol); p = 0.05) and children who witnessed or had been victim of violence in the neighborhood (β:0.71 (5.4 mmol/mol); p = 0.02). ACEs were highly prevalent among children with T1DM and had a positive association with glycemic control., Competing Interests: The authors declare no conflict of interest

BACKGROUND Direct oral anticoagulant agents (DOACs) have become increasingly more popular in recent years and have largely replaced warfarin in the treatment of certain conditions, such as atrial fibrillation, and in the prevention of thromboembolic events. Rivaroxaban is one of the most commonly used direct anticoagulant drugs for conditions such as atrial fibrillation and thromboprophylaxis. CASE REPORT We present a case of a 70-year-old male who developed acute interstitial nephritis after starting rivaroxaban, and who responded to medical treatment, which included corticosteroid therapy. A renal biopsy was not performed because the patient was on essential anticoagulation therapy secondary to a high CHADS2VASc score. CONCLUSIONS Dose adjustments when using rivaroxaban are necessary in patients with underlying renal failure. Acute interstitial nephritis is a rare condition associated with direct anticoagulant drugs. The treatment of acute interstitial nephritis is usually to remove the offending agent and treat the underlying cause.

BACKGROUND Spontaneous fungal peritonitis (SFP) is a life-threatening infection which occurs more commonly in patients with liver failure. SFP is not as common as spontaneous bacterial peritonitis (SBP) and has higher mortality rates due to late recognition and difficulty in differentiation between SFP and SBP. Spontaneous fungal peritonitis is extremely uncommon in patients with cardiac ascites due to a high protein content, which predisposes to a low risk of infections. CASE REPORT This report presents a rare case of spontaneous fungal peritonitis in a patient with cardiogenic ascites. To the best of our knowledge, this is the second known case of SFP occurring in a patient with cardiac cirrhosis. The patient did not respond to initiation of SBP treatment and after ascitic fluid grew Candida glabrata, the diagnosis of SFP was made. The patient's clinical status improved after initiation of intravenous caspofungin. CONCLUSIONS SFP should be a differential diagnosis in patients who have cardiac or liver cirrhosis, who are not improving with empirical antibiotic therapy for spontaneous bacterial peritonitis.

Background: Heart Rhythm Society guidelines recommend obtaining thyroid function tests (TFTs) at amiodarone initiation and every 6 months thereafter in adults, with no specific pediatric recommendations. Untreated hypothyroidism in young children negatively affects brain development and somatic growth, yet the optimal screening frequency for pediatric patients remains unclear, and limited data exist on pediatric amiodarone-induced thyroid dysfunction., Objective: The purpose of this study was to describe the patterns of amiodarone-induced thyroid dysfunction in pediatric patients., Methods: We established a retrospective cohort of 527 pediatric patients who received amiodarone between 1997 and 2017. We defined amiodarone therapy lasting 3-30 days as "short term" and >30 days as "long term.", Results: The final cohort (n = 150) consisted of 27 neonates (18%), 25 infants (16%), 27 young children (18%), and 71 children (47%). Of the children in whom TFTs were checked, half (50.8%) developed a thyroid-stimulating hormone (TSH) value above the reference for age. Neonates had the highest median peak TSH values in both short- and long-term groups: 23.5 mIU/L (interquartile range 11.4-63.1) and 28.8 mIU/L (interquartile range 11.4-34.4), respectively. Although concurrent use of inotropic support was significantly associated with lower initial TSH values, no variable related to cardiac illness or type of heart disease was associated with peak TSH values., Conclusion: Neonates and infants receiving amiodarone had more thyroid dysfunction with greater degrees of TSH elevation than older children. TSH elevations occurred early, even with short-term exposure. Given the concern for brain development and growth in hypothyroid children, our results suggest the need for more rigorous pediatric-specific thyroid monitoring guidelines., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to evaluate the effectiveness of submucosal injection of tramadol in treating postoperative pain after surgical extraction of impacted mandibular third molars., Materials and Methods: We implemented a randomized controlled trial. The sample was divided into 30 cases (receiving tramadol injection) and 30 controls (receiving saline solution injection). Patients were asked to complete a visual analog pain scale (VAPS) at 0.5, 1, 2, 4, 6, 12, 24, and 48 hours. Patients also were asked to note the time at which rescue analgesics were taken, as well as the total number of analgesics taken. The VAPS data were analyzed using the unpaired Student t test. Other variables were analyzed using analysis of variance with the Bonferroni t test and Pearson χ 2 test. P < .05 was considered significant., Results: A total of 60 patients, 32 men and 28 women (mean age, 27.78 years; age range, 19 to 45 years), took part in this study. Postoperative pain scores, as recorded on the VAPS, were significantly lower in the tramadol group, with the differences being statistically significant at 0.5, 1, 2, 4, and 6 hours (P < 0.001, P = .006, P < 0.001, P < 0.001, and P < 0.001, respectively). The mean time at which the first tablet was taken and the total number of tablets taken by the tramadol group also were statistically significant (P = .001 for both)., Conclusions: The results suggest that submucosal injection of tramadol has a significant effect on postoperative pain control after surgical extraction of impacted third molars., (Copyright © 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Little is known about how metabolites couple tissue-specific stem cell function with physiology. Here we show that, in the mammalian small intestine, the expression of Hmgcs2 (3-hydroxy-3-methylglutaryl-CoA synthetase 2), the gene encoding the rate-limiting enzyme in the production of ketone bodies, including beta-hydroxybutyrate (βOHB), distinguishes self-renewing Lgr5 + stem cells (ISCs) from differentiated cell types. Hmgcs2 loss depletes βOHB levels in Lgr5 + ISCs and skews their differentiation toward secretory cell fates, which can be rescued by exogenous βOHB and class I histone deacetylase (HDAC) inhibitor treatment. Mechanistically, βOHB acts by inhibiting HDACs to reinforce Notch signaling, instructing ISC self-renewal and lineage decisions. Notably, although a high-fat ketogenic diet elevates ISC function and post-injury regeneration through βOHB-mediated Notch signaling, a glucose-supplemented diet has the opposite effects. These findings reveal how control of βOHB-activated signaling in ISCs by diet helps to fine-tune stem cell adaptation in homeostasis and injury., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Hepatic portal venous gas is a radiologic sign and is associated with several abdominal disorders. The prognosis and survival of the patient depends on the underlying etiology. Most cases respond to broad-spectrum antibiotics, but some may need surgical intervention. We report a case of hepatic portal venous gas after colonoscopy in a patient with Crohn's disease., (© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Background Severe obesity is associated with a number of cardiometabolic risk factors. Thyroid-stimulating hormone (TSH) levels are often slightly increased in children with obesity. The clinical significance of the mild elevation in TSH in children with obesity is unclear. Objective To examine the association between TSH and lipids in children with severe obesity. Methods We performed a retrospective analysis of records of children with severe obesity with simultaneous measurements of TSH and lipids. Children with TSH <0.3 mIU/L and ≥10 mIU/L were excluded. The relationship between TSH and lipids was evaluated using univariate/multiple variable linear and logistic regression. Results The study included 834 children (age 13.8 ± 4.1 years, males 46%, body mass index [BMI]: 36.9 ± 7.6 kg/m2; BMI z-score 2.6 ± 0.4). Seventy-four (8.9%) children had TSH between 5 and <10 mIU/L (high TSH [HTSH]). TSH was positively associated with non-high-density lipoprotein (HDL) cholesterol (β: 1.74; 95% confidence interval [CI] 0.29-3.20, p = 0.02). Total cholesterol and non-HDL cholesterol were higher in males with HTSH compared to those with normal TSH (175.5 vs. 163.5 mg/dL, p = 0.02 and 133.7 vs. 121.4 mg/dL, p = 0.02, respectively). The odds of elevated non-HDL cholesterol (≥145 mg/dL) was higher in males with HTSH relative to those with normal TSH (odds ratio [OR]: 2.78; 95% CI 1.35-5.69, p = 0.005). Conclusions TSH levels were positively associated with non-HDL cholesterol in children with severe obesity. Males with mildly elevated TSH had higher total cholesterol and non-HDL cholesterol compared to males with normal TSH. Further studies are warranted to determine if levothyroxine therapy would result in improvement in total cholesterol or non-HDL cholesterol in children with severe obesity with mildly elevated TSH.

