The Safety and Efficacy of the Early Use of Sacubitril/Valsartan After Acute Myocardial Infarction: A Meta-Analysis of Randomized Controlled Trials

Acute myocardial infarction (AMI) is a significant global cause of mortality, necessitating the exploration of innovative treatments against the condition. Angiotensin receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor-neprilysin inhibitors (ARNIs) such as sacubitril/valsartan have demonstrated promise in managing acute heart failure (HF). However, despite favorable evidence from clinical trials for the use of sacubitril/valsartan in AMI, its overall efficacy remains a subject of debate. Hence, we conducted this review and meta-analysis, by adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and aligned with European Society of Cardiology recommendations, to compare sacubitril/valsartan with traditional ACEI/ARB treatments for AMI. We employed Review Manager 5.4 for statistical analysis, the Risk of Bias Tool 2.0 was utilized for quality assessment, and publication bias was assessed using a funnel plot. A p-value <0.05 was considered statistically significant. Eight randomized controlled trials (RCTs) were included in this meta-analysis. Our findings revealed that participants treated with sacubitril experienced significantly improved outcomes in terms of HF (OR=0.79; 95% CI: 0.66-0.95; p=0.01; I2=23%), N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (MD = -1.58; 95% CI: -1.78 to -1.37, p<0.00001; I2=97%), and major adverse cardiovascular events (MACE) (OR=0.84; 95% CI: 0.72-0.99; p=0.03; I2=44%). However, left ventricular ejection fraction (LVEF) (MD=3.68; 95% CI: 3.35-4.01, p<0.00001; I2=71%) showed greater improvement in the control group compared to the experimental group. Our meta-analysis suggests that sacubitril offers a favorable balance between safety and effectiveness. Sacubitril significantly improved outcomes in terms of HF, MACE, and NT-proBNP levels when compared to the control group. However, improvement in LVEF was notably higher in the control group over the sacubitril/valsartan group.

Pulmonary fibrosis: Is stem cell therapy the way forward?

Pulmonary fibrosis, a chronic and fatal lung disease affecting millions of people worldwide, is characterized by the scarring of lung tissue, thereby impairing oxygen exchange between the lungs and blood. The etiology of pulmonary fibrosis is multifactorial, involving environmental exposures, comorbidities, and genetic mutations. Current pharmacological treatments can only slow the disease progression, and lung transplantation is limited by donor availability and complications. Stem cell therapy has emerged as a potential alternative treatment for pulmonary fibrosis, in which stem cells modulate the inflammatory response, differentiate into lung epithelial cells, secrete growth factors and extracellular matrix components, and enhance vascularization and tissue regeneration. Various sources of stem cells, such as endogenous lung stem cells, embryonic stem cells, induced pluripotent stem cells, and mesenchymal stem cells, have been investigated in animal models and human trials. Various delivery routes, such as intravenous injection, intratracheal instillation, and inhalation, have been tested for safety and efficacy. However, several challenges and limitations remain to be overcome, such as high costs, ethical issues, immunological compatibility, cell survival and homing, and long-term outcomes. Further research is needed to optimize the protocols and parameters in stem cell therapy for pulmonary fibrosis, and to evaluate the clinical benefits and risks for patients.

Analysis of Conflicts of Interest in Studies Related to Robotics in Gastrointestinal and Abdominal Wall Surgery

BACKGROUND

Industry payments to physicians represent a potential conflict of interest (COI) and can influence the study conclusions. This study aimed to evaluate the accuracy of the COIs reported in major surgical journals.

STUDY DESIGN

Studies with at least one American author published between 2016 and 2021 that discussed observational and intervention studies assessing robotic surgery were included in the analysis. The Centers for Medicare & Medicaid Services' Open Payments database was used to collect the industry payments. A COI is defined as receiving funding from a robotics company while publishing research directly related to the company's products. A COI statement was defined as disclosed (or accurate) if the disclosure statement for the study in question acknowledged funding from the robotics companies. A COI was defined as undisclosed (or inaccurate) if the disclosure statement for the study in question did not acknowledge funding from the robotics companies.

RESULTS

A total of 314 studies and 1978 authors were analyzed. Only 13.6% of the studies had accurate COI statements, whereas the majority (86.4%) had inaccurate COI disclosures. Additionally, 48.9% of the authors who received funding of $10,000 to $100,000 failed to report this amount in their disclosures, and 18% of the authors who received funding of $100,000 or more did not report it in their disclosures.

CONCLUSIONS

There was a significant discordance between the self-reported COI in gastrointestinal and abdominal wall surgeries. This study calls for continued efforts to improve the definitions of what constitutes a relevant COI and encourages a standardized reporting process. It is imperative for investigators to make accurate disclosure statements.

