Management of post-pancreatectomy haemorrhage using resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Delayed massive post-pancreatectomy haemorrhage (PPH) is a highly lethal complication after pancreatectomy. Angiographic procedures have led to improved outcomes in the management of these patients. In the setting of an acute haemorrhage, laparotomy and packing are often required to help stablise the patient. However, re-operative surgery in the post-pancreatectomy setting is technically challenging. METHODS: A novel strategy of incorporating the resuscitative endovascular balloon occlusion of the aorta (REBOA) is described. RESULTS: Two patients where the specific application of this technique uses the REBOA were described. CONCLUSION: The REBOA serves as a useful adjunct in haemorrhage control and haemodynamic stablisation to allow successful management of delayed massive PPH.

Evaluation of electric vehicle response capability in power grid.

In recent years, frequent and substantial area-wide power outages have underscored the critical need for cities to possess robust backup power sources capable of swift response to prevent prolonged power system disruptions. Electric vehicles can contribute electricity to the power grid using vehicle-to-grid technology. The power delivered by electric vehicles in this context is termed as response capability. However, existing studies have overlooked response capability dynamics during transitions between electric vehicle states-such as the shift from charging or discharging to an idle state, thereby hindering a comprehensive understanding of this aspect. Hence, this paper introduces a multi-timescale response capability prediction model that evaluates the electric vehicle's state of charge to ensure users' requirements are met for upcoming trips. To better assess users' travel demand, the gravity model is employed as a precursor to response capability prediction to further enhance the validity of the prediction outcomes. Three neighborhoods in Los Angeles have been chosen for analysis: Downtown, Lincoln Heights, and Silver Lake. Predictions indicate that neglecting the response capability when electric vehicles undergo state transformation can lead to a differential response capability ranging from 2000 kWh to 4000 kWh, resulting in a loss of prediction accuracy by 20 % to 25 %.•The response capability of EV is non-zero during state transformations•Users' travel demand assessment•Seamless integration of vehicle-to-grid technology into the power grid.

Endovascular repair of aortoiliac aneurysmal disease with the helical iliac bifurcation device and the bifurcated-bifurcated iliac bifurcation device.

BACKGROUND: Iliac branch device (IBD) treatment of common and internal iliac artery (CIA and IIA) aneurysms has been controversial in the context of available embolization techniques or off-label adjunctive procedures. Two devices exist, a straight IBD (S-IBD) and a helical IBD (H-IBD). We report our midterm results with the latter and present outcomes with a third device intended to treat disease in the presence of short CIAs termed the bifurcated-bifurcated IBD (BB-IBD). METHODS: Data were prospectively collected from IBD-treated patients with infrarenal aortoiliac or thoracoabdominal aortoiliac aneurysms. Preoperative aneurysmal characteristics were collected in accordance with the endovascular reporting standards document, including presence of IIA stenosis, CIA diameters, and the presence of an IIA aneurysm. Technical success was defined as IBD device placement, branch placement, and patency without type I or III endoleak at implantation in addition to 24 hours survival. Follow-up computed tomography scans at 1, 6 (optional), 12 months, and annually thereafter were performed and reinterventions, sac morphology changes, and endoleaks noted. Survival and patency were evaluated with life-table analyses, and differences among anatomic groups were compared with log-rank tests, whereas t-tests and Fisher exact tests were used to compare simple variables. RESULTS: Between 2003 and 2012, 138 IBD devices were placed into 130 patients (98 H-IBD and 40 BB-IBD). Median follow-up was 20.3 months (range, 1-72 months) with 30- day, 12-month, 3- and 5-year survival rates of 99%, 90%, 79%, and 62%, respectively. Technical success was 94%, and branch patency was 94.6% at 30 days and 81.8% at 5 years. Thirty-five percent (35%) of branches were placed into patients with IIA aneurysms (in addition to their proximal disease), 20% into stenotic IIAs, and 46% into iliac systems with narrow (<16 mm) CIAs. Technical success was significantly lower in patients with IIA stenosis (81.5 vs 96.4%; Fisher exact test, P = .015) but not affected by the presence of an IIA aneurysm or narrow CIA. Branch patency was similar in all groups throughout follow-up. No stent fractures or component separations were noted in the IBDs or mating devices throughout the study period. CONCLUSIONS: The H-IBD and BB-IBD configurations have high technical success and acceptable long-term patency for the treatment of CIA and IIA aneurysms, including those with challenging anatomy difficult to treat with the straight branch design.

