Within the last decade significant progress has been accomplished in the field of allogeneic hematopoietic cell transplantation (HCT). The articles in this special topics series present progress in improving clinical outcomes using some of the most vibrant current research and translational approaches, including novel reduced-intensity conditioning regimens, donor graft engineering, quantification of the microbiome, and tailored immunosuppressive therapies. Much of the progress described is due to improvements in immune reconstitution that results in durable allograft tolerance. Consequently, there is reduced graft-vs.-host disease (GVHD) and improvement in controlling infectious disease complications. In addition, improved immune reconstitution also appears to facilitate much-needed graft-vs.-leukemia effects, as relapse remains the major challenge of our field. Many of the articles in this special topics series are organized around our increasing understanding of GVHD and a suite of new tools and approaches to prevent and treat this dreaded immune complication.Thangavelu and Blazar from the University of Minnesota provide an overview of our current understanding of GVHD pathophysiology and thoroughly review novel therapeutic strategies to induce immune tolerance focusing on biologicals, epigenetic modulation, and adoptive cell therapy. In particular, light is shed on the role of the intestinal microbiome for GVHD induction by Köhler and Zeiser: within the last years it became evident in various preclinical and clinical studies that changes of the bacterial composition affects the risk of intestinal GVHD which also constitutes a potential target to prevent deleterious damage of the gut. For patients with steroid-refractory acute and chronic GVHD, extracorporeal photopheresis (ECP) is an established procedure to induce immune tolerance and a significant impact of apoptotic bodies to modulate dendritic-cell function has been established. Ni et al. now suggest that also NK-cell subsets are influenced by ECP in such a way that CD56highCD16− NK cells were decreased and cytotoxicity shifted toward a regulatory phenotype while maintaining antileukemic activity.Soares et al. who performed a prospective comparative analysis that suggests that thymic damage results in dysfunctional thymic output with increased CD8+ terminally differentiated effector memory T cells and decreased T-cell receptor diversity. This study emphasizes the thymus as critical organ for central immune tolerance during immune reconstitution and sustained immune tolerance after allogeneic HCT. Simonetta et al. performed a comprehensive analysis of PD-1 expression on T cells following allogeneic HCT noticing an increase early after transplantation without impaired production of cytotoxic effector molecules. This study provides insight into dynamic T-cell regulation also suggesting that timing should be considered when check point inhibitors are applied.Efforts to define normal and healthy from abnormal and immune reconstitution that puts recipients at increased risk of GVHD continues to develop with the application of immune monitoring, as illustrated by Bertaina and Roncarolo from Stanford University review such approaches focusing on T- and B-cell depletion strategies as well as regulatory T cells. In particular, three papers included in this Research Topic explore double-negative T cells, myeloid-derived suppressor cells (MDSCs) and invariant natural killer T (iNKT) cells for GVHD prevention. Haug et al. found that TCRαβ+CD4−CD8− T cells inhibit mammalian target of rapamycin (mTOR) signaling and prevent metabolic adaption of conventional T helper cells resulting in decreased homing receptor expression and production of proinflammatory cytokines. The expansion of MDSCs from hematopoietic stem cells has been studied by Park et al. showing that these cells retain a suppressive phenotype and ameliorate GVHD in a xenogeneic GVHD model also resulting in improved survival. Jahnke et al. demonstrate that human iNKT cells that have been shown to promote immune tolerance after allogeneic HCT can also be expanded from cryopreserved donor lymphocytes efficiently lysing patient AML blasts.Efforts to engineer donor grafts have shown evidence in pre-clinical and clinical studies of improved immune reconstitution. Stahl et al. summarize preclinical and clinical data about the CD4 antibody MAX.16H5 that has been investigated in auto- and alloimmunity. Wajant and Beilhack from Würzburg highlight the impact of tumor necrosis factor signaling on the regulation of FoxP3 regulatory T cells being known as central players for sustained immune tolerance after allogeneic HCT.Finally, two review articles provide detailed insights into innovative approaches of immune tolerance induction. This Research Topic bundles cutting-edge, innovative, and translational original research articles as well as excellent reviews from renowned scientists highlighting recent progress in the field of transplant immunology and immune tolerance.DS and EM wrote the editorial.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The routine use of sentinel lymph node biopsy (SLNB) to accurately stage melanoma patients has been incorporated into most international melanoma guidelines. On average, over 80% of patients are sentinel node negative.The melanoma follow-up (MelFO) study is an international phase III randomized controlled trial where participants are randomized into two groups—one following the conventional schedule recommended in the UK National Institutes for Health and Care Excellence (NICE) melanoma guidelines,These reflections were written at a time when most modern healthcare services have been disrupted beyond recognition during the COVID-19 pandemic. It is likely that many services will be rationalized in the future, once the pandemic subsides. Accordingly, evidenced-based follow-up regimens will be needed to ensure that the appropriate balance is struck between diagnosing early the few recurrences in low-risk groups such as these and not overburdening both patients and society alike.The UK MelFO study has shown that 3 years after staging with a negative SLNB, AJCC stage IB–IIC cutaneous melanoma patients assigned to the prescribed reduced stage-adjusted follow-up schedule reported no difference in levels of anxiety, cancer worry, and mental health-related QoL when compared with those of patients assigned to the follow-up schedule as currently advised in the UK NICE melanoma guideline. These results mirror the findings of the Dutch group who recently reported very similar results using the same protocol in 2019.


