A document by Siddhartha Mishra. Click on the document to view its contents.

Coronavirus disease 2019 (COVID-19) was first described in December 2019 in Wuhan, the capital of China’s Hubei province. 1,2. On March 11, 2020, WHO declared COVID-19 as a pandemic3. The first confirmed case of COVID-19 in Egypt was reported on February 14, 2020. As of May 10, 2020, there have been 8,964 confirmed cases, 2,002 recovered and 514 deaths4.

Gynecology in the Time of CoronavirusJennifer O. Howell3009 Old Clinic BuildingCampus Box 7570Chapel Hill, NC 27599919-966-5280 (p)johowell@med.unc.eduHealthcare delivery has undergone a rapid transformation as we grapple with reality in the time of the novel coronavirus. I daresay, regardless of specialty, we are all adapting new models to care for our patients, mitigate contagion, and preserve resources. Every day we structure a measured response to the number of new cases, the amount of personal protective equipment on hand, as well as the projections of lost revenue. The response of modern medicine to this pandemic is astounding. The sheer volume of e-mail memoranda, power point presentations, web-based tools, and other electronic weapons amassed against this disease cannot be underestimated. Indeed, we have a duty to treat. Can we fulfill this duty as obstetrician/gynecologists in present times without further endangering our patients, or depleting the healthcare workforce?To answer this question, it may be useful to reflect on the practice of our vocation during past pandemics. In the 14thcentury, the Black Plague caused by the bacillus Yersinia Pestiskilled twenty million people in Europe. Those who cared for the sick had only crude treatments such as bloodletting, burning incense, and bathing brows in rosewater or vinegar. Doctors commonly refused the care of patients, priests avoided burying the dead, and family members were forced to abandon their loved ones in desperation. The cause was unknown, but divine retribution was suspected. Thus, instead of advocating wearing facemasks in public, displays of self-flagellation were encouraged as protective.During the influenza pandemic of 1918, fifty million people perished worldwide. While we then understood the concepts of antisepsis and microbiology, we had little but ourselves to offer. There were still no diagnostic tests, no antibiotics, no effective vaccines, nor mechanical ventilators. There was basic ‘PPE’ to don while administering aspirin, epinephrine, and oxygen by face mask. Fortunately, the healthcare ethical code during the 1918 pandemic was robust. Patient welfare came first, even in the face of a serious risk to physician health. Public health measures such as mass closures, quarantines, and masks were in effect. There is documentation of doctors, hospitals, and morgues being overwhelmed in certain ‘hot spots,’ but there are no stories of the medical establishment closing shop. This was still the age when doctors came to your house – and by all accounts, they continued to do this work.In our work as OBGYNs, we treat many hidden conditions which require relatively invasive exams to properly assess and diagnose. Surely, there must be something in our technologic armamentarium that will allow us to persevere in the digital pandemic age. While I may not know what it was like to be healer during the Black Plague, or a doctorduring the “Spanish” flu, I am learning quickly how to be ahealth care provider during COVID-19. I introduce to you a new framework that will be adopted in the OBGYN department at our institution. I welcome all to adapt as you see fit in your local facilities. We simply must marry safety and duty. And while naturally money is a secondary concern, we simply must keep our fiscal heads above water. Our patients depend on us.______________________________________________________________________________VIRTUAL Gynecologic visitsDocument for workflow in the Ambulatory Environment.Approved by the Sub-committee of Ambulatory Operations, the Taskforce for Increasing Virtual Visits, and the Gynecology Working Group.As many of you have now heard the good news, reimbursements for “virtual” visits will be at the same rate as “in-person” appointments during COVID-19. Therefore, effective immediately please adopt this new 9-step protocol.Patients may now obtain a speculum for home use with a provider’s prescription. An updated e-tip sheet will be forthcoming on the durable goods pharmacies that are providing this service including the 10 easy steps you must follow for getting this equipment mailed to our patients.Must use only approved electronic platforms for these transactions given the sensitive patient information to be transmitted. Providers and nurses must watch an e-learning module entitled “Oh