Family history of aortic disease predicts disease patterns and progression and is a significant influence on management strategies for patients and their relatives.

BACKGROUND: While a positive family history (FH) is a known risk factor for developing an aneurysm, its association with the extent of disease has not been established. We evaluated the influence of a FH of aortic disease with respect to the pattern and distribution of aortic aneurysms in a given patient. METHODS AND RESULTS: From November 1999 to November 2011, 1263 patients were enrolled in physician-sponsored endovascular device trials to treat aortic aneurysms. Of the 555 patients who were alive and returning for follow-up, we obtained 426 (77%) family histories. Three-dimensional imaging studies were used to identify the presence of aneurysms; 36% (155/426) of patients had a FH of aortic aneurysms and 5% (21/155) had isolated intracranial aneurysms. A logistic regression model was used to compare aortic morphology between patients with a positive or negative FH for aneurysms. Patients with a positive FH of aortic aneurysms were younger at their initial aneurysm (63 vs 70 years; P < .0001), more frequently had proximal aortic involvement (root: odds ratio [OR], 5.4; P < .0001; ascending: OR, 2.9; P < .001; thoracic: OR, 2.2; P = .01) with over 50% of FH patients ultimately developing suprarenal aortic involvement (P = .0001) and had a greater incidence of bilateral iliac artery aneurysm (OR, 1.8; P = .03). CONCLUSIONS: FH is an important tool that provides insight into the expected behavior of the untreated aorta and has significant implications for the development of treatment strategies. These findings should be used to guide patient's management with regard to treatment, follow-up paradigms, genetic testing, and screening of other family members.

The role of mandatory lifelong annual surveillance after thoracic endovascular repair.

Thoracic endovascular aortic repair (TEVAR) has become an attractive and well-accepted option for the management of the various thoracic aortic pathologies that vascular surgeons are confronted with. As in the abdominal aorta, current management trends include the treatment of younger patients with longer life expectancies, raising the issue of postoperative surveillance. There are several relevant differences between these anatomic areas when it comes to surveillance, including the relative inaccessibility of the thoracic aorta to ultrasound interrogation and the increased variability of thoracic aortic pathologies and post-TEVAR complications. In addition, concerns regarding radiation-induced carcinogenesis and contrast-induced nephropathy reduce the enthusiasm of many surgeons for regular computed tomography surveillance. Most agree that surveillance is important after TEVAR, but the method, duration, and frequency of that surveillance is much less clear and is the topic of this debate.

An evaluation of online Edcraft gamified learning (EGL) to understand motivation and intention of recycling among youth.

Recycling is a process carried out by various organizations and individuals to enhance the environment's long-term sustainability. Some youth think that recycling is a monotonous action as it may seem inconvenient, less aware of the environmental issues and more time-consuming than they think and rather go for video games. Therefore, this study investigates the relationship between motivation and recycling intention in gamified learning among youth. To address the research aim, this study uses gamification as a motivational driver for a game-like learning experience to improve recycling intentions among youth. Self-determination theory (SDT) and the theory of Planned Behavior (TPB) will be this study's main motivational and behavioral theories. (n = 124) high schools and college students were invited to take part in an online gamified recycling activity, Edcraft Gamified Learning (EGL), consisting of two levels of gamified unused plastic-crafting recycling activities. After the activity, the participants will answer a post-event questionnaire and the data collected were analyzed. The result shows that controlled motivation (CM) and autonomous motivation (AM) positively influenced youth attitudes and social norms. Besides, attitude is the only psychosocial determinant that positively influences the recycling intention of the youth. Gamification only moderates positively between attitude and recycling intention. This study has clearly shown the effectiveness of gamified learning activity towards recycling intention directly and as a component that moderates the relationship between attitude and recycling intention, which shows a favorable evaluation towards recycling intention with gamified learning involved. Moreover, the findings showed that not all relationships are positive in a gamified learning environment, and it gives a good view on the weakness and strengths with the guideline of SDT and TPB.

Genetic associated complications of type 2 diabetes mellitus.

