Coronary artery complications with left bundle branch area pacing: A review of literature.

Left bundle branch area pacing (LBBAP) is an emerging technique in cardiac resynchronization therapy that shows promise in improving ventricular synchrony and clinical outcomes in patients with heart failure. However, the potential risk of coronary artery complications with LBBAP necessitates careful attention and management. This literature review explores the mechanisms, acute coronary events, and clinical implications associated with coronary artery complications in LBBAP. The mechanism of coronary injury with LBBAP involves mechanical trauma, altered coronary blood flow dynamics, and endothelial damage. Acute coronary events such as myocardial ischemia, acute coronary syndromes, and coronary artery dissection can occur during or after LBBAP, leading to significant clinical implications including the need for prompt intervention and potential impact on long-term outcomes. To avoid coronary injury and acute coronary syndrome with LBBAP, specific care strategies are recommended. These include thorough pre-procedural evaluation, expert operator technique, optimization of hemodynamics and ventricular synchrony, close monitoring for ischemic events, collaboration with cardiology specialists, and long-term follow-up. The clinical implications of coronary artery complications with LBBAP necessitate careful patient selection, informed decision-making, and a multidisciplinary approach. Future directions in this field include advancements in procedural techniques, technological innovations, risk stratification strategies, enhanced imaging modalities, research on mechanisms and prevention, and collaboration among stakeholders. By implementing these strategies and focusing on future advancements, healthcare providers can minimize the risk of coronary artery complications with LBBAP and optimize patient outcomes in cardiac resynchronization therapy.

AALLA: Attack-Aware Logical Link Assignment Cost-Minimization Model for Protecting Software-Defined Networks against DDoS Attacks.

Software-Defined Networking (SDN), which is used in Industrial Internet of Things, uses a controller as its "network brain" located at the control plane. This uniquely distinguishes it from the traditional networking paradigms because it provides a global view of the entire network. In SDN, the controller can become a single point of failure, which may cause the whole network service to be compromised. Also, data packet transmission between controllers and switches could be impaired by natural disasters, causing hardware malfunctioning or Distributed Denial of Service (DDoS) attacks. Thus, SDN controllers are vulnerable to both hardware and software failures. To overcome this single point of failure in SDN, this paper proposes an attack-aware logical link assignment (AALLA) mathematical model with the ultimate aim of restoring the SDN network by using logical link assignment from switches to the cluster (backup) controllers. We formulate the AALLA model in integer linear programming (ILP), which restores the disrupted SDN network availability by assigning the logical links to the cluster (backup) controllers. More precisely, given a set of switches that are managed by the controller(s), this model simultaneously determines the optimal cost for controllers, links, and switches.

Seizing the Connection: Exploring the Interplay Between Epilepsy and Glycemic Control in Diabetes Management.

Epilepsy, a neurological disorder characterized by recurrent seizures, and diabetes, a metabolic disorder characterized by impaired regulation of glucose levels, are two distinct conditions that may appear unrelated at first glance. Nevertheless, recent scholarly investigations have revealed these entities' intricate and ever-evolving interplay. This review initially delves into the intricate interplay between epilepsy and its potential ramifications on glycemic control. Seizures, particularly those accompanied by convulsive manifestations, have the potential to induce acute perturbations in blood glucose levels via diverse mechanisms, encompassing the liberation of stress hormones, the emergence of insulin resistance, and the dysregulation of the autonomic nervous system. Comprehending these intricate mechanisms is paramount in customizing productive strategies for managing diabetes in individuals with epilepsy. On the contrary, it is worth noting that diabetes can substantially impact the trajectory and control of epilepsy. The correlation between hyperglycemia and an elevated susceptibility to seizures, as well as the potential for exacerbating the intensity of epilepsy, has been established. This narrative review offers a concise exposition of the intricate interplay between epilepsy and glycemic control within diabetes management. The objective of exploring reciprocal influences, underlying mechanisms, and common risk factors is to augment the clinical comprehension of this intricate interconnection. In essence, this acquired knowledge possesses the potential to serve as a guiding compass for healthcare professionals, enabling them to craft bespoke therapeutic approaches that enhance the holistic welfare of individuals grappling with the coexistence of epilepsy and diabetes.

