Purpose: The FDA-issued PLATO trial dataset revealed that some primary deaths causes (PDC) were inaccurately reported favoring ticagrelor. However, the PLATO Investigators operated the shorter death list of uncertain quality. We compared if PDC match when trial fatalities were reported to the FDA and by the PLATO investigators. Method: The FDA list contains precisely detailed 938 PLATO deaths, while shorter investigators dataset consists of 905 deaths. We matched 4 vascular (sudden, post-MI, heart failure and stroke), and 3 non-vascular (cancer, sepsis and suicide) PDC between death lists. Results: There were more sudden deaths in the shorter list than in the FDA dataset (161 vs.138; p<0.03), post-AMI (373 vs.178; p<0.001) but fewer heart failure deaths (73 vs.109; p=0.02). Stroke numbers match well (39 vs. 37; p=NS) with only 2 ticagrelor cases removed. Cancer matched well (32 vs.31; p=NS), and sepsis cases were identical (30 vs. 30; P=NS). However, 2 extra clopidogrel suicides in the shorter list are impossible to comprehend. Conclusions: The PLATO trial PDC were mismatched between FDA and Investigators sets. We are kindly asking the ticagrelor sponsor or/and concerned PLATO Investigators to clarify the PDC dataset match.

Atrial septal device embolization within transcather structural heart disease although rare is life threatening. We present a case of a 15-year-old female who presented with a large 17mm septum secundum atrial septal defect associated with a left to right shunt and right heart dilation. The closure with atrial septal occluder (ASO) embolised into the left ventricle and couldn’t be retrieved by percutaneous methods. This otherwise healthy young female underwent emergency retrieval of the ASO via minimal access surgery with a right anterolateral mini thoracotomy. It’s important to highlight the role of minimal access surgery for retrieval of embolised percutaneous devices.

Objectives: To evaluate the efficacy of the combination of platelet-rich fibrin (PRF) and mineralized bone allograft on the volume of the new bone formation in the sinus floor augmentation of the severely atrophic residual alveolar crest with simultaneous dental implant placement. Materials and Methods: All clinical and radiological data of patients treated with sinus floor augmentation using the combination of PRF and demineralized bone allograft with simultaneous dental implant placement between 01/04/2013 and 01/03/2020 were retrieved from the archives. The main inclusion criterion for the study was a residual ridge height less than 2 mm. The volume of the maxillary sinus cavity was measured by a software program on pre-operative and post-operative cone beam computerized tomography (CBCT) sections. The graft volume was calculated by subtracting pre-operative and post-operative total sinus volume. Residual and post-operative ridge heights were measured by the software program on the mid-coronal and mid-sagittal sections of pre-operative and post-operative CBCT images. Results: Eighteen patients with 26 sinus augmentations were included in the study. Forty-six dental implants were placed simultaneously with sinus floor augmentation. The follow-up periods of cases varied between 19 and 29 months. All cases showed new bone regeneration on axial, coronal and sagittal sections of post-operative CBCT data. The mean volume of newly regenerated bone was calculated as 2.1(±0.9) ml. Post-operative ridge heights was significantly increased compared to pre-operative residual ridge heights (p<0.05). There was no sign of a relationship between residual and post-operative ridge heights (p>0.05). Conclusion: The PRF and demineralized bone allograft combination used in sinus floor augmentation may provide healthy new bone that supports simultaneously placed dental implants in function in the severely atrophic alveolar crests with a residual ridge height less than 2 mm. Keywords: Sinüs floor augmentation ; allograft ; cone-beam computed tomography ; dental implant

IntroductionGraft-versus-host disease (GVHD) is a potentially serious complication of allogenic stem cell transplantation (allo-SCT), but patients who develop GVHD also have a low incidence rate of leukemia recurrence, suggesting a graft-versus-leukemia effect due to the donor lymphocytes.1 This effect has also been suggested in solid tumors. In the case here, cervical cytology transformed from squamous cell carcinoma to negative for intraepithelial lesion or malignancy (NILM), possibly due to a graft-versus-tumor (GVT) effect following allo-SCT. The cervical cytology has continued changing, although the dose of immunosuppressant likely also has an effect. Here we describe our experience in this case and review the literature.