According to the International Diabetes Federation, the number of adults (age of 20-79) being diagnosed with diabetes mellitus (DM) have increased from 285 million in year 2009 to 463 million in year 2019 which comprises of 95% type 2 DM patient (T2DM). Research have claimed that genetic predisposition could be one of the factors causing T2DM complications. In addition, T2DM complications cause an incremental risk to mortality. Therefore, this article aims to discuss some complications of T2DM in and their genetic association. The complications that are discussed in this article are diabetic nephropathy, diabetes induced cardiovascular disease, diabetic neuropathy, diabetic foot ulcer (DFU) and Alzheimer's disease (AD). According to the information obtained, genes associated with diabetic nephropathy (DN) are gene GABRR1 and ELMO1 that cause injury to glomerular. Replication of genes FRMD3, CARS and MYO16/IRS2 shown to have link with DN. The increase of gene THBS2, NGAL, PIP, TRAF6 polymorphism, ICAM-1 encoded for rs5498 polymorphism and C667T increase susceptibility towards DN in T2DM patient. Genes associated with cardiovascular diseases are adiponectin gene (ACRP30) and apolipoprotein E (APOE) polymorphism gene with ξ2 allele. Haptoglobin (Hp) 1-1 genotype and mitochondria superoxide dismutase 2 (SOD2) plays a role in cardiovascular events. As for genes related to diabetic neuropathy, janus kinase (JAK), mutation of SCN9A and TRPA1 gene and destruction of miRNA contribute to pathogenesis of diabetic neuropathy among T2DM patients. Expression of cytokine IL-6, IL-10, miR-146a are found to cause diabetic neuropathy. Besides, A1a16Va1 gene polymorphism, an oxidative stress influence was found as one of the gene factors. Diabetic retinopathy (DR) is believed to have association with monocyte chemoattractant protein-1 (MCP-1) and insulin-like growth factor 1 (IGF1). Over-expression of gene ENPP1, IL-6 pro-inflammatory cytokine, ARHGAP22's protein rs3844492 polymorphism and TLR4 heterozygous genotype are contributing to significant pathophysiological process causing DR, while research found increases level of UCP1 gene protects retina cells from oxidative stress. DFU is manifested by slowing in re-epithelialization of keratinocyte, persistence wound inflammation and healing impairment. Re-epithelialization disturbance was caused by E2F3 gene, reduction of Tacl gene encoded substance P causing persistence inflammation while expression of MMp-9 polymorphism contributes to healing impairment. A decrease in HIF-1a gene expression leads to increased risk of pathogenesis, while downregulation of TLR2 increases severity of wound in DFU patients. SNPs alleles has been shown to have significant association between the genetic dispositions of T2DM and AD. The progression of AD can be due to the change in DNA methylation of CLOCK gene, followed with worsening of AD by APOE4 gene due to dyslipidemia condition in T2DM patients. Insulin resistance is also a factor that contributes to pathogenesis of AD.

Playing Edcraft at Home: Gamified Online Learning for Recycling Intention during Lockdown.

Background: Gamification is an innovative approach to engaging in activities that people believe as less interesting. Recycling has been an issue not taken aware by the people in environmental sustainability. There are substantial studies on recycling intention due to the continual growth of unethical and unsustainable waste disposal. Creative approaches to recycling awareness activities should be made to fulfil youths' increasing interest in and demand for recycling. The main objective of this study is to explore the factors related to youths' recycling intentions after experiencing a gamified online recycling learning activity, Edcraft Gamified Learning (EGL). Gamified recycling education is believed to be a practical and engaging approach for youths. Methods: 100 students participated in EGL, consisting of two levels of plastic crafting and recycling activities. They experienced online EGL at home between May and September in 2020, during the COVID-19 pandemic total lockdown in Malaysia, namely, Movement Control Order (MCO). 29 participants were selected to participate in five focus group discussions (FGDs) with five to eight participants per session to explore their opinions towards gamified learning, motivation and recycling intention. Results: This paper reports the findings of the FGDs. A codebook was developed based on the codes from the FGD feedback. The codes were rated by two raters, followed by an assessment of inter-rater reliability and thematic analysis. The findings emerged and were confirmed with four themes as factors that influence recycling intention. They are gameful experience, social influence, intrinsic motivation, and extrinsic motivation. Conclusion: The dependent variable, recycling intention, was connected to the four themes to verify the conceptual framework. One limitation of the study was the design of the EGL activity, which was only carried out over two days with two levels of gamified recycling education, as students had concurrent academic online classes during that period.