Sustainable wastewater purification with crab shell-derived biochar: Advanced machine learning modeling & experimental analysis

Detoxifying ecologically persistent dyes is vital for environmental and human well-being. Herein, crabshell waste is transformed into porous carbon (CB900) through pyrolysis, achieving a remarkable removal rate of 90.5% (CR-RR) and adsorption capacity (∼256.36 mg g-1, qCR). Employing XGBoost modeling, with a robust R2 ∼0.996, proved its superiority over others in predicting CR adsorption. PSO-XGB optimization led to an optimal configuration: 0.051 g adsorbent, 460.56 mg L-1 CR concentration, pH 3.16, and a 94.01 min contact time, resulting in 68.39% CR-RR and 822.15 mg g-1 qCR, simultaneously; sensitivity analysis unveiled the pivotal role of pH and adsorbent dose. CB900 exhibited physical, spontaneous, endothermic following both Langmuir and Freundlich isotherms. Remarkably, CB900 effectively eliminated various contaminants, including chromium and sulfasalazine antibiotic. Pilot-scale CB900 production cost via pyrolysis was $8.5/kg, a fraction of commercial powdered activated carbon, underscoring its economic viability and potential as a sustainable solution for the elimination of toxic contaminants from aqueous environments.

Arthroscopic Stabilisation in Anterior Shoulder Instability: An Analysis of Mid-term Outcome

OBJECTIVE

To assess the clinical outcome of arthroscopic stabilisation for recurrent anterior glenohumeral joint dislocations.

STUDY DESIGN

Case series. Place and Duration of the Study: Ghurki Trust Teaching Hospital, Lahore, from May 2018 to December 2022.

METHODOLOGY

Fifty-two patients who underwent arthroscopic repair of Bankart lesion were studied. Those who had concomitant fractures, neurological injury or underwent any surgery on the same shoulder were excluded. The outcome was assessed in terms of improvement in pain, constant and Rowe scores, postoperatively.

RESULTS

The mean delay in the procedure after the first dislocation was 65.15+38.23 months, and the mean follow-up period was 26.61+7.55 months. On final follow-up, improvement in pain was statistically significant (p<0.05): (VAS: 2.17+1.77 to 0.69+0.64 at rest and from 4.5+2.24 to 1.58+1.85 at motion). On subjective assessment, 50% of the sample was very satisfied, and an objective assessment showed statistically significant (p<0.05) improvement in Constant score from 65.4 to 78.6. Rowe score not only showed a significant improvement (from 31.6 to 80.3 with p<0.05), but 69.2% of the follow-up scores lied in the good and excellent results range as well. Recurrence was noted in 8 cases (15.3%).

CONCLUSION

Significant clinical improvement was seen after arthroscopic stabilisation in anterior shoulder instability. However, further research is required regarding the recurrence rate and restriction in the range of motion.

KEY WORDS

Glenohumeral joint, Dislocation, Stabilisation, Shoulder arthroscopy.

Microplastic-Assisted Removal of Phosphorus and Ammonium Using Date Palm Waste Derived Biochar

Microplastics (MPs) are emerging environmental pollutants worldwide, posing potential health risks. Moreover, MPs may act as vectors for other contaminants and affect their fate, transport, and deposition in the environment. Therefore, efficient and economical techniques are needed for the removal of contemporary MPs and contaminants from the environment. The present research study investigated the sorption of phosphorus (P) and ammonium (NH4+) onto date palm waste-derived biochar (BC) from an aqueous solution in the presence of polyamide (PA) and polyethylene (PE) MPs. The BC was prepared at 600 °C, characterized for physio-chemical properties, and applied for P and NH4+ removal via isotherm and kinetic sorption trials. The results of the sorption trials demonstrated the highest removal of NH4+ and P was obtained at neutral pH 7. The highest P sorption (93.23 mg g-1) by BC was recorded in the presence of PA, while the highest NH4+ sorption (103.76 mg g-1) was found with co-occurring PE in an aqueous solution. Sorption isotherm and kinetics models revealed that P and NH4+ removal by MP-amended BC followed chemisorption, electrostatic interaction, precipitation, diffusion, and ion exchange mechanisms. Overall, co-existing PA enhanced the removal of P and NH4+ by 66% and 7.7%, respectively, while co-existing PE increased the removal of P and NH4+ by 55% and 30%, respectively, through the tested BC. Our findings suggested that converting date palm waste into BC could be used as a competent and economical approach to removing P and NH4+ from contaminated water. Furthermore, microplastics such as PE and PA could assist in the removal of P and NH4+ from contaminated water using BC.

