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Prosthetic valve endocarditis after transcatheter aortic valve replacement (PVE after TAVR) is a feared complication most often observed during the early postprocedural period. We report a case of severe, multivalvular PVE after TAVR with complete heart block caused by an uncommon organism. A 78-year-old female with prior Streptococcus agalactiae mitral valve endocarditis treated with antibiotics presented one year later with severe, symptomatic aortic insufficiency. She subsequently underwent TAVR given high surgical risk. Six weeks post-TAVR, she presented with syncope, fever, and complete heart block. Transthoracic echocardiogram was not demonstrative of vegetation. Blood cultures were positive for Staphylococcus lugdunensis. Transesophageal echocardiogram (TEE) demonstrated vegetations of the aortic, mitral, and tricuspid valves and aorto-mitral continuity. While awaiting surgery, the patient developed cardiac arrest; she was resuscitated and taken to surgery emergently. The patient underwent TAVR explantation, bovine pericardial tissue aortic and porcine bioprosthetic mitral valve replacements, and tricuspid valve repair. Additionally, left main coronary artery endarterectomy was performed due to presence of infectious vegetative material. Staphylococcus lugdunensis is an unusual but virulent organism that may damage both native and prosthetic valves. Early surgery is recommended for PVE after TAVR, especially in cases with perivalvular disease causing conduction abnormalities. Learning Objectives. TAVR has revolutionized the management of severe aortic stenosis and has even been successfully utilized in select cases of aortic regurgitation. Unfortunately, there are a number of associated complications that can be difficult to diagnose, such as prosthetic valve endocarditis (PVE). We emphasize maintaining a high clinical suspicion for PVE after TAVR in patients presenting with conduction abnormalities and highlight the importance of early surgical management in cases complicated by heart block, abscesses, or destructive penetrating lesions.

Cardiac tamponade is a rare but potentially fatal complication of inferior vena cava filter retrieval. We discuss such a case to facilitate prompt recognition and prevention of this complication by medical providers. (Level of Difficulty: Beginner.), Graphical abstract, Cardiac tamponade is a rare but potentially fatal complication of inferior vena cava filter retrieval. We discuss such a case to facilitate prompt…

OBJECTIVE The incidence of childhood-onset type 1 diabetes (T1D) has been reported to be rising but there is also evidence that it has been attenuated in recent years. We described the time trends and the incidence of T1D in children in Hong Kong from 2008 to 2017 and compared with the previous local registry in 1997 to 2007. METHODS Data were extracted from the Hong Kong Childhood Diabetes Registry, which was established in 2016. It consists of a retrospective registry (including all childhood diabetes diagnosed in 2008 to 2015) and a prospective registry (including all T1D children diagnosed from 2016 onwards). All T1D children diagnosed at the age of less than 18 years from 1 January 2008 to 31 December 2017 and managed in the public system were included in this study. RESULTS For the incident years in the 2008 to 2017 period, a total of 498 children with T1D was identified. The crude incidence rate was 4.3 per 100 000 person/year (95% confidence interval 3.96-4.72), which was much higher than the last registry of 2.2 per 100 000 persons/year. Using general linear model, the increment is statistically significant (P = .02). When compared to the last registry, the rate of increment had attenuated, with annual increment in crude incidence in the two periods for T1D

Pulmonary vascular resistance (PVR) and PVR index (PVRI) are key variables in a broad range of contexts, including prediction of outcomes in heart and liver transplantation, determining candidacy for closure of atrial or ventricular septal defects, and guiding treatment of pulmonary hypertension. Significant variability exists among the units used to report PVRI in current literature, making the interpretation of data and translation into clinical practice difficult. Here, we will review the measurement and derivation of PVR and PVRI and demonstrate the extent of confusion in the literature. We conducted a literature search of all published articles in PubMed using the term "PVRI." This yielded 218 sources with defined units for PVRI, including 33 unique variants. Among all reviewed literature, 45.4% of sources reported PVRI with units ending in m2 (meters squared), which we defined as correct, whereas 54.6% reported PVRI with units not ending in m2 , which we defined as incorrect. This lack of uniformity has led to considerable confusion among researchers and clinicians, with potentially life-altering consequences.