Fostering disaster mitigation through community participation- case of Kochi residents following the Kerala floods of 2018 and 2019.

Community participation has grown in prominence in mitigating disasters globally. It involves the active involvement in search and rescue to reconstruction that people affected by disasters undertake unsolicited. Predictive power in disaster recovery has further increased its relevance. However, quantitative analysis that community participation has on disaster mitigation measures is scant. The study analyses community participation's impact on disaster mitigation measures following the Kochi flood of 2018 and 2019 in India. We use a Multivariate Probit Regression model with a sample size of 750 to analyse the relationship between disaster mitigation measures (namely, disaster event planning, previous experience, following disaster-related news closely, and neighbourhood relationship) and community participation. The results show participants who were active in community events were 23% more likely to adopt all the disaster mitigation measures than those who did not. In addition, households with special needs members were more likely to be prepared for an unanticipated event. The results also showed higher education levels directly correlated to implementing more significant disaster mitigation measures. Implications for government policy formation include schemes to enhance community rehabilitation and promote social participation to mitigate future disaster events.

Modelling a community resilience index for urban flood-prone areas of Kerala, India (CRIF).

Communities are ever-evolving, cities are constantly expanding, and the threat of natural hazards has escalated like never before. Cities can develop and prosper only if their society is resilient to external shocks. Measuring community resilience over time is crucial with the influence of technology and change in community lifestyles. With the frequent onset of floods in Kerala in recent years, the community must be well-prepared for future calamities. Thus, this paper develops a community resilience index for Kerala's urban flood-prone areas (CRIF) through a rigorous bottom-up approach. The criteria for the index were developed using multi-criteria decision analysis that covered a fuzzy Delphi study, an empirical study using multi-variate probit regression, and an AHP analysis. The fuzzy Delphi study selected seven criteria: 'social', 'economical', 'governance/political', 'health', 'communication/coordination, 'education', and 'infrastructure' from 65 experts. The empirical study helped apprehend the public's viewpoints under each criterion. Finally, the AHP analysis helped assign appropriate weights to the criteria which 28 experts designated. The index is also designed according to the Sendai Framework for Disaster Risk Reduction (2015-2030). Further, the CRIF Index is put into action through a case study of the Kochi Municipal Corporation area, and the results are also validated using the Spearman's rank correlation coefficient method. Results from validation returned a value of 0.7209 for the perceived CRIF method and 0.5798 for the external validation method, which corresponds to a 'high' and 'moderate' correlation, respectively. Supplementary Information: The online version contains supplementary material available at 10.1007/s11069-022-05299-7.

Design, Development and Evaluation of Thermal Properties of Polysulphone-CNT/GNP Nanocomposites.

Polysulphone (PSU) composites with carbon nanotubes (PSU-CNT) and graphene nanoplatelets (PSU-GNP) were developed through the solution casting process, using various weight load percentages of 1, 3, 5, and 10 wt% of CNT and GNP nanofillers. The microstructural and thermal properties of the PSU-based composites were compared. The microstructural characterisation of both composites (PSU-CNTs and PSU-GNPs) showed a strong matrix-filler interfacial interaction and uniform dispersion of CNTs and GNPs in the PSU matrix. The analysis demonstrated that both the thermal conductivity and effusivity improved with the increase in the weight percentage (wt%) of CNTs and GNPs because of the percolation effect. The polysulphone-based composite containing 10 wt% CNTs showed a remarkably high thermal conductivity value of 1.13 (W/m·K), which is 163% times higher than pure PSU. While the glass transition temperature (Tg) was shifted to a higher temperature, the thermal expansion was reduced in all the PSU-CNT and PSU-GNP composites. Interestingly, the CNTs allowed homogeneous distribution and a reasonably good interfacial network of interaction with the PSU matrix, leading to better microstructural characteristics and thermal properties than those of the PSU-GNP composites. The findings highlight the importance of controlling the nature, distribution, and content of fillers within the polymeric matrix.

