Early pregnancy ruptured intraparenchymal renal artery aneurysm associated with fetal down syndrome: A case report and literature review.

Pregnancy-associated spontaneous rupture of renal artery aneurysm (PSRRAA) is a rare emergency that may lead to deleterious maternal and fetal outcomes. We present the first report of PSRRAA during early pregnancy and to be associated with trisomy-21 in a six-week pregnant lady. Intraabdominal bleeding suspicion confirmed by contrast-enhanced computed tomography showing aneurysmal rupture which was managed by percutaneous angioembolization. PSRRAA is a challenging diagnosis and a life-threatening emergency. A high index of suspicion to diagnose PSRRAA even in early pregnancy is needed. Management of PSRRAA has a high risk of fetal radiation exposure that may lead to congenital anomalies.

Real-time expression and in silico characterization of pea genes involved in salt and water-deficit stress.

BACKGROUND: To tolerate salt and water-deficit stress, the plant adapts to the adverse environment by regulating its metabolism and expressing certain stress-induced metabolic pathways. This research analyzed the relative expression of four pea genes (P5CR, PAL1, SOD, and POX) in three pea varieties (Climax, Green grass, and Meteor) under different levels of salt and water-deficit stress. METHODS AND RESULTS: The experiments on salt stress and water-deficit stress were carried out within greenhouse settings under controlled environment. The saturation percentage was employed to create artificial salinity conditions: Control without NaCl treatment, Treatment 1: 50 mM NaCl treatment, Treatment 2: 75 mM NaCl treatment, and Treatment 3: 100 mM NaCl treatment. Field capacity (FC) was used for the development of artificial water-deficit treatments in the pots, i.e., Treatment 1 (Control; water application 100% of FC), Treatment 2 (water application 75% of FC), and Treatment 3 (water application 50% of FC). Pea genes involved in biosynthetic pathways of proline, flavonoids, and enzymatic antioxidant enzymes including P5CR, PAL1, SOD, and POX were selected based on literature. Quantitative real-time PCR using cDNA as a template was used to analyze the gene expression. Pea genes were analyzed for phylogenetic analysis in closely related crops having similarity percent identity 80% and above. In silico characterization of selected proteins including the family classification was done by the NCBI CDD and INTERPRO online servers. Results from RT-qPCR analysis showed increased expression of P5CR, PAL1, and POX genes, while SOD gene expression decreased under both stresses. Climax exhibited superior stress tolerance with elevated expression of P5CR and PAL1, while Meteor showed better tolerance through increased POX expression. Phylogenetic analysis revealed common ancestry with other species like chickpea, red clover, mung bean, and barrel clover, suggesting the cross relationship among these plant species. Conserved domain analysis of respective proteins revealed that these proteins contain PLNO 2688, PLN02457, Cu-Zn Superoxide dismutase, and secretory peroxidase conserved domains. Furthermore, protein family classification indicated that the oxidation-reduction process is the most common chemical process involved in these stresses given to pea plant which validates the relationship of these proteins. CONCLUSIONS: Salt and water-deficit stresses trigger distinct metabolic pathways, leading to the up-regulation of specific genes and the synthesis of corresponding proteins. These findings further emphasize the conservation of stress-tolerance-related genes and proteins across various plant species. This knowledge enhances our understanding of plant adaptation to stress and offers opportunities for developing strategies to improve stress resilience in crops, thereby addressing global food security challenges.

The Short- and Long-Term Safety and Efficacy Profile of Subtotal Cholecystectomy: A Single-Centre, Long-Term, Follow-Up Study.

