A Triad of Intricacies: An Exploration of Concomitant Codominant Coronary Artery Pattern, Patent Foramen Ovale, and Chiari Network in a Cadaveric Study.

Although findings related to codominant coronary artery circulation, patent foramen ovale (PFO), and Chiari network (CN) have been documented in isolation, there is a gap in literature detailing the unique case with the presence of all three cardiac anomalies concomitantly present in a single heart. The purpose of this case report is to detail a unique cadaveric heart case, to serve as reference to provide useful data for interventionalists and clinicians. This observational cadaveric study assessed a single donor heart obtained through the University of Houston College of Medicine's Willed Donor Program. After meticulous dissection, relevant heart surface structures were isolated and identified. Morphometric analysis and measurements were obtained via a digital vernier caliper. The donor heart exhibited a typical codominant coronary arterial scheme, in that the posterior interventricular artery arose as a merger between the right coronary and the circumflex on the postero-inferior surface of the heart when placed in the valentine orientation. Interestingly, the antero-lateral surface of the heart was supplied via a left marginal artery (LMA) and an accessory left anterior interventricular artery.Contribution to the existing knowledge base of unique concomitant cardiac anomalies, may prove to be a beneficial future reference for interventionalists in hopes that an expanded knowledge base may lead to comprehensive and safe implementation of a wide variety of procedures.

Research study on the effects of multi-component exercise on older adults with chronic conditions.

BACKGROUND: Multicomponent exercises involving eccentric contraction (ECC) exercise, chair yoga (CY) and tai chi (TC) are practiced extensively to treat older adults with chronic conditions. The study investigated the effect of CY and TC performance after various intensity of ECC exercise induced muscle pain, delayed onset of muscle sores (DOMS), and strength in sedentary older adults. METHODS: Nine sedentary older adults with chronic condition(s) aged between 60 and 90 performed CY and TC after ECC exercise protocol for 9 weeks. The medical preprotocol, ECC exercise, CY, and TC performance, subjective (health activities of daily living [ADL] difficulty scale; Visual Analog Scale [VAS], and DOMS), objective (pressure pain threshold [PPT]), and medical postprotocol assessments were carried out and compared the physical status before and after the protocol. RESULTS: Our results show that functional limitations, DOMS, VAS, and PPT levels were improved in the CY and TC performed weeks 3, 4, 7, and 8 compared to ECC exercise weeks 2 and 6. The manual muscle testing (MMT), active range of motion (AROM), and maximal voluntary isometric contraction (MVIC) were improved and showed significant differences on the weak muscle groups. The mean Tinetti balance and gait score, and general endurance showed significant difference. CONCLUSIONS: Our findings have important implications for clinical exercise prescription as low perceived CY and TC, and ECC exercise might suit well for older adults with chronic conditions. Performing multicomponent exercises can help to reduce the risk of injury from falls and prevent age-related mobility, balance, and physical function decline in older adults.

Propagating Uncertainty Across Cascaded Medical Imaging Tasks for Improved Deep Learning Inference.

Although deep networks have been shown to perform very well on a variety of medical imaging tasks, inference in the presence of pathology presents several challenges to common models. These challenges impede the integration of deep learning models into real clinical workflows, where the customary process of cascading deterministic outputs from a sequence of image-based inference steps (e.g. registration, segmentation) generally leads to an accumulation of errors that impacts the accuracy of downstream inference tasks. In this paper, we propose that by embedding uncertainty estimates across cascaded inference tasks, performance on the downstream inference tasks should be improved. We demonstrate the effectiveness of the proposed approach in three different clinical contexts: (i) We demonstrate that by propagating T2 weighted lesion segmentation results and their associated uncertainties, subsequent T2 lesion detection performance is improved when evaluated on a proprietary large-scale, multi-site, clinical trial dataset acquired from patients with Multiple Sclerosis. (ii) We show an improvement in brain tumour segmentation performance when the uncertainty map associated with a synthesised missing MR volume is provided as an additional input to a follow-up brain tumour segmentation network, when evaluated on the publicly available BraTS-2018 dataset. (iii) We show that by propagating uncertainties from a voxel-level hippocampus segmentation task, the subsequent regression of the Alzheimer's disease clinical score is improved.

Missed Case of Pancreatogenic Diabetes Diagnosed Using Ultrasound.

Nonalcoholic pancreatogenic diabetes mellitus (type 3c DM) is an often-misdiagnosed entity usually seen in young men of tropical countries. Although most of the patients present with abdominal pain and symptoms of exocrine pancreatic insufficiency, there is still a subset that does not present with these classical symptoms, which emphasizes the need for special diagnostic considerations. The significance of identifying this subset of diabetic lies not only in the change in management of the disease but also in early detection for pancreatic carcinoma that is more common among those patients. In our case, ultrasound with X-ray played a vital role in diagnosis, prompting us to consider it as an essential part of the investigation panel in all newly diagnosed nonobese diabetic individuals.

