Phylogenetic classification of the world's tropical forests.

Knowledge about the biogeographic affinities of the world's tropical forests helps to better understand regional differences in forest structure, diversity, composition, and dynamics. Such understanding will enable anticipation of region-specific responses to global environmental change. Modern phylogenies, in combination with broad coverage of species inventory data, now allow for global biogeographic analyses that take species evolutionary distance into account. Here we present a classification of the world's tropical forests based on their phylogenetic similarity. We identify five principal floristic regions and their floristic relationships: (i) Indo-Pacific, (ii) Subtropical, (iii) African, (iv) American, and (v) Dry forests. Our results do not support the traditional neo- versus paleotropical forest division but instead separate the combined American and African forests from their Indo-Pacific counterparts. We also find indications for the existence of a global dry forest region, with representatives in America, Africa, Madagascar, and India. Additionally, a northern-hemisphere Subtropical forest region was identified with representatives in Asia and America, providing support for a link between Asian and American northern-hemisphere forests.

Rice Root Architectural Plasticity Traits and Genetic Regions for Adaptability to Variable Cultivation and Stress Conditions.

Future rice (Oryza sativa) crops will likely experience a range of growth conditions, and root architectural plasticity will be an important characteristic to confer adaptability across variable environments. In this study, the relationship between root architectural plasticity and adaptability (i.e. yield stability) was evaluated in two traditional × improved rice populations (Aus 276 × MTU1010 and Kali Aus × MTU1010). Forty contrasting genotypes were grown in direct-seeded upland and transplanted lowland conditions with drought and drought + rewatered stress treatments in lysimeter and field studies and a low-phosphorus stress treatment in a Rhizoscope study. Relationships among root architectural plasticity for root dry weight, root length density, and percentage lateral roots with yield stability were identified. Selected genotypes that showed high yield stability also showed a high degree of root plasticity in response to both drought and low phosphorus. The two populations varied in the soil depth effect on root architectural plasticity traits, none of which resulted in reduced grain yield. Root architectural plasticity traits were related to 13 (Aus 276 population) and 21 (Kali Aus population) genetic loci, which were contributed by both the traditional donor parents and MTU1010. Three genomic loci were identified as hot spots with multiple root architectural plasticity traits in both populations, and one locus for both root architectural plasticity and grain yield was detected. These results suggest an important role of root architectural plasticity across future rice crop conditions and provide a starting point for marker-assisted selection for plasticity.

Pre-operative renal volume predicts peak creatinine after congenital heart surgery in neonates.

OBJECTIVE: Acute kidney injury is common in neonates following surgery for congenital heart disease. We conducted a retrospective analysis to determine whether neonates with smaller pre-operative renal volume were more likely to develop post-operative acute kidney injury. DESIGN/SETTING: We conducted a retrospective review of 72 neonates who underwent congenital heart surgery for any lesion other than patent ductus arteriosus at our institution from January 2007 to December 2011. Renal volume was calculated by ultrasound using the prolate ellipsoid formula. The presence and severity of post-operative acute kidney injury was determined both by measuring the peak serum creatinine in the first 7 days post-operatively and by using the Acute Kidney Injury Network scoring system. RESULTS: Using a linear change point model, a threshold renal volume of 17 cm³ was identified. Below this threshold, there was an inverse linear relationship between renal volume and peak post-operative creatinine for all patients (p = 0.036) and the subgroup with a single morphologic right ventricle (p = 0.046). There was a non-significant trend towards more acute kidney injury using Acute Kidney Injury Network criteria in all neonates with renal volume ≤17 cm³ (p = 0.11) and in the subgroup with a single morphologic right ventricle (p = 0.17). CONCLUSIONS: Pre-operative renal volume ≤17 cm³ is associated with a higher peak post-operative creatinine and potentially greater risk for post-operative acute kidney injury for neonates undergoing congenital heart surgery. Neonates with a single right ventricle may be at higher risk.

Hypoplastic left heart syndrome and pulmonary veno-occlusive disease in an infant.

This report describes an infant with heterotaxy syndrome and severe hypoplasia of the left heart who presented with profound cyanosis at birth despite a large patent ductus arteriosus. Pulmonary venous return was difficult to demonstrate by echocardiography. Angiography showed total anomalous pulmonary venous return via a plexus that drained through the paravertebral veins and bilateral superior vena cavae. Autopsy confirmed these findings, and histopathology demonstrated severe occlusive changes within the pulmonary veins.