OBJECTIVE With increasing prevalence of childhood obesity worldwide, the incidence of pediatric-onset type 2 diabetes (T2D) is also increasing in many countries. We aim to analyze the time trend and incidence of T2D in children in Hong Kong from 2008 to 2017, and to characterize clinical characteristics at diagnosis. METHODS Data were retrieved from the Hong Kong Childhood Diabetes Registry. All children with T2D diagnosed at the age of less than 18 years from January 1, 2008 to December 31, 2017 and managed in the public health care system were included in this study. RESULTS In the incident years of 2008-2017 period, 391 children were diagnosed with T2D. The crude incidence rate was 3.42 per 100,000 persons/year [95% confidence interval (CI) 3.08-3.76], which was much higher than that in last registry of 1.27 per 100,000 persons/year in 1997-2007 (P

Myocarditis is a disease with variable clinical presentation, ranging from an uncomplicated febrile illness to cardiogenic shock. Herein, we report a case of fulminant myocarditis secondary to murine typhus in a 52-year-old male that initially mimicked an acute coronary syndrome. Emergent coronary angiography showed angiographically normal coronary arteries. Left ventriculography showed global hypokinesis with an ejection fraction of 10%. The patient required mechanical support with an intra-aortic balloon pump and fully recovered.

Purpose Benign parotid tumors are adequately treated with partial parotidectomy, which is often performed under general anesthesia (GA). We have reported our preliminary results on the feasibility to perform parotidectomy under local anesthesia (LA). We hereby present our accumulated experience of partial parotidectomy under LA to further consolidate its feasibility, efficacy and safety in a larger series. Materials and methods Case series review was carried out using our own center patients' database. 50 patients with parotid tumors were treated with partial parotidectomy under LA, using a retrograde nerve dissection approach from January 2006 to October 2016. The inclusion criteria encompassed mobile parotid nodules primarily operated after non-suspicious fine-needle aspiration cytology. Their demographics, complications and outcomes were evaluated. Results No procedure required conversion to GA. There were 48 benign tumors and 2 lymphomas based on the histopathologic examination. The commonest pathologies were pleomorphic adenoma (40%), Warthin's tumor (38%) and cyst (8%). The mean tumor size was 2.68 ± 1.5 cm and the mean operative time was 91.5 ± 34.7 min. Forty-two operations were done as day cases. Ten (20%) patients suffered from transient ear lobe numbness and two (4%) patients had sialocele. Transient facial palsy occurred in 2(4%) patients while another patient (2%) had persistent House-Brackmann grade II facial palsy. No tumor recurrence was noted during follow-up period. Conclusions Partial parotidectomy adopting a retrograde nerve dissection under LA is feasible and minimally invasive in treating benign parotid tumors. It can avoid the adverse effects of general anesthesia and promote day surgery or minimize hospital stay.

The implication of gastrointestinal infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its transmission remains to be fully understood. We studied 4 paediatric patients with several weeks of faecal excretion of SARS-CoV-2 RNA who had only mild symptoms. International consensus on isolation practices is urgently needed.

Background The benefits of central compartment dissection (CCD) in papillary thyroid carcinoma (PTC) are still debatable and should be weighed against its potential risks. We aim to compare the complication rates in total thyroidectomy with and without CCD for patients with PTC. Methods This is a retrospective study on prospectively collected data from our cancer registry over a 15-year period. Patients with pathologically proven PTC treated with total thyroidectomy alone or with CCD were included. CCD was performed at the operating surgeon's discretion. A total of 105 patients were included and divided into two groups for analysis: group A – total thyroidectomy alone (51 patients, 49%) and group B – total thyroidectomy with CCD (54 patients, 51%). The operative complications between the two groups were then evaluated. Results Overall, 6.9% and 0.98% patients had transient and permanent recurrent laryngeal nerve palsies, respectively. About 19.0% and 2.9% patients had transient and permanent hypoparathyroidism, respectively and 27.6% patients had parathyroid glands found to be included in the resected specimen. Complication rates in terms of transient or permanent recurrent laryngeal nerve palsy or hypoparathyroidism did not differ significantly between groups A and B. Within group B, 41 patients had unilateral CCD and 12 had bilateral CCD. Transient hypoparathyroidism was more frequent in bilateral CCD (50% versus 12.2%, P = 0.01). Conclusions Total thyroidectomy with prophylactic unilateral CCD is a safe procedure for PTC without added complication rates compared with total thyroidectomy alone. It is recommended for patients with PTC and clinically negative neck lymph nodes.