A combination of left ventricular aneurysm (LVA) and ventricular septal rupture (VSR) in an acute myocardial infarction (AMI) patient presenting as heart failure is extremely rare. Here, we report a rare case of concurrent true inferoposterior LVA and VSR secondary to inferior wall myocardial infarction (IWMI) presenting as chronic heart failure (CHF). To the best of our knowledge, this is the third reported case in the literature.A 61-year-old man, who had an IWMI about one month prior, presented with CHF. Echocardiography revealed true inferoposterior LVA and VSR. Coronary angiography revealed double vessel disease involving the right coronary artery (RCA) and left circumflex artery (LCX). Left ventricular angiography confirmed a large posterobasal aneurysm and VSR. The patient underwent successful coronary artery bypass grafting (CABG) and ventriculoplasty along with VSR patch repair. Mechanical complications after acute myocardial infarction (AMI) are rare and account for <1% of the total cases. Left ventricular aneurysm (LVA) is the most common mechanical complication of ST-elevation myocardial infarction (STEMI). However, the incidence of LVA has decreased dramatically to 0.2% due to early revascularization therapy. The most common site of LVA is the anterior wall and true LVA involving the inferoposterior wall is rare, comprising only 9% of total cases Mortality with an IWMI, when complicated with VSR, is substantially high. But our case is exceptional, as the patient was hemodynamically stable with the symptoms of gradually progressive heart failure for almost one month. It might be because a giant aneurysm may act as a buffer area to shunting flow thereby preventing the surge of pulmonary artery pressure.There are only a few case reports in the literature for concurrent true vertical reduction aortoplasty and VSR after MI -14. WhilMechanical complications after AMI are rare but still prevalent. Concurrent true inferoposterior LVA and VSR secondary to IWMI can present as symptoms of CHF. High clinical suspicion and thorough physical examination at first medical contact can lead to the early identification of these cases. Echocardiography and LV angiography are valuable in diagnosing these types of rare cases. Combined CABG and ventriculoplasty with VSR patch repair are effective in treating this often fatal complication of inferior STEMI.


The XENON1T collaboration recently reported the excess of events from recoil electrons, possibly giving an insight into new area beyond the Standard Model (SM) of particle physics. We try to explain this excess by considering effective interactions between the sterile neutrinos and the SM particles. In this paper, we present an effective model based on one-particle-irreducible interaction vertices at low energies that are induced from the SM gauge symmetric four-fermion operators at high energies. The effective interaction strength is constrained by the SM precision measurements, astrophysical and cosmological observations. We introduce a novel effective electromagnetic interaction between sterile neutrinos and SM neutrinos, which can successfully explain the XENON1T event rate through inelastic scattering of the sterile neutrino dark matter from Xenon electrons. We find that sterile neutrinos with masses around 90 keV and specific effective coupling can fit well with the XENON1T data where the best fit points preserving DM constraints and possibly describe the anomalies in other experiments.


