Efficacy and safety of laser ablation and microwave ablation to treat papillary thyroid microcarcinoma: A retrospective study.

OBJECTIVE: To retrospectively analyze the efficacy and safety of laser ablation (LA) and microwave ablation (MWA) in the treatment of papillary thyroid microcarcinoma (PTMC). METHODS: This was a retrospective study of 103 patients (109 nodules) who underwent thermal ablation for PTMC between October 2019 and March 2023; 61 underwent LA and 48 underwent MWA. The mean patients' age was 43.50 ± 12.42 years. After ablation, changes in tumor size at different time points, local recurrence, new lesions, lymph node metastasis, and complications were evaluated and recorded. The feasibility, success rate, and safety of LA and MWA were analyzed. RESULTS: Complete absence of enhancement on contrast-enhanced ultrasonography was observed in all target tumors after ablation. At the last follow-up, the mean volume of the PTMC nodules decreased from 0.09 ± 0.09 to 0.03 ± 0.03 ml (LA group) and from 0.11 ± 0.10 to 0.06 ± 0.08 ml (MWA group) (both, P < 0.05). There was no significant difference in volume change between the groups (P (groups): 0.520; P (groups over time): 0.423), indicating similar efficacy between the groups. There was also no significant difference in the volume reduction rate between the groups during follow-up, except for at 3 months (P = 0.023). The complication rates did not differ between the LA group (8.2 %) and MWA group (6.3 %) (P > 0.05). CONCLUSION: During the short-term follow-up, ultrasound-guided LA and MWA were effective and safe for PTMC, and there were no significant differences in treatment outcomes between the methods.

Diagnostic efficacy of the contrast-enhanced ultrasound thyroid imaging reporting and data system classification for benign and malignant thyroid nodules.

Background: The contrasted-enhanced ultrasound thyroid imaging reporting and data system (CEUS TI-RADS) is the first international risk stratification system for thyroid nodules based on conventional ultrasound (US) and CEUS. This study aimed to evaluate the diagnostic efficacy of CEUS TI-RADS for benign and malignant thyroid nodules and to assess the related interobserver agreement. Methods: The study recruited 433 patients who underwent thyroid US and CEUS between January 2019 and June 2023 at the Affiliated Hospital of Guangdong Medical University. A retrospective analysis of 467 thyroid nodules confirmed by fine-needle aspiration (FNA) and/or surgery was performed. Further, a CEUS TI-RADS classification was assigned to each thyroid nodule based on the CEUS TI-RADS scoring criteria for the US and CEUS features of the nodule. The nodules were grouped based on their sizes as follows: size ≤1 cm, group A; size >1 and ≤4 cm, group B; and size >4 cm, group C. Multivariate logistic regression was used to analyze independent risk factors for malignant thyroid nodules. Pathological assessment was the reference standard for establishing the sensitivity (SEN), specificity (SPE), accuracy (ACC), positive predictive value (PPV), and negative predictive value (NPV) of CEUS TI-RADS in diagnosing malignant thyroid nodules. The area under the curve (AUC) in the receiver operating characteristic (ROC) curve analysis was used to compare the diagnostic efficacy of the scoring system in predicting malignancy in three groups of nodules. The intragroup correlation coefficient (ICC) was adopted to assess the interobserver agreement of the CEUS TI-RADS score. Results: Out of the 467 thyroid nodules, 262 were malignant and 205 were benign. Logistic regression analysis revealed that the independent risk factors for malignant thyroid nodules included punctate echogenic foci (P<0.001), taller-than-wide shape (P=0.015), extrathyroidal invasion (P=0.020), irregular margins/lobulation (P=0.036), hypoechoicity on US (P=0.038), and hypoenhancement on CEUS (P<0.001). The AUC for the CEUS TI-RADS in diagnosing malignant thyroid nodules was 0.898 for all nodules, 0.795 for group A, 0.949 for group B, and 0.801 for group C, with the optimal cutoff values of the CEUS TI-RADS being 5 points, 6 points, 5 points, and 5 points, respectively. Among these groups of nodules, group B had the highest AUC, with the SEN, SPE, ACC, PPV, and NPV for diagnosing malignant nodules being 95.9%, 88.1%, 92.8%, 92.6%, and 93.2%, respectively. The ICC of the CEUS TI-RADS classification between senior and junior physicians was 0.862 (P<0.001). Conclusions: In summary, CEUS TI-RADS demonstrated significant efficacy in distinguishing thyroid nodules. Nonetheless, there were variations in its capacity to detect malignant nodules across diverse sizes, and it demonstrate optimal performance in 1- to 4-cm nodules. These findings may serve as important insights for clinical diagnoses.