Scavenging microplastics and heavy metals from water using jujube waste-derived biochar in fixed-bed column trials

Extensive production and utilization of plastic products have resulted in the generation of microplastics (MPs), subsequently polluting the environment. The efficiency of biochars (BCs) derived from jujube (Ziziphus jujube L.) biomass (300 °C and 700 °C) for nylon (NYL) and polyethylene (PE) removal from contaminated water was explored in fixed-bed column trials. The optimum pH for the removal of both MPs was found 7. Both of the produced biochars demonstrated >99% removal of the MPs, while the sand filter exhibited a maximum of 78% removal of MPs. BC produced at 700 °C (BC700) showed 33-fold higher MPs retention, while BC produced at 300 °C (BC300) exhibited 20-fold higher retention, as compared to sand filters, indicating the higher efficiency of BC produced at higher pyrolysis temperature. Entrapment into the pores, entanglement with flaky structures of the BCs, and electrostatics interactions were the major mechanism for MPs retention in BCs. The efficiency of MPs-amended BCs was further explored for the removal of Pb(II) and Cd(II) in fixed-bed column trials. BC700 amended with PE and NYL exhibited the highest 50% breakthrough time (2114.23 and 2024.61 min, respectively, for Pb(II) removal and 2107.92 and 1965.19 min, respectively, for Cd(II) removal), as compared to sand filters (38.07 and 60.49 min for Pb(II) and Cd(II) removal, respectively). Thomas model predicted highest adsorption capacity was exhibited by BC700 amended with PE (584.34 and 552.80 mg g-1, for Pb(II) and Cd(II) removal, respectively), followed by BC700 amended with NYL (557.65 and 210.59 mg g-1 for Pb(II) and Cd(II) removal, respectively). Therefore, jujube waste-derived BCs could be used as efficient adsorbents to remove PE and NYL from contaminated water, while MPs-loaded BCs can further be utilized for higher adsorption of Pb(II) and Cd(II) from contaminated aqueous media. These findings suggest that BC could be used as an efficient adsorbent to remove the co-existing MPs-metals ions from the environment on a sustainable basis.

Comparison of Outcomes Between Metabolic Dysfunction-Associated Fatty Liver Disease and Non-alcoholic Fatty Liver Disease: A Meta-Analysis

Non-alcoholic fatty liver disease (NAFLD) encompasses a range of conditions, from fatty liver to cirrhosis. In response to evolving research and to better reflect the complex metabolic underpinnings, the term metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed. The aim of this meta-analysis was to compare cardiovascular events and all-cause mortality between NAFLD and MAFLD patients. The present study was conducted following the Preferred Reporting of Systematic Review and Meta-analysis (PRISMA) guidelines. We systematically searched PubMed, EMBASE, and the Web of Science to identify studies that compared cardiovascular outcomes in MAFLD and NAFLD from inception to July 31, 2023. Outcomes assessed in this meta-analysis included all-cause mortality, cardiovascular mortality, and cardiovascular events. A total of 11 studies were included in this meta-analysis. The risk of cardiovascular mortality was significantly higher in patients with MAFLD patients compared to NAFLD patients (risk ratio (RR): 1.48, 95% confidence interval (CI): 1.11 to 1.98). The risk of all-cause mortality was higher in MAFLD patients compared to NAFLD, and the difference was statistically significant (RR: 2.80, 95% CI: 2.39 to 3.28). The risk of cardiovascular events was significantly higher in MAFLD patients compared to NAFLD (RR: 1.18, 95% CI: 0.86 to 1.61). The key findings underscore that individuals diagnosed with MAFLD face a notably higher risk of all-cause mortality, cardiovascular mortality, and cardiovascular events when compared to those with NAFLD.

Comparison Between Dexmedetomidine and Propofol for Sedation on Outcomes After Cardiac Surgery in Patients Requiring Mechanical Ventilation: A Meta-Analysis of Randomized-Control Trials