Right-ventricular global longitudinal strain may predict neo-aortic arch obstruction after Norwood/Sano procedure in children with hypoplastic left heart syndrome.

Neo-aortic arch obstruction (NAAO) is a common complication following the Norwood/Sano procedure (NP) for hypoplastic left heart syndrome (HLHS) and is associated with increased morbidity and mortality. However, there is currently no objective method for predicting which patients will develop NAAO. This study was designed to test the hypothesis that hemodynamic changes from development of NAAO after NP in patients with HLHS will lead to changes in myocardial dynamics that could be detected before clinical symptoms develop with strain analysis using velocity vector imaging. Patients with HLHS who had at least one cardiac catheterization after NP were identified retrospectively. Strain analysis was performed on all echocardiograms preceding the first catheterization and any subsequent catheterization performed for intervention on NAAO. Twelve patients developed NAAO and 30 patients never developed NAAO. Right ventricular strain was worse in the group that developed NAAO (-6.2 vs. -8.6 %, p = 0.040) at a median of 59 days prior to diagnosis of NAAO. Those patients that developed NAAO following NP were significantly younger at the time of first catheterization than those that did not develop NAAO (92 ± 50 vs. 140 ± 36 days, p = 0.001). This study demonstrates that right ventricular GLS is abnormal in HLHS patients following NP and worsening right ventricular strain may be predictive of the future development of NAAO.

An angiographic predictor of pulmonary artery stenosis after the Norwood-Sano operation for hypoplastic left heart syndrome.

The objective of this study was to determine angiographic predictors of future pulmonary artery stenosis (PS) in patients with hypoplastic left heart syndrome (HLHS) at the time of pre-stage 2 cardiac catheterization (PS2C). The Sano modification of the Norwood operation (NSO) for HLHS includes placement of a right ventricle-to-pulmonary artery (RV-PA) conduit. Branch PS is a recognized complication. Data from patients with HLHS who underwent NSO from 2005 to 2009 and who underwent PS2C were reviewed retrospectively. Nakata and McGoon indices were calculated in the traditional fashion, and modified Nakata and McGoon indices were calculated using the narrowest branch PA diameters. Thirty-three patients underwent NSO and 28 patients underwent PS2C. Mean follow-up was 35.8 ± 7.5 months. Ten (36 %) patients had significant left branch PS, with two requiring balloon angioplasty and eight requiring stent placement, a median of 15.2 months after PS2C (interquartile range 1.2, 32.8). The modified Nakata index was predictive of future intervention for left PS (receiver operating characteristic curve area under the curve 0.811), with a cut-off of 135 mm(2)/m(2) and a sensitivity of 100 % and specificity of 72.2 %. A modified Nakata index <135 mm(2)/m(2) at PS2C predicts future need for intervention on left-branch PS in patients with HLHS after the NSO. Surgical pulmonary arterioplasty at the time of stage 2 surgical palliation may obviate the need for future interventions.

A Modified LBP Operator-Based Optimized Fuzzy Art Map Medical Image Retrieval System for Disease Diagnosis and Prediction.

Medical records generated in hospitals are treasures for academic research and future references. Medical Image Retrieval (MIR) Systems contribute significantly to locating the relevant records required for a particular diagnosis, analysis, and treatment. An efficient classifier and effective indexing technique are required for the storage and retrieval of medical images. In this paper, a retrieval framework is formulated by adopting a modified Local Binary Pattern feature (AvN-LBP) for indexing and an optimized Fuzzy Art Map (FAM) for classifying and searching medical images. The proposed indexing method extracts LBP considering information from neighborhood pixels and is robust to background noise. The FAM network is optimized using the Differential Evaluation (DE) algorithm (DEFAMNet) with a modified mutation operation to minimize the size of the network without compromising the classification accuracy. The performance of the proposed DEFAMNet is compared with that of other classifiers and descriptors; the classification accuracy of the proposed AvN-LBP operator with DEFAMNet is higher. The experimental results on three benchmark medical image datasets provide evidence that the proposed framework classifies the medical images faster and more efficiently with lesser computational cost.

Preserving Health Care Data Security and Privacy Using Carmichael's Theorem-Based Homomorphic Encryption and Modified Enhanced Homomorphic Encryption Schemes in Edge Computing Systems.