Loss of Wasl improves pancreatic cancer outcome.

Several studies have suggested an oncogenic role for the neural Wiskott-Aldrich syndrome protein (N-WASP, encoded by the Wasl gene), but thus far, little is known about its function in pancreatic ductal adenocarcinoma (PDAC). In this study, we performed in silico analysis of WASL expression in PDAC patients and found a correlation between low WASL expression and prolonged survival. To clarify the role of Wasl in pancreatic carcinogenesis, we used 2 oncogenic Kras-based PDAC mouse models with pancreas-specific Wasl deletion. In line with human data, both mouse models had an increased survival benefit due to either impaired tumor development in the presence of the tumor suppressor Trp53 or the delayed tumor progression and senescent phenotype upon genetic ablation of Trp53. Mechanistically, loss of Wasl resulted in cell-autonomous senescence through displacement of the N-WASP binding partners WASP-interacting protein (WIP) and p120ctn; vesicular accumulation of GSK3ß, as well as YAP1 and phosphorylated ß-catenin, which are components of the destruction complex; and upregulation of Cdkn1a(p21), a master regulator of senescence. Our findings, thus, indicate that Wasl functions in an oncogenic manner in PDAC by promoting the deregulation of the p120-catenin/ß-catenin/p21 pathway. Therefore, strategies to reduce N-WASP activity might improve the survival outcomes of PDAC patients.

Iatrogenic Spinal Epidural Hematoma Associated with Intracranial Hypotension.

Epidural steroid injections (ESIs) are one of the few modalities currently in use for treating chronic spinal pain. There are two approaches: interlaminar ESIs and transforaminal ESIs. Complications arising from either approach are rare, but one such complication is cerebrospinal fluid (CSF) leak leading to intracranial hypotension. Even rarer is the development of iatrogenic spinal epidural hematoma in the context of the injections. Interestingly, an association with intracranial hypotension and spinal epidural hematoma has yet to be established. Even the characteristics of an iatrogenic spinal epidural hematoma are not well defined as there are different theories of how this develops and whether we are dealing with arterial or venous blood. Our case is unique as it appears our patient had developed not one, but both clinical symptoms supportive of intracranial hypotension from a CSF leak induced iatrogenically from a cervical epidural injection and imaging demonstrated thoracic-level spinal epidural hematoma. It is unclear whether the injection directly led to the spinal leak causing the intracranial hypotension, which then brought on the formation of the hematoma or if the injection led to both intracranial hypotension and hematoma formation independent of each other. From a clinical practice standpoint, given our case suggests the hematoma was concomitantly associated with intracranial hypotension, and the possibility exists that the hematoma may have formed in the context of the intracranial hypotension, then targeted blood patches may need to be done with greater urgency to preventing hematoma formation. Further studies are needed involving clotting factors comparing arterial and venous blood. It is also puzzling why the epidural blood from the hematoma did not clot the leak. This concomitancy deserves further attention and may lead to changes in how we manage cervical epidural injection patients who are found to have CSF leak and a spinal epidural hematoma.

Spinal Cord Stimulator Explant and Revision Complicated by Syrinx Formation: A Case Report and Literature Review.

Spinal cord stimulation (SCS) has been shown to be a safe, effective, and drug-free treatment option for many chronic pain conditions including refractory low back pain. The most commonly reported complication of SCS is equipment failure. We report a case of spinal cord injury (SCI) during SCS explant and revision. This 61-year-old female veteran complained of intermittent shock-like sensations 3-4 times a week for three months prior to her clinic visit. The device was initially implanted in 2009 secondary to neurogenic claudication with appropriate relief. The battery was replaced in 2015. Pain Management Service referred the patient to neurosurgery for replacement of the original SCS unit. Immediately following surgery she complained of severe left lower extremity pain concentrated in the medial thigh radiating into the groin and buttock. She also complained of pain, weakness and numbness in both legs (left more than right). Magnetic resonance imaging (MRI) revealed an edematous area in the left spinal cord between T11-T12. The patient was placed on steroids, ketamine infusion for pain control, and MRI the next day showed slight improvement of the edema and she was discharged home. Follow-up MRI two months later revealed mild diminution in the size of the cord edema. Her pre-operative shock-like sensations had not returned. While rare, spinal cord injury can occur and should be identified and managed expeditiously. Our case here reports for the first time an association between SCS explant/revision and syrinx formation.

