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Class II obesity affects 1 in 5 patients with left ventricular assist device (LVAD) and is considered a potential barrier to heart transplantation (HT). Studies about the outcomes of bariatric surgery in this population are scarce.We identified Medicare beneficiaries who had an LVAD placed from 2012 to 2019 and had at least class II obesity at the time of LVAD placement and identified patients who underwent bariatric surgery during or after the LVAD implantation admission. The primary outcome was major adverse cardiovascular events (MACE) at 30 days (mortality, cerebral hemorrhage, or ischemic stroke) after bariatric surgery.Among patients who underwent LVAD implantation from 2012 to 2019, 2798 (19.4%) had at least class II obesity, and 198 (7.1%) patients had bariatric surgery (24 on same admission and 174 after a median of 702 days). After bariatric surgery in LVAD patients, 30-day MACE was 6.1%, 30-day mortality was5.5%, and 1-year mortality was 12.6%. Heart failure readmission burden declined after bariatric surgery (incidence rate ratio 0.20 (95% CI 0.11-0.38), p0.001). Thirty-seven patients underwent HT after a median of 371 days (IQR 246-575 days), and 13 patients underwent LVAD explant due to recovery. On time-dependent, competing risk, Cox regression, bariatric surgery was associated with a 3-fold higher probability of HT in follow-up compared to patients who did not get bariatric surgery (sub-distribution HR 2.95, 95% CI 2.09-4.17, p0.001).Bariatric surgery in patients with LVAD support is associated with decreased heart failure events and higher chances of heart transplantation.

Right ventricular (RV) failure remains a major complication after surgical implantation of a left ventricular assist device (LVAD). While the use of a percutaneous RV assist device has been described as a short‐term bridge to recovery in end‐stage heart failure patients with early post‐operative RV failure after index LVAD implant, management of refractory late RV failure remains challenging in these patients. We report the first successful case of extended Impella RP use as a safe and effective bridge to orthotopic heart transplant in an LVAD patient with refractory, haemodynamically significant late RV failure. The Impella RP provided support for 37 days. Haemodynamically intolerant arrhythmia precluded use of inotropic support. No adverse complications related to percutaneous Impella RP support were seen. We also review potential considerations for mechanical circulatory support strategies in this setting: central RV assist device cannulation requires sternotomy incision that can impact subsequent cardiac surgeries, while percutaneous Protek Duo insertion requires adequate vessel size and patency. With an LVAD in situ, veno‐arterial extracorporeal membrane oxygenation was not considered for isolated RV support in this case. The patient is currently over 6 months post‐orthotopic heart transplant.

Outcomes for critically ill people living with human immunodeficiency virus (PLHIV) have changed with the use of antiretroviral therapy (ART). To identify these outcomes and correlates of mortality in a contemporary critically ill cohort in an urban academic medical center in Baltimore, a city with a high burden of HIV, we conducted a retrospective cohort study of individuals admitted to a medical intensive care unit (MICU) at a tertiary care center between 2009 and 2014. PLHIV who were at least 18 years of age with an index MICU admission of ≥24 hours during the 5-year study period were included in this analysis. Data were obtained for participants from the time of MICU admission until hospital discharge and up to 180 days after MICU admission. Logistic regression was used to identify independent predictors of hospital mortality. Between June 2009 and June 2014, 318 PLHIV admitted to the MICU met inclusion criteria. Eighty-six percent of the patients were non-Hispanic Blacks. Poorly controlled HIV was very common with 70.2% of patients having a CD4 cell count200 cells/mm3 within 3 months prior to admission and only 34% of patients having an undetectable HIV viral load. Hospital mortality for the cohort was 17%. In a univariate model, mortality did not differ by demographic variables, CD4 cell count, HIV viral load, or ART use. Regression analysis adjusted by relevant covariates revealed that MICU patients admitted from the hospital ward were 6.4 times more likely to die in hospital than those admitted from emergency department. Other positive predictors were a diagnosis of end-stage liver disease, cardiac arrest, ventilator-dependent respiratory failure, vasopressor requirement, non-Hodgkin lymphoma, and symptomatic cytomegalovirus disease. In conclusion, in this critically ill cohort with HIV infection, most predictors of mortality were not directly related to HIV and were similar to those for the general population.

