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Jonathan Curtis

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Objectives The association between diagonal ear lobe crease (DELC) and cardiovascular disease was first suggested in 1973 although some studies have attributed this to confounding cardiovascular factors. This review looked to see if there is a significant association between DELC and angiography-confirmed coronary artery disease (CAD) independent of other risk factors. Design Systematic review and meta-analysis of selected studies using the PRISMA checklist. Setting 12 different hospitals with angiography in eight countries. Participants 4960 adult patients undergoing coronary angiography. Main Outcome Measures • Presence/absence of diagonal ear lobe crease • Diagnostic Odds Ratio • Sensitivity/Specificity Results 12 studies were included in the meta-analysis. Findings from our study suggest: • Patients with DELC have a 4x increased likelihood of having CAD (OR 4.61 P<0.00001). • The relationship between DELC and CAD was independent of age and all other conventional cardiovascular risk factors. • Bilateral DELC has a stronger association with CAD than unilateral DELC. • Presence of DELC has insufficient sensitivity / specificity to be used as a diagnostic test for cardiovascular disease but instead should be used as a risk marker. Conclusions We found that DELC is associated with CAD independently of other known cardiovascular risk factors including age. Histology studies indicate that atherosclerosis is causing DELC and patients with DELC appear to have an increased risk of CAD. It has insufficient sensitivity or specificity to be used as a diagnostic test but should be used as a valuable risk marker to be aware of whilst examining ears.

Ahmet Doblan

and 1 more

Abstract: Although there is plenty of research on the etiology and treatment of tinnitus, a definitive conclusion has not been reached in most studies. Among etiological factors, vascular and hematological abnormalities can be defined as an important cause in the evaluation of tinnitus cases, and these factors may underly many structural and functional problems. In this study, we aimed to investigate whether there was a correlation between platelet mass index (PMI) and tinnitus. To our knowledge, this is the first study exploring the effect of platelet mass on tinnitus. After reviewing the detailed medical records of 1,079 tinnitus patients that presented to our clinic between January 2019 and May 2020, the hemogram values of 177 cases meeting the study criteria were evaluated. There was no statistically significant difference between the patient and control groups in terms of mean age, gender distribution, and RBC (Red Blood Cell) neutrophil, lymphocyte, PLR and NLR levels (p>0.05). Compared to the control group, the hemoglobin and MPV levels of the patient group were statistically significantly higher (p<0.001), and the platelet level was statistically significantly lower (p=0.033). In addition, the PMI level of the patient group was significantly higher than that of the control group (p<0.001). In conclusion, the NLR, PLR and MPV values were found to be higher in the tinnitus group compared to the control group, as expected. Furthermore, the additional data for tinnitus cases showed that PMI was also observed to be significantly higher compared to the control group, indicating that the study objective was reached. PMI seems to be a predictive value for tinnitus, even in patients with MPV values lower than the normal range. Therefore, we consider that PMI is more sensitive than other markers, especially MPV in inflammatory events.

Pudji Widodo

and 1 more

Phlegmariurus is a genus of lycophyte plants in the family Lycopodiaceae which is sensitive to climate change. In the past, there were four species namely 1) Phlegmariurus phlegmaria, 2) P. nummulariifolius, 3) P. carinatus, and 4) P. squarrosus found as epiphytic clubmosses on many trees such as pines and Agathis on the southern slope of Mt. Slamet. During 42 years there has been a significant loss of Phlegmariurus at the slope which covers approximately 15,000 ha rain forest covering the subdistrict of Cilongok in the west, Baturraden in the middle, and Sumbang in the east. Some surveys that had been conducted from 1978 to 2020 showed that the presence frequency of the plant decreased. We correlated the temperature increase data from NOAA and precipitaion data from the local meteorology and geophysics data to the frequency of the plants. Furthermore, we also interviewed ten nurseries which sold the Phlegmariurus of approximately 60 nurseries (Figure 6). The information we gathered showed that the location of the plant sources was above the previous locations. We also observed the cultivated Phlegmariurus at different altitudes namely at 95-97 m, 300-400 m, and 600-800 m a.s.l. The result of this study showed that in the past there were a lot of Phlegmariurus spp. However, in 2020 Phlegmariurus were absent in most areas at the southern slope of Mt. Slamet. We proposed three causes of the migration and loss of Phlegmariurus at the southern part of Mt. Slamet namely: 1) The increase of temperature, the decrease of precipitation, and 3) commercial hunting.