The aim of this study was to compare outcomes between dexmedetomidine and propofol for sedation after cardiac surgery in patients requiring mechanical ventilation. This meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Online databases, including EMBASE, PubMed, and the Cochrane Library, were comprehensively searched to identify relevant randomized controlled trials (RCTs) comparing the safety and efficacy of dexmedetomidine and propofol in patients undergoing cardiac surgery and requiring mechanical ventilation. The examined outcomes included the mean length of intensive care unit (ICU) stay in hours, duration of mechanical ventilation in hours, length of hospital stay in days, and number of patients diagnosed with delirium. A total of 14 studies were included in the present meta-analysis while 1360 patients undergoing cardiac surgery were involved in these studies. Pooled results showed that the duration of mechanical ventilation was lower in the dexmedetomidine group compared to the propofol group (mean difference (MD): 0.75, 95% confidence interval (CI): 0.06-1.44, p-value: 0.03). We also found a significantly low length of stay in ICU in the dexmedetomidine group compared to the propofol (MD: 0.89, 95% CI: 0.04-1.74, p-value: 0.04). The length of hospital stay was also significantly lower in patients receiving dexmedetomidine as compared to the propofol group (MD: 0.51, 95% CI: 0.32-0.70, p-value<0.001). Risk of delirium was significantly higher in patients receiving propofol compared to patients receiving dexmedetomidine (RR: 2.02, 95% CI: 1.48-2.74, p-value<0.001). In conclusion, our meta-analysis provides evidence of the beneficial impacts of dexmedetomidine on clinical outcomes in patients undergoing cardiac surgery. Dexmedetomidine was associated with a significant reduction in the duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and the risk of delirium.

Ticagrelor Versus Clopidogrel in Patients With Acute Coronary Syndrome and on Dialysis: A Meta-Analysis

This study aims to compare the safety and efficacy of clopidogrel and ticagrelor in patients with acute coronary syndrome (ACS) and undergoing dialysis. This study was conducted per the guidelines of the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search was performed using electronic databases, including PubMed, EMBASE, and Web of Science, to identify relevant studies comparing clopidogrel and ticagrelor in patients undergoing dialysis. To ensure the inclusion of all relevant articles, a combination of the following keywords, along with medical subject heading (MeSH) terms, was used: "clopidogrel," "ticagrelor," "acute coronary syndrome," and "dialysis." The primary endpoint of this meta-analysis was the incidence of major adverse cardiovascular events (MACE), which consisted of cardiovascular death, myocardial infarction, stroke, and revascularization. The secondary endpoint was all-cause mortality. The occurrence of any bleeding events (including major and nonmajor bleeding events) and major bleeding events was chosen as the safety endpoints. A total of four studies were included in the pooled analysis. The pooled sample size was 5,417 patients, including 892 in the ticagrelor group and 4525 in the clopidogrel group. The findings indicate that ticagrelor, compared to clopidogrel, is associated with a significantly higher risk of MACEs, all-cause death, and major bleeding events. The findings suggest that clopidogrel may be a better choice for individuals with ACS undergoing dialysis due to its lower risk of MACE, all-cause death, and major bleeding events compared to ticagrelor.

Comparison of the Effectiveness and Safety of Chlorthalidone and Hydrochlorothiazide in Patients With Hypertension: A Meta-Analysis

The aim of this study was to compare the effectiveness and safety of chlorthalidone and hydrochlorothiazide in patients with hypertension. The present meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search for relevant articles was conducted on PubMed, Scopus, and CINAHIL databases from their inception until March 31, 2023. Keywords used to search for relevant articles included "hydrochlorothiazide," "chlortalidone," "hypertension," "cardiovascular," and "blood pressure." The outcomes assessed in this meta-analysis included changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP). Myocardial infarction, stroke, and all-cause mortality were also assessed. For safety analysis, we evaluated the risk of hypokalemia between the two groups. Any disagreement between the two authors in the data extraction process was resolved through discussion. Eight studies fulfilled the inclusion criteria included in the present meta-analysis. Our analysis showed that chlorthalidone was superior to hydrochlorothiazide in controlling both SBP and DBP, with no significant heterogeneity reported. However, there was no significant difference between the two groups in terms of the risk of myocardial infarction, stroke, all-cause mortality, and hospitalization due to heart failure. The hypokalemia rate was reported to be higher with chlorthalidone compared to hydrochlorothiazide.

Targeting ARID1A-Deficient Cancers: An Immune-Metabolic Perspective

Epigenetic remodeling and metabolic reprogramming, two well-known cancer hallmarks, are highly intertwined. In addition to their abilities to confer cancer cell growth advantage, these alterations play a critical role in dynamically shaping the tumor microenvironment and antitumor immunity. Recent studies point toward the interplay between epigenetic regulation and metabolic rewiring as a potentially targetable Achilles' heel in cancer. In this review, we explore the key metabolic mechanisms that underpin the immunomodulatory role of AT-rich interaction domain 1A (ARID1A), the most frequently mutated epigenetic regulator across human cancers. We will summarize the recent advances in targeting ARID1A-deficient cancers by harnessing immune-metabolic vulnerability elicited by ARID1A deficiency to stimulate antitumor immune response, and ultimately, to improve patient outcome.