We previously reported that flagellin-expressing Pseudomonas aeruginosa (Pa) provokes NEU1 sialidase-mediated MUC1 ectodomain (MUC1-ED) desialylation and MUC1-ED shedding from murine lungs in vivo. Here, we asked whether Pa in the lungs of patients with ventilator-associated pneumonia might also increase MUC1-ED shedding. The levels of MUC1-ED and Pa-expressed flagellin were dramatically elevated in bronchoalveolar lavage fluid (BALF) harvested from Pa-infected patients, and each flagellin level, in turn, predicted MUC1-ED shedding in the same patient. Desialylated MUC1-ED was only detected in BALF of Pa-infected patients. Clinical Pa strains increased MUC1-ED shedding from cultured human alveolar epithelia, and FlaA and FlaB flagellin-expressing strains provoked comparable levels of MUC1-ED shedding. A flagellin-deficient isogenic mutant generated dramatically reduced MUC1-ED shedding compared with the flagellin-expressing wild-type strain, and purified FlaA and FlaB recapitulated the effect of intact bacteria. Pa:MUC1-ED complexes were detected in the supernatants of alveolar epithelia exposed to wild-type Pa, but not to the flagellin-deficient Pa strain. Finally, human recombinant MUC1-ED dose-dependently disrupted multiple flagellin-driven processes, including Pa motility, Pa biofilm formation, and Pa adhesion to human alveolar epithelia, while enhancing human neutrophil-mediated Pa phagocytosis. Therefore, shed desialylated MUC1-ED functions as a novel flagellin-targeting, Pa-responsive decoy receptor that participates in the host response to Pa at the airway epithelial surface.

Cardiac sarcoidosis is a component of an often multiorgan granulomatous disease of still uncertain cause. It is being recognized with increasing frequency, mainly as the result of heightened awareness and new diagnostic tests, specifically cardiac magnetic resonance imaging and18F-fluorodeoxyglucose positron emission tomography scans. The purpose of this case-based review is to highlight the potentially life-saving importance of making the early diagnosis of cardiac sarcoidosis using these new tools and to provide a framework for the optimal care of patients with this disease. We will review disease mechanisms as currently understood, associated arrhythmias including conduction abnormalities, and atrial and ventricular tachyarrhythmias, guideline-directed diagnostic criteria, screening of patients with extracardiac sarcoidosis, and the use of pacemakers and defibrillators in this setting. Treatment options, including those related to heart failure, and those which may help clarify disease mechanisms are included.

A 68-year-old woman with a medical history significant for psoriatic arthritis was found to have an enlarged, painful lump on her left hip 15 months after intramedullary rod placement for a left subtrochanteric femur fracture sustained in a fall. Histopathological findings showed rice body formation (RBF) with concurrent H. parainfluenza. RBF is a relatively rare arthropathy of a subset of chronic inflammatory disease such as rheumatoid arthritis or tuberculous arthropathy. RBF associated with psoriatic arthritis or orthopedic hardware placement has been reported in a handful of cases in the literature but there has not been any definitive evidence for RBF as a result of Haemophilus parainfluenza infections and is a rather unusual characteristic of this case.

Background Functional capacity is associated with mortality, although the prognostic value of achieved estimated metabolic equivalents (METs) across various exercise protocols is not established. We sought to determine whether achieved METs had different prognostic implications according to the protocol employed. Methods and Results From 1991 to 2015, we identified 120 705 consecutive patients from a stress testing registry who underwent the following 7 different standardized exercise protocols: Bruce, modified Bruce, Cornell 0%, Cornell 5%, Cornell 10%, Naughton, and modified Naughton. The primary outcome was all‐cause mortality. There were 74 953 Bruce, 8368 modified Bruce, 2648 Cornell 0%, 9972 Cornell 5%, 20 425 Cornell 10%, 1226 Naughton, and 3113 modified Naughton protocols. During a mean follow‐up of 8.7 years, a total of 8426 deaths (6.9%) occurred. When compared with the Bruce protocol, after multivariable adjustment for clinical risk factors, medications, and functional capacity, test protocol was independently associated with mortality (modified Naughton [hazard ratio (HR), 2.51; 95% CI, 2.26–2.8], Naughton [HR, 1.79; 95% CI, 1.57–2.04], Cornell 0% [HR, 1.79; 95% CI, 1.59–2.01], modified Bruce [HR, 1.62; 95% CI, 1.48–1.76], Cornell 5% [HR, 1.61; 95% CI, 1.47–1.75], and Cornell 10% [HR, 1.32; 95% CI, 1.22–1.42]). Across all protocols, higher estimated METs were associated with lower mortality, although the equivalent METs achieved were associated with a worse prognosis in less‐demanding protocols. Conclusions Higher estimated METs are reliably associated with lower mortality in all exercise protocols, although the prognostic value is not transferable across different tests. Consequently, the prognostic value of METs achieved during a stress test should be considered protocol dependent.