With the tremendous growth of technology, providing data security to critical applications such as smart grid, health care, and military is indispensable. On the other hand, due to the proliferation of external data threats in these applications, the loss incurred is incredibly high. Standard encryption algorithms such as RSA, ElGamal, and ECC facilitate in protecting sensitive data from outside attackers; however, they cannot perform computations on sensitive data while being encrypted. To perform computations and to process encrypted query on encrypted data, various homomorphic encryption (HE) schemes are proposed. Each of the schemes has its own shortcomings either related to performance or with storage that acts as the barrier for applying in real-time applications. With that conception, our objective is to design HE schemes that are simple by design, efficient in performance, and highly unimpeachable against attacks. Our first proposed scheme is based on Carmichael's Theorem, referred to as Carmichael's Theorem-based Homomorphic Encryption (CTHE), and the second is an improved version of Gorti's Enhanced Homomorphic Encryption Scheme, referred to as Modified Enhanced Homomorphic Encryption (MEHE). For brevity, the schemes are referred to as CTHE and MEHE. Both the schemes are provably secure under the hardness of integer factorization, discrete logarithm, and quadratic residuosity problems. To reduce the noise in these schemes, the modulus switching method is adopted and proved theoretically. The schemes' efficiency is proven by collecting the data from cardiovascular dataset (statically)/blood pressure monitor (dynamically) and is homomorphically encrypted in the edge server. Further analysis on encrypted data is carried out to identify whether a person has hypotension or hypertension with the aid of parameters, namely, mean arterial pressure. As the schemes are probabilistic in nature, breaking the schemes by a polynomial time adversary is impossible and is proven in the article.

Anatomically corrected malposition of the great arteries.

We present cardiac magnetic resonance images of a 6-year-old with a suspected great artery abnormality in the setting of mesocardia, atrial situs solitus, D-looping of the ventricles, and anatomically corrected malposition of the great arteries with subaortic and subpulmonary conus.

Predicting Source and Age of Brain Tumor Using Canny Edge Detection Algorithm and Threshold Technique

Objective: We propose an iterative method and associated with thresholding technique for detecting the tumor source and the age of tumor. Methods: The technique is based on Euclidean distance with strong edge and weak edge for identifying the spreading area of disease and also detecting the tumor age. The work involves the use of canny edge detection algorithm and thresholding technique, which exploits the information detection of brain tumor source through Magnetic Resonance Image (MRI). This system helps in the calculation of the age of tumor (approximate) using Euclidean distance. Results: Calculation of the age range between 0 -100 as 0th stage, between 100 - 250 as 1st stage, between 250 - 400 as 2nd stage, 400 ­ 650 as 3rd stage and also detection of the spread area, helps stopping the tumor from invading the neighbor cells thereby reducing the percentage of invasion of cancerous cells. Conclusion: This method provides the simulation output of proposed algorithm in additional noise resilient and improved in edge and well defined tumor detection than the existing algorithm.

Reports of 2 Rare Associations of Hypoplastic Left Heart Syndrome.

This report describes 2 contrasting yet rare associations of hypoplastic left heart syndrome, 1 in a patient with pulmonary valve stenosis that was successfully surgically palliated and the other in a patient with an intact atrial septum and stenotic bilateral levoatriocardinal veins who was offered comfort care. These cases underscore the point that although both infants were born with hypoplastic left heart syndrome, the outcomes can dramatically differ as a result of anatomic and physiological variables. (Level of Difficulty: Advanced.).

Senning Procedure for Physiological Atrial Inversion With Left Atrial Isomerism.

We present the case of an infant with left atrial isomerism with complex pulmonary and systemic venous connections that resulted in physiological parallel circulation in the setting of ventriculoarterial concordance who was surgically treated using the Senning procedure. This case highlights a rare cause for cyanosis due to poor mixing from a parallel circulation and an issue with nomenclature. (Level of Difficulty: Advanced.).

Evaluating the Performance of Rice Genotypes for Improving Yield and Adaptability Under Direct Seeded Aerobic Cultivation Conditions.