Polynomial interpolation with equidistant nodes is notoriously unreliable due to the Runge phenomenon, and is also numerically ill-conditioned. By taking advantage of the optimality of the interpolation processes on Chebyshev nodes, one of the best strategies to defeat the Runge phenomenon is to use the mock-Chebyshev points, which are selected from a satisfactory uniform grid, for polynomial interpolation. Yet, little literature exists on the computation of these points. In this study, we investigate the properties of the mock-Chebyshev nodes and propose a subsetting method for constructing mock-Chebyshev grids. Moreover, we provide a precise formula for the cardinality of a satisfactory uniform grid. Some numerical experiments using the points obtained by the method are given to show the effectiveness of the proposed method and numerical results are also provided.

Abdominal pregnancy is a very rare, life-threatening form of ectopic pregnancy, in which implantation occurs within the peritoneal cavity. The advantages of a laparoscopic approach over a laparotomy in this setting include a reduced estimated blood loss, a shorter operating time, reduced analgesic requirements, shorter hospital stay and convalescence.

A case of a 42-year-old woman, Para 3 who had an unplanned pregnancy despite bilateral tubal ligation for contraception, and Novasure® endometrial ablation for persistent Heavy Menstrual Bleeding (HMB). The pregnancy was complicated by missed miscarriage at 14 weeks and placenta accreta. This is an uncommon event.

Plasmapheresis for the management of acute cyanide poisoning : A case report and review of literatureNavid Namakizadeh EsfahaniIsfahan University of Medical Sciences, Isfahan, Irannavidnamakizadeh@gmail.comShafeajafar ZoofaghariDepartment of Clinical Toxicology, Isfahan Clinical Toxicology Research Center, Khorshid hospital, Isfahan, Iranshafeajafar@med.mui.ac.irAmirhossein Akhavan Sigari (corresponding author)Isfahan University of Medical Sciences, Isfahan, Iranamirsigari@aol.comTel: +989132151729PO: 8174673461Gholamali DorooshiDepartment of Clinical Toxicology, Isfahan Clinical Toxicology Research Center, Khorshid hospital, Isfahan, Irangdorvashy@med.mui.ac.ir

Background: Cystic fibrosis (CF) pulmonary exacerbations (PEx) are associated with significant drop in pulmonary function. The clinical value of measuring bronchodilator (BD) responsiveness during treatment for PEx to monitor or predict recovery of lung function is unclear. Methods: A retrospective analysis of spirometry with BD response testing obtained during hospital admissions for PEx in pediatric CF patients. Repeated events were included for patients with BD testing during multiple admissions. Results: 249 spirometries with BD testing in 102 patients were completed around day 7 (day 4-10) of hospital admission for treatment of CF PEx. Median (IQR) forced expiratory volume in one second (FEV1) was 70.6% predicted (58.1, 84.6) prior to the PEx event (best FEV1 in 6 months prior to admission), 54.4% (41.5, 66.9) at admission, 62.3% (48.4, 74.7) around day 7 of admission and 67.1% predicted (53.8, 78.2) at end of treatment. BD response around day 7 correlated poorly with FEV1 prior to PEx (r=-0.16, p=0.02), and did not correlate with recovery to baseline FEV1 at end of treatment (r=0.08, p=0.22). Only 23/249 (9%) patients had a BD response of ≥12 % and 200 ml. BD response was not related to age or severity of lung disease and led to an immediate change in clinical management in only 4 cases. CONCLUSIONS: BD response in CF patients treated for PEx is poorly correlated with baseline pulmonary function and does not correlate with recovery of FEV1 with treatment. These data suggest that routine testing for BD response is not indicated during PEx.

Unloading compliance (UC) method and normalization method (NM) are two of the most commonly used methods for determining the fracture toughness of materials. However, considerable differences often exist in the fracture toughness determined by these two methods, which solicits a new method to determine the fracture toughness accurately. In this paper, the compliance of crack length differences as measured by the crack length difference ratio Si is discovered, analysed and verified by experiments. Based on this compliance, a new accurate method, known as AJR, is developed and verified by test results. Factors that exhibit the advantages of the developed new AJR method are also investigated. It is found that the J-R curves determined by the new AJR method are more accurate than those determined by UC and NM. The new AJR method should be the first choice for steels with a small strain hardening ratio and low effective yield strength, and thicker CT specimens with shallower initial crack length. This is because the disagreement between UC and NM is unacceptably large. The developed new AJR method and the results presented in this paper can assist engineers and researchers to determine J-R curves and fracture toughness of steels more accurately and can contribute to the body of knowledge of fracture mechanics.