Yes We Can: Handling Sensitive Information 2.0 - Privacy Concerns, Questions, and the Law”Action item: It is expected you will watch the module in the next 24 hours!Schedulers will call the patient and inform them of their “virtual speculum tutorial.” This is a new visit type available on the last update of our EMR – called SPEC TUT, 20-minute slot. Write in notes section on the schedule tab – “patient agrees to home speculum teaching.”Patient instructed to sign up for ‘MyChart’ app and message provider directly when home equipment has arrived. We understand that many of our patients speak other languages and this may be difficult. Thanks for the incredible work you do. Kudos to our Personnel Support Managers for putting together this helpful resource entitled “My speculum has arrived” in 19 languages – click this hyperlinkmi espéculo casero ha llegado to access.Nurses will then call the patient from a private location and perform a demonstration using the ‘MySpeculum’ app which can be downloaded in 5 easy steps. An e-tip sheet from your EEP (Embedded Electronic Medical Record Professional) will be forthcoming. Nurse will then write in Notes section: “patient successful” initials, date, timeOn the day of the video pelvic exam visit, there will be a light-up speculum icon on the schedule that will turn green when your patient is “checked in” for the visit. Click the wrench icon on the schedule bar to get this notification column to appear if you do not see it. E-tip sheet coming – stay tuned.Providers – Be on time for your visit, introduce yourself, and make sure you know your patient’s location. They must be in a state, province, county, district, and territory where your medical license is valid. This is changing rapidly so in order to protect you from litigation we ask you to go to this website to check on licensing reciprocity www.incredibleamountsofbureaucracy.com. In addition, you must ensure patient location is not a fast-food drive through before connecting the camera.After the patient has placed the speculum and positioned the camera correctly – be sure to use the verbiage: “I am all done looking now.” The patient will then know they can take the speculum out.As always, be sure to properly document and use this e-smart phrase which has all the billing embedded: .COVIDDIDVIRTUALPAP______________________________________________________________________________By now the astute reader has guessed that this ‘modest proposal1’ for virtual pelvic exams is not for implementation. Instead this perspective is offered as a wry critique of our increasingly technocratic response to the crisis. A response, which I believe, has drastically changed the standard of care in our field. We must recognize that we are delaying or divorcing needed care from the laying on of hands unencumbered by evidence that this will result in acceptable outcomes. When I think of something as ludicrous as a virtual gynecologic assessment, I am haunted by yet one other epidemic not yet mentioned.Whether justified or not, the mythology of the medical establishment’s early response to HIV is not flattering. Reports abound of medical professionals dodging the ‘duty to treat’ ethos. Physicians and nurses were assured transmission would be unlikely with a bloodborne pathogen. Yet, anxious perceptions kindled debate over the long-embraced professional code of self-sacrifice. Ultimately, our better selves prevailed. Medical societies worldwide issued guidance in the 1990’s reaffirming our obligation to care for contagious patients. And now we find ourselves in an ever more bureaucratic and entrepreneurial healthcare landscape. Just how will history view our retrenchment to care via computer screen for a virus spread by droplets? Surely, the spread between two masked individuals taking proper precautions during a medical visit must be quite low. Shall we stand by our commitment to care with a human (gloved) touch and a physical exam as the gold standard? Indeed, I stand ready to wipe my patient’s brow with rosewater and vinegar, however ineffectual.If perhaps you smiled as you recognized your institution in this satire’s looking glass, then I am satisfied. Presently, it may be that humor is the best medicine we have. Perhaps laughter will lower the viral transmission rate. I will wager it is at least as effective as self-flagellation, and better than bloodletting. I will end this reflection to return to my screen with a sense of urgency – there are workflows and memos to attend to. Afterall, leadership expects this protocol to be in place next week to achieve our triple aim: reduced exposure, maximum reimbursement, and operational efficiency in these unprecedented times. You are all heroes. Thank-you for all that you do. Stay safe!

