An Unusual Case of Takotsubo Cardiomyopathy with Cardiac Arrest: The Importance of Clinical Context in Implanted Cardioverter Defibrillator Candidacy.

Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, is characterized by acute heart failure, reversible left ventricular dysfunction, and other complications such as life-threatening arrhythmias. The management of TTS is challenging due to its unpredictable clinical course and the lack of evidence-based treatment recommendations. In this case report, we present a 71-year-old female who developed TTS with ventricular tachycardia (VT) cardiac arrest following septic shock and an exploratory laparotomy for appendicitis. Despite the presence of VT cardiac arrest and a left ventricular ejection fraction of 30-35%, an implanted cardioverter-defibrillator (ICD) was not indicated due to the rapid and satisfactory recovery of the patient's ventricular function. This case highlights the importance of considering the clinical context and the transient nature of TTS in the decision-making process for ICD candidacy.

A Hybrid Approach for Alluring Ads Phishing Attack Detection Using Machine Learning.

Phishing attacks are evolving with more sophisticated techniques, posing significant threats. Considering the potential of machine-learning-based approaches, our research presents a similar modern approach for web phishing detection by applying powerful machine learning algorithms. An efficient layered classification model is proposed to detect websites based on their URL structure, text, and image features. Previously, similar studies have used machine learning techniques for URL features with a limited dataset. In our research, we have used a large dataset of 20,000 website URLs, and 22 salient features from each URL are extracted to prepare a comprehensive dataset. Along with this, another dataset containing website text is also prepared for NLP-based text evaluation. It is seen that many phishing websites contain text as images, and to handle this, the text from images is extracted to classify it as spam or legitimate. The experimental evaluation demonstrated efficient and accurate phishing detection. Our layered classification model uses support vector machine (SVM), XGBoost, random forest, multilayer perceptron, linear regression, decision tree, naïve Bayes, and SVC algorithms. The performance evaluation revealed that the XGBoost algorithm outperformed other applied models with maximum accuracy and precision of 94% in the training phase and 91% in the testing phase. Multilayer perceptron also worked well with an accuracy of 91% in the testing phase. The accuracy results for random forest and decision tree were 91% and 90%, respectively. Logistic regression and SVM algorithms were used in the text-based classification, and the accuracy was found to be 87% and 88%, respectively. With these precision values, the models classified phishing and legitimate websites very well, based on URL, text, and image features. This research contributes to early detection of sophisticated phishing attacks, enhancing internet user security.

Right Atrial and Endocardial Lead Mass Secondary to Anterior Mediastinal Mass Encasing Left Subclavian Vein.

INTRODUCTION: Multimodality cardiac imaging is a valuable tool for the noninvasive evaluation of right atrial masses (tumor, vegetation, or thrombus). CASE PRESENTATION: We report a case of right atrial mass that was discovered on a transthoracic echocardiogram ordered for pacemaker-pocket erythema in a 101-year-old man with heart failure/reduced left-ventricular ejection fraction and a dual-chamber pacemaker. Transthoracic and transesophageal echocardiogram showed a large hypoechoic mobile RA mass extending from the superior vena cava, with pacemaker device lead attachment. Infective endocarditis was excluded (no symptoms of systemic infection; negative blood cultures). CT angiography of the chest revealed an anterior mediastinal mass, highly suspicious for malignancy, encasing the left subclavian vein. The patient chose not to pursue invasive assessment of the mediastinal mass. Role of anticoagulation is unclear. CONCLUSION: Computed tomography complemented echocardiographic assessment and management of a right atrial mobile echo density due to a large anterior mediastinal mass.

Transient Complete Atrioventricular Block Associated With Herbal Supplement Use.

INTRODUCTION: Increasing and easy availability of so-called natural/herbal supplements pose the unique challenge of identifying associated side effects, including arrhythmias in otherwise-healthy individuals. CASE PRESENTATION: A 25-year-old female patient presented to the emergency department with fatigue and lightheadedness. The electrocardiogram showed complete AV block with a junctional escape rhythm at 55 beats per minute with QT prolongation (542ms). One week ago, she started to use a herbal medication (Muscle Eze Advanced) for muscle cramps after workouts. Extensive cardiac testing, including complete blood count, complete metabolic panel, TSH, transthoracic echocardiography, urine drug analysis, Lyme antibody were negative. Normal sinus rhythm was restored spontaneously within 1 day of discontinuing the herbal medication. PR and corrected QT intervals returned to baseline over the next two weeks. CONCLUSION: Muscle Eze Advanced consists of seven ingredients, including Melissa officinalis and Valeriana officinalis that have negative chronotropic, negative dromotrophic and QT prolonging effects. Recognizing the association between certain over-the-counter supplements and brady-arrhythmias may circumvent need for permanent pacemakers - an important consideration especially in the young.