Further Evidence that Onabotulinum Toxin is a Viable Treatment Option for Pediatric Chronic Migraine Patients.

Introduction Chronic migraine is particularly devastating. It affects school work, extracurricular activities, and quality of life, including relationships with other family members, and can also influence the mental health of both the migraineurs and family members. According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), chronic migraine is defined as 15 or more headache days per month for greater than three months, where at least on eight days per month, there are features of migraine headache. Although botulinum toxin type A (BoNTA) has been proven effective for treating chronic migraine in adults, little literature exists about its use in children. Here, we present the treatment response in children with chronic migraines treated with BoNTA at our institutions Duke and State University of New York (SUNY) Upstate. Method A retrospective analysis of 30 adolescent migraineurs who met ICHD-3 criteria for chronic migraine were treated with BoNTA injection according to the standardized adult protocol. Descriptive statistics and paired t-tests were performed. A total of 185 units of botulinum toxin were injected intramuscularly per patient, as in addition to the standard 31 sites for a total of 155 units, an additional 30 units were given in areas that were felt to provide further benefit. Results Participants (n=30) were 16.5 ± 1.83 years old. The headaches were precipitated by trauma in seven cases. All had failed standard pharmacotherapy, including amitriptyline and topiramate. An average of 2.47 ± 1.6 BoNTA injection cycles was performed. Migraine severity decreased significantly from 7.47 ± 1.89 on a 10-point scale to 4.34 ± 3.02 (p<.001). Additionally, headache frequency improved from 24.4 ± 7.49 painful days per month to 14.8 ± 12.52 painful days per month (p<.001). One patient developed nausea related to injections; all others tolerated it well, with no side effects. Discussion BoNTA injection was a safe and effective therapy for chronic migraine in our cohort of children recalcitrant to medical therapy. Further research with multi-centered, double-blinded, randomized, placebo-controlled trials is warranted to evaluate the long-term safety and efficacy in this population.

Use of Digital Infrared Thermal Imaging in the Electromyography Clinic: A Case Series.

INTRODUCTION: Foot drop often results from denervation of the dorsiflexor muscles in the leg. Neurological evaluation begins with lower extremity motor testing followed by electromyography needle electrode examination (EMG-NEE). We explored digital infrared thermography (IRT) as a complementary tool in diagnosing peripheral nerve disorders. METHODS: Using a digital IRT camera, we recorded differences in skin surface temperatures from affected and unaffected limbs in three patients with unilateral foot drop. Denervation in the affected limb was confirmed with EMG-NEE. RESULTS: IRT imaging revealed lower relative skin surface temperatures in regions of the leg corresponding to denervated dorsiflexor muscles for all three consecutive patients who presented to the EMG Clinic with foot drop.  Conclusions: Denervation appears to cause a decrease in thermal energy output from affected muscle groups. Alongside the EMG and magnetic resonance imaging (MRI), IRT may have an important role in assessing the severity and prognosis of a nerve injury. This observation may have implications for chronic pain syndromes, such as complex regional pain syndrome (CRPS), in which thermal change is a diagnostic criterion.

Presbylaryngis: a state-of-the-art review.