Musa Dogara

and 8 more

Following a preliminary investigation a study was carried from April to October, 2019 to establish more information on the abundance and distribution of freshwater snails in relation to physiochemical factors of Warwade dam. Four sampling sites; human activity, vegetation cover, lentic and lotic were selected for the study along the bank of the dam. Freshwater snails were collected in each of the four sampling sites using long handled scoop net with mesh 0.2mm and hand picking methods. Water samples from the sampling sites were analyzed in the laboratory using standard procedures. A total of 2,027 of fresh water snails belonging to ten species were identified with Bulinus globosus 12(0.6%) and Lymnaea natalensis 12(0.6%) having the lowest abundance while Melanoides tuberculata 1553(76.6%) had the highest. Snail abundance was highest in site characterized by human activities (670) followed by vegetation (482), lotic (442) and lentic (433) waters. Most of the physico-chemical factors measured appeared to favour the growth and survival of fresh water snails. pH (p = 0.01), water current (p = <0.01) and magnesium ion concentration (p = < 0.01) varied significantly across the four sites. Only calcium ion concentration was significantly associated with snail abundance (p = 0.04). Snail abundance showed weak positive relationship with water temperature, color, turbidity and concentration of magnesium ion. The dominance of M. tuberculata over all species particularly those of medical and veterinary importance could have positive implication for their control in the dam.