Balanced Energy-Aware and Fault-Tolerant Data Center Scheduling.

Fault tolerance, performance, and throughput have been major areas of research and development since the evolution of large-scale networks. Internet-based applications are rapidly growing, including large-scale computations, search engines, high-definition video streaming, e-commerce, and video on demand. In recent years, energy efficiency and fault tolerance have gained significant importance in data center networks and various studies directed the attention towards green computing. Data centers consume a huge amount of energy and various architectures and techniques have been proposed to improve the energy efficiency of data centers. However, there is a tradeoff between energy efficiency and fault tolerance. The objective of this study is to highlight a better tradeoff between the two extremes: (a) high energy efficiency and (b) ensuring high availability through fault tolerance and redundancy. The main objective of the proposed Energy-Aware Fault-Tolerant (EAFT) approach is to keep one level of redundancy for fault tolerance while scheduling resources for energy efficiency. The resultant energy-efficient data center network provides availability as well as fault tolerance at reduced operating cost. The main contributions of this article are: (a) we propose an Energy-Aware Fault-Tolerant (EAFT) data center network scheduler; (b) we compare EAFT with energy efficient resource scheduling techniques to provide analysis of parameters such as, workload distribution, average task per servers, and energy consumption; and (c) we highlight effects of energy efficiency techniques on the network performance of the data center.

Post COVID-19 Large Atrial Thrombus Found Incidentally.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has become a leading cause of morbidity and mortality worldwide. One of the major complications of COVID-19 infection is the hypercoagulability state. Cardiac thrombi and venous thromboembolism (VTE) have been documented with severe COVID-19 infection. We present a case of large right atrial (RA) thrombus in transit incidentally diagnosed following a mild COVID-19 in a previously vaccinated patient. CASE SUMMARY: An 85-year-old male presented to the emergency department two weeks following resolution of a mild COVID-19 infection due to an incidentally discovered large RA thrombus. Computed tomography with angiography of the chest was positive for acute pulmonary thromboembolic disease with large clot burden and findings consistent with right heart strain. The patient remained hemodynamically stable and was successfully managed with anticoagulation. CONCLUSION: RA thrombi and VTE can occur in patients with mild COVID-19 infection and in the setting of full COVID-19 vaccination. Echocardiography is a useful imaging modality in this patient population.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA) in a Patient Taking Lisdexamfetamine.

Stimulant medications like amphetamines have been associated with various cardiovascular complications like coronary artery spasm, coronary dissections and thrombus formation, the pathophysiology of which is theorized to be the endothelial damage induced by the medication and the inflammatory cascade that follows. We report a case of 52-year-old male on lisdexamfetamine, a newer stimulant agent used for attention deficit hyperactivity disorder (ADHD) who presented with sudden chest pain and ECG changes concerning for myocardial infarction and mildly elevated troponins. However, coronary angiogram showed no obstructive coronary artery disease and there was spontaneous resolution of his symptoms and ECG changes.

Delayed Presentation of Inferior STEMI Complicated by Ventricular Septal Rupture: An Indirect Consequence of the COVID-19 Pandemic.

The COVID-19 pandemic has adversely impacted healthcare delivery. An indirect consequence of the rational fear of contracting the virus is delayed medical attention for life threatening conditions. We present the case of inferior ST elevation myocardial infarction leading to the rare complication of a ventricular septal rupture reflecting transmural infarction. COVID hesitancy caused a 48-hour delay in seeking medical attention after symptom onset. We also discuss the use of MRI to guide decision for timing of VSD repair in an otherwise asymptomatic patient post-revascularization.

Heart Failure with Preserved Ejection Fraction: Concise Review.

Heart failure with preserved ejection fraction (HFpEF) is a highly prevalent disease, causing a significant burden to the elderly population. Due to the inconsistencies in the standard definition and criteria for diagnosis, HFpEF is often underdiagnosed and left untreated. Although diastolic dysfunction is one of the key driving factors of the disease process, other factors like systolic limitations, endothelial dysfunction, arterial stiffness, and poor ventricular-arterial coupling are also contributing factors. While various treatment modalities have been investigated, the management continues to remain supportive. This review highlights the various American College of Cardiology/American Heart Association and European Society of Cardiology definitions, pathophysiology, and current treatment modalities available for HFpEF.