1. Insects are responsible for the quantity and quality of one-third of all agricultural production worldwide through pollination. The quality of the pollination service and the safety of the honey production depends on the health and nutritional condition of the hives, which, for an important part is related to management practices. 2. This study aims to identify the stressors that lead to the loss of bee health and its consequences for the productivity of the hives. Different aspects related to management practices, productivity, clinical observations related to diseases, presence of health issues in the hives or in the apiaries, to the structure of the hives, weather and infestation rates by Varroa sp. mites were measured. The information was collected during two field surveys in 53 apiaries in the Province of Santa Fe, Argentina. 3. The results show correlations among many of the management practices, health condition and productivity of the hive, with most importantly the change of the bee queen, the disinfection of the beekeeping material and the number of combs in the brood chamber. 4. Although honey production is important in the region, the hive structure was deficient and inadequate during both surveys. Due to its dependence on management by the beekeeper, this suggests that a holistic approach can improve the hive structure, increasing the honey production.

CABG (Coronary Artery Bypass Grafting) has been the treatment of choice for coronary artery disease for over 50 years and is the most common cardiac surgery procedure performed. Traditionally CABG was performed with the use of cardiopulmonary bypass and the use of cardioplegia to allow the surgeon to operate on a stable field. In the mid-1990s, interest emerged in performing CABG without the use of cardiopulmonary bypass - off pump CABG. This invited commentary focuses on sharing our experience with Low Ejection fraction off-pump CABG and why this approach could be beneficial to this patient population.

Amyloid arthropathy is often underdiagnosed. The articular forms of AL amyloidosis may mimick the rheumatoid arthritis. The presence of macroglossia should draw attention to chronic polyathralgia.

Artiodactyl prey species of Chile, especially guanacos (Lama guanicoe) are reported to be very susceptible to predation by pack hunting feral dogs. It has been previously suggested that guanacos and endemic South American deer may have evolved in the absence of pack-hunting cursorial predators. However, the paleoecology of canid presence in southern South America and Chile is unclear. Here, we review the literature on South American and Chilean canids, their distributions, ecologies and hunting behaviour. We consider both wild and domestic canids, including Canis familiaris breeds. We establish two known antipredator defense behaviours of guanacos: predator inspection of ambush predators, e.g. Puma concolor, and rushing at and kicking smaller cursorial predators, e.g. Lycalopex culpaeus. We propose that since the late Pleistocene extinction of hypercarnivorous group-hunting canids east of the Andes, there were no native species creating group-hunting predation pressures on guanacos. Endemic deer of Chile may have never experienced group hunting selection pressure from native predators. Even hunting dogs (or other canids) used by indigenous groups in the far north and extreme south of Chile (and presumably the center as well) appear to have been used primarily within ambush hunting strategies. This may account for the susceptibility of guanacos and other prey species to feral dog attacks. We detail seven separate hypotheses that require further investigation in order to assess how best to respond to the threat posed by feral dogs to the conservation of native deer and camelids in Chile and other parts of South America.

The paper presents an a posteriori error estimator for a (piecewise linear) nonconforming finite element approximation of the problem defining the interaction between a free fluid and poroelastic structure. The free fluid is governed by the Stokes equations, while the flow in the poroelastic medium is modeled using the Biot poroelasticity system. Equilibrium and kinematic conditions are imposed on the interface. The approach utilizes the same nonconforming Crouzeix-Raviart element discretization on the entire domain [Houédanou Koffi Wilfrid, Results in Applied Mathematics 7 (2020) 100127, Elsevier]. For this discretization, we derive a residual indicator based on the jumps of normal derivative of the nonconforming approximation. Lower and upper bounds form the main results with minimal assumptions on the mesh.