Effect of Large Versus Small Range of Motion in the Various Intensities of Eccentric Exercise-Induced Muscle Pain and Strength.

The purpose was to investigate eccentric (ECC) exercise with full range of motion (FROM) induce a greater magnitude of delayed onset muscle soreness (DOMS), pain, functional limitations compared to partial range of motion (PROM; outer 60° of ROM). Thirty-four participants (men and women) aged between 18 and 30 years performed ECC exercise protocol on elbow and knee muscles (5 × 10 repetitions each session) using their 15%/25%/35% of maximal voluntary isometric contraction (MVIC) with PROM (week 2-4) and FROM (week 6-8). Two days a week, ECC exercises and remaining days the subjective and objective assessments were carried out (activities of daily living (ADL), pain (visual analogue scale (VAS), pain pressure threshold (PPT)), and MVIC. The ECC exercise with FROM showed moderate pain (0-3.5) in ADL (pulling a heavy object and descending stairs), VAS, and PPT for elbow extensors and knee flexors and showed a statistically significant difference (p ≤ 0.05) compared to PROM ECC protocol. The muscle strength was increased in FROM ECC exercise than PROM ECC exercise and ranged between 23.16% and 28.22%. ECC exercise performed with FROM induced a higher degree of DOMS, pain, ADL limitations than PROM. The study outcomes can be used for beginner sedentary older adults as well as young athletes.

Improving surgical site infection prevention in Asia-Pacific through appropriate surveillance programs: Challenges and recommendation.

BACKGROUND: Surgical site infections (SSIs) represent a substantial clinical and economic burden on patients and the healthcare system. The prevention of SSIs entails surveillance activities which lead to effective mitigation strategies, which are lacking across Asia Pacific (APAC). This manuscript aims to document gaps and challenges across APAC that affect the undertaking of a successful SSI surveillance activities and to provide recommendations on overcoming such challenges. METHODS: A targeted literature review with relevance to APAC identified a series of salient points pertaining to SSI prevention guidelines, implementation, surveillance and outcomes, which was discussed in July 2019 at the APAC Surgical Site Infection Prevention Symposium. An expert panel, comprising eight multidisciplinary experts from APAC and the USA, subsequently amalgamated the key discussion points from the Symposium and their clinical experiences in developing this article. RESULTS: The barriers to implementing a successful and effective APAC SSI surveillance program were identified as: (a) lack of standardized definitions, reporting methodology and accountability, (b) lack of fiscal resources, (c) reporting variability and under-reporting, and (d) lack of safety culture. Implementing an effective surveillance program in APAC will require countries to develop a well-designed and robust surveillance plan and ensure adequate training for staffs involved. CONCLUSION: To improve SSI prevention in the region, it is imperative to encourage implementation of national programs with standardized methodologies and accountabilities. An ongoing APAC information exchange, including data and methodologies, will enable continuous learning within the APAC region.

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia-Pacific Region.

INTRODUCTION: Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia-Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country's healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30-31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC. METHODS: The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention. RESULTS: The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability. CONCLUSIONS: Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.

Production, purification and application of Cutinase in enzymatic scouring of cotton fabric isolated from Acinetobacter baumannii AU10.

Conventional cotton scouring in the textile industry using alkali results in huge environmental impact which can be overcome by using enzymes. Pectinase along with cutinase gives enhanced bioscouring results. Cutin was extracted from tomato peels and was used as substrate in the microbial media. The strain isolated from tomato peel was identified as Acinetobacter baumannii AU10 by 16S rDNA sequencing. The cutinase production was optimized by Placket-Burman and Response Surface Methodology (RSM) and the maximum production of 82.75 U/mL obtained at sucrose 6.68% (w/v), gelatin 2.74 g/L at a temperature of 35.93 °C. Cutinase was purified by ammonium sulfate precipitation, hydrophobic interaction chromatography and ion exchange chromatography with a recovery of 25.6% and specific activity of 38030 U/mg. The confirmation test for the purity of cutinase was analyzed by RP-HPLC. The molecular mass of cutinase was determined as 28.9 kDa by SDS-PAGE technique. Scanning electron microscopic analysis showed a rough and open primary wall surface on the cutinase bioscoured fabric which confirmed its activity on cutin present in the cotton fabric. Additionally, the cutinase-bioscoured samples showed better absorbency than the untreated samples. Therefore, enzymatic scouring increases wetting capacity of scoured cotton and also helps to reduce environmental pollution.