Background Subtotal cholecystectomy (STC) has been reported as an effective method to remove the gallbladder if the hepatocystic triangle anatomy is unfavourable. However, the evidence regarding its long-term outcomes from the United Kingdom (UK) is lacking. This study aimed to assess its short and long-term outcomes with a minimum of one-year follow-up. Methodology We retrospectively analysed all elective and emergency STCs performed in a single UK NHS Trust between 2014 and 2020. Relevant data were collected using electronic patient records and questionnaire-based, long-term, telephonic follow-up (median follow-up of 3.7 years). Outcomes examined were immediate/short-term complications (biliary injury, bile leak, return-to-theatre) and long-term problems (recurrent symptoms, choledocholithiasis, cholangitis/pancreatitis). Results There were a total of 50 STC cases (58% females) out of 4,341 cholecystectomies performed (1.15%), with the median age, body mass index, and length of stay being 69.5 years, 29 kg/m2 and eight days, respectively. Twenty-eight (56%) were emergency. No patient endured bile duct injury. Seven (14%) patients had postoperative bile leak which was significantly more common when Hartmann's pouch was left open (33% vs. 8%; p = 0.03). No bile duct injury was reported. Most were managed conservatively (endoscopic retrograde cholangiopancreatography + stent: four; radiological drainage: one; no intervention: one). Only one patient required laparoscopic lavage and drainage. The true incidence of developing choledocholithiasis over the long term was 4/50 (8%) in our study. The median interval between STC and the diagnosis of postoperative choledocholithiasis was 15.9 months. All four patients had undergone type 1 STC (where the remnant of Hartmann's pouch was closed with sutures); however, subsequent cross-sectional imaging (magnetic resonance cholangiopancreatography or computed tomography) showed that the gallbladder remnant was visible in only two of these four patients. Conclusions STC is a safe option in difficult situations and prevents bile duct injury. Although the risk of bile leak can be reduced by closing Hartmann's pouch remnant, this may slightly increase the risk of subsequent stone formation. Infrequent occurrence of recurrent gallstone-related symptoms or complications favours its use.

Minimally Invasive versus Open Distal Pancreatectomy in the 2020s: Recent Institutional Experience and a Narrative Review of Current Evidence.

(1) Background: Distal pancreatectomy is a standard treatment for tumours of the pancreatic body and tail. Minimally invasive techniques for all types of pancreatic tumours (benign and malignant) are being established, while concerns regarding oncological safety, cost effectiveness and learning curves are being explored with prospective studies. This paper presents our unit's data in the context of the above concerns and provides a relevant narrative review of the current literature. (2) Methods: Data were collected retrospectively between 2014 and 2021 for all adult patients who underwent elective distal pancreatectomy in our tertiary care referral HPB Unit. Data on demographics, underlying pathology, perioperative variables and post-operative complications were collected and reported using descriptive statistics. On review of the Miami guidelines, four important but less validated areas regarding distal pancreatectomy are presented in light of the current evidence; these are recent randomised controlled trials, oncological safety, cost effectiveness and learning curves in minimally invasive distal pancreatectomy (MIDP). (3) Results: 207 patients underwent distal pancreatectomy in total from 2014-2021, with 114 and 93 patients undergoing open and minimally invasive techniques, respectively. 44 patients were operated on for PDAC in the open vs. 17 in the minimally invasive group. The operative time was 212 min for the open and 248 min for the minimally invasive group. The incidence of pancreatic fistula was higher in the minimally invasive group vs. the open group (16% vs. 4%). (4) Conclusions: Our unit's data conform with the published literature, including three randomised control trials. These published studies will not only pave the way for establishing minimally invasive techniques for suitable patients, but also define their limitations and indications. Future studies will inform us about the oncological safety, cost effectiveness, overall survival and learning curves regarding patients undergoing minimally invasive distal pancreatectomy.

Use of Near-Infrared Fluorescence Techniques in Minimally Invasive Surgery for Colorectal Liver Metastases.

Colorectal liver metastases (CRLM) afflict a significant proportion of patients with colorectal cancer (CRC), ranging from 25% to 30% of patients throughout the course of the disease. In recent years, there has been a surge of interest in the application of near-infrared fluorescence (NIRF) imaging as an intraoperative imaging technique for liver surgery. The utilisation of NIRF-guided liver surgery, facilitated by the administration of fluorescent dye indocyanine green (ICG), has gained traction in numerous medical institutions worldwide. This innovative approach aims to enhance lesion differentiation and provide valuable guidance for surgical margins. The use of ICG, particularly in minimally invasive surgery, has the potential to improve lesion detection rates, increase the likelihood of achieving R0 resection, and enable anatomically guided resections. However, it is important to acknowledge the limitations of ICG, such as its low specificity. Consequently, there has been a growing demand for the development of tumour-specific fluorescent probes and the advancement of camera systems, which are expected to address these concerns and further refine the accuracy and reliability of intraoperative fluorescence imaging in liver surgery. While NIRF imaging has been extensively studied in patients with CRLM, it is worth noting that a significant proportion of published research has predominantly focused on the detection of hepatocellular carcinoma (HCC). In this study, we present a comprehensive literature review of the existing literature pertaining to intraoperative fluorescence imaging in minimally invasive surgery for CRLM. Moreover, our analysis places specific emphasis on the techniques employed in liver resection using ICG, with a focus on tumour detection in minimal invasive surgery (MIS). Additionally, we delve into recent developments in this field and offer insights into future perspectives for further advancements.