112-GBaud mode-division-multiplexing IM-DD transmission beyond net 6.4†Tb/s over weakly coupled FMF for optical interconnections.

Weakly coupled mode-division-multiplexing (MDM) systems based on intensity modulation and direct detection (IM-DD) are a good candidate for further improving the capacity of short-reach optical interconnections. However, restrained by the modal crosstalk of the transmission link and the reception of degenerate mode groups (DMGs) utilizing bandwidth-limited multimode photodetectors (PDs), high-speed MDM IM-DD has encountered a capacity bottleneck. In this Letter, we investigate a high-speed weakly coupled MDM IM-DD transmission system utilizing a degenerate mode diversity receiver scheme adopting high-bandwidth single-mode PDs over a multiple-ring-core (MRC) few-mode fiber (FMF) and a low-crosstalk mode multiplexer/demultiplexer (MUX/DMUX). An MDM IM-DD transmission with four DMGs and eight wavelengths is experimentally demonstrated with 112-GBaud four-level pulse-amplitude modulation (PAM4) and probabilistically shaped PAM8 per lane over 200-m weakly coupled MRC-FMF. To the best of our knowledge, this is the first experimental demonstration of the MDM IM-DD transmission system with up to 112-GBaud baud rate and beyond 6.4-Tb/s net rate. Meanwhile, the experimental results show that the proposed MDM IM-DD transmission link has a superior performance only adopting a low-complexity feedforward equalizer, making it a promising candidate for high-speed optical interconnections.

Clinical efficacy and immune response of neoadjuvant camrelizumab plus chemotherapy in resectable locally advanced oesophageal squamous cell carcinoma: a phase 2 trial.

BACKGROUND: Neoadjuvant immunotherapy is under intensive investigation for esophageal squamous cell carcinoma (ESCC). This study assesses the efficacy and immune response of neoadjuvant immunochemotherapy (nICT) in ESCC. METHODS: In this phase II trial (ChiCTR2100045722), locally advanced ESCC patients receiving nICT were enrolled. The primary endpoint was the pathological complete response (pCR) rate. Multiplexed immunofluorescence, RNA-seq and TCR-seq were conducted to explore the immune response underlying nICT. RESULTS: Totally 42 patients were enrolled, achieving a 27.0% pCR rate. The 1-year, 2-year DFS and OS rates were 89.2%, 64.4% and 97.3%, 89.2%, respectively. RNA-seq analysis highlighted T-cell activation as the most significantly enriched pathway. The tumour immune microenvironment (TIME) was characterised by high CD4, CD8, Foxp3, and PD-L1 levels, associating with better pathological regression (TRS0/1). TIME was categorised into immune-infiltrating, immune-tolerant, and immune-desert types. Notably, the immune-infiltrating type and tertiary lymphoid structures correlated with improved outcomes. In the context of nICT, TIM-3 negatively influenced treatment efficacy, while elevated TIGIT/PD-1 expression post-nICT correlated positively with CD8+ T cell levels. TCR-seq identified three TCR rearrangements, underscoring the specificity of T-cell responses. CONCLUSIONS: Neoadjuvant camrelizumab plus chemotherapy is effective for locally advanced, resectable ESCC, eliciting profound immune response that closely associated with clinical outcomes.

Mediating effects of insomnia and resilience on COVID-19-related post-traumatic stress disorder and quality of life in adolescents.