With the changing climatic conditions and reducing labor-water availability, the potential contribution of aerobic rice varieties and cultivation system to develop a sustainable rice based agri-food system has never been more important than today. Keeping in mind the goal of identifying high-yielding aerobic rice varieties for wider adaptation, a set of aerobic rice breeding lines were developed and evaluated for grain yield, plant height, and days to 50% flowering in 23 experiments conducted across different location in Philippines, India, Bangladesh, Nepal, and Lao-PDR between 2014 and 2017 in both wet and dry seasons. The heritability for grain yield ranged from 0.52 to 0.90. The season-wise two-stage analysis indicated significant genotype x location interaction for yield under aerobic conditions in both wet and dry seasons. The genotype × season × location interaction for yield was non-significant in both seasons indicating that across seasons the genotypes at each location did not show variability in the grain yield performance. Mean grain yield of the studied genotypes across different locations/seasons ranged from 2,085 to 6,433 Kg ha-1. The best-fit model for yield stability with low AIC value (542.6) was AMMI(1) model. The identified stable genotypes; IR 92521-143-2-2-1, IR 97048-10-1-1-3, IR 91326-7-13-1-1, IR 91326-20-2-1-4, and IR 91328-43-6-2-1 may serve as novel breeding material for varietal development under aerobic system of rice cultivation. High yield and stable performance of promising breeding lines may be due to presence of the earlier identified QTLs including grain yield under drought, grain yield under aerobic conditions, nutrient uptake, anaerobic germination, adaptability under direct seeded conditions, and tolerance to biotic stress resistance such as qDTY 2.1 , qDTY 3.1 , qDTY 12.1 , qNR 5.1 , AG 9.1 , qEVV 9.1 , qRHD 1.1 , qRHD 5.1, qRHD 8.1 qEMM 1.1 , qGY 6.1 , BPH3, BPH17, GM4, xa4, Xa21, Pita, and Pita2. The frequency of xa4 gene was highest followed by qAG 9.1, GM4, qDTY 3.1 , qDTY 2.1 , qGY 6.1, and qDTY 12.1.

Structural investigation and molecular docking studies of 2-amino-1H-benzimidazolium 2-hydroxybenzoate and 2-amino-1H-benzimidazolium pyridine 2-carboxylate single crystal.

The molecular complexes of 2-amino-1H-benzimidazolium 2-hydroxybenzoate (2ABHB) and 2-amino-1H-benzimidazolium pyridine 2-carboxylate (2ABP2C) were synthesised from a donor 2-aminobenzimidazole (2AB), and acceptors, 2-hydroxybenzoate (2HB) and pyridine 2-carboxylic acid (P2C) respectively. The brown colour single crystals were successfully grown by slow evaporation solution growth technique. The densities of grown crystals 2ABHB and 2ABP2C were measured by floatation method using carbon tetrachloride and xylene as solvents. The single crystal X-ray diffraction reveals the molecular structures of compounds 2ABHB and 2ABP2C. Both the structures contain positively charged 2-aminobenzimidazolium cation, 2ABHB contains negatively charged 2-hydroxybenzoate anion and 2ABP2C contains pyridine 2 carboxylic acid anions. 1H and 13C NMR spectral analyses were used to predict the presence of proton and carbon in the title compounds. The FTIR and Raman spectra have been recorded to detect the vibrational modes of functional groups present in the 2ABHB and 2ABP2C compounds. The proton transfer between the cation and anion was confirmed by UV-Vis spectra of both compounds. For both the compounds, thermal behaviour and stability of the crystals were studied using thermogravimetric and differential thermal analyses technique respectively. Further, the anti-bacterial activity of 2ABHB and 2ABP2C complex against Staphylococcus aureus, Klebsiella pneumonia, Pseudomonas eruginos and E. coli pathogens were investigated.

Development of quality metrics for ambulatory pediatric cardiology: Transposition of the great arteries after arterial switch operation.