Bulbar Dysfunction in Idiopathic Normal Pressure Hydrocephalus: A Case Report

Normal pressure hydrocephalus (NPH) is a rare condition characterized by pathologically enlarged ventricles and a normal cerebrospinal fluid (CSF) opening pressure measured by lumbar puncture. NPH typically presents as a triad of cognitive decline, gait disturbance, and urinary incontinence. Rarely, NPH can present with bulbar involvement, particularly with difficulty swallowing. Here, we present a case of NPH in a 75-year-old man who presented with an episode of choking and a recent onset of swallowing difficulties with a three-month history of ataxia and progressive memory loss. His CT scan revealed ventriculomegaly, which was consistent with the clinical presentation of NPH and was further confirmed by a normal opening pressure on the CSF tap. Furthermore, ventriculoperitoneal shunts showed a marked improvement in patients' dysphagia and the classical triad of NPH symptoms. Through this case report, we want to highlight that NPH can present as a difficulty in swallowing.

Multi-Class Skin Lesions Classification Using Deep Features

Skin cancer classification is a complex and time-consuming task. Existing approaches use segmentation to improve accuracy and efficiency, but due to different sizes and shapes of lesions, segmentation is not a suitable approach. In this research study, we proposed an improved automated system based on hybrid and optimal feature selections. Firstly, we balanced our dataset by applying three different transformation techniques, which include brightness, sharpening, and contrast enhancement. Secondly, we retrained two CNNs, Darknet53 and Inception V3, using transfer learning. Thirdly, the retrained models were used to extract deep features from the dataset. Lastly, optimal features were selected using moth flame optimization (MFO) to overcome the curse of dimensionality. This helped us in improving accuracy and efficiency of our model. We achieved 95.9%, 95.0%, and 95.8% on cubic SVM, quadratic SVM, and ensemble subspace discriminants, respectively. We compared our technique with state-of-the-art approach.

Data-Driven Non-Linear Current Controller Based on Deep Symbolic Regression for SPMSM

This study designs a simple current controller employing deep symbolic regression (DSR) in a surface-mounted permanent magnet synchronous machine (SPMSM). A novel DSR-based optimal current control scheme is proposed, which after proper training and fitting, generates an analytical dynamic numerical expression that characterizes the data. This creates an understandable model and has the potential to estimate data that have not been seen before. The goal of this study was to overcome the traditional linear proportional-integral (PI) current controller because the performance of the PI is highly dependent on the system model. Moreover, the outer speed control loop gains are tuned using the cuckoo search algorithm, which yields optimal gain values. To demonstrate the efficacy of the proposed design, we apply the control design to different test cases, that is varied speed and load conditions, as well as sinusoidal speed reference, and compare the results with those of a traditional vector control design. Compared with traditional control approaches, we deduce that the DSR-based control design could be extrapolated far beyond the training dataset, laying the foundation for the use of deep learning techniques in power conversion applications.

Hyperpigmentation as a Primary Symptom of Vitamin B12 Deficiency: A Case Report

The presentation of vitamin B12 deficiency varies from being asymptomatic to affecting multiple organ systems. In addition, several systemic diseases can be associated with generalized weakness and hyperpigmentation. However, vitamin B12 deficiency rarely presents with hyperpigmentation as an initial symptom. We present a rare case of a 22-year-old college student who presented with hyperpigmentation as the only physical manifestation of early vitamin B12 deficiency. This case underlines the need to rule out vitamin B12 deficiency when clinicians encounter hyperpigmentation as a solo presentation and also emphasizes the significance of early treatment in preventing the irreversible neurological manifestations of vitamin B12 deficiency.

An Unusual Association Between Metformin and Nightmares: A Case Report

Metformin remains the oral drug of choice for patients with type 2 diabetes mellitus (T2DM). It is an ideal anti-diabetic drug for maintaining good glycemic control in diabetics. However, the side effect profile of metformin varies from minor or no effects to substantial impact on the GI tract. In addition, metformin is rarely known for its association with nightmares. Here we present the case of a newly diagnosed 40-year-old diabetic who developed recurrent nightmares within a week of starting metformin treatment. The patient had no previous history of psychiatric or sleep disorders. However, it was the first time he had experienced such recurrent nightmares, especially after the start of 500 mg metformin thrice a day. Based on the Naranjo Adverse Drug Reaction (ADR) Probability Scale, and sudden onset and disappearance of nightmares after metformin initiation and discontinuation made metformin the primary cause of his nightmares.