The coronavirus disease-2019 (COVID-19) pandemic has impaired the quality of life (QoL) for many due to its extensive impacts. However, few studies have addressed the specific impact of COVID-19 on the mental health of adolescents, particularly post-traumatic stress disorder (PTSD). This study considered the impact of COVID-19-related PTSD on the QoL of adolescents in China, the mediating effects of insomnia, and the moderating effects of resilience. Participants included 50,666 adolescents aged 12-18 years selected using a comprehensive sampling method. We performed data collection from January 8th to January 18th, 2023, using the Children's Revised Impact of Event Scale, Pittsburgh Sleep Quality Index, Ten-item Connor-Davidson Resilience Scale, and Screening for and Promotion of Health-related QoL in Children and Adolescents Questionnaire for data collection. Male adolescents exhibited significantly lower levels of PTSD and insomnia compared to females and scored significantly higher in psychological resilience and overall QoL. Insomnia played a mediating role between PTSD and QoL. Psychological resilience moderated the impact of COVID-19-related stress on adolescents' QoL through its influence on insomnia. PTSD resulting from the COVID-19 pandemic affects the QoL of adolescents through the presence of insomnia. Psychological resilience plays a moderating role in this process. Cultivating psychological resilience in adolescents can effectively enhance their ability to cope with the impacts of sudden public events.

Effects of semaglutide on gut microbiota, cognitive function and inflammation in obese mice.

Objective: This study aims to investigate the effects of semaglutide on gut microbiota, cognitive function, and inflammation in obese mice. Method: Twenty-four C57BL/6J male mice were randomly assigned to three groups: a normal-chow diet group (NCD, n = 8), high-fat diet group (HFD, n = 8), and HFD+semaglutide group (Sema, n = 8). The mice were fed a HFD to establish an animal model of obesity and then administered with semaglutide or saline for 12 weeks. Cognitive function was assessed using the Morris water maze test. Serum pro-inflammatory cytokines were measured. 16S rRNA gene sequencing technology was used to explore gut microbiota characteristics in obese mice. Result: Obese mice showed significant cognitive impairment and inflammation. Semaglutide improved cognitive function and attenuated inflammation induced by a HFD diet. The abundance of gut microbiota was significantly changed in the HFD group, including decreased Akkermansia, Muribaculaceae, Coriobacteriaceae_UCG_002, Clostridia_UCG_014 and increased Romboutsia, Dubosiella, Enterorhabdus. Whereas semaglutide could dramatically reverse the relative abundance of these gut microbiota. Correlation analysis suggested that cognitive function was positively correlated with Muribaculaceae and Clostridia_UCG_014, and negatively associated with Romboutsia and Dubosiella. Romboutsia was positively correlated with TNFα, IL-6 and IL-1ß. While Clostridia_UCG_014 was negatively related to TNFα, IL-6 and IL-1ß. Conclusions: For the first time semaglutide displayed different regulatory effects on HFD-induced gut microbiota dysbiosis. Semaglutide could regulate the structure and composition of gut microbiota associated with cognitive function and inflammation. Thus, affecting gut microbiota might be a potential mechanism of semaglutide in attenuating cognitive function and inflammation.

Melon: metagenomic long-read-based taxonomic identification and quantification using marker genes.

Long-read sequencing holds great potential for characterizing complex microbial communities, yet taxonomic profiling tools designed specifically for long reads remain lacking. We introduce Melon, a novel marker-based taxonomic profiler that capitalizes on the unique attributes of long reads. Melon employs a two-stage classification scheme to reduce computational time and is equipped with an expectation-maximization-based post-correction module to handle ambiguous reads. Melon achieves superior performance compared to existing tools in both mock and simulated samples. Using wastewater metagenomic samples, we demonstrate the applicability of Melon by showing it provides reliable estimates of overall genome copies, and species-level taxonomic profiles.

Alterations in amygdala subregions-Default mode network connectivity after treatment in patients with schizophrenia.

Disrupted connectivity in the default mode network (DMN) during resting-state functional MRI (rs-fMRI) is well-documented in schizophrenia (SCZ). The amygdala, a key component in the neurobiology of SCZ, comprises distinct subregions that may exert varying effects on the disorder. This study aimed to investigate variations in functional connectivity (FC) between distinct amygdala subregions and the DMN in SCZ individuals and explore the effects of treatment on these connections. Fifty-six SCZ patients and 51 healthy controls underwent FC analysis and questionnaire surveys during resting state. The amygdala was selected as the region of interest (ROI) and subdivided into four parts. Changes in FC were examined, and correlations between questionnaire scores and brain activity were explored. Pre-treatment, SCZ patients exhibited reduced FC between the amygdala and DMN compared to HCs. After treatment, significant differences persisted in the right medial amygdala, while other regions did not differ significantly from controls. In addition, PANSS scores positively correlated with FC between the Right Medial Amygdala and the left SMFC (r = .347, p = .009), while RBANS5A scores showed a positive correlation with FC between the Left Lateral Amygdala and the right MTG (rho = -.347, p = .009). The rsFC between the amygdala and the DMN plays a crucial role in the treatment mechanisms of SCZ. This could provide a promising predictive indicator for understanding the neural mechanisms behind treatment and symptomatic improvement.