Corticosterone Methyl Oxidase Type 1 (CMO1) Deficiency Due to CYP11B2 Mutation: Two Case Reports.

Aldosterone synthase deficiency (ASD) is a rare autosomal recessive condition due to an inactivating mutation in CYP11B2. There are two types of ASD depending upon level of defect in aldosterone synthesis, corticosterone methyl oxidase type 1 (CMO 1) and type 2 (CMO 2) deficiency. We are reporting two cases of CMO 1 deficiency presented with failure to thrive. Both cases were born to consanguineous parents and presented at around 17 months and 15 months with complaints of repeated vomiting and failure to thrive. They were found to have persistent hyponatremia, hyperkalemia, low aldosterone level, raised renin levels, normal cortisol and normal 17 hydroxyprogesterone level, suggesting the diagnosis of isolated aldosterone deficiency. Whole exome sequencing revealed that Case 1 is carrying a novel homozygous mutation in CYP11B2, c.1391_1393dup p.(Leu464dup) and Case 2 has a homozygous pathogenic variant in CYP11B2, c.922T>C p.(Ser308Pro), confirming the diagnosis of CMO 1 deficiency in both cases. After initial stabilization, both cases were started on oral fludrocortisone. They responded well and showed a good catch-up in growth and development. Aldosterone synthase deficiency is a rare condition, but it shall be suspected in infants presented with failure to thrive, hyponatremia and hyperkalemia without pigmentation and virilization.

Inadvertent Placement of Thoracic Epidural Catheter in Pleural Cavity: A Case Report and Review of Published Literature.

Thoracic epidural placement is considered the gold standard for pain management for abdominal or thoracic surgery. It provides analgesia superior to that provided by opioids with a decreased risk of pulmonary complications. Insertion of a thoracic epidural catheter requires the knowledge and expertise of an anesthetist; epidural catheter insertion may be challenging especially when sited in the higher thoracic region, in patients with unusual neuraxial anatomy, patients unable to position adequately for insertion or morbidly obese patients. Postoperatively the anesthetic team is required to look after the patient and assess for any complications such as hypotension. Even though the incidence of complications may be low; however, some of these could have detrimental consequences for the patients such as epidural abscess, hematoma formation, and temporary or permanent neurological damage. In this case report, we will discuss a patient who underwent a three-stage esophagectomy for esophageal squamous cell carcinoma under general anesthesia with epidural analgesia. The epidural catheter (Portex® Epidural Minipack System with NRFit® connector, ICUmedical, USA) was found in the intrapleural space during video-assisted thoracoscopy for the thoracic part of esophagectomy. To facilitate surgical access, the catheter was removed immediately, and the patient was given patient-controlled analgesia with morphine for postoperative pain control.