BACKGROUND Marijuana is a commonly abused illicit drug in the United States (US). Regular marijuana usage has been linked to many adverse cardiovascular effects. Our case describes the association of abusing marijuana and the development of sick sinus syndrome. CASE REPORT A 27-year-old male carpenter was admitted to the hospital for recurrent syncopal episodes. He reported 2 episodes of syncope every month for the last 5 years. He denied alcohol or nicotine intake but reports using marijuana daily. He also reported cervical injuries due to syncope in the past. Physical examination was unremarkable. Orthostatic vitals were negative. Electrocardiogram (ECG) showed sinus bradycardia. A series of investigations, including a stress test and tilt table testing, were negative. The drug screen was positive for marijuana. A loop recorder was implanted to evaluate the cause of syncope and was positive for a long sinus pause of more than 3 second, indicative of sick sinus syndrome. The patient was successfully treated with a permanent pacemaker with no further events on follow-up after 6 months. CONCLUSIONS The case we report here adds to the literature that several reversible etiologies are shown to be associated with the development of sick sinus syndrome, in which marijuana abuse can be one of them. We strongly suspect that marijuana was the cause of this patient's sick sinus syndrome after ruling out all the possible etiologies. The relation between marijuana use and sick sinus syndrome needs to be further investigated in the future.

Cardiac myxoma is an uncommon diagnosis but presents with common manifestations. There is a wide range of symptomatology from non-specific fever and weight loss to stroke-like symptoms. It is also one of the rare causes of cardiac syncope and thromboembolic events. We present a case of a 67-year-old female who presented with seemingly benign vertigo symptoms which she ignored for years before seeking medical attention. An echocardiogram revealed a 3.5 x 3.0 x 1.0 cm atrial myxoma which was surgically excised. Her symptoms have resolved entirely with no recurrence since surgery., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Jupalli et al.)

Septic pulmonary emboli is a rare condition due to the dislodgement of an infected thrombus traveling to the pulmonary vasculature via the venous system. Staphylococcus spp. and Candida spp. are the most common causative agents. The most common risk factor is intravenous drug abuse, but there has been an association with intravenous catheters. Delftia acidovorans (DA) is a rare organism causing catheter-related infection, which has a tendency to embolize and clog up major vessels. It is highly resistant to all available aminoglycoside agents. There are only a few cases reported in children showing DA as a cause of septic emboli with none of the cases reported in a young patient. We report a similar case but in a young adult who developed septic emboli due to DA that was caused by an infected peripherally inserted central catheter (PICC) line. Since the organism is highly susceptible to recurrent embolization, the PICC line was removed and the patient was treated successfully with an appropriate antibiotic regime.

Neurofibromatosis Type 1 ( NF1 ) is an autosomal dominant genetic disorder with an incidence of approximately 1 in 4,000 live births [1] . Pulmonary arterial hypertension (PAH) is a rare but extremely life-threatening complication associated with NF1 . Timely recognition of this unusual and severe association between NF1 and PAH is imperative in prolonging the survival in this specific patient population. We present the clinical outcomes of a 47-year old female previously diagnosed with NF1 , who presented with progressively worsening dyspnea.