Aim: There is an emerging role of steroids in the management of COVID-19. We aimed to compare the outcome of COVID-19 patients (recovery versus mortality) who were treated with steroids with those who were not treated with steroids during their course of hospital stay. Methods: A retrospective analysis of all moderately to severely ill COVID-19 patients, meeting the inclusion and exclusion criteria, admitted to our center during the study period of four months, was performed. The patients were categorized into two groups: Group I included 25 patients who were given steroids, and Group II also included 25 patients who were not given any steroids during their hospital stay. The primary outcome (recovery versus mortality), length of hospital stay as well as other features were compared between the two groups. Results: The mean length of hospital stay was 9.3 days in the steroids group and 10.9 days in the non-steroids group with a p value of 0.249. None of the patients was shifted to a ventilator in either group. One patient in the steroids group (4%) and two patients in the non-steroids group (8%) needed to be put on high flow nasal cannula. One patient died in the steroids group with a recovery rate of 96%, while two patients died in the non-steroids group with a recovery rate of 92% (p value 0.552). Conclusion: Treatment with steroids in moderately to severely ill COVID-19 patients did not decrease the length of hospital stay or mortality in our study.

The sympatric existence of genetically distinct populations of the same species remains a puzzle in ecology. Coexisting salmonid fish populations are known from over 100 freshwater lakes. Most studies of sympatric populations have used limited numbers of genetic markers making it unclear if genetic divergence involves only certain parts of the genome. We return to the first reported case of salmonid sympatry, initially detected through contrasting homozygosity at a single allozyme locus (lactate dehydrogenase, LDH-A1) in brown trout in the small Lakes Bunnersjöarna, central Sweden. We use DNA from samples collected in the 1970s and a 96 SNP fluidigm array to verify the existence of the coexisting demes. We then apply whole-genome resequencing of pooled DNA to explore genome-wide diversity within and between these demes; strong genetic divergence is observed with genome-wide FST=0.13. Nucleotide diversity is estimated to 0.0013 in Deme I but only 0.0005 in Deme II. Individual whole-genome resequencing of two individuals per deme suggests considerably higher inbreeding in Deme II vs. Deme I. Comparing with similar data from other lakes we find that the genome-wide divergence between the demes is similar to that between reproductively isolated populations. We located two genes for LDH-A and found divergence between the demes in a regulatory section of one of the genes, but we could not find a perfect fit between allozyme and sequence data. Our data demonstrate genome-wide divergence governed by genetic drift and diversifying selection, confirming reproductive isolation between the sympatric demes.

Bouveret syndrome is a rare cause of gastric outlet obstruction by passage of gallstone through a fistula between the gallbladder and proximal gastrointestinal tract, it is considered a proximal form of gallstone ileus. The clinical presentation is nonspecific, and imaging plays an important role in the diagnosis of this entity.