Leveraging a Clinical Phase Ib Proof-of-Concept Study for the GPR40 Agonist MK-8666 in Patients With Type 2 Diabetes for Model-Informed Phase II Dose Selection.

GPR40 mediates free fatty acid-induced insulin secretion in beta cells. We investigated the safety, pharmacokinetics, and glucose response of MK-8666, a partial GPR40 agonist, after once-daily multiple dosing in type 2 diabetes patients. This double-blind, multisite, parallel-group study randomized 63 patients (placebo, n = 18; 50 mg, n = 9; 150 mg, n = 18; 500 mg, n = 18) for 14-day treatment. The results showed no serious adverse effects or treatment-related hypoglycemia. One patient (150-mg group) showed mild-to-moderate transaminitis at the end of dosing. Median MK-8666 Tmax was 2.0-2.5 h and mean apparent terminal half-life was 22-32 h. On Day 15, MK-8666 reduced fasting plasma glucose by 54.1 mg/dL (500 mg), 36.0 mg/dL (150 mg), and 30.8 mg/dL (50 mg) more than placebo, consistent with translational pharmacokinetic/pharmacodynamic model predictions. Maximal efficacy for longer-term assessment is projected at 500 mg based on exposure-response analysis. In conclusion, MK-8666 was generally well tolerated with robust glucose-lowering efficacy.

d-Tagatose production by permeabilized and immobilized Lactobacillus plantarum using whey permeate.

The aim of the work is to produce d-Tagatose by direct addition of alginate immobilized Lactobacillus plantarum cells to lactose hydrolysed whey permeate. The cells were untreated and immobilized (UIC), permeabilized and immobilized (PIC) and the relative activities were compared with purified l-arabinose isomerase (l-AI) for d-galactose isomerization. Successive lactose hydrolysis by ß-galactosidase from Escherichia coli and d-galactose isomerization using l-AI from Lactobacillus plantarum was performed to investigate the in vivo production of d-tagatose in whey permeate. In whey permeate, maximum conversion of 38% and 33% (w/w) d-galactose isomerization by PIC and UIC has been obtained. 162mg/g and 141mg/g of d-tagatose production was recorded in a 48h reaction time at 50°C, pH 7.0 with 5mM Mn2+ ion concentration in the initial substrate mixture.

Biocatalytic production of D-tagatose: A potential rare sugar with versatile applications.

D-tagatose is a naturally existing rare monosaccharide having prebiotic properties. Minimal absorption, low metabolizing energy, and unique clinical properties are the characteristics of D-tagatose. D-tagatose gained international attention by matching the purpose of alternate sweeteners that is much needed for the control of diabetes among world population. Recent efforts in understanding tagatose bioconversion have generated essential information regarding its production and application. This article reviews the evolution of D-tagatose as an important rare sugar by appreciable improvements in production results and its significant applications resulted of its unique physical, chemical, biological, and clinical properties thus considering it an appropriate product for requisite improvements in technical viability. Based on current knowledge and technology projections, the commercialization of D-tagatose rare sugar as food additive is close to reality.

Biodiesel production from different algal oil using immobilized pure lipase and tailor made rPichia pastoris with Cal A and Cal B genes.

In this investigation, oil extraction was performed in marine macroalgae Gracilaria edulis, Enteromorpha compressa and Ulva lactuca. The algal biomass was characterized by Scanning Electron Microscopy and Fourier Transform-Infra Red Spectroscopy. Six different pre-treatment methods were carried out to evaluate the best method for maximum oil extraction. Optimization of extraction parameters were performed and high oil yield was obtained at temperature 55°C, time 150min, particle size 0.10mm, solvent-to-solid ratio 6:1 and agitation rate 500rpm. After optimization, 9.5%, 12.18% and 10.50 (g/g) of oil extraction yield was achieved from the respective algal biomass. The rate constant for extraction was obtained as first order kinetics, by differential method. Stable intracellular Cal A and Cal B lipase producing recombinant Pichia pastoris was constructed and used as biocatalyst for biodiesel production. Comparative analysis of lipase activity and biodiesel yield was made with immobilized Candida antarctica lipase.

Aneurysmal bone cyst of the lumbar spine.

An aneurysmal bone cyst (ABC) is a benign, locally proliferative vascular disorder of non-neoplastic osseous lesions in children and young adults. Seventy-five percent of ABCs occur before the age of 20 years. They comprise 1.4% of all primary bone tumors, and commonly occur in the long bones. Spinal ABCs are much rarer. We present to you one such rare case of ABC involving the lumbar spine which was successfully treated with surgery. The clinical pathological and radiological features are described. The treatment options available are discussed.