Cluster Analysis and Model Comparison Using Smart Meter Data.

Load forecasting plays a crucial role in the world of smart grids. It governs many aspects of the smart grid and smart meter, such as demand response, asset management, investment, and future direction. This paper proposes time-series forecasting for short-term load prediction to unveil the load forecast benefits through different statistical and mathematical models, such as artificial neural networks, auto-regression, and ARIMA. It targets the problem of excessive computational load when dealing with time-series data. It also presents a business case that is used to analyze different clusters to find underlying factors of load consumption and predict the behavior of customers based on different parameters. On evaluating the accuracy of the prediction models, it is observed that ARIMA models with the (P, D, Q) values as (1, 1, 1) were most accurate compared to other values.

Segmental Coronary Vasospasm Mimicking ST-Elevation Myocardial Infarction in an Incidentally COVID-Positive Patient.

Coronary vasospasm is an underdiagnosed cause of myocardial infarction in the absence of obstructive coronary artery disease. Systemic inflammation is one of several triggers associated with coronary vasospasm. We report the case of a 47-year woman incidentally found to be COVID-positive (RT-PCR) during evaluation of constitutional symptoms and breast cellulitis. Later in the hospitalization, she developed sudden-onset typical angina at rest; 12 lead EKG showed inferolateral ST-elevations. Urgent coronary angiogram showed nitrate-responsive subtotal focal occlusions in the right coronary and circumflex arteries. In the absence of sepsis, it is difficult to attribute coronary vasospasm solely to cellulitis. Focal coronary artery spasm mimicking ST-elevation myocardial infarction successfully managed solely with intracoronary nitroglycerine in an incidentally COVID-positive patient adds to the diverse manifestations of COVID infection. The exact mechanism of focal, as opposed to diffuse coronary vasospasm is unclear.

Index Case of COVID-19 Myocarditis Requiring BiV-ICD for Primary Prevention of Sudden Cardiac Death.

INTRODUCTION: The severity of clinical presentation of COVID-19 myocarditis ranges from incidental identification of depressed left ventricular ejection fraction, cardiogenic shock requiring percutaneous mechanical circulatory support, to fatal fulminant myocarditis. In previously reported cases, surviving patients experienced improvement in left ventricular ejection fraction with the use of glucocorticoids and antivirals (+/- intravenous immunoglobulin/ convalescent plasma). We report the first case of COVID-myocarditis in a surviving patient where a persistently depressed left ventricular ejection fraction (less than 35 percent) despite optimal therapy prompted implantable cardioverter-defibrillator (ICD) implantation for primary prevention of sudden cardiac death. CASE PRESENTATION: A previously healthy 67-year-old man, diagnosed with mild COVID-19 pneumonia five days prior, presented to the emergency department with suspected STEMI (hypoxia, substernal chest pain and known left bundle branch block). Left heart catheterization showed patent coronary arteries. Transthoracic echocardiogram showed severely depressed ejection fraction (15-20 percent). CT showed bilateral infiltrates: treatment was started with dexamethasone, remdesivir and convalescent plasma for acute hypoxic respiratory failure due to COVID-19 pneumonia. After a four-day hospitalization, guideline-directed medical therapy at maximum tolerated doses over three months did not improve left ventricular ejection fraction. CONCLUSION: This is the index case of COVID-19 myocarditis-mediated heart failure with reduced ejection fraction requiring ICD for primary prevention of sudden cardiac death.

Hybrid Multi-Level Detection and Mitigation of Clone Attacks in Mobile Wireless Sensor Network (MWSN).