A Study on Arrhythmia via ECG Signal Classification Using the Convolutional Neural Network.

Cardiovascular diseases (CVDs) are the leading cause of death today. The current identification method of the diseases is analyzing the Electrocardiogram (ECG), which is a medical monitoring technology recording cardiac activity. Unfortunately, looking for experts to analyze a large amount of ECG data consumes too many medical resources. Therefore, the method of identifying ECG characteristics based on machine learning has gradually become prevalent. However, there are some drawbacks to these typical methods, requiring manual feature recognition, complex models, and long training time. This paper proposes a robust and efficient 12-layer deep one-dimensional convolutional neural network on classifying the five micro-classes of heartbeat types in the MIT- BIH Arrhythmia database. The five types of heartbeat features are classified, and wavelet self-adaptive threshold denoising method is used in the experiments. Compared with BP neural network, random forest, and other CNN networks, the results show that the model proposed in this paper has better performance in accuracy, sensitivity, robustness, and anti-noise capability. Its accurate classification effectively saves medical resources, which has a positive effect on clinical practice.

Antiplatelet therapy in peripheral occlusive arterial disease.

BACKGROUND: Antiplatelet therapy (APT) in patients with peripheral occlusive arterial disease (POAD) may reduce cardiovascular (CV) morbidity and mortality by inhibiting atherothrombosis. This article reviews the current evidence for APT in patients with stable POAD and in patients undergoing revascularization procedures for POAD. METHODS: A Medline and Pubmed literature search (January 1966 to February 2003) was conducted to identify articles relating APT and POAD. Manual cross referencing was also used. RESULTS AND CONCLUSIONS: Meta-analyses suggest that APT (most commonly aspirin) in patients with stable POAD significantly reduces the incidence of nonfatal stroke, myocardial infarction and CV death. However, this conclusion is based on subset analysis of data predominantly involving patients with coronary and cerebrovascular atherosclerosis. There is a little direct evidence for the use of aspirin in patients with isolated POAD, but in practice, aspirin remains the most commonly used antiplatelet agent as high rates of coronary and cerebrovascular diseases are observed in this patient population. For patients with POAD without additional indicators of vascular risk, the protective effect of aspirin is unclear and dependent on the balance of risks and benefits in the individual patient. For patients undergoing peripheral revascularization, ticlopidine and aspirin in combination with dipyridamole are effective in maintaining patency after bypass procedures and following angioplasty/femoral endarterectomy. The efficacy of thienopyridines in peripheral angioplasty is uncertain, and the optimum timing and duration of APT relative to intervention are not known.

Point of care testing of aspirin resistance in patients with vascular disease.

INTRODUCTION: The reported range in rates of aspirin resistance (5.5-60%) may reflect difficulties in studying platelet function and the variety of tests used. This study used a platelet function analyzer (PFA-100) to prospectively document aspirin resistance in a cohort of patients with arterial disease. METHODS: Patients with internal carotid artery (ICA) stenosis or intermittent claudication (IC) were recruited. Exclusion criteria were contraindications to aspirin, prescription of other medication with known antiplatelet effects or known platelet abnormalities. After prescription of 100 mg aspirin/day for 2 weeks an uncuffed venous blood sample was taken and analysed with the PFA-100. Aspirin resistance was defined as closure time (CT) less than the upper limit of normal (158 s collagen/epinephrine agonist; 118 s collagen/adenosine diphosphate (ADP) agonist). RESULTS: Thirty-three patients with IC and 12 patients with ICA stenosis were recruited (n = 45). Median (range) age was 74 years (49-85) and the male to female ratio was 1.5:1. The median (range) CT was >300 (85 to >300) s with collagen/epinephrine and 100 (52 to >300) s with collagen/ADP agonist. Twelve patients (27%) in the collagen/epinephrine group had normal CT despite treatment with 100 mg aspirin, indicating resistance. Of the 33 patients with collagen/epinephrine CT prolonged by aspirin, 10 patients also had prolonged collagen/ADP CT, suggesting excessive platelet inhibition. CONCLUSION: A significant proportion of patients taking aspirin do not show laboratory evidence of platelet inhibition and may not be protected from atherothrombotic events. The PFA-100 appears to be a useful tool to screen for both aspirin resistance and excessive aspirin mediated platelet inhibition.