Catheter-Directed Thrombolysis in the treatment of acute Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Portomesenteric Vein Thrombosis (PMVT) following Laparoscopic Sleeve Gastrectomy (LSG) is an uncommon but potentially debilitating complication. Catheter-Directed Thrombolysis (CDT) has an evolving role in recanalizing the venous flow and preventing thrombus propagation. Therefore, it can be used as an alternative or in combination with systemic anticoagulants in selected patients. We report two trans-hepatic and trans-splenic CDT. The patient's clinical details, radiological findings, safety, and efficacy are reported. CASES PRESENTATION: Two patients presented to the Emergency Department (ED) within 14 days of surgery. The presenting complaints were generally nonspecific. The diagnosis of PMVT was established in both patients based on abdominal Contrast-Enhanced Computed Tomography (CECT). The two patients received a combined therapy of subcutaneous (SC) heparinization and CDT using a trans-hepatic approach in case 1 and a trans-splenic approach in case 2. Subsequent post-procedure venograms and CECT were performed and showed significant thrombus resolution. Both patients received oral anticoagulant therapy upon discharge with a successful overall recovery. CONCLUSION: PMVT is an infrequent and severe post LSG complication. Various approaches for re-establishing the portal venous flow have been described according to the severity of venous thrombosis. This article describes CDT therapy as a safe and effective option for treating PMVT in symptomatic patients.

Learning curves in minimally invasive pancreatic surgery: a systematic review.

BACKGROUND: The learning curve of new surgical procedures has implications for the education, evaluation and subsequent adoption. There is currently no standardised surgical training for those willing to make their first attempts at minimally invasive pancreatic surgery. This study aims to ascertain the learning curve in minimally invasive pancreatic surgery. METHODS: A systematic search of PubMed, Embase and Web of Science was performed up to March 2021. Studies investigating the number of cases needed to achieve author-declared competency in minimally invasive pancreatic surgery were included. RESULTS: In total, 31 original studies fulfilled the inclusion criteria with 2682 patient outcomes being analysed. From these studies, the median learning curve for distal pancreatectomy was reported to have been achieved in 17 cases (10-30) and 23.5 cases (7-40) for laparoscopic and robotic approach respectively. The median learning curve for pancreaticoduodenectomy was reported to have been achieved at 30 cases (4-60) and 36.5 cases (20-80) for a laparoscopic and robotic approach respectively. Mean operative times and estimated blood loss improved in all four surgical procedural groups. Heterogeneity was demonstrated when factoring in the level of surgeon's experience and patient's demographic. CONCLUSIONS: There is currently no gold standard in the evaluation of a learning curve. As a result, derivations are difficult to utilise clinically. Existing literature can serve as a guide for current trainees. More work needs to be done to standardise learning curve assessment in a patient-centred manner.

A Long Short-Term Memory Biomarker-Based Prediction Framework for Alzheimer's Disease.

The early prediction of Alzheimer's disease (AD) can be vital for the endurance of patients and establishes as an accommodating and facilitative factor for specialists. The proposed work presents a robotized predictive structure, dependent on machine learning (ML) methods for the forecast of AD. Neuropsychological measures (NM) and magnetic resonance imaging (MRI) biomarkers are deduced and passed on to a recurrent neural network (RNN). In the RNN, we have used long short-term memory (LSTM), and the proposed model will predict the biomarkers (feature vectors) of patients after 6, 12, 21 18, 24, and 36 months. These predicted biomarkers will go through fully connected neural network layers. The NN layers will then predict whether these RNN-predicted biomarkers belong to an AD patient or a patient with a mild cognitive impairment (MCI). The developed methodology has been tried on an openly available informational dataset (ADNI) and accomplished an accuracy of 88.24%, which is superior to the next-best available algorithms.

Post-COVID-19 pneumonia pneumatoceles: a case report.

INTRODUCTION: Pneumatocele formation in COVID-19 pneumonia is arguably a common occurrence. CASE PRESENTATION: We present a case of pneumatoceles, developing as a sequel of COVID-19 infection. We argue that pneumatocele formation in COVID-19 pneumonia is a common occurrence. Importantly pneumothorax, which can lead to a raised morbidity and mortality in these patients, can be a complication of a pneumatocele rupture. CONCLUSION: As pneumatocele in COVID-19 pneumonia patients can lead to life-threatening complications, we emphasize the need to formulate appropriate and standardized monitoring and management guidelines. Our literature review also discusses various plausible mechanisms leading to pneumatocele formation and points to management strategies that may prevent pneumatocele formation and its complications.

Exploring Careers in Medicine: Implementation and Perceived Value of a Multi-Specialty Elective.