A document by Yueping Qiu. Click on the document to view its contents.

Keeping up with the surgical training might be difficult during the time of COVID-19 pandemic: with most of the health care resources dedicated to face this reality, trainees can improve themselves deep diving in scientific literature, study, Telemedicine and Social Media professional platforms. Moreover, they might be directly involved in COVID patient care, facing a still a still elusive disease with a high lethality rate. Often the frustration of having no valid treatment and a poor incisiveness on the natural course of the COVID19 could lead to a blue mood or a burnout. Eventually, the natural adaptability and the survival instinct prevail and teach us the real meaning of resilience. Every trainee has to be prepared for the second phase, when the new normality will force everyone to cohabit with the virus. Even the obvious teething troubles, this could be the right moment for all the Residents to “grow-up” and develop their own future Character.

Tricuspid regurgitation progression after left-sided surgery and its correlation with worse postoperative and long-term outcomes is a highly debated topic. Some studies support prophylactic tricuspid repair based on annulus dimension rather than on tricuspid regurgitation severity only, while others are in favor of more conservative management. Furthermore, the advent of percutaneous tricuspid valve intervention and its promising short-term outcomes has introduced a new factor to be taken into account on the tricuspid intervention decision-making process. We present a review on prophylactic tricuspid valve intervention, covering currently available data, as well as the role of transcatheter tricuspid valve intervention in this equation.

Background: In severe cases, the COVID-19 viral pathogen produces hypoxic respiratory failure unable to be adequately supported by mechanical ventilation. The role of extracorporeal membrane oxygenation (ECMO) remains unknown, with the few publications to date lacking detailed patient information or management algorithms all while reporting excessive mortality. Methods: Case report from a prospectively maintained institutional ECMO database for COVID-19. Results: We describe veno-venous (VV) ECMO in a COVID-19 positive woman with hypoxic respiratory dysfunction failing mechanical ventilation support while prone and receiving inhaled pulmonary vasodilator therapy. After nine days of complex management secondary to her hyperdynamic circulation, ECMO support was successfully weaned to supine mechanical ventilation and the patient was ultimately discharged from the hospital. Conclusions: With proper patient selection and careful attention to hemodynamic management, ECMO remains a reasonable treatment option for COVID-19 patients.

Title: Pasteurella Multiocida Infection Resulting in a Descending Thoracic Aorta Mycotic Pseudoaneurysm Objective: Highlight our management of a P. Multiocida infected descending thoracic aorta mycotic pseudoaneurysm Methods: Report a case of canine bite resulting in a P. Multiocida descending thoracic aorta mycotic pseudoaneurysm Results: We present a 61-year-old gentleman who was initially seen in an Emergency Department after a canine bite. He was admitted and treated with a course of IV antibiotics for P. Multiocida bacteremia and discharged. Three weeks post discharge, he continued to feel generalized malaise and work-up was significant for a descending thoracic aorta mycotic pseudoaneurysm. The patient underwent a low left posterior lateral thoracotomy and femoral-femoral cardiopulmonary bypass for complete resection and replacement with a 24 mm GelweaveTM graft (Terumo Cardiovascular Group, Ann Arbor, Michigan). Given purulence and gross infection we planned for a staged approach, with a secondary washout and omental flap for biologic coverage of the graft. The patient did well clinically and was discharged at 14 days to rehabilitation with six-week intravenous course of antibiotics. Conclusions: The patient’s clinical course with subsequent follow-up suggest that complete resection of the mycotic pseudoaneurysm, followed by omental flap coverage is a viable strategy to manage mycotic aortic infections with virulent organisms.

Cardiac wounds have been described for centuries and still remain often fatal. For a long period of time suture of a myocardial laceration was thought to be absolutely impossible if not sacrilege. It is only at the end of the 19th century that pioneers decided to defy such dogma in desperate cases. Nowadays it seems obvious that a cardiac stab wound require emergent surgery whenever possible. The story of cardiac wounds highlights nicely the change of mind that is required to accept progress and new procedures in medicine.