Wireless sensor networks (WSNs) are often deployed in hostile environments, where an adversary can physically capture some of the sensor nodes. The adversary collects all the nodes' important credentials and subsequently replicate the nodes, which may expose the network to a number of other security attacks, and eventually compromise the entire network. This harmful attack where a single or more nodes illegitimately claims an identity as replicas is known as the node replication attack. The problem of node replication attack can be further aggravated due to the mobile nature in WSN. In this paper, we propose an extended version of multi-level replica detection technique built on Danger Theory (DT), which utilizes a hybrid approach (centralized and distributed) to shield the mobile wireless sensor networks (MWSNs) from clone attacks. The danger theory concept depends on a multi-level of detections; first stage (highlights the danger zone (DZ) by checking the abnormal behavior of mobile nodes), second stage (battery check and random number) and third stage (inform about replica to other networks). The DT method performance is highlighted through security parameters such as false negative, energy, detection time, communication overhead and delay in detection. The proposed approach also demonstrates that the hybrid DT method is capable and successful in detecting and mitigating any malicious activities initiated by the replica. Nowadays, crimes are vastly increasing and it is crucial to modify the systems accordingly. Indeed, it is understood that the communication needs to be secured by keen observation at each level of detection. The simulation results show that the proposed approach overcomes the weaknesses of the previous and existing centralized and distributed approaches and enhances the performance of MWSN in terms of communication and memory overhead.

Simultaneous effects of biochar and nitrogen fertilization on nitrous oxide and methane emissions from paddy rice.

Synthetic fertilizers are major agents of gaseous emissions including nitrous oxide (N2O), and rice cultivation is a primary source of methane (CH4) emission. Biochar (BC) addition to agricultural soils is a potential approach to mitigate N2O and CH4 emissions. This greenhouse study was conducted to assess the simultaneous effects of BC and nitrogen (N) fertilization to reduce N2O and CH4 emissions along with higher biomass accumulation in rice under controlled conditions. Nine treatment combinations of BC amendments at 0, 2 and 4% by weight (weight of BC/weight of soil) mixed into 3500 g of unsterile soil with 0, 70 and 140 kg N ha-1 were used in growing rice. Results show that BC-only treatments enhanced the volumetric water contents (VWC) by 9-14% and soil pH by 5-7% coupled with higher daily and cumulative seasonal CH4-C fluxes by 85-95% and 48-51%, respectively, compared with control treatment. Under 2% and 4% BC amendments, N at 140 kg ha-1 lowered the daily and cumulative seasonal CH4-C fluxes by 24-42% and 20-30%, respectively as compared to 70 kg N ha-1. Furthermore, BC amendments in N-treated soils reduced the daily and total seasonal N2O-N emissions by 27-67% and 49-61%, respectively, relative to N-only treatments. However, N addition in BC-amended soils showed 10-16% decreased VWC compared with the BC-only treated soils. In terms of rice growth, BC-only reduced the above- and below-ground biomass accumulation, delayed the tillering phase, and resulted in fewer vegetative tillers except for BC-treated pots with 140 kg N ha-1. Thus, this study suggests that the use of BC amendment at 2% with 140 kg N ha-1 may be a beneficial strategy to reduce the net GHG emissions from paddy rice in an Alfisol.

Comparison of the clinical presentations of Naegleria fowleri primary amoebic meningoencephalitis with pneumococcal meningitis: a case-control study.

BACKGROUND: Primary amoebic meningoencephalitis (PAM) is a rare but fatal infection caused by Naegleria fowleri. The infection is acquired by deep nasal irrigation with infected water. Patients present with signs and symptoms similar to pneumococcal meningitis, leading to delayed diagnosis and treatment and hence high mortality. METHODS: We conducted a case-control study comparing culture proven cases of PAM with pneumococcal meningitis presenting to our center between April 2008 and September 2014. Only patients with blood and/or cerebrospinal fluid cultures positive for Streptococcus pneumoniae during the same time period were included for comparison. RESULTS: There were 19 cases of PAM and pneumococcal meningitis, each. When comparing PAM with pneumococcal meningitis, patients with PAM were more likely to be male (89.5 vs. 36.8 %), younger (mean age: 30 vs. 59 years), present with seizures (42.1 vs. 5.3 %). Both groups of patients presented with similar vital signs and there were no remarkable differences on physical examinations, Glasgow Coma Scale scores, laboratory and radiological investigations and cerebrospinal fluid parameters. PAM was also more likely to present if the city's average maximum temperature was higher in the previous week (mean: 34.6 vs. 30 °C). There was history of fresh water contact in only one patient. On multivariate analysis, PAM was more likely if patients presented when the city's average maximum temperature was high, being young males. CONCLUSION: PAM and pneumococcal meningitis remain virtually indistinguishable; however, these predictive features should be validated in a prospective study and may lead to a viable algorithm for early management of these patients.