INTRODUCTION: Choosing a medical specialty is one of the most crucial and difficult decisions made during medical school. Given that specialty exposure is among the most important factors in decision-making, the Careers in Medicine (CiM) multi-specialty elective was designed to provide clerkship students an avenue to explore three or more specialties of interest during a single elective. METHODS: A cross-sectional study was conducted at Vanderbilt University School of Medicine using anonymous surveys and de-identified written reflections submitted by students enrolled in the CiM course between August 2015 and June 2018. Data were analyzed using a mixed-methods approach. RESULTS: The majority of students reported the elective guided them in ruling out (80%) and ruling in (65%) specialties. About half (51%) of students decided between the procedural versus critical-thinking dichotomy. Finally, 80% of students reported that they would take the course again rather than a focused elective. Major themes identified from student reflections included course attributes, specialty impacts, and student values. DISCUSSION: Implementation of a multi-specialty elective during the clerkship year was an effective way to help students understand their career values, gain early exposure to specialties not featured in core clinical curriculums, and determine future fields of interest. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01311-0.

The Intersection of Type 2 Myocardial Infarction and Heart Failure.

Background Type 2 myocardial infarction (T2MI) is common and associated with high cardiovascular event rates. However, the relationship between T2MI and heart failure (HF) is uncertain. Methods and Results We identified patients with T2MI at a large tertiary hospital between October 2017 and May 2018. Patient characteristics, causes of T2MI, and subsequent HF hospitalizations were determined by physician chart review. We identified 359 patients with T2MI over the study period; 184 patients had a history of HF. Among patients with ejection fraction (EF) assessment (N=180), the majority had preserved EF (N=107; 59.4%), followed by reduced EF (N=54; 30.0%), and mid-range EF (N=19; 10.6%). Acute HF was the most common cause of T2MI (20.9%). Of those whose T2MI was precipitated by HF (N=75), the mean EF was 53.0±16.8% and 16 (21.3%) were de novo diagnoses of HF. Among patients with T2MI who were discharged alive with available follow-up (N=289), 5.5% were hospitalized with acute HF within 30 days, 17.3% within 180 days, and 22.1% within 1 year. In subgroup analyses, among patients with T2MI with prevalent or new HF (N=161), the rate of HF hospitalization at 1 year was 34.2%, considerably higher than those with T2MI and no HF diagnosis at discharge (7.0%; N=9/128). Conclusions Index presentations of HF or worsening chronic HF represent the most common causes of T2MI. ≈1 in 5 patients with T2MI will be readmitted for HF within 1 year of their event. Strategies to prevent HF events after a T2MI are needed.

Association between Intercanine Width and Mandibular Dental Arch Forms.

A descriptive cross-sectional study was conducted to investigate the association between intercanine width and the mandibular arch form in 109 dentate subjects, who visited Orthodontics Department from October 2018 to December 2019. Using Vernier caliper, the intercanine width was measured as the distance between the left and right canines on each cast with the arch form, also categorized as tapered, square or ovoid, using predefined criteria. Spearman's rank correlation demonstrated highly significant association between intercanine width and mandibular dental arch forms, with p value of 0.005. Key Words: Dentate subjects, Mandibular arch forms, Inter-canine width, Sexual dimorphism, Mandibular dental cast.

In silico analysis of quranic and prophetic medicinals plants for the treatment of infectious viral diseases including corona virus.