Relapsed acute lymphoblastic leukemia (ALL) with high minimal residual disease (MRD) after reinduction has poor prognosis. ALL patients with Down syndrome (DS) have a higher rate of relapse and treatment related mortality. We describe a DS and ALL patient with late bone marrow relapse who was treated per British ALL R3 reinduction chemotherapy. His therapy was discontinued due to severe systemic infections. The patient remained in remission for approximately two years without further treatment. We hypothesize that the sustained remission is attributed to chemotherapy combined with increased cortisol production and cytokine release as a result of systemic stress from infections.

Thrombohemorrhagic disorders are the main cause of morbidities and mortalities of essential thrombocythemia (ET), which are typically observed at age 50–60 years and rarely encountered in adolescence or childhood. Recently, anagrelide, a quinazinolone derivative, has been used as a therapeutic agent for ET. Although it is used to reduce platelet count, its cardiotoxicity has been reported. Here, we present an 18-year-old boy with ET who was treated with anagrelide and developed acute myocardial infarction. This was presumed to be an effect of anagrelide administration and, specifically, damage to the coronary arterial endothelial cell exacerbated by ET.

Climatic variability in the Andean regions of Colombia is high, both spatially and temporally. It should be analyzed in the short and long term, depending on the information available. This type of spatio-temporal analysis generates tools for environmental planning and management in urban areas. Given the high complexity of the meteorological processes that occur in the Andean region and in the tropics, these must be studied, understood and disseminated. This research focuses on a diagnosis of the diurnal cycle, the analysis of the monthly structure of precipitation and rain events, based on information collected from ground stations located in the city of Manizales, Caldas (Colombia), which contributes to the estimation of the city’s design storm. Results show a strong influence of the Intertropical Confluence Zone (ITCZ) on intra-annual city rain behavior: intra-daily, there are significant variations in precipitation across the city; and throughout the day, it rains the least in the morning and the most at night. Recorded rain events are intense, with average durations of 20 minutes, confirming the high spatial-temporal variability. The dimensionless pattern of the observed rainstorms are the basis for the design storm for the city’s hydraulic infrastructures.

SARS-COV-2 infection can be asymptomatic or mildly symptomatic. The effect of chemotherapy on an asymptomatic infected patient is unknown. Three hundred-thirty-four and 56 NFS were performed as screening for SARS-CoV-2 infection in 247 and 34 pediatric patients undergoing chemotherapy and stem cell transplantation, respectively. NFS was positive in 10 patients. All positive patients withdrew from chemotherapy. Nine patients became negative. One patient is still positive after 38 days.The identification of asymptomatic SARS-COV-2 infection is important to reduce the hospital spread of infection. Further studies are needed to define the least risky management of chemotherapy in asymptomatic SARS-CoV-2 patients.

Background: 6-Mercaptopurine (6-MP) is the most frequently used chemotherapy agent in the management of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LL). Skewed drug metabolism can decrease the effectiveness of 6-MP and result in unnecessary toxicities. Current guidelines suggest holding or lowering 6-MP doses with toxicity; however, this approach results in decreased intensity of 6-MP treatment, potentially risking disease relapse. Allopurinol can alter 6-MP metabolism to maximize therapeutic effects while reducing adverse toxicities. Methods: This single institution, retrospective cohort study, quantified the incidence of mercaptopurine related toxicities and the number of mercaptopurine metabolite shunters. For those patients started on allopurinol, we collected clinical follow up information. Results: Of 42 eligible patients, 74% and 88% had at least one episode of hypoglycemia and elevated alanine aminotransferase (ALT), respectively. Mercaptopurine metabolite data were available in 66% of our patients. 6-methylmercaptopurine nucleotide (6-MMPN) levels were >10 000 in 55% of the cohort, suggesting 6-MP shunting. Allopurinol was initiated for metabolite and laboratory derangements in 12 of 23 shunters. All patients who received allopurinol had resolution of toxicities. Discussion: In our population of children and young adults treated for ALL and LL, we found a high incidence of shunters, many with associated toxicities. The patients who received allopurinol in combination with scheduled chemotherapy showed reversal of undesired toxicities, suggesting combination therapy may be beneficial for certain patients. Based on our institutional experience, we propose an algorithm to incorporate allopurinol into chemotherapy regimens for patients with ALL or LL who have inappropriate 6-MP metabolism.