PURPOSE OF REVIEW: Presbylaryngis is the term used to describe changes in the larynx with ageing. It represents an increasingly common complaint as global populations continue to grow and get older. Presbylaryngis has a significantly negative impact on patients' quality of life and their ability to participate in society. This article will review the relevant literature on the incidence, pathophysiology, clinical evaluation, and treatment modalities for presbylaryngis. RECENT FINDINGS: The recently developed Ageing Voice Index (AVI) constitutes the first validated instrument for voice complaints specifically for the elderly. The evidence suggests that the bedrock of treating presbylaryngis centres on voice therapy. Thus, voice therapy should represent the primary treatment offered with surgery reserved for those failing to adequately respond. However, the comparative effectiveness of the different surgical interventions, namely injection laryngoplasty and thyroplasty, remains undetermined highlighting the need for larger, prospective, comparative studies. SUMMARY: Presbylaryngis is characterized by specific changes at the microscopic level resulting in age-related vocal fold atrophy. However, its presence alone does not always result in symptomatic dysphonia and equally, presbyphonia is often multifactorial involving the lower respiratory tract in addition to the larynx. Thus, the role of a multidisciplinary voice clinic for presbylaryngis cannot be overstated.

A new frog species from the central western Ghats of India, and its phylogenetic position.

Tropical evergreen forests of Indian subcontinent, especially of the Western Ghats, are known hot spots of amphibian diversity, where many new anuran species await to be identified. Here we describe from the Sharavathi River basin of central Western Ghats a new shrub-frog taxon related to the anuran family Rhacophoridae. The new frog possesses the characteristic features of rhacophorids (dilated digit tips with differentiated pads circumscribed by a complete groove, intercalary cartilages on digits, T-shaped terminal phalanges and granular belly, the adaptive characters for arboreal life forms), but also a suite of unique features that distinguish it from all known congeners in the region. Morphogenetic analysis based on morphological characteristics and diversity in the mitochondrial 12S and 16S rRNA genes revealed it to be a new Philautus species that we named Philautus neelanethrus sp. nov. The phylogenetic analysis suggests the new frog to represent a relatively early Philautus species lineage recorded from the region. The distribution pattern of the species suggests its importance as a bioindicator of habitat health. In general, this relatively widespread species was found distributed only in non-overlapping small stretches, which indirectly indicates the fragmentation of the evergreen to moist deciduous forests that characterize the Western Ghats. Thus the discovery of the new rhacophorid species described here not only further reinforces the significance of the Western Ghats as a major hotspot of amphibian biodiversity, but also brings into focus the deterioration of forest habitats in the region and the need for prioritization of their conservation.

Postoperative conversion disorder.

Conversion disorder is a psychiatric disorder in which psychological stress causes neurologic deficits. A 28-year-old female surgical patient had uneventful general anesthesia and emergence but developed conversion disorder 1 hour postoperatively. She reported difficulty speaking, right-hand numbness and weakness, and right-leg paralysis. Neurologic examination and imaging revealed no neuronal damage, herniation, hemorrhage, or stroke. The patient mentioned failing examinations the day before surgery and discontinuing her prescribed antidepressant medication, leading us to diagnose conversion disorder, with eventual confirmation by neuroimaging and follow-up examinations.

Topical, Biological and Clinical Challenges in the Management of Patients with Acne Vulgaris.

Acne vulgaris is one of the most common chronic inflammatory skin disorders among adolescents and young adults. It is associated with substantial morbidity and, rarely, with mortality. The exact worldwide incidence and prevalence are currently unknown. Current challenges involve improving understanding of the underlying pathophysiology of acne vulgaris and developing a practical treatment consensus. Expert panel discussions were held in 2013 and 2014 among a group of scientists and clinicians from the Omani and United Arab Emirate Dermatology Societies to ascertain the current optimal management of acne vulgaris, identify clinically relevant end-points and construct suitable methodology for future clinical trial designs. This article reviews the discussions of these sessions and recent literature on this topic.

Differential expression of human COMT alleles in brain and lymphoblasts detected by RT-coupled 5' nuclease assay.