Scalable Multi-FPGA HPC Architecture for Associative Memory System.

Associative memory is a cornerstone of cognitive intelligence within the human brain. The Bayesian confidence propagation neural network (BCPNN), a cortex-inspired model with high biological plausibility, has proven effective in emulating high-level cognitive functions like associative memory. However, the current approach using GPUs to simulate BCPNN-based associative memory tasks encounters challenges in latency and power efficiency as the model size scales. This work proposes a scalable multi-FPGA high performance computing (HPC) architecture designed for the associative memory system. The architecture integrates a set of hypercolumn unit (HCU) computing cores for intra-board online learning and inference, along with a spike-based synchronization scheme for inter-board communication among multiple FPGAs. Several design strategies, including population-based model mapping, packet-based spike synchronization, and cluster-based timing optimization, are presented to facilitate the multi-FPGA implementation. The architecture is implemented and validated on two Xilinx Alveo U50 FPGA cards, achieving a maximum model size of 200×10 and a peak working frequency of 220 MHz for the associative memory system. Both the memory-bounded spatial scalability and compute-bounded temporal scalability of the architecture are evaluated and optimized, achieving a maximum scale-latency ratio (SLR) of 268.82 for the two-FPGA implementation. Compared to a two-GPU counterpart, the two-FPGA approach demonstrates a maximum latency reduction of 51.72× and a power reduction exceeding 5.28× under the same network configuration. Compared with the state-of-the-art works, the two-FPGA implementation exhibits a high pattern storage capacity for the associative memory task.

Moving in an Uncertain World: Robust and Adaptive Control of Locomotion from Organisms to Machine Intelligence.

Whether walking, running, slithering, or flying, organisms display a remarkable ability to move through complex and uncertain environments. In particular, animals have evolved to cope with a host of uncertainties-both of internal and external origin-to maintain adequate performance in an ever-changing world. In this review, we present mathematical methods in engineering to highlight emerging principles of robust and adaptive control of organismal locomotion. Specifically, by drawing on the mathematical framework of control theory, we decompose the robust and adaptive hierarchical structure of locomotor control. We show how this decomposition along the robust-adaptive axis provides testable hypotheses to classify behavioral outcomes to perturbations. With a focus on studies in non-human animals, we contextualize recent findings along the robust-adaptive axis by emphasizing two broad classes of behaviors: 1) compensation to appendage loss and 2) image stabilization and fixation. Next, we attempt to map robust and adaptive control of locomotion across some animal groups and existing bio-inspired robots. Finally, we highlight exciting future directions and interdisciplinary collaborations that are needed to unravel principles of robust and adaptive locomotion.

Controlled interconversion of macrocyclic atropisomers via defined intermediates.

Macrocyclic conformations play a crucial role in regulating their properties. Our understanding of the determinants to control macrocyclic conformation interconversion is still in its infancy. Here we present a macrocycle, octamethyl cyclo[4](1,3-(4,6)-dimethylbenzene)[4]((4,6-benzene)(1,3-dicarboxylate) (OC-4), that can exist at 298 K as two stable atropisomers with C2v and C4v symmetry denoted as C2v-OC-4 and C4v-OC-4, respectively. Heating induces the efficient stepwise conversion of C2v- to C4v-OC-4 via a Cs-symmetric intermediate (Cs-OC-4). It differs from the typical transition state-mediated processes of simple C-C single bond rotations. Hydrolysis and further esterification with a countercation dependence promote the generation of C2v- and Cs-OC-4 from C4v-OC-4. In contrast to C2v-OC-4, C4v-OC-4 can bind linear guests to form pseudo-rotaxans, or bind C60 or C70 efficiently. The present study highlights the differences in recognition behavior that can result from conformational interconversion, as well as providing insights into the basic parameters that govern coupled molecular rotations.

Knowledge, Attitude, and Practice Toward Varicocele in Patients with Varicoceles: A Cross-Sectional Study in Chinese Patients.