TITLE PAGETitle: Retiring as a Physician during the 2020 Coronavirus PandemicAuthor: Philippa G. Sprinz, MD, MScHasbro Children’s HospitalDivision of Pediatric Hematology/Oncology593 Eddy StProvidence, RI. 02903philippa.sprinz@lifespan.orgCorresponding Author: Philippa G. Sprinz, MD, MScHasbro Children’s HospitalDivision of Pediatric Hematology/Oncology593 Eddy StProvidence, RI. 02903philippa.sprinz@lifespan.orgphone: (401) 444-5171fax: (401) 444 -8845Main Text Word Count: 1194 wordsNo Tables, Figures or other materialKeywords: Retiring, Pandemic, COVID 19,Congratulations! Well done! Bravo! Our compliments and best wishes! I sat outside, looking up at the night sky trying to make sense of everything. I could not. I had hoped, in the silence of night, that I might be able to find some peace and understanding, something positive to hold on to, some equipoise with where I was at in my life, in the midst of a global pandemic. Unfortunately, the cloud ceiling was too low; there were no stars to be seen, to add perspective to my life. I could not grasp my retirement from clinical practice, at this globally distressing time.My retirement was planned before Covid-19 was a name in the medical lexicon.I thought I had planned appropriately. Our son-in-law matched for his clinical fellowship some 2600 miles away. I was 65 years old, and had had a wonderful career as a pediatric hematologist/oncologist, training in the UK but moving to and practicing in the US for almost 40 years. My new job was going to be to help with grandchildren, so our children could pursue their own medical careers. As I clearly could not work and commute 2600 miles on a regular basis, I reasoned that I should retire from clinical practice.Practicing as a physician has been incredibly satisfying. It has been my identity. It is how I presented myself to my family, colleagues and friends. I have given so much of my life to my work. At the same time, unfortunately, I had not taken the time to develop other skills that were anywhere near as rewarding. I acquired some hobbies: diversions from the responsibilities of helping and supporting ‘my’ patients and colleagues, but not skills to keep my mind or body active when I stopped working. As I contemplated no longer working clinically, I developed an anxiety for ‘my’ patients. I knew I had excellent colleagues to hand my patients on to, but I could not escape the thought that I would be letting my patients down by not continuing to care for them, myself. I argued that I knew their health care needs ‘best’. Only, surely I was doing right by our kids and grandkids by helping them at this time.I found myself thinking over my years in practice. During that time, I saw the five-year survival rate of children with a cancer diagnosis increase from 58% to 86% (1); Hodgkin Lymphoma essentially became straightforwardly curable (5 year survival rate of 99.5% by 2016) (1). Even brain tumors experienced a twenty percent increase in their overall cure rate, (57.2% to 76.3%)(1). For individuals with sickle cell disease (SCD) (my particular area of expertise) the survival gain has been more modest: in the 1970s (ten years before the start of my fellowship) 80% of individuals with SCD died by age 30 years (2). In the 1990s females with sickle cell anemia had an average life expectancy of 48 years and males 42 years (3). Despite these improvements, the care of individuals with SCD still needs new drugs and better curative approaches. Life expectancy, for patients with SCD, is currently 54 years for both sexes (4). This is still signifiantly less than the non-SCD population of 76 years in the US(4). I do, nevertheless, look to the future in my field with optimism. Immunotherapy is in the forefront of cancer care, and sensitive molecular tests are allowing earlier diagnoses and hopefully, more successful treatments. There are a number of new, albeit expensive, drugs now being marketed for SCD. Stem cell transplantation is accepted as a ‘curative’ option for the disease, and gene therapy is not too far in the future.Then February 2020: SARS-CoV-2 arrived in the US. This virus has impacted so many lives in so many ways, in circumstances much, much worse than mine. For me, however, it reformatted my retirement. I could not travel to help our children: borders were closed and international travel all but halted. I would stop work with ‘nothing to do’. I suddenly needed to understand ‘Retirement from being a full time MD’, without a ‘plan B’. I recognised that not having to share life-threatening diagnoses with families, would take a weight off my shoulders. Instead, nonetheless, I would cease to be one of a team working painstakingly to help children and their families understand life-impacting illnesses: to hopefully feel better, for at least some periods of time. Despite sadnesses, ‘pedi heme-onc’ definitely has many rewards. Retirement from it includes the loss of deep family relationships and also daily interactions and stimulating meetings with friends and colleagues.I then wondered: why does one retire when one has a secure job (and no new occupation to move on to), with rewarding work, and a sense of serving ‘the greater good’. This, particularly if one is without ‘burn-out’ that over the years I have watched some of my colleagues experience? Does one really have to retire? A critical aspect of retirement may be to afford practices the opportunity to replenish the workforce with younger, more adaptable workers. Individuals trained recently on newer, clinical approaches and disease management present new skills and may improve efficiency. Does the fact that junior doctors have lesser salaries than those who have been in practice for many years make a difference? Recognising my predicament, I suggested I could help part-time during the pandemic. The coronavirus was not causing so many childhood illnesses, however, to need more pediatric staff and I am no expert in adult medicine.Notwithstanding concerns over my retirement, I did have an excitement to think that my leaving would afford a younger physician the opportunity to take a leading role in patients’ care and eventually have as rewarding a career in pediatric hematology/oncology as I had. So, I took stock: maybe I could volunteer in the community? I reached out to a number of organisations, all of which were very happy to have my help, ‘just not now’, in the middle of a pandemic. I listened in to as many medical and non-medical on-line lectures as I could. I ‘attended’ virtual conferences, easily, regionally and nationally, without any travel, and contributed to ‘Zoom’ teaching at my own institution. I worked for an online publishing company and reviewed manuscripts. I was in touch with ‘everyone’ and tried to support all the vulnerable people I knew.Ten months into the pandemic, nevertheless, I am still struggling to come to terms with not being a clinician. Did I devote too much time to my patients – that could not be? Should I have paid more attention to hobbies and have developed a ‘Plan B’? Probably ‘yes’. Will there be a time, after the pandemic has passed, when again I can contribute to ‘the greater good’ and do more clinical work? Perhaps it is true: ‘once a doctor, always a doctor’. But it is more than that: having spent all of my working days caring for others, with responsibilities of making accurate diagnoses, recommending potentially curative management and providing compassionate care when the cure did not come, I now have to learn a new life: a life of giving back without the rewards of clinical practice.References:SEER (Surveillance, Epidemiology and End Results program,) 2017Platt O et al Mortality in sickle cell disease. Life expectancy and risk factors for early death: N Eng J Med. 1994, Jun 9; 330(23):1639-443) Lanzkron S, Carroll CP, Haywood C Jr. Mortality rates and age at death from sickle cell disease: US, 1979 – 2005. Public Health Rep. 2013; 128: 110-116 4) Lubek et al Estimated Life Expectancy and Income of Patients With Sickle Cell Disease Compared With Those Without Sickle Cell Disease: JAMA Network Open. 2019;2(11):e1915374. doi:10.1001/jamanetworkopen.2019.15374, accessed 12/26/2020