Mozafar Aznab

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The sinoatrial node in medication-resistant inappropriate sinus tachycardia: to modify or to ablate?Khalil El Gharib1*1Hôtel-Dieu de France, Beirut, Lebanon*Author for correspondence: khalil.gharib@outlook.comKEYWORDS: IST, sinus node modification, sinus node ablation, radiofrequency ablation, surgical ablationNo conflict of interest to discloseFunding: noneInappropriate sinus tachycardia (IST) is defined as a resting heart rate >100 beats per minute (with a mean heart rate >90 beats per minute over 24 hours) associated with highly symptomatic palpitations(1). The syndrome is associated neither with structural heart disease nor with any secondary cause of sinus tachycardia(2) and evidence suggests that enhanced intrinsic automaticity of the sinoatrial node, which can be due to anti-β-adrenergic antibodies, is behind its genesis(3). However, it is benign in terms of clinical outcomes and echocardiographic evidence of ventricular dysfunction(4), being rarely associated with tachycardia-induced cardiomyopathy(3).Patients with IST are essentially treated with ß-blockers to alleviate their symptoms(5). Ivabradine, a drug that inhibits funny calcium channels, particularly abundant in the SA node, showed modest benefit, receiving class IIa recommen­dation in the treatment of IST(4). But, the duration of medical therapy might be indefinite, and, a considerable number of patients would respond inadequately, or have no response, even after prolonged therapy(5). Historically, such patients would have subtotal right atrial excision, atrioventricular junctional ablation with permanent pacemaker implantation, or chemical occlusion of the sinus node artery(6). These options are considered today unacceptable in this setting, and other therapeutic approaches should be unveiled when resistance to medical treatment appears.Electrophysiological study was initially purely diagnostic, but recent advances in technology have allowed us to intervene(7); patients with ventricular and supraventricular tachyarrhythmias are successfully treated with percutaneous catheter procedures. Of these, SA node ablation/ modification has been proposed as alternative approaches in IST that is not responding to medical treatment; trials reported auspicious results, highlighted here.Electrophysiologic mapping to the site of the earliest endocardial activation during either spontaneous sinus tachycardia or isoproterenol-induced sinus tachycardia has rendered these procedures feasible(8). Additionally, combination with intracardiac echocardiography permitted a more accurate electrophysiologic and anatomic localization of the sinoatrial node(9).Sinus node modification is not a focal ablation, but requires complete abolition of the cranial portion of the SA node complex, the one that exhibits the most of the autonomic activity(9). It is defined as successful when the heart rate decreases by 30 beats per minute (bpm) during isoproterenol infusion(8). Short-term success was also defined by other investigators when there was a reduction of the baseline sinus rate to less than 90 bpm and the sinus rate during isoproterenol infusion by more than 20% or by 25%(8). The acute success rate for modification has been varying between 76 and 100 % across trials, while long-term clinical outcomes are modest at best, with reported freedom from IST ranging from 23 to 85%(10).Complications specific to SA node modification include superior vena cava (SVC) syndrome, diaphragmatic paralysis, and sinus node dysfunction(10). And while modification with conventional methods has its setbacks, modification using laser energy can be considered in the setting of IST. This modality creates clear-cut homogenous transmural lesions of the myocardium that comprises the scattered “functional” SA node(11). The burnt myocardium will then heal into a dense fibrous scar, decreasing potential amplitudes. And when adapting laser energy settings to the thickness of the myocardial wall, collateral dam­ages such as esophageal fistulae, lung burns, and phrenic nerve palsy will be avoided(11); thus, this technique may prove itself as a new intriguing alternative for the safe and effective treatment of IST.SA node modification is apt in achieving acute reductions in postprocedural heart rate. However, and as aforementioned, success rates are suboptimal in terms of symptomatic control with a significant recurrence rate(12). Catheter ablation aiming at either total exclusion and obliteration of the SA node has been described and performed, success being defined as a slowing of >50% from the baseline rate of tachycardia along with a junctional escape rhythm(12). With radiofrequency (RF) applications, the earliest local atrial activation time would shift from a cranial location to a more caudal one, usually at the mid-lateral right atrium(5). Reviews have reported that acute success rates were consistently to be as high as 88.9%, with an overall frequency of recurrence of 19.6%, the latter occurring within a wide range of post-ablation intervals, anywhere from a few weeks to several months after the procedure(12). Additionally, Takemoto and colleagues documented a significant drop in B-type natriuretic peptide levels, 6 to 12 months after ablation, suggesting fewer stretching shears on cardiac muscle.Two types of response of the sinus tachycardia to RFA were observed across studies, whether a step-wise reduction in sinus rate accompanying migration of the site of earliest atrial activation in a cranial-caudal direction along the lateral right atrial wall, or an abrupt drop in heart rate in response to RFA at a focal site of earliest atrial activation(13).However, RFA of inappropriate sinus tachycardia requires a large number of applications of radiofrequency energy and is, as in SA node modification, associated with a high recurrence rate(13). Complete remission is achieved only in approximately 50% of patients in some studies(14); longer history of IST and those reporting near syncope/syncope having a higher probability of recurrence(15).While other studies have shown that RF ablation of the SA node can achieve even longer-term reductions in the sinus rate and relief of symptoms in two-thirds of patients with drug-refractory, inappropriate sinus tachycardia(13), aiming specific sites related to the SA node should be elaborated, for better and optimal outcomes Killu and colleagues created a lesion in the arcuate ridge resulting in complete abolition of the tachycardia, since arrhythmias arising in this region may exhibit both electrocardiographic and clinical similarities to IST(16). This has led to consider ablation of the arcuate ridge as a treatment of refractory IST, necessitating larger trials to confirm its potential role.Phrenic nerve injury is a severe and dreaded complication of SN ablation(12). Pericarditis, right diaphragmatic paralysis, and SVC syndrome are other undesirable side effects of the procedures, variously reported in studies. but a common complication was observed in them all, atrial tachyarrhythmias(12). It has been hypothesized that myocardial pathology, such as inflammation and fibrosis, considered iatrogenic due to the ablation procedures, may be promoting arrhythmias both in the region of the SA node, as well as in remote locations(12). Through multivariable analysis, higher resting heart rates post-ablation and smaller cranial-to-caudal shifts have been defined as predictors of atrial arrhythmias(15). In conclusion, catheter ablation could be considered an effective treatment for highly symptomatic, drug-refractory patients, even for those who did not respond to SA node modification(5).The sinus node is located close to the epicardial surface and catheter-based ablations do not always make full-thickness lesions across the atrial muscle, leading to failure of the ablation(17), besides the numerous trabeculae and the widely variable anatomy.Surgical ablation is not a first-line or routine management strategy for IST, but it has been proposed when IST resists or recurs after SN modification/ endocardial ablation(17). Effectively, in several studies, epicardial lesions, through a single small incision in one of the intercostal spaces, successfully slowed heart rate and shifted activation to a more caudal location, and surprisingly, subsequent endocardial lesions led to an even greater drop in heart rate and more caudal site of earliest activation(18). These outcomes were again replicated when using minimally invasive thoracoscopic ablation of the epicardial site of the SA node, concluding of the promising efficacy and the safety of this approach, since it preserves the phrenic nerve(17), although continued follow-up after surgery is required.Medication-resistant IST remains a medical challenge for physicians and cardiologists; and in the era of great advances in interventional cardiology, its treatment remains debatable. Sinus node modification/ ablation is not recommended as first-line therapy in IST, this procedure should be considered only in drug-refractory patients who have severe symptoms(13). Although the number of patients in the available studies is generally small, both procedures have documented an encouraging success rate in the short-term, while being less impressive in the long-term. It has been hypothesized that this discrepancy is due to the relatively large potential area of atrial pacemaker cells(18); modification or ablation may fail to ablate or isolate all the pathways that comprise the functional SA node because they often target the anatomic part and the area of earliest atrial activation(19). Others have explained that the long-term slowing in rhythm fails because these procedures inconsistently produce transmural lesions in the right atrium. Surgical treatment of IST has proposed a solution to the latter conflict when isolating the SA node with a wide cuff of surrounding atrial muscle(19). And with the advent of bipolar RF clamps and minimally invasive cardiac surgical techniques with thoracoscopic guidance, this approach appears more appealing than before, especially when combined with endocardial ablation(19). But again, current data specifies employing these techniques in highly selected cases.