Objective: To explore patients' knowledge, attitude, and practice (KAP) toward varicocele in China and the relationship between treatment selection and KAP. Methods: This cross-sectional study enrolled varicocele patients at the Third Affiliated Hospital of Soochow University (September to October 2023). Structural equation modeling (SEM) was used to explore the relationship between clinical factors and KAP. A score >mean score for each dimension was defined as adequate knowledge, positive attitude, and proactive practice. The patients were grouped according to varicocelectomy vs no surgery. Univariable and multivariable logistic regression analyses were used to identify the factors independently associated with KAP. A structural equation modeling (SEM) analysis was performed to examine how the KAP dimensions influenced each other. Results: Among 502 patients, 44.02%, 35.86%, and 20.12% were ≤30, 31-40, and >40 years old, respectively. Those who underwent varicocelectomy (n=407) had significantly higher knowledge (20 (15-22) vs 0 (0-6), P<0.001), attitude (26 (24-26) vs 14 (10-18), P<0.001), and practice (20 (17-24) vs 8 (6-16), P<0.001) than those who did not. A higher proportion of patients with varicocelectomy were <40 years old, more educated, had higher income, and were unmarried compared with those without surgery (all P<0.001). High school or higher education level and varicocelectomy (irrespective of type) were independently associated with adequate knowledge (all P<0.001). Knowledge, college/bachelor's degree education, and varicocelectomy type (irrespective of type) were associated with positive attitudes (all P<0.05). In the SEM, knowledge directly influenced attitude, knowledge directly influenced practice, and attitude directly influenced practice (all P<0.001). Having knowledge of the subject may direct varicocele patients to varicocelectomy. Conclusion: Chinese patients who underwent varicocelectomy exhibit appropriate KAP regarding varicocele, while non-surgery patients have poorer KAP. These results suggest that patients who did not undergo surgery should nevertheless be properly informed about their disease.

Oleandrin enhances radiotherapy sensitivity in lung cancer by inhibiting the ATM/ATR-mediated DNA damage response.

Despite active clinical trials on the use of Oleandrin alone or in combination with other drugs for the treatment of solid tumors, the potential synergistic effect of Oleandrin with radiotherapy remains unknown. This study reveals a new mechanism by which Oleandrin targets ATM and ATR kinase-mediated radiosensitization in lung cancer. Various assays, including clonogenic, Comet, immunofluorescence staining, apoptosis and Cell cycle assays, were conducted to evaluate the impact of oleandrin on radiation-induced double-strand break repair and cell cycle distribution. Western blot analysis was utilized to investigate alterations in signal transduction pathways related to double-strand break repair. The efficacy and toxicity of the combined therapy were assessed in a preclinical xenotransplantation model. Functionally, Oleandrin weakens the DNA damage repair ability and enhances the radiation sensitivity of lung cells. Mechanistically, Oleandrin inhibits ATM and ATR kinase activities, blocking the transmission of ATM-CHK2 and ATR-CHK1 cell cycle checkpoint signaling axes. This accelerates the passage of tumor cells through the G2 phase after radiotherapy, substantially facilitating the rapid entry of large numbers of inadequately repaired cells into mitosis and ultimately triggering mitotic catastrophe. The combined treatment of Oleandrin and radiotherapy demonstrated superior inhibition of tumor proliferation compared to either treatment alone. Our findings highlight Oleandrin as a novel and effective inhibitor of ATM and ATR kinase, offering new possibilities for the development of clinical radiosensitizing adjuvants.

A new luminescent nickel nanocluster with solvent and ion induced emission enhancement toward heavy metal analysis.

Expanding the family of fluorescent metal clusters beyond gold, silver, and copper has always been an issue for researchers to solve. In this study, a novel type of cysteine-capped nickel nanoclusters (Cys-Ni NCs) with bright turquoise emission was developed. The as-synthesized Ni NCs showed aggregation-induced emission enhancement (AIEE) properties across Cd2+ and various polar organic solvents. Concurrently, solvents with different viscosities were used to explore the principle of solvent-induced AIEE of Cys-Ni NCs, revealing a positive correlation between fluorescence intensity and solution viscosity. In addition, the concentration of Cd2+ that induced the AIEE effect was reduced by nearly two orders of magnitude in highly viscous solvents, indicating the possibility of Cys-Ni NCs as a promising nanomaterial platform for Cd2+ sensing analysis. Moreover, we propose a novel fluorescent sensing method for rapid detection of Cu2+ based on the carboxyl group of Cys-Ni NCs coupling with Cu2+. Further, validation of Cu2+ detecting methodologies in environmental water samples with the accuracy up to 93.94% underscores their potential as robust and efficient sensing platforms. This study expands the repertoire of fluorescent metal nanoclusters for highly sensitive and selective sensing of hazardous ions and paves the way for further exploration and wide applications in Cu2+ detection in biological and medicine fields.