Previous data has shown that elective left ventricular assist device (LVAD) implantation in ambulatory advanced heart failure patients can improve event-free survival and quality of life. The patient selection criteria for mechanical circulatory support (MCS) are complex as it involves integrating data from INTERMACS profile, clinical variables, invasive hemodynamic assessment, and recent hospitalization history. Identifying patients before incipient end organ failure ensues is key to prevent irreversible damage prior to LVAD implantation. Specific red flags that should warrant referral for advanced therapies include repeat hospitalizations, medication intolerance, worsening exercise cardiopulmonary stress testing, worsening cardiac hemodynamics, or inotrope dependence.

Key Clinical Message Herpes simplex virus hepatitis is a rare but potentially fatal disease without early intervention. Impaired immunity is a major predisposing risk factor but infection in immunocompetent individuals is not unheard of. Diagnosis is complicated by its rarity and nonspecific signs and symptoms on presentation. Identification by liver biopsy is often limited due to concurrent coagulopathy. Early and aggressive treatment is centered on antiviral therapy with acyclovir. We present a case of herpes hepatitis in an immunocompetent woman following abdominal instrumentation.

N-methyl-d-aspartate receptor (NMDAR) antibody encephalitis is a potentially fatal autoimmune syndrome in which there is antibody production against the NMDAR causing profound dysregulation of neurotransmission. The syndrome is frequently associated with ovarian teratomas and women are disproportionately affected. Patients most often present with a constellation of neuropsychiatric signs and symptoms, including memory loss, hallucinations, and decreased level of consciousness. This condition is lethal if left untreated. Immunotherapy and surgical resection of the culprit malignancy often results in the rapid resolution of symptoms.

Heart failure is a heterogeneous clinical syndrome with a variety of causes, risk factors, and pathology. The challenge in using biomarkers to assess and guide management of heart failure is that no one biomarker is sufficient to encompass all heart failure phenotypes. We also know that a large number of factors influence biomarker levels, including age, renal function, obesity, and other concurrent conditions. The majority of drug therapies and titrations were developed before the development of biomarkers, but recent guidelines support its use in the diagnosis of acute heart failure and in certain instances to guide therapy. This chapter summarizes the data on cardiac biomarkers and its use in diagnosing and managing heart failure.

Introduction With increasing number of patients living with chronic systolic heart failure, the number of patients with recovery of their left ventricular ejection fraction (LVEF) has increased over time. Similarly the number of patients that have had LVEF recovery and has relapse of reduced ejection fraction is a patient group that is under recognized and not well characterized. The purpose of this study was to describe our single-center long-term experience of patients with who have had recovery in LVEF and relapse of reduced ejection fraction during that time, and to describe what clinical predictors might be associated with this improvement or relapse. Hypothesis We hypothesized that gender and race is associated with LVEF recovery and relapse. Methods We reviewed serial LVEF in patients with a diagnosis of heart failure with reduced ejection fraction (defined as ejection fraction ≤ 35%) from 2000-2016. Hazard ratios (HR) for independent clinical predictors of recovery (defined by original LVEF ≤ 35% and follow-up LVEF ≥ 40%), relapse (defined by patients that had recovery, that subsequently had LVEF Results In our study cohort of 19,888 patients (67% male; 22.4% white), 7,327 (37%) experienced recovery of LVEF over a maximum time course of 5 years. Male gender was significantly associated with a lack LVEF recovery (HR 0.7, P Conclusions In our large single center experience of patients with chronic systolic heart failure, over a third of patients experienced recovery of their LVEF. Males were significantly less likely to recovery than females. Additionally a history of atrial fibrillation, valvular heart disease, and guideline-directed medications for heart failure were associated with LVEF recovery. In terms of relapse, African American race, CABG, and diuretic use were associated with relapse.