Dirac relativistic partial wave analysis has been employed to analyze the angular distributions and critical minima along with maximum spin polarization for the elastic scattering of electrons from copper atoms over the energy range 1 - 2000 eV. Integrated elastic, inelastic, total and momentum transfer cross sections have also been calculated. This work uses a complex electron-atom optical potential that includes static, exchange, correlation-polarization and absorption potentials. Comparison of our calculations with the available experimental data and other theoretical calculations show a satisfactory agreement. As far as we are concern, critical minima and corresponding maximum spin polarization points have not yet been reported in literature.

Raspberry Pi (RPi) is a well known single-board computer natively equipped with a Linux-based operating system, Raspbian, and a powerful programming language, Python. In this work, we propose an integrated project on physics and computer science exploiting RPi and Python: a set of lab activities, coding, and discussion related to the study of charging and discharging phases of a capacitor in an RC circuit. In our simple experiments, entirely computer-controlled, the RPi and Python scripts are used to: (i) apply a known constant voltage to the circuit at a desired time; (ii) measure the voltage on selected circuit elements as a function of time; (iii) evaluate and analyze experimental data. This approach is based on inexpensive hardware and open source software. It allows a hands-on experience with electric circuits and with dedicated examples of Python coding. The codes involve Python modules such as Numpy, Scipy, and Matplotlib that prove to be easy to use and efficient for our goals, supporting the choice of Python language for further study or research tasks.  

SARS-CoV-2 is a novel RNA coronavirus responsible of a deadly pandemic: the clinical illness COVID-19. With only one authorized drug for emergency use in critically ill patients: Remdesivir, there is not any other approved drug or vaccine yet with proven potential to overcome this infection. We exposed here many scientific evidences to support our novel idea that a macrolide, basically Clarithromycin, could be effective as a single agent for treatment and prophylaxis of COVID-19. Clarithromycin could change the history of this pandemic. It could reduce the costs of treatment and the potential adverse effects when combining more than one drug such as with Hydroxychloroquine. Clarithromycin treatment and prophylaxis as a single agent could be much more simple, safe and cheaper as giving Chloroquine or Hydroxychloroquine alone or in combination with Azithromycin as well as other therapeutic options.

In this paper, we use the Hirota bilinear method to nd the N-soliton solution of a (3+1)-dimensional generalized Kadovtsev-Petviashvili equation. Then, we obtain the T-order breathers of the equation, and combine the long-wave limit method to give the M-order lumps. Resorting to the extended homoclinic test technique, we obtain the breather-kink solutions for the equation. Last, the interaction solution composed of the K-soliton solution, T-breathers and M-lumps for the (3+1)-dimensional generalized KP equation is constructed.

In this paper, we show a regularity criteria for three dimensional nematic liquid crystal flows. More precisely, we prove that the strong solution $(u,d)$ can be extended beyond $T$, provided $\nabla u_{3}\in{L^{p}(0,T; L^{q}(\mathbb{R}^{3}))}$, $\frac{2}{p}+\frac{3}{q}\leq{\frac{19}{12}+\frac{1}{2q}}(\frac{30}{19}3)$ with some conditions about the orientation field $\nabla_{h}d\in{L^{\alpha}(0,T; L^{\beta}(\mathbb{R}^{3}))}$, $\frac{2}{\alpha}+\frac{3}{\beta}\leq{\frac{3}{4}+\frac{1}{2\beta}}(\beta>{\frac{10}{3}})$.