Dimethyl sulfoxide, an alternative for control of Nosema ceranae infection in honey bees (Apis mellifera).

Nosema ceranae is a microsporidian parasite that threatens current apiculture. N. ceranae-infected honey bees (Apis mellifera) exhibit morbid physiological impairments and reduced honey production, malnutrition, shorter life span, and higher mortality than healthy honey bees. In this study, we found that dimethyl sulfoxide (DMSO) could enhance the survival rate of N. ceranae-infected honey bees. Therefore, we investigated the effect of DMSO on N. ceranae-infected honey bees using comparative RNA sequencing analysis. Our results revealed that DMSO was able to affect several biochemical pathways, especially the metabolic-related pathways in N. ceranae-infected honey bees. Based on these findings, we conclude that DMSO may be a useful alternative for treating N. ceranae infection in apiculture.

Construction of central and axial chirality via Pd(II)/Bim-catalyzed asymmetric dearomative Michael reaction of polycyclic tropones.

A highly enantioselective Pd/Bim-catalyzed dearomative Michael reaction applying polycyclic tropones as non-benzenoid aromatic Michael acceptors and arylboronic acids as aryl pronucleophiles has been developed. The bridged biaryls bearing central and axial chirality, including pentacyclic cyclohepta[b]indoles and 6,7-dihydrodibenzo[a,c][7]annulen-5-ones, are generally generated in good to high yields and excellent enantioselectivities and can be readily transformed into useful derivatives.

Taking Photoacoustic Force into Account in Liquid-Phase Peak Force Infrared Microscopy.

The microscopic structure of the material's solid-liquid interface significantly influences its physicochemical properties. Peak force infrared microscopy (PFIR) is a powerful technique for analyzing these interfaces at the nanoscale, revealing crucial structure-activity relationships. PFIR is recognized for its explicit photothermal signal generation mechanism but tends to overlook other photoinduced forces, which can disturb the obtained infrared spectra, thereby reducing spectral signal-to-noise ratio (SNR) and sensitivity. We have developed a multiphysics-coupled theoretical model to assess the magnitudes of various photoinduced forces in PFIR experiments and have found that the magnitude of the photoacoustic force is comparable to that of the photothermal expansion force in a liquid environment. Our calculations show that through simple modulation of the pulse waveform it is possible to effectively suppress the photoacoustic interference, thereby improving the SNR and sensitivity of PFIR. This work aims to alert researchers to the potential for strong photoacoustic interference in liquid-phase PFIR measurements and enhance the performance of PFIR by clarifying the photoinduced forces entangled in the signals.

Echocardiography used for treatment in heart failure accompanied by thyroid storm: Case report and literature review.

Key Clinical Message: This case highlights the importance of carefully weighing the benefits and risks of beta-adrenergic blockade therapy based on symptoms, echocardiography, and BNP values in thyroid storm patients. Abstract: Thyroid storm is a rare but life-threatening condition in thyrotoxic patients. The keys to successful management of thyroid storm are early diagnosis, immediate anti-thyroid medications, and preventing multiorgan failure. We present a case of thyroid storm, acute decompensated heart failure, and atrial fibrillation with rapid ventricular response. We initiated propranolol to control thyroid storm. Soon after, the patient developed more severe heart failure with decreased ejection fraction (EF). We switched to diltiazem to control tachycardia, but the therapeutic effect was unsatisfactory. Finally, we used an ultra-short-acting beta-adrenergic blockade with strict monitoring of heart rate and echocardiography, and the patient survived. Beta-adrenergic blockades should be used cautiously in thyroid storm, especially patients with severe heart failure. Echocardiography can be used to aid in selection and monitoring of therapeutic drugs and prognostic outcomes in patients with thyroid storm and heart failure.