Importance The role of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) in the setting of the coronavirus disease 2019 (COVID-19) pandemic is hotly debated. There have been recommendations to discontinue these medications, which are essential in the treatment of several chronic disease conditions, while, in the absence of clinical evidence, professional societies have advocated their continued use. Objective To study the association between use of ACEIs/ARBs with the likelihood of testing positive for COVID-19 and to study outcome data in subsets of patients taking ACEIs/ARBs who tested positive with severity of clinical outcomes of COVID-19 (eg, hospitalization, intensive care unit admission, and requirement for mechanical ventilation). Design, Setting, and Participants Retrospective cohort study with overlap propensity score weighting was conducted at the Cleveland Clinic Health System in Ohio and Florida. All patients tested for COVID-19 between March 8 and April 12, 2020, were included. Exposures History of taking ACEIs or ARBs at the time of COVID-19 testing. Main Outcomes and Measures Results of COVID-19 testing in the entire cohort, number of patients requiring hospitalizations, intensive care unit admissions, and mechanical ventilation among those who tested positive. Results A total of 18 472 patients tested for COVID-19. The mean (SD) age was 49 (21) years, 7384 (40%) were male, and 12 725 (69%) were white. Of 18 472 patients who underwent COVID-19 testing, 2285 (12.4%) were taking either ACEIs or ARBs. A positive COVID-19 test result was observed in 1735 of 18 472 patients (9.4%). Among patients who tested positive, 421 (24.3%) were admitted to the hospital, 161 (9.3%) were admitted to an intensive care unit, and 111 (6.4%) required mechanical ventilation. Overlap propensity score weighting showed no significant association of ACEI and/or ARB use with COVID-19 test positivity (overlap propensity score–weighted odds ratio, 0.97; 95% CI, 0.81-1.15). Conclusions and Relevance This study found no association between ACEI or ARB use and COVID-19 test positivity. These clinical data support current professional society guidelines to not discontinue ACEIs or ARBs in the setting of the COVID-19 pandemic. However, further study in larger numbers of hospitalized patients receiving ACEI and ARB therapy is needed to determine the association with clinical measures of COVID-19 severity.

The newest centrifugal-flow (CF) left ventricular assist device (LVAD), the HeartMate 3 (HM3), has significantly lower rates of pump thrombosis. There is lack of literature regarding HM3 thrombosis in situ. A 55 year old man with an ischemic cardiomyopathy (LVEF 15%) and chronic idiopathic

Fabry's disease (FD) is a rare X linked lysosomal storage disorder which results in deleterious tissue distribution of glycophospholipids. Cardiac manifestations can occur due to glycophospholipids deposition, signaling for myocytes hypertrophy, outflow tract obstruction, scar formation, valvular

Introduction: Stress is a complex, dynamic process of interaction between a person and his or her life. It is the war one reacts physically, mentally and emotionally to the various conditions. The purpose of the present study was to investigate stress, its relationships with selected factors among women. Study Design: A descriptive survey design was used to identify the stress and its relationship with selected factors among (200) women aged 18-45 years. Results: The present study reveals that level of stress was high among unmarried women (85%) when compared to married women (76%). The present study also revealed that there was a significant association between stress and age, age at menarche, education, BMI and dysmenorrhea among the married and unmarried women. Conclusions: Stress was more prevalent among unmarried women, age, educational status, age at menarche; BMI and dysmenorrhea were strongly associated with stress.

The Muller F element (4.2 Mb, ~80 protein-coding genes) is an unusual autosome of Drosophila melanogaster; it is mostly heterochromatic with a low recombination rate. To investigate how these properties impact the evolution of repeats and genes, we manually improved the sequence and annotated the genes on the D. erecta, D. mojavensis, and D. grimshawi F elements and euchromatic domains from the Muller D element. We find that F elements have greater transposon density (25–50%) than euchromatic reference regions (3–11%). Among the F elements, D. grimshawi has the lowest transposon density (particularly DINE-1: 2% vs. 11–27%). F element genes have larger coding spans, more coding exons, larger introns, and lower codon bias. Comparison of the Effective Number of Codons with the Codon Adaptation Index shows that, in contrast to the other species, codon bias in D. grimshawi F element genes can be attributed primarily to selection instead of mutational biases, suggesting that density and types of transposons affect the degree of local heterochromatin formation. F element genes have lower estimated DNA melting temperatures than D element genes, potentially facilitating transcription through heterochromatin. Most F element genes (~90%) have remained on that element, but the F element has smaller syntenic blocks than genome averages (3.4–3.6 vs. 8.4–8.8 genes per block), indicating greater rates of inversion despite lower rates of recombination. Overall, the F element has maintained characteristics that are distinct from other autosomes in the Drosophila lineage, illuminating the constraints imposed by a heterochromatic milieu.