OBJECTIVE: To develop quality metrics (QMs) for the ambulatory care of patients with transposition of the great arteries following arterial switch operation (TGA/ASO). DESIGN: Under the auspices of the American College of Cardiology Adult Congenital and Pediatric Cardiology (ACPC) Steering committee, the TGA/ASO team generated candidate QMs related to TGA/ASO ambulatory care. Candidate QMs were submitted to the ACPC Steering Committee and were reviewed for validity and feasibility using individual expert panel member scoring according to the RAND-UCLA methodology. QMs were then made available for review by the entire ACC ACPC during an "open comment period." Final approval of each QM was provided by a vote of the ACC ACPC Council. PATIENTS: Patients with TGA who had undergone an ASO were included. Patients with complex transposition were excluded. RESULTS: Twelve candidate QMs were generated. Seven metrics passed the RAND-UCLA process. Four passed the "open comment period" and were ultimately approved by the Council. These included: (1) at least 1 echocardiogram performed during the first year of life reporting on the function, aortic dimension, degree of neoaortic valve insufficiency, the patency of the systemic and pulmonary outflows, the patency of the branch pulmonary arteries and coronary arteries, (2) neurodevelopmental (ND) assessment after ASO; (3) lipid profile by age 11 years; and (4) documentation of a transition of care plan to an adult congenital heart disease (CHD) provider by 18 years of age. CONCLUSIONS: Application of the RAND-UCLA methodology and linkage of this methodology to the ACPC approval process led to successful generation of 4 QMs relevant to the care of TGA/ASO pediatric patients in the ambulatory setting. These metrics have now been incorporated into the ACPC Quality Network providing guidance for the care of TGA/ASO patients across 30 CHD centers.

QTL Hotspots for Early Vigor and Related Traits under Dry Direct-Seeded System in Rice (Oryza sativa L.).

Strong seedling vigor is desirable trait in dry direct-seeded rice (DSR) for enhancing crop establishment and the ability to compete against weeds. A set of 253 BC3F4 lines derived from cross between Swarna and Moroberekan was phenotyped for early vigor (EV) and 8 related traits viz., early uniform emergence (EUE), shoot length (SHL), stem length (SL), shoot fresh weight (SFW), total fresh weight (TFW), shoot dry weight (SDW), total dry weight (TDW), and root dry weight (RDW). Composite interval mapping analysis using genotypic data from 194 SNP markers identified six genomic regions associated with traits on chromosomes 3, 4, 5, and 6 with phenotypic variance ranging from 2.5 to 18.6%. Among them 2 QTL regions; one on chr3 (id3001701-id300833) and the other on chr5 (wd5002636-id5001470) were identified as QTL hotspots A and B respectively and expressed consistently in field as well as glasshouse condition. The majority of QTLs identified for early vigor, and related traits were clustered in the QTL hotspots A (qEV3.1, qEUE3.1, qSHL3.1, qSL3.1, qSFW3.1, qTFW3.1, qRDW3.1 ) and QTL hotspot B (qEV5.1, qEUE5.1, qSHL5.1, qSL5.1, qSFW5.1, qSDW5.1, qTDW5.1 ). Ten putative candidate genes viz., 1-alpha-amylase precursor, 2-glutamate decarboxylase, 1-ethylene-insensitive 3, 3-expansin precursor, and 3-phenylalanine ammonia-lyase associated with the target traits were identified in the selected QTL regions. Mutations were identified in the coding region of alpha-amylase precursor and ethylene-insensitive 3 gene between the parents which can be utilized in marker assisted breeding. Trait relationships among the agro-physiological traits were examined to select the best genotypes for the given traits for use in future breeding programs.

Molecular Mapping of QTLs Associated with Lodging Resistance in Dry Direct-Seeded Rice (Oryza sativa L.).

Dry direct-seeded rice (DSR) is an alternative crop establishment method with less water and labor requirement through mechanization. It provides better opportunities for a second crop during the cropping season and therefore, a feasible alternative system to transplanted lowland rice. However, lodging is one of the major constraints in attaining high yield in DSR. Identification of QTLs for lodging resistance and their subsequent use in improving varieties under DSR will be an efficient breeding strategy to address the problem. In order to map the QTLs associated with lodging resistance, a set of 253 BC3F4 lines derived from a backcross between Swarna and Moroberekan were evaluated in two consecutive years. A total of 12 QTLs associated with lodging resistance traits [culm length (qCL), culm diameter (qCD), and culm strength (qCS)] were mapped on chromosomes 1, 2, 6, and 7 using 193 polymorphic SNP markers. Two major and consistent effect QTLs, namely qCD1.1 (with R2 of 10%) and qCS1.1 (with R2 of 14%) on chromosome 1 with id1003559 being the peak SNP marker (flanking markers; id1001973-id1006772) were identified as a common genomic region associated with important lodging resistance traits. In silico analysis revealed the presence of Gibberellic Acid 3 beta-hydroxylase along with 34 other putative candidate genes in the marker interval region of id1001973-id1006772. The positive alleles for culm length, culm diameter, and culm strength were contributed by the upland adaptive parent Moroberekan. Our results identified significant positive correlation between lodging related traits (culm length diameter and strength) and grain yield under DSR, indicating the role of lodging resistant traits in grain yield improvement under DSR. Deployment of the identified alleles influencing the culm strength and culm diameter in marker assisted introgression program may facilitate the lodging resistance under DSR.