The spatiotemporal dynamics for general reaction-diffusion systems of Brusselator type under the homogeneous Neumann boundary condition is considered. It is shown that the reaction-diffusion system has a unique steady state solution. For some suitable ranges of the parameters, we prove that the steady state solution can be a codimension-2 Turing-Hopf point. To understand the spatiotemporal dynamics in the vicinity of the Turing-Hopf bifurcation point, we calculate and analyze the normal form on the center manifold by analytical methods. A wealth of complex spatiotemporal dynamics near the degenerate point are obtained. It is proved that the system undergoes a codimension-2 Turing-Hopf bifurcation. Moreover, several numerical simulations are carried out to illustrate the validity of our theoretical results.

La cattiva gestione delle attività antropiche è una fra le  principali cause della contaminazione delle matrici ambientali. Negli ultimi anni, Il crescente interesse per l’ambiente e per la sostenibilità ha portato alla necessità di adottare nuovi approcci e favorire la bonifica delle matrici ambientali. Tra i processi disponibili, trova applicazione la bioremediation  ed in particolare il biosparging che, tramite processi di natura biologica,  permette la degradazione dei composti indesiderati nell’ambiente. Il biosparging è particolarmente adatto per la rimozione degli idrocarburi. Il presente studio riporta l'analisi di un caso studio di un sito contaminato da idrocarburi policiclici aromatici (IPA) e idrocarburi di petrolio (TPHs), in cui, grazie all’utilizzo combinato di aria e specifici bioattivatori e nutrienti, si sono ottenute alte efficienze di abbattimento sia nel terreno che in falda.  

The article investigates the efficacy of gemini surfactant/polymer/nanoparticle flooding on chemical EOR. Initially, physicochemical behavior of aqueous chemical fluids were investigated via interfacial tension reduction, wettability alteration, adsorption, viscosity moderation and oil displacement experiments. During compositional analysis, Cartesian model with specified grid properties, injection flow-rate, well pattern, and rock-fluid characteristics was developed using CMG-STARS tool. Contour map analyses showed that oil saturation decreased from ~80% (initial) to 31.96%, 30.68% and 29.30% after {14-6-14 GS + chase water}, {14-6-14 GS + PHPA + chase water} and {14-6-14 GS + PHPA + SiO2 chase water} flooding respectively. Tertiary recoveries of 15-19% were achieved, depending on injected fluid composition. Experimental data were history matched via CMOST tool to achieve good matching of simulated results. The CMG flooding simulator provides a holistic approach to investigate oil displacement profiles, assess flooding recovery capabilities with near-accuracy and predict the feasibility of proposed chemical EOR projects.

EP RoundsA 24-year-old male with no past medical history presents to an urgent care center with palpitations. Four days prior he noticed that his heart rate was elevated and sometimes irregular which he recorded on his fitness watch. He had associated intermittent diaphoresis and dyspnea with exertion. Initial ECG obtained is shown in Figure 1A. He was instructed to follow up with a cardiologist. Transthoracic echocardiogram (TTE) obtained in the office demonstrated global left ventricular (LV) dysfunction with an ejection fraction (EF) of 35%. After being sent to the hospital, administration of intravenous amiodarone terminated the patient’s tachycardia and a subsequent ECG was obtained (Figure 1B). Repeat TTE showed normalization of the EF to 55% and cardiac magnetic resonance imaging (cMRI) demonstrated a normal LV without evidence of myocardial pathology. What is the most likely diagnosis of the tachycardia? What is the etiology of the abnormalities seen in the patient’s ECG as shown in Figure 1A? What is the appropriate management for this patient?

Cardiac leiomyosarcoma is an extremely rare tumor with a poor prognosis. We reported an 18- year-old girl with a left atrial leiomyosarcoma extending to right lower pulmonary veins. We performed complete tumor excision by the right anterolateral mini-thoracotomy approach using minimally invasive techniques. After pathological confirmation of the tumor, right lower lobectomy was performed with the same incision one week later to prevent a recurrence. Although no tumor remnant was found in the lobectomy specimen, adjuvant chemotherapy was started. No recurrence was detected during the 12-month follow-up.