Genetic Diversity and Natural Selection of the Plasmodium knowlesi Circumsporozoite Protein Nonrepeat Regions.

BACKGROUND: Plasmodium knowlesi is a simian malaria parasite that has been identified to cause malaria in humans. To date, several thousand cases of human knowlesi malaria have been reported around Southeast Asia. Thus far, there is no detailed study on genetic diversity and natural selection of P. knowlesi circumsporozoite protein (CSP), a prominent surface antigen on the sporozoite of the parasite. In the present study, the genetic diversity and natural selection acting on the nonrepeat regions of the gene encoding P. knowlesi CSP were investigated, focusing on the T-cell epitope regions at the C-terminal of the protein. METHODS: Blood samples from 32 knowlesi malaria patients and 2 wild monkeys (Macaca fascicularis) were used. The CSP of the P. knowlesi isolates was amplified by PCR, cloned into Escherichia coli, and sequenced. The nonrepeat regions of the CSP gene were analysed for genetic diversity, natural selection and haplotypic grouping using MEGA5 and DnaSP version 5.10.00 programmes. A haplotype network was constructed based on the C-terminal (Th2R/Th3R) T-cell epitope regions using the Median-Joining method in the NETWORK version 4.6.1.2 programme. Previously published sequences from other regions (Malaysia Borneo, Singapore) were also included in the analysis. RESULTS: A total of 123 P. knowlesi CSP sequences were analysed. Multiple sequence alignment revealed 58 amino acid changes, and 42 novel amino acid haplotypes were identified. Polymorphism was higher in the C-terminal Th2R/Th3R epitope (π = 0.0293, n = 123) region compared to the overall combined nonrepeat regions (π = 0.0120, n = 123). Negative natural selection was observed within the nonrepeat regions of the CSP gene. Within the C-terminal Th2R/Th3R epitope regions, there was evidence of slight positive selection. Based on haplotype network analysis of the Th2R/Th3R regions, five abundant haplotypes were identified. Sharing of haplotypes between humans and macaques were observed. CONCLUSION: This study contributes to the understanding of the type and distribution of naturally occurring polymorphism in the P. knowlesi CSP gene. This study also provides a measurement of the genetic diversity of P. knowlesi and identifies the predominant haplotypes within Malaysia based on the C-terminal Th2R/Th3R regions.

Genetic polymorphism in domain I of the apical membrane antigen-1 among Plasmodium knowlesi clinical isolates from Peninsular Malaysia.

The simian malaria parasite Plasmodium knowlesi is now recognized as a species that can cause human malaria. The first report of large scale human knowlesi malaria was in 2004 in Malaysia Borneo. Since then, hundreds of human knowlesi malaria cases have been reported in Southeast Asia. The present study investigates the genetic polymorphism of P. knowlesi DI domain of the apical membrane antigen-1 (AMA-1), a protein considered as a promising vaccine candidate for malaria. The DI domain of AMA-1 gene of P. knowlesi clinical isolates from Peninsular Malaysia was amplified by PCR, cloned into Escherichia coli, then sequenced and analysed. Ninety-seven DI domain sequences were obtained. Comparison at the nucleotide level against P. knowlesi strain H as reference sequence showed 21 synonymous and 25 nonsynonymous mutations. Nonetheless, nucleotide sequence analysis revealed low genetic diversity of the DI domain, and it was under purifying (negative) selection. At the amino acid level, 26 different haplotypes were identified and 2 were predominant haplotypes (H1, H2) with high frequencies. Phylogenetic analysis revealed that the 26 haplotypes could be clustered into 2 distinct groups (I and II). Members of the groups were basically derived from haplotypes H1 and H2, respectively.

On Equivalence of FIS and ELM for Interpretable Rule-Based Knowledge Representation.