Root Traits Enhancing Rice Grain Yield under Alternate Wetting and Drying Condition.

Reducing water requirements and lowering environmental footprints require attention to minimize risks to food security. The present study was conducted with the aim to identify appropriate root traits enhancing rice grain yield under alternate wetting and drying conditions (AWD) and identify stable, high-yielding genotypes better suited to the AWD across variable ecosystems. Advanced breeding lines, popular rice varieties and drought-tolerant lines were evaluated in a series of 23 experiments conducted in the Philippines, India, Bangladesh, Nepal and Cambodia in 2015 and 2016. A large variation in grain yield under AWD conditions enabled the selection of high-yielding and stable genotypes across locations, seasons and years. Water savings of 5.7-23.4% were achieved without significant yield penalty across different ecosystems. The mean grain yield of genotypes across locations ranged from 3.5 to 5.6 t/ha and the mean environment grain yields ranged from 3.7 (Cambodia) to 6.6 (India) t/ha. The best-fitting Finlay-Wilkinson regression model identified eight stable genotypes with mean grain yield of more than 5.0 t/ha across locations. Multidimensional preference analysis represented the strong association of root traits (nodal root number, root dry weight at 22 and 30 days after transplanting) with grain yield. The genotype IR14L253 outperformed in terms of root traits and high mean grain yield across seasons and six locations. The 1.0 t/ha yield advantage of IR14L253 over the popular cultivar IR64 under AWD shall encourage farmers to cultivate IR14L253 and also adopt AWD. The results suggest an important role of root architectural traits in term of more number of nodal roots and root dry weight at 10-20 cm depth on 22-30 days after transplanting (DAT) in providing yield stability and preventing yield reduction under AWD compared to continuous flooded conditions. Genotypes possessing increased number of nodal roots provided higher yield over IR64 as well as no yield reduction under AWD compared to flooded irrigation. The identification of appropriate root architecture traits at specific depth and specific growth stage shall help breeding programs develop better rice varieties for AWD conditions.

Cardiac transplantation after the Fontan or Glenn procedure.

OBJECTIVES: The purpose of this study was to review the clinical course and outcome of cardiac transplantation after a failed Glenn or Fontan procedure. BACKGROUND: Late complications of the Glenn or Fontan procedure, including ventricular failure, cyanosis, protein-losing enteropathy, thromboembolism, and dysrhythmias often lead to significant morbidity and mortality. If other therapies are ineffective, cardiac transplantation is the only therapeutic recourse. Transplantation in this unique population presents significant challenges in the operative and perioperative periods. METHODS: The anatomic diagnoses, previous operations, clinical status, and indications for transplantation were characterized in patients transplanted after a Glenn or Fontan procedure. Outcomes after transplantation, including postoperative complications and mortality, were reviewed. Comparisons were made between survivors and nonsurvivors. RESULTS: Primary orthotopic cardiac transplantation was performed in 35 patients (mean age 15.7 +/- 8.5 years) with a mean follow-up of 54 +/- 46 months. A total of 11 patients had undergone a Glenn shunt and 24 patients a Fontan procedure. Indications for transplantation were a combination of causes including ventricular dysfunction, failed Fontan physiology, and/or cyanosis. Ten patients died

Neuroendocrine carcinoma of breast: a rare case vignette.

Neuroendocrine tumour of breast is an extremely rare condition. It may present as focal neuroendocrine differentiation with other histological subtypes of breast cancer or primary neuroendocrine tumour of breast or a metastatic foci in breast. There are no radiologic or clinical signs specific to this subtype. With rarity of its occurrence and absence of randomised trials regarding neuroendocrine tumour of breast, very little is known about the behaviour, prognosis and proper management of this condition. Only the available case reports suggests the necessary strategies for optimal management of this minimally explored medical condition.