The Co-Existence of Agranulocytosis and Stevens-Johnson Syndrome (SJS) in Carbamazepine Therapy: A Case Report

The therapeutic significance of carbamazepine in individuals with trigeminal neuralgia, epilepsy, and bipolar disorder is well recognized. Although it has high effectiveness, it raises the patient's risk for some adverse effects. The relationship between carbamazepine usage and agranulocytosis is well-established. Agranulocytosis is characterized by an unusually low number of neutrophils. This disorder poses a grave hazard to the patient since they are more likely to get potentially lethal bacterial or fungal infections. Moreover, carbamazepine is one of the most common causes of Stevens-Johnson syndrome (SJS), a severe skin condition with a high mortality rate. In cases where agranulocytosis and Stevens-Johnson syndrome coexist, the prognosis is relatively poor. We report a rare case of a patient who developed agranulocytosis and Stevens-Johnson syndrome after taking carbamazepine. Neutrophils accounted for 2.1% of the patient's differential leukocyte count. Furthermore, Naranjo's scale found a score of 8 for Stevens-Johnson syndrome, placing it in the "probable" category, while a score of 9 for agranulocytosis indicated that it was a confirmed adverse reaction to carbamazepine.

476 Sleep-Disordered Breathing is More Predictive than Obesity of Increased Left Ventricular Mass Index in Bariatric Surgery Patients

Introduction

Obesity and obstructive sleep apnea (OSA) are associated with left ventricular hypertrophy and increased cardiovascular risk. Alternatively, the “obesity paradox” describes an improved prognosis from heart failure in obesity, though potentially attributable to confounding/bias. We sought to determine the contributions of obesity and sleep-disordered breathing (SDB) to left ventricular function and morphology in bariatric surgery candidates.

Methods

Patients undergoing polysomnography prior to bariatric surgery from 2011–2018 had demographic (age, gender, race), anthropometric (body mass index [BMI], neck circumference), comorbidities (atrial fibrillation, coronary artery disease, diabetes, hypertension, hyperlipidemia), echocardiographic and sleep-disordered breathing (apnea-hypopnea index [AHI], peak end-tidal CO2 [etCO2]) variables retrospectively examined. The echocardiographic visit closest to polysomnogram within two years was selected with missing values filled by available values within 6 months. Linear regression assessed the relationship of BMI, AHI, and etCO2 with left ventricular mass index (LVMI) after adjustment of demographics and comorbidities. Echocardiographic measures were logarithm transformed before regression analysis. Coefficients and 95% confidence intervals (CI) were calculated by exponential transformation. The analysis was performed based on an overall significance level of 0.05 using SAS software (version 9.4, Cary, NC).

Results

The total of 832 patients had 24% males, mean age 48.8±12, 60% white, and BMI:49.4±9.5kg/m2. Ejection fraction (%) was 60.0±7.0, and LVMI (g/m2): 80.9±23.7. In adjusted models, LVMI decreased by 2.1% for each 5kg/m2 increase in BMI (coefficient=0.979, 95%CI 0.961–0.997, p=0.022) and increased by 4.3% for each 5 mmHg increase in etCO2 (coefficient=1.043, 95%CI 1.013–1.073, p=0.005). Without adjustment, patients with AHI ≥ 5 had 15.3% higher LVMI than non-OSA group (coefficient=1.153, 95%CI 1.034–1.286, p=0.011) and moderate/severe OSA was associated with a 7.6% higher LVMI than those with AHI&lt;15 (coefficient 1.076, 95%CI 1.003–1.153, p=0.040), but not statistically significant after adjustment.

Conclusion

In obese patients, nocturnal hypoventilation rather than obesity may have adverse influences on left ventricular morphology. Future studies should focus on clarifying whether obesity is truly protective in terms of LV mass, i.e. reflective of paradox versus a product of bias. The potential benefit of identifying/treating SDB in bariatric surgery candidates to mitigate cardiovascular risk also deserves further investigation.

Support (if any)

Cleveland Clinic Transformative Resource Neuroscience Award

Challenges of left atrial appendage closure device and anticoagulation in a patient with immune thrombocytopenia (ITP)

Among patients with atrial fibrillation (AF) who have high risk of bleeding secondary to haematologic disorders, left atrial appendage (LAA) occlusion therapy has been shown to be an excellent alternative to long-term use of oral anticoagulation for thromboembolic stroke prevention. However, there remains a major concern of device-associated thrombosis post-procedure, that can lead to life-threatening embolic events. To this date, there is no systematic guideline for the selection and management of patients with haematological disorders with LAA occlusion therapy, especially in those with platelet disorders such as immune thrombocytopenia (ITP). Patients with platelet disorders are at a higher risk for bleeding; however, that does not prevent such patients from thromboembolic events secondary to AF. We present a case of ITP with permanent AF, where an LAA device was complicated by thrombus formation due to challenges faced with anticoagulation therapy.