This paper presents a fuzzy extreme learning machine (F-ELM) that embeds fuzzy membership functions and rules into the hidden layer of extreme learning machine (ELM). Similar to the concept of ELM that employed the random initialization technique, three parameters of F-ELM are randomly assigned. They are the standard deviation of the membership functions, matrix-C (rule-combination matrix), and matrix-D [don't care (DC) matrix]. Fuzzy if-then rules are formulated by the rule-combination Matrix of F-ELM, and a DC approach is adopted to minimize the number of input attributes in the rules. Furthermore, F-ELM utilizes the output weights of the ELM to form the target class and confidence factor for each of the rules. This is to indicate that the corresponding consequent parameters are determined analytically. The operations of F-ELM are equivalent to a fuzzy inference system. Several benchmark data sets and a real world fault detection and diagnosis problem have been used to empirically evaluate the efficacy of the proposed F-ELM in handling pattern classification tasks. The results show that the accuracy rates of F-ELM are comparable (if not superior) to ELM with distinctive ability of providing explicit knowledge in the form of interpretable rule base.

Preoperative cardiac assessment for patients with infrarenal abdominal aortic aneurysms: a survey of current practice by vascular surgeons in New South Wales and Australian Capital Territory.

BACKGROUND: The reported mortality rate following open elective repair of abdominal aortic aneurysm (AAA) varies between 0 and 12%. Much of the mortality and major morbidity is caused by cardiac events. The evidence regarding best practice for cardiac assessment and optimization of this patient group is unclear. The aim of the present study was to evaluate current practice of cardiac risk factor assessment by vascular surgeons in New South Wales (NSW) and Australian Capital Territory (ACT) for patients undergoing open elective repair of infrarenal AAA. METHODS: A postal questionnaire was sent to 46 surgeons in NSW and ACT identified as expressing a principal or major interest in vascular surgery. If no response was received within 3 weeks, a second questionnaire was sent and if no response was received after the second mailing, a telephone survey of non-responders was conducted. Data were collated regarding the importance of risk factors elicited by clinical history, preoperative investigation, referral for cardiological opinion, use of perioperative beta-blockade and the timing of aortic surgery in relation to coronary artery revascularization and acute myocardial infarction. RESULTS: The overall response rate was 87% (40/46) and the median (range) response time was 14 (4-109) days. Only 22 of 40 and 23 of 40 surgeons consider diabetes mellitus or renal impairment, respectively, to be important when assessing cardiac risk and 34 of 40 surgeons do not employ a validated risk index in preoperative assessment. Sixteen of 40 surgeons refer all patients needing AAA repair to a cardiologist, while 24 of 40 would initiate cardiac investigations themselves (either stress electrocardiography, scintigraphy or echocardiography). Seventeen surgeons always or usually commenced perioperative beta-blockade with wide variations in the commencement (1 to > 28 days preoperatively) and duration (< 1 week to > 28 days postoperatively) of treatment. The timing of AAA repair following coronary revascularization ranged from < 1 week to 6 months and delay in surgical repair of AAA following myocardial infarction ranged from < 1 week to > 6 months. CONCLUSION: Preoperative assessment of cardiac risk in patients for repair of AAA lacks consensus among vascular surgeons in NSW and ACT. The diversity of clinical practice may rest with the paucity of prospective trials published in the medical literature or the influence of local institutional facilities.

Novel sulfation of curdlan assisted by ultrasonication.

This study carried out a novel sulfation process on curdlan. Results document that sulfation of the polysaccharide was more effective with the assistance of ultrasonication. Ultrasonication significantly increased the DS value of samples by almost fourfold (from about 0.030 to 0.115). Evaluation of the extent of sulfation has been made using FTIR, (1)H NMR, (13)C NMR and SEC. Both FTIR and (1)H NMR spectra confirmed the occurrence of sulfation. The combined effect of ultrasonication and acid resulted in relatively small molecular weights (e.g., sample 360_360: MW approximately 49.0 kDa), as opposed to curdlan (MW approximately 807 kDa). This work contributes to better understanding of the molecular mechanism governing the sonochemical processes of polysaccharide modification with improved physicochemical properties, and potential biomedical application.

Atypical presentation of intramedullary spinal cord lesion.

We report a patient who presented with atypical clinical manifestations including worsening abdominal pain from an intramedullary spinal cord lesion. It is important to consider non-abdominal causes of abdominal pain for patients with an atypical presentation. The described case demonstrates the challenges facing the physician with the early diagnosis of acute abdominal pain. Spinal cord lesions, although uncommon, remain a potentially disabling and life-threatening cause of abdominal pain.