and 10 more

Background: There is insufficient evidence regarding the comparison of Rapid Deployment aortic valve replacement(RDAVR) to TAVR in intermediate-risk patients with severe symptomatic aortic stenosis(AS) Aims: We compare the 2-years outcomes between RDAVR with INTUITY and TAVR with SAPIEN 3 in intermediate-risk patients with AS. Methods: Inclusion criteria: severe AS implanted with RDAVR or TAVR; EUROSCORE II ≥ 4% and clinical evaluation by Heart Team. Regression adjustment for the propensity score was used to compare RDAVR with TAVR(1:1). Primary endpoint: composite criterion of death, disabling stroke or rehospitalization. Secondary endpoints: occurrence of major bleeding post-operative complications, paravalvular regurgitation (PVR)≥2 and patient-prosthesis mismatch(PPM) at 1 month and pacemaker implantation at 2 years. Results: A total of 152 patients were included from 2012 to 2018: 48 in the RDAVR group and 104 in the TAVR group. Mean age was 82.7±6, 51.3% were female, mean Euroscore II was 6.03±1.6% and mean baseline LVEF was 56±13%,mean indexed iEOA was 0.41±0.1cm/m2, mean gradient was 51.7±14.7mmHg. Patients with RDAVR were younger(79.5±6vs82.6±6,p=0.01), at higher risk (EUROSCORE2 6,61±1,8%vs5,63±1,5%, p=0.005), combined surgery was performed in 28 patients(58.3%). Twenty-two patients(45.99%) met the primary outcome in the RDAVR group and 32 patients(66.67%) in the TAVR group. By 1:1propensity score matching analysis, there was a significant difference between both groups in favor of RDAVR(HR=0.58[95%CI:0.34;1.00],p=0.04). No difference were observed in PPM occurrence(0.83;[0.35-1.94];p=0.67),major bleeding events(1.33;[0.47-3.93];p=0.59),PVR≥2(0.33[0-6.28],p=0.46), and pacemaker implantation (0.84[0.25-2.84],p=0.77).Conclusion: RDAVR is associated with better 2-years outcomes than TAVR in intermediate-risk patients with severe symptomatic AS.

Francesca Mori

and 10 more

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