BST2 (HM1.24; CD317; tetherin) is an interferon-inducible transmembrane protein that restricts the release of several enveloped viruses, including HIV, from infected cells. Before its activity as an antiviral factor was described, BST2 was identified as an inducer of NF-κB activity. Here we show that human BST2 induces NF-κB in a dose-dependent manner. This activity is separable from the restriction of virus release: a YxY sequence in the cytoplasmic domain of BST2 is required for the induction of NF-κB but is dispensable for restriction, whereas the glycosylphosphatidylinositol (GPI) addition site in the protein's ectodomain is required for restriction but is largely dispensable for the induction of NF-κB. Mutations predicted to disrupt the coiled-coil structure of the BST2 ectodomain impaired both signaling and restriction, but disruption of the tetramerization interface differentially affected signaling. The induction of NF-κB by BST2 was impaired by inhibition of transforming growth factor β (TGF-β)-activated kinase 1 (TAK1) or by calcium chelation, suggesting potential linkage to the mitogen-activated protein kinase and endoplasmic reticulum (ER) stress response pathways. Consistent with a role for TAK1, BST2 coimmunoprecipitated with TAK1 and the TAK1-associated pseudophosphatase TAB1; these interactions required the YxY sequence in BST2. Moreover, signaling by BST2 was blocked by expression of an IκB-mutant that inhibits the canonical pathway of NF-κB activation. The expression of HIV-1 Vpu inhibited the induction of NF-κB by BST2; this inhibition required Vpu's ability to bind the cellular β-TrCP-E3-ubiquitin ligase complex. The expression of HIV-1 lacking vpu augmented the induction of NF-κB activity by BST2, suggesting that BST2 can act as a virus sensor. This augmentation was also inhibited by Vpu in a β-TrCP-dependent manner. The role of BST2 in the host-pathogen relationship is apparently multifaceted: signaling during the innate immune response, sensing of viral gene expression, and direct restriction of virus release. HIV-1 Vpu counteracts each of these functions.

The interferon-inducible transmembrane protein BST-2 (CD317, tetherin) restricts the release of several enveloped viruses from infected cells. BST-2 is broadly active against retroviruses, including HIV-1 and HIV-2. To counteract this host defense, HIV-1 uses the accessory protein Vpu, whereas HIV-2 uses its envelope glycoprotein (Env). In both cases, viral antagonism is associated with decreased expression of BST-2 at the cell surface. Here, we provide evidence supporting a role for the clathrin-mediated endocytic pathway in the downregulation of BST-2 from the cell surface and the counteraction of restricted virion release. A catalytically inactive, dominant negative version of the vesicle “pinch-ase” dynamin 2 (dyn2K44A) inhibited the downregulation of BST-2 by Vpu, and it inhibited the release of wild-type (Vpu-expressing) HIV-1 virions. Similarly, dyn2K44A inhibited the downregulation of BST-2 by HIV-2 Env, and it inhibited the release of vpu -negative HIV-1 virions when HIV-2 Env was provided in trans . dyn2K44A inhibited Env more robustly than Vpu, suggesting that dynamin 2, while a cofactor for both Env and Vpu, might support just one of several pathways though which Vpu counteracts BST-2. In support of a role for clathrin in these effects, the C-terminal domain of the clathrin assembly protein AP180 also inhibited the downregulation of BST-2 by either Vpu or HIV-2 Env. Consistent with modulation of the postendocytic itinerary of BST-2, Vpu enhanced the accumulation of cell surface-derived BST-2 in transferrin-containing endosomes. Vpu also inhibited the transport of BST-2 from a brefeldin A-insensitive compartment to the cell surface, consistent with a block to endosomal recycling. We propose that HIV-1 Vpu, and probably HIV-2 Env, traps BST-2 in an endosomal compartment following endocytosis, reducing its level at the cell surface to counteract restricted viral release.

Objective: To examine factors that influence emotional adjustment, adherence to diabetic care, and glycemic control in Hong Kong youths with insulin-dependent diabetes mellitus (IDDM). Methods: Seventy youths, their mothers, and matched controls provided information on health beliefs, authoritarian parenting style, parent-child conflict, emotional adjustment, and adherence to medical regimen. Glycosylated hemoglobin levels were obtained to measure glycemic control. Results: Predictors explained 34% of the variance in emotional adjustment and 39% of the variance in glycemic control. The data supported a pathway from emotional adjustment to self-efficacy to adherence behaviors to glycemic control. In contrast to Western culture and consistent with prediction, parenting style did not associate with negative outcomes, and even relatively low levels of parent-child conflict correlated negatively with emotional adjustment in this culture. Conclusions: Management of conflict and self-efficacy enhancing interactions are suggested interventions to enhance adherence to diabetic care in Hong Kong youths with IDDM.