Securing Machine Learning in the Cloud: A Systematic Review of Cloud Machine Learning Security

With the advances in machine learning (ML) and deep learning (DL) techniques, and the potency of cloud computing in offering services efficiently and cost-effectively, Machine Learning as a Service (MLaaS) cloud platforms have become popular. In addition, there is increasing adoption of third-party cloud services for outsourcing training of DL models, which requires substantial costly computational resources (e.g., high-performance graphics processing units (GPUs)). Such widespread usage of cloud-hosted ML/DL services opens a wide range of attack surfaces for adversaries to exploit the ML/DL system to achieve malicious goals. In this article, we conduct a systematic evaluation of literature of cloud-hosted ML/DL models along both the important dimensions—attacks and defenses—related to their security. Our systematic review identified a total of 31 related articles out of which 19 focused on attack, six focused on defense, and six focused on both attack and defense. Our evaluation reveals that there is an increasing interest from the research community on the perspective of attacking and defending different attacks on Machine Learning as a Service platforms. In addition, we identify the limitations and pitfalls of the analyzed articles and highlight open research issues that require further investigation.

Speech Technology for Healthcare: Opportunities, Challenges, and State of the Art

Speech technology is not appropriately explored even though modern advances in speech technology-especially those driven by deep learning (DL) technology-offer unprecedented opportunities for transforming the healthcare industry. In this paper, we have focused on the enormous potential of speech technology for revolutionising the healthcare domain. More specifically, we review the state-of-the-art approaches in automatic speech recognition (ASR), speech synthesis or text to speech (TTS), and health detection and monitoring using speech signals. We also present a comprehensive overview of various challenges hindering the growth of speech-based services in healthcare. To make speech-based healthcare solutions more prevalent, we discuss open issues and suggest some possible research directions aimed at fully leveraging the advantages of other technologies for making speech-based healthcare solutions more effective.

Assessing Fitness-To-Drive among Older Drivers: A Comparative Analysis of Potential Alternatives to on-Road Driving Test

To enable older drivers to maintain mobility without endangering public safety, it is necessary to develop more effective means of assessing their fitness-to-drive as alternatives to an on-road driving test. In this study, a functional ability test, simulated driving test, and on-road driving test were carried out for 136 older drivers. Influencing factors related to fitness-to-drive were selected based on the correlation between the outcome measure of each test and the pass/fail outcome of the on-road driving test. Four potential alternatives combining different tests were considered and three modeling techniques were compared when constructing the fitness-to-drive assessment model for the elderly. As a result, 92 participants completed all of the tests, of which 61 passed the on-road driving test and the remaining 31 failed. A total of seven influencing factors from all types of tests were selected. The best model was trained by the technique of gradient boosted machine using all of the seven factors, generating the highest accuracy of 92.8%, with sensitivity of 0.94 and specificity of 0.90. The proposed fitness-to-drive assessment method is considered an effective alternative to the on-road driving test, and the results offer a valuable reference for those unfit-to-drive older drivers to either adjust their driving behavior or cease driving.

Evaluation Of Modified Alvarado, Ripasa And Lintula Scoring System As Diagnostic Tools For Acute Appendicitis

BACKGROUND

Commonest surgical emergency presenting to emergency departments with abdominal pain is acute appendicitis. Thus, to enable quick and accurate diagnosis of the condition various scoring systems have been developed. Among these, Alvarado and its modified version (Modified Alvarado) are the commonest. Whereas Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score showed promising results in Asian population. Similarly, Lintula score, which was initially developed for paediatric population, has now been validated for elderly too. This study is aimed to compare these in our regional population.

METHODS

Project included consecutive 125 clinically suspected acute appendicitis patients. All were scored using Modified Alvarado, RIPASA and Lintula systems. Final diagnosis was based on histopathologic evaluation of excised specimen. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were computed for all these systems by using SPSS statistical software and ROC curves were plotted.

RESULTS

With cut-off of 7, Modified Alvarado was 62% specific, 83% sensitive and 65% accurate. While PPV and NPV were 94% and 33%, respectively. Whereas RIPASA yielded better results, i.e., sensitivity of 98.4%, specificity of 87%, PPV of 97%, NPV of 77% and diagnostic accuracy of 92%. Whereas Lintula showed sensitivity of 71%, specificity of 87%, PPV of 96%, NPV of 40 and accuracy of 73%.

CONCLUSIONS

RIPASA demonstrated higher sensitivity, PPV, NPV and diagnostic accuracy than Modified Alvarado and Lintula scores. Hence this study approves use of RIPASA score in the region. However further research on the subject is required to back this inference.