Neonatal Pain and Infection Relate to Smaller Cerebellum in Very Preterm Children at School Age.

OBJECTIVE: To examine whether specific neonatal factors differentially influence cerebellar subregional volumes and to investigate relationships between subregional volumes and outcomes in very preterm children at 7 years of age. STUDY DESIGN: Fifty-six children born very preterm (24-32 weeks gestational age) followed longitudinally from birth underwent 3-dimensional T(1)-weighted neuroimaging at median age 7.6 years. Children with severe brain injury were excluded. Cerebellar subregions were automatically segmented using the multiple automatically generated templates algorithm. The relation between cerebellum subregional volumes (adjusted for total brain volume and sex) and neonatal clinical factors were examined using constrained principal component analysis. Cognitive and visual-motor integration functions in relation to cerebellar volumes were also investigated. RESULTS: Higher neonatal procedural pain and infection, as well as other clinical factors, were differentially associated with reduced cerebellar volumes in specific subregions. After adjusting for clinical risk factors, neonatal procedural pain was distinctively associated with smaller volumes bilaterally in the posterior VIIIA and VIIIB lobules. Specific smaller cerebellar subregional volumes were related to poorer cognition and motor/visual integration. CONCLUSIONS: In very preterm children, exposure to painful procedures, as well as additional neonatal risk factors such as infection, were associated with reduced cerebellar volumes in specific subregions and poorer outcomes at school age.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC).

We report on the effect of the International Nosocomial Infection Control Consortium's (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17.43/1000 mechanical ventilator days during baseline, and 10.81 for intervention, showing a 38% VAP rate reduction (relative risk 0.62, 95% confidence interval 0.5-0.78, P = 0.0001).

(E)-N'-[1-(Thio-phen-2-yl)ethyl-idene]isonicotinohydrazide.

In the title compound, C(12)H(11)N(3)OS, the dihedral angle between the pyridine and thio-phene rings is 46.70 (9)° and the C-N-N-C torsion angle is 178.61 (15)°. In the crystal, inversion dimers linked by pairs of N-H⋯O hydrogen bonds generate R(2) (2)(8) loops.

Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: We aimed to evaluate the impact of a multidimensional infection control strategy for the reduction of the incidence of catheter-associated urinary tract infection (CAUTI) in patients hospitalized in adult intensive care units (AICUs) of hospitals which are members of the International Nosocomial Infection Control Consortium (INICC), from 40 cities of 15 developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon, Macedonia, Mexico, Morocco, Panama, Peru, Philippines, and Turkey. METHODS: We conducted a prospective before-after surveillance study of CAUTI rates on 56,429 patients hospitalized in 57 AICUs, during 360,667 bed-days. The study was divided into the baseline period (Phase 1) and the intervention period (Phase 2). In Phase 1, active surveillance was performed. In Phase 2, we implemented a multidimensional infection control approach that included: (1) a bundle of preventive measures, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CAUTI rates, and (6) feedback of performance. The rates of CAUTI obtained in Phase 1 were compared with the rates obtained in Phase 2, after interventions were implemented. RESULTS: We recorded 253,122 urinary catheter (UC)-days: 30,390 in Phase 1 and 222,732 in Phase 2. In Phase 1, before the intervention, the CAUTI rate was 7.86 per 1,000 UC-days, and in Phase 2, after intervention, the rate of CAUTI decreased to 4.95 per 1,000 UC-days [relative risk (RR) 0.63 (95% confidence interval [CI] 0.55-0.72)], showing a 37% rate reduction. CONCLUSIONS: Our study showed that the implementation of a multidimensional infection control strategy is associated with a significant reduction in the CAUTI rate in AICUs from developing countries.

1H-Indole-3-carbaldehyde.

In the title compound, C(9)H(7)NO, the benzene ring forms a dihedral angle of 3.98 (12)° with the pyrrole ring. In the crystal, N-H⋯O hydrogen bonds links the mol-ecules into chains which run parallel to [02-1].

Could the mechanisms of bariatric surgery hold the key for novel therapies? report from a Pennington Scientific Symposium.

Bariatric surgery is the most effective method for promoting dramatic and durable weight loss in morbidly obese subjects. Furthermore, type 2 diabetes is resolved in over 80% of patients. The mechanisms behind the amelioration in metabolic abnormalities are largely unknown but may be due to changes in energy metabolism, gut peptides and food preference. The goal of this meeting was to review the latest research to better understand the mechanisms behind the 'magic' of bariatric surgery. Replication of these effects in a non-surgical manner remains one of the ultimate challenges for the treatment of obesity and diabetes. Promising data on energy metabolism, gastrointestinal physiology, hedonic response and food intake were reviewed and discussed.