Suboptimal colon preparation is a significant barrier to quality colonoscopy. The impact of pharmacologic agents associated with gastrointestinal dysmotility on quality of colon preparation has not been well characterized.Evaluate impact of opiate pain medication and psychoactive medications on colon preparation quality in outpatients undergoing colonoscopy.Outpatients undergoing colonoscopy at a single medical centre during a 6-month period were retrospectively identified. Demographics, clinical characteristics and pharmacy records were extracted from electronic medical records. Colon preparation adequacy was evaluated using a validated composite colon preparation score.2600 patients (57.3 ± 12.9 years, 57% female) met the inclusion and exclusion criteria. 223 (8.6%) patients were regularly using opioids, 92 antipsychotics, 83 tricyclic antidepressants and 421 non-tricyclic antidepressants. Opioid use was associated with inadequate colon preparation both with low dose (OR = 1.4, 95%CI 1.0-2.1, p = 0.05) and high dose opioid users (OR = 1.7, 95%CI 1.1-2.9, p = 0.039) in a dose dependent manner. Other significant predictors of inadequate colon preparation included use of tricyclics (OR = 1.9, 95%CI 1.1-3.0, p = 0.012), non-tricyclic antidepressants (OR = 1.5, 95%CI 1.1-2.0, p = 0.013), and antipsychotic medications (OR = 2.2, 95%CI 1.4-3.4, p = 0.001).Opiate pain medication use independently predicts inadequate quality colon preparation in a dose dependent fashion; furthermore psychoactive medications have even more prominent effects and further potentiates the negative impact of opiates with concurrent use.

Adults with Tetralogy of Fallot (ToF) experience increased risk of sudden cardiac death (SCD). Known risk factors include QRS duration >180 ms, extensive right ventricular (RV) scarring, nonsustained ventricular tachycardia (VT) and left ventricular (LV) systolic or diastolic dysfunction. High

This p aper proposes a content-based image retrieval system based on an efficient combination of both feature and color algorithms. According to Kekre Transform we derive feature vectors using a combination of row mean and column mean of both query as well as the database images, to measure the extent of similarity in features using Euclidian distance. Experimentation shows that taking row mean, column mean and combination improves the performance of image retrieval as compared to taking Kekre Transform of the whole image. Similarly, HSV colour space quantifies the colour space into different regions and thereby calculating its mean and Euclidian distance the colour vector can be derived. Taking mean or Euclidian distance of the individual Euclidian distances of both the algorithms improves the accuracy of the image retrieval process implemented . B y calculating the precision and recall parameters of selective images from the database, comparison between the two algorithms and the effectiveness of the combination of both the algorithms can be measured.

The MAPK kinase kinase Wallenda is regulated by the Highwire E3 ubiquitin ligase and initiates injury signaling in axons., Regenerative responses to axonal injury involve changes in gene expression; however, little is known about how such changes can be induced from a distant site of injury. In this study, we describe a nerve crush assay in Drosophila melanogaster to study injury signaling and regeneration mechanisms. We find that Wallenda (Wnd), a conserved mitogen-activated protein kinase (MAPK) kinase kinase homologous to dual leucine zipper kinase, functions as an upstream mediator of a cell-autonomous injury signaling cascade that involves the c-Jun NH2-terminal kinase MAPK and Fos transcription factor. Wnd is physically transported in axons, and axonal transport is required for the injury signaling mechanism. Wnd is regulated by a conserved E3 ubiquitin ligase, named Highwire (Hiw) in Drosophila. Injury induces a rapid increase in Wnd protein concomitantly with a decrease in Hiw protein. In hiw mutants, injury signaling is constitutively active, and neurons initiate a faster regenerative response. Our data suggest that the regulation of Wnd protein turnover by Hiw can function as a damage surveillance mechanism for responding to axonal injury.

Seven percent of mediastinal tumors are of thyroidal origin. The incidence of mediastinal/substernal thyroid masses ranges from 2.6% to 21% of patients undergoing thyroidectomy. The wide range in reported incidence is largely due to variation in the definition of substernal thyroid masses. They can be defined as a thyroid gland with cervical extension that descended below the thoracic inlet. The purpose of this report is to discuss an 84-year-old male with shortness of breath, pain radiating to the chest, dysphagia, and odynophagia. The patient was admitted to the hospital for retrosternal chest pain and pneumonia. A computerized axial tomography scan of the chest revealed a mediastinal mass compressing the trachea. The patient underwent neck and mediastinal exploration, with complete excision of the mediastinal thyroid. We were able to deliver the mass into the neck from the mediastinum avoiding the need for sternotomy or thoracotomy.