A Survey on Recent Trends and Open Issues in Energy Efficiency of 5G

The rapidly increasing interest from various verticals for the upcoming 5th generation (5G) networks expect the network to support higher data rates and have an improved quality of service. This demand has been met so far by employing sophisticated transmission techniques including massive Multiple Input Multiple Output (MIMO), millimeter wave (mmWave) bands as well as bringing the computational power closer to the users via advanced baseband processing units at the base stations. Future evolution of the networks has also been assumed to open many new business horizons for the operators and the need of not only a resource efficient but also an energy efficient ecosystem has greatly been felt. The deployment of small cells has been envisioned as a promising answer for handling the massive heterogeneous traffic, but the adverse economic and environmental impacts cannot be neglected. Given that 10% of the world’s energy consumption is due to the Information and Communications Technology (ICT) industry, energy-efficiency has thus become one of the key performance indicators (KPI). Various avenues of optimization, game theory and machine learning have been investigated for enhancing power allocation for downlink and uplink channels, as well as other energy consumption/saving approaches. This paper surveys the recent works that address energy efficiency of the radio access as well as the core of wireless networks, and outlines related challenges and open issues.

Advances In Research On Genome Editing Crispr-Cas9 Technology

BACKGROUND

The current era of genome engineering has been revolutionized by the evolution of a bacterial adaptive immune system, CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) into a radical technology that is making an expeditious progress in its mechanism, function and applicability..

METHODS

A systematic literature review study was carried out with the help of all available information and online resources..

RESULTS

In this review, we intend to elucidate different aspects of CRISPR in the light of current advancements. Utilizing a nonspecific Cas9 nuclease and a sequence specific programmable CRISPR RNA (crRNA), this system cleaves the target DNA with high precision. With a vast potential for profound implications, CRISPR has emerged as a mainstream method for plausible genomic manipulations in a range of organisms owing to its simplicity, accuracy and speed. A modified form of CRISPR system, known as CRISPR/Cpf1 that employs a smaller and simpler endonuclease (Cpf1) than Cas9, can be used to overcome certain limitations of CRISPR/Cas9 system. Despite clear-cut innovative biological applications, this technology is challenged by off-target effects and associated risks, thus safe and controlled implementation is needed to enable this emerging technique assist both biological research and translational applications.

CONCLUSIONS

CRISPR/Cas9 systems will undoubtedly revolutionize the study and treatment of both immunologic and allergic diseases. Concerned authorities should formulate and authorize such laws and regulations that permit the safe and ethical use of this emerging technology for basic research and clinical purposes.

Chaos-Based Simultaneous Compression and Encryption for Hadoop

Data compression and encryption are key components of commonly deployed platforms such as Hadoop. Numerous data compression and encryption tools are presently available on such platforms and the tools are characteristically applied in sequence, i.e., compression followed by encryption or encryption followed by compression. This paper focuses on the open-source Hadoop framework and proposes a data storage method that efficiently couples data compression with encryption. A simultaneous compression and encryption scheme is introduced that addresses an important implementation issue of source coding based on Tent Map and Piece-wise Linear Chaotic Map (PWLM), which is the infinite precision of real numbers that result from their long products. The approach proposed here solves the implementation issue by removing fractional components that are generated by the long products of real numbers. Moreover, it incorporates a stealth key that performs a cyclic shift in PWLM without compromising compression capabilities. In addition, the proposed approach implements a masking pseudorandom keystream that enhances encryption quality. The proposed algorithm demonstrated a congruent fit within the Hadoop framework, providing robust encryption security and compression.

Hemodynamic performance of stentless porcine bioprosthesis and mechanical bileaflet prosthesis using dobutamine stress echocardiography

Currently available aortic valve prostheses have satisfactory hemodynamic performance during rest, but with exercise they possess different responses. The objective was to compare the hemodynamic response of the stentless porcine bioprosthesis (SP) and the mechanical bileaflet prosthesis (MB) at rest and during peak exercise using dobutamine stress echocardiography (DSE). DSE was used to evaluate the effective orifice area index (EOAI), peak and mean pressure gradients at rest and during maximum stress in 15 patients with SP (group T, mean age, 30.9 year) and another 15 patients with MB (group M, mean age, 28.6 year). The increment in pressure gradient (mean/peak) was significantly less in patients with SP than those with MB (P <.01). The EOAI did not change with exercise. At rest, both valve substitutes have satisfactory hemodynamics, but during exercise the stentless porcine bioprosthesis has better hemodynamics because it is less obstructive that justifies its use in young population.