RATIONALE: A common polymorphism, Val158Met, alters catechol- O-methyltransferase (COMT) enzyme activity and has been linked to psychiatric phenotypes. Bray et al. (2003) reported that COMT is subject to differential allele expression in brain, finding modest (13-22%) underexpression of a haplotype containing Val158. However, disparate findings by another group who used the same method, but in lymphoblasts, raise the issues of tissue specificity, magnitude of differential expression, and identity of loci altering expression. OBJECTIVES: We measured COMT allele expression ratios in heterozygous human lymphoblast cell lines and brains. METHODS: Using transcribed single nucleotide polymorphisms as endogenous reporters, we developed an RT-coupled 5' nuclease assay for allele expression ratios and applied it to 63 COMT rs4818(C>G) heterozygotes and 68 Val158Met [rs4680(G>A)] heterozygotes. RESULTS: For rs4818(C>G), the C allele was overexpressed relative to the G allele in 18 of 27 lymphoblast lines and 23 of 36 brains. For Val158Met, Met158 was overexpressed relative to Val158 in all (29 of 29) lymphoblast lines and all (39 of 39) brains. Each of the 22 rs4818 heterozygotes without differential allele expression was a Val158/Val158 homozygote. The Met158 allele was overexpressed by 65-77% when compared with Val158 in lymphoblasts and brain. Haplotype augmented ability to predict expression in brain only. However, the expression of the Val158 allele on the high-expressing haplotype was only 19% higher than Val158 alleles on the other haplotype background. CONCLUSIONS: COMT alleles are differentially expressed. The Met158 allele predicts higher mRNA expression in both brain and lymphoblasts. As exemplified here, the RT-coupled 5' nuclease assay is a reliable method for the quantitative evaluation of cis-acting regulatory effects.

Multimedia education increases elder knowledge of emergency department care.

INTRODUCTION: Elders who utilize the emergency department (ED) may have little prospective knowledge of appropriate expectations during an ED encounter. Improving elder orientation to ED expectations is important for satisfaction and health education. The purpose of this study was to evaluate a multi-media education intervention as a method for informing independently living elders about ED care. The program delivered messages categorically as, the number of tests, providers, decisions and disposition decision making. METHODS: Interventional trial of representative elders over 59 years of age comparing pre and post multimedia program exposure. A brief (0.3 hour) video that chronicled the key events after a hypothetical 911 call for chest pain was shown. The video used a clinical narrator, 15 ED health care providers, and 2 professional actors for the patient and spouse. Pre- and post-video tests results were obtained with audience response technology (ART) assessed learning using a 4 point Likert scale. RESULTS: Valid data from 142 participants were analyzed pre to post rankings (Wilcoxon signed-rank tests). The following four learning objectives showed significant improvements: number of tests expected [median differences on a 4-point Likert scale with 95% confidence intervals: 0.50 (0.00, 1.00)]; number of providers expected 1.0 (1.00, 1.50); communications 1.0 (1.00, 1.50); and pre-hospital medical treatment 0.50 (0.00, 1.00). Elders (96%) judged the intervention as improving their ability to cope with an ED encounter. CONCLUSION: A short video with graphic side-bar information is an effective educational strategy to improve elder understanding of expectations during a hypothetical ED encounter following calling 911.

Effect of heated and humidified carbon dioxide on patients after laparoscopic procedures: a meta-analysis.

OBJECTIVE: To systematically analyze the role of heated humidified carbon dioxide (CO2) in laparoscopy. METHODS: Clinical trials on laparoscopic procedures using standard dry CO2 versus heated humidified CO2 for pneumoperitoneum were analyzed. RESULTS: Ten randomized controlled trials on 565 patients were analyzed. In both the fixed and random effect models, postoperative pain was significantly less in heated humidified CO2 group. Heated humidified CO2 group was also associated with significantly lower risk of hypothermia and lower analgesic requirement. However, statistically there was no difference in total hospital stay and lens fogging rate. CONCLUSIONS: The use of heated humidified CO2 for pneumoperitoneum in laparoscopic procedures is associated with lesser postoperative pain, lower risk of postoperative hypothermia, and lower analgesic requirements. However, total hospital stay and lens fogging rates do not differ. Hence, the heated and humidified CO2 may be considered as the first choice for pneumoperitoneum in laparoscopic procedures.