Abstract Unicuspid aortic valve (UAV) is a rare congenital malformation, related to an aggressive evolution of valve function. Its diagnosis represents an important cardiac imaging challenge, since it is often difficult to differentiate between other anomalies like bicuspid aortic valve. Recently, bicuspid aortic valve has been associated with IE, especially when aortic valve function shows significant stenosis, however, the relationship between IE and UAV is unclear. The anatomical characteristics of UAV could predispose to IE. This report describes a young patient affected by infective endocarditis (IE) with UAV and the case reviews the echocardiographic criteria used to improve its management.

We present the method for detection of particle groups involved in collective motion based on network analysis. Knowing the positions and velocities of individual particles, a “velocity similarity graph’‘ is built, where the graph vertices represent the particles. The vertex pairs are connected by the edge if the distance between the respective particles is small enough. The edge weight is calculated to be inversely proportional to the difference in the respective particle velocities, i.e., the vertex pairs representing nearby particles having similar velocities are connected by edges of larger weight. If a group of particles moves in a coordinated matter, the particles in this group will have similar velocities, therefore, the corresponding vertices in the graph will be connected by edges of larger weight in the representing graph. Having produced the velocity similarity graph, identification of particle groups becomes equivalent to the problem of “community detection” in graph analysis. The algorithms and techniques developed for community detection in graphs can be thereby applied for identification of particle groups involved in coordinated motion in granular matter. We illustrate this approach by an example of granular media filled in a rotating cylinder.

Isolated tubal torsion is a rare cause of acute abdominal pain in women and is even less frequent in the patients younger than 18 years. We present the interesting case report of a tubal torsion accompanied with hydrosaplinx, diagnosed in a 17-year old patient that was sexually inactive adolescent

The clinical course of our patient highlights an atypical presentation of thromboembolic disease related to pregnancy, a thrombophlebitis of the right ovarian vein with endocaval floating thrombus in the postpartum. The diagnosis remains difficult since it is a rare entity with an atypical presentation but with serious medical consequences.

Anti-tumor necrosis factor alpha (TNFα) agents are effective in diseases including Crohn’s disease (CD) but may cause cytopenias. The mechanisms involved in anti-TNFα agents induced thrombocytopenia are scarce. We report a 73-year-old male with Crohn’s disease for which he currently used adalimumab, an anti-TNFα agent. He had received mesalazine and infliximab before the treatment of adalimumab. No comorbidities were present. Routine laboratory tests revealed a deep thrombocytopenia (thrombocytes 24x10*9/L) after which adalimumab was discontinued. Bleeding symptoms included cutaneous hematomas and mild epistaxis. Direct monoclonal antibody-specific immobilization of platelet antigens (MAIPA assay) revealed autoantibodies specific to glycoprotein IIb/IIIa (GPIIb/IIIa) and glycoprotein V (GPV) platelet receptors. There was no bone marrow suppression. Other causes of the thrombocytopenia were ruled out. The platelet count normalized after adalimumab discontinuation. No further interventions were required. Monitoring thrombocyte levels after initiating anti-TNFα agents is recommended, which could lead to prevention of this potential fatal phenomenon.