Impact of Air-Drying Temperatures on Drying Kinetics, Physicochemical Properties, and Bioactive Profile of Ginger.

Ginger (Zingiber officinale Roscoe) is a perishable commodity that requires proper processing to maintain its bioactivity. This study evaluated the effect of different air-drying temperatures (50 °C, 60 °C, and 70 °C) on ginger's drying kinetics and quality attributes. For an enhanced understanding of the drying kinetics, we employed a detailed approach by combining an existing drying model (namely, Midilli) with the Arrhenius model. This combined model facilitates a thorough analysis of how temperature and time concurrently affect the moisture ratio, offering more profound insights into the drying mechanism. A higher drying rate was achieved at 70 °C, yet elevated drying temperatures could compromise the quality attributes of ginger slices. Ginger slices dried at 50 °C displayed improved physicochemical properties and less color browning. The evaluation of the bioactivity profile of resultant ginger extracts also revealed higher total phenolic contents (1875.87 ± 31.40 mg GAE/100 g) and DPPH radical scavenging activity (18.2 ± 0.9 mg TE/kg) in 50 °C treated ginger samples. Meanwhile, the hydroethanolic mixture (70% ethanol) was also reorganized with better extraction efficiency than water and MWF (a ternary blend of methanol, water, and formic acid) solution. The promising outcomes of this study endorse the influence of drying temperature on the quality characteristics and bioactive profile of ginger and the selection of suitable extraction solvents to acquire phenolic-rich extract.

Clinical impact of preemptive pharmacogenomic testing on antiplatelet therapy in a real-world setting.

CYP2C19 genotyping to guide antiplatelet therapy after patients develop acute coronary syndromes (ACS) or require percutaneous coronary interventions (PCIs) reduces the likelihood of major adverse cardiovascular events (MACE). Evidence about the impact of preemptive testing, where genotyping occurs while patients are healthy, is lacking. In patients initiating antiplatelet therapy for ACS or PCI, we compared medical records data from 67 patients who received CYP2C19 genotyping preemptively (results >7 days before need), against medical records data from 67 propensity score-matched patients who received early genotyping (results within 7 days of need). We also examined data from 140 patients who received late genotyping (results >7 days after need). We compared the impact of genotyping approaches on medication selections, specialty visits, MACE and bleeding events over 1 year. Patients with CYP2C19 loss-of-function alleles were less likely to be initiated on clopidogrel if they received preemptive rather than early or late genotyping (18.2%, 66.7%, and 73.2% respectively, p = 0.001). No differences were observed by genotyping approach in the number of specialty visits or likelihood of MACE or bleeding events (all p > 0.21). Preemptive genotyping had a strong impact on initial antiplatelet selection and a comparable impact on patient outcomes and healthcare utilization, compared to genotyping ordered after a need for antiplatelet therapy had been identified.

Oro-Anal Transit Time and Colon Manometry: Predictability and Outcomes in Children With Functional Constipation.

OBJECTIVES: The primary objective of the study was to evaluate the correlation of oro-anal transit time (OTT) using SITZMARKS® (Konsyl Pharmaceuticals Inc., Easton, MD, USA) with colonic manometry (CM) in children with chronic idiopathic constipation (CIC). The secondary objective was to determine the clinical utility of these studies in directing treatment strategies. METHODS: A retrospective chart review of 44 children with CIC was evaluated with both OTT and CM. The median follow-up was one year (0.3 to 7). RESULTS: Seventeen children had normal OTT, and 27 had abnormal OTT (slow-transit constipation (STC)). There was no statistical difference between the percentage of children with abnormal CM (13) test results categorized by OTT (23.5% normal OTT vs. 33% abnormal OTT, p = 0.73). A change in therapy was accepted by all 13 children with abnormal CM, but only 26/31 (84%) of the children had normal CM. The CM test results prompted acceptance of treatment change (appendicectomy or medication escalation) in 89% of children. Overall, 31/44 (70%) of children undergoing CM testing had improvement in clinical symptoms. More children with abnormal CM testing improved vs. normal CM but did not reach significance (85% vs. 65%, p = 0.28). CONCLUSION: Contrary to previous studies, OTT results did not predict the presence of colonic dysmotility based on colon motility testing. Colonic manometry testing resulted in the acceptance of a change in therapy in approximately 90% of children. More children with colonic dysmotility improved versus those with normal CM studies. Other interventions beyond stimulant laxatives should be considered in children with refractory constipation.