Coronavirus disease (COVID-19) is an infection of the respiratory system caused by single standard RNA viruses named as Severe Acute Respiratory Syndrome 2 (SARS-CoV-2). The disease appeared as a serious problem and the leading cause of death in human beings throughout the world. The main source of different phytochemicals are plants, which helps in the development of new drugs against various ailments. Islam is comprehensive religion and a complete code of life for Muslims. The teaching of Islam, according to the Holy Quran and Hadith are universal for the benefit of humanity. Islam believes that every ailment is from God and who made the disease definitely made its medication. There is a complete guideline with regard to taking measures against infectious diseases such as quarantine and seeking medicinal treatment. The research objective is to gather the knowledge of medicinal plants described in the Holy Quran or utilized by the Prophet (SAW) for the treatment of different ailments or advised to use them to boost immunity and strengthen the body. Scientists across the globe have found these plants beneficial for many diseases and have antiviral potential. In present study, the six plant species including Olea europaea, Nigella sativa, Allium Sativum, Allium cepa, Zingiber officinale and Cassia senna were selected which contain phytochemicals like Calcium Elenolate, Thymoquinone, S-Allylcysteine, Dipropyl Disulfide, Sesquiterpene, Monoterpene, Pelargonidin 3-Galactoside ion and Kaempferol. The phytochemicals monoterpene (from Zingiber officinale) shows best interaction with target proteins RdRP, 3CLPro, ACE2. Calcium Elonate (from olive) bonds with 3CLPro, ACE2 and Kemoferol and Pelargomidine (from Senna Makki) bonds with RdRP, ACE2. The ligands show a unique set of intersections i.e. hydrogen bonding, and alkyl interaction. These medicinal plants can be utilized immediately for the treatment of COVID-19 as their safety is already established. This treatment can enhance recovery when combined with other treatments. Furthermore, the screening of bioactive compounds or phytochemicals found in these plants can be utilized to design new therapeutic drug to treat COVID-19 pandemic.

Proteomic Analysis of Medicinal Plant Calotropis Gigantea by In Silico Peptide Mass Fingerprinting.

Medicinal plants are the basic source of medicinal compounds traditionally used for the treatment of human diseases. Calotropis gigantea is a medicinal plant belonging to the family of Apocynaceae in the plant kingdom and subfamily Asclepiadaceae usually bearing multiple medicinal properties to cure a variety of diseases. BACKGROUND: The Peptide Mass Fingerprinting (PMF) identifies the proteins from a reference protein database by comparing the amino acid sequence that is previously stored in the database and identified. OBJECTIVE: The purpose of the study is to identify the peptides having anti-cancerous properties by in silico peptide mass fingerprinting. METHODS: The calculation of in silico peptide masses is done through the ExPASy PeptideMass and these masses are used to identify the peptides from the MASCOT online server. Anticancer probability is calculated by iACP server, docking of active peptides is done by CABS-dock the server. RESULTS: The anti-cancer peptides are identified with the MASCOT peptide mass fingerprinting server, the identified peptides are screened and only the anti-cancer are selected. De-novo peptide structure prediction is used for 3D structure prediction by PEP-FOLD 3 server. The docking results confirm strong bonding with the interacting amino acids of the receptor protein of breast cancer BRCA1 which shows the best peptide binding to the active chain, the human leukemia protein docking with peptides shows the accurate binding. CONCLUSION: These peptides are stable and functional and are the best way for the treatment of cancer and many other deadly diseases.

nCOV-19 peptides mass fingerprinting identification, binding, and blocking of inhibitors flavonoids and anthraquinone of Moringa oleifera and hydroxychloroquine.

An rare pandemic of viral pneumonia occurs in December 2019 in Wuhan, China, which is now recognized internationally as Corona Virus Disease 2019 (COVID-19), the etiological agent classified as Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). According to the World Health Organization (WHO), it has so far expanded to more than 213 countries/territories worldwide. Our study aims to find the viral peptides of SARS-COV-2 by peptide mass fingerprinting (PMF) in order to predict its novel structure and find an inhibitor for each viral peptide. For this reason, we calculated the mass of amino acid sequences translated from the SARS-CoV2 whole genome and identify the peptides that may be a target for inhibition. Molecular peptide docking with Moringa oleifera, phytochemicals (aqueous and ethanolic) leaf extracts of flavonoids (3.56 ± 0.03), (3.83 ± 0.02), anthraquinone (11.68 ± 0.04), (10.86 ± 0.06) and hydroxychloroquine present therapy of COVID-19 in Pakistan for comparative study. Results indicate that 15 peptides of SARS-CoV2 have been identified from PMF, which is then used as a selective inhibitor. The maximum energy obtained from AutoDock Vina for hydroxychloroquine is -5.1 kcal/mol, kaempferol (flavonoid) is -6.2 kcal/mol, and for anthraquinone -6 kcal/mol. Visualization of docking complex, important effects are observed regarding the binding of peptides to drug compounds. In conclusion, it is proposed that these compounds are effective antiviral agents against COVID-19 and can be used in clinical trials.Communicated by Ramaswamy H. Sarma.