Seven fish vertebrae were chosen for analysis from the 49-KEN-147 archaeological site in the Kenai Peninsula, Alaska. Mitochondrial DNA analysis of the ancient fish bones revealed that they were from sockeye and coho salmon. Here, we report the ancient mitochondrial genomes for three sockeye salmon and one coho salmon fish bone. Seven fish vertebrae were chosen for analysis from the 49-KEN-147 archaeological site . A single fish bone had CYTB and D-loop sequences that matched coho salmon (Oncorhynchus kisutch). All but one of the corresponding GenBank sequences were exact matches (100% identity) for the entire fish bone sequence (100% coverage). One D-loop sequence that matched sockeye salmon had a 99% identity for 100% coverage due to a single indel.DNA extractions were carried out in a dedicated clean room at the ancient DNA laboratory in the Carl R. Woese Institute for Genomic Biology of the University of Illinois at Urbana-Champaign (UIUC) following a protocol optimized for ancient DNA extraction  using bowtie2 . Variants were called in SNVer  phylogeny was inferred using RaXML v. 8 (Stamatakis The species identifications are consistent with interpretations of a salmon-intensive subsistence strategy of the Riverine Kachemak tradition targeting sockeye salmon and including other species such as coho salmon Reger .


SCs were demonstrated to express more genes of neurotrophic factors in alginate shell. Enhanced proliferation and differentiation tendency of NSCs was observed when they were co-cultured with SCs. This model has strong potential for application in SCI repair.Cellular therapies play a critical role in the treatment of spinal cord injury (SCI). Compared with cell-seeded conduits, fully cellular grafts have more similarities with autografts, and thus might result in better regeneration effects. In this study, we fabricated Schwann cell (SC)-neural stem cell (NSC) core–shell alginate hydrogel fibers in a coaxial extrusion manner. The rat SC line RSC96 and mouse NSC line NE-4C were used in this experiment. Fully cellular components were achieved in the core portion and the relative spatial positions of these two cells partially mimic the construction of nerve fibers  G2017002].Conflict of interest statement. None declared.


A 70-year-old male with prior aorta endovascular aneurysm repair presented with progressive lower extremity weakness over the course of several hours. There was noted loss of palpable bilateral femoral pulses in the emergency department. Computed tomography angiography revealed a kinked and occluded aortic endograft. He subsequently underwent successful axillobifemoral bypass revascularization.Kinking of endograft limbs and occlusion has been reported in a small percentage of patients. Bilateral leg ischemia due to aortic endograft occlusion is rare. A 70-year-old male with a history of abdominal aorta endovascular aneurysm repair (EVAR) presented to the emergency department (ED) as a trauma activation after a fall and subsequent lower extremity weakness. The patient reported a near-syncopal episode the night preceding the fall and progressive lower extremity weakness over the course of the morning. On arrival to the ED, he complained of lower extremity weakness with noted initial 2+ palpable, bilateral femoral and dorsalis pedis pulses. Shortly thereafter, he lost palpable femoral pulses bilaterally and had noted cool lower extremities. Computed tomography angiography (CTA) was remarkable for kinking and occlusion of the abdominal aorta endograft below the renal vessels –3. The pThe patient had undergone EVAR approximately three years prior and had been taking aspirin and clopidogrel but, per the patient, clopidogrel was recently discontinued by his primary care physician to decrease endoleak at aneurysm repair. CTA demonstrated a kinked endograft and thrombus within the graft into the iliac arteries. Kinking of endograft limbs and occlusion has been reported in 2–4% of patients, which can result in acute limb ischemia.3What do we already know about this clinical entity?Kinking and occlusion has been reported as a complication in 2–4% of patients who underwent endovascular aneurysm repair (EVAR) of the abdominal aorta.What is the major impact of the image(s)?These images demonstrate kinking and occlusion of the abdominal aorta EVAR endograft with resulting bilateral leg ischemia, which is very rare.How might this improve emergency medicine practice?Emergency physicians should consider endograft complications in patients with a history of EVAR presenting with lower extremity neurovascular complaints.


Objectives: This study aimed to investigate the effects of transitioning into spousal caregiving, changes in social participation, and their interactions on depressive symptoms among community dwelling old adults over time. Methods: The samples included old adults who were non-caregivers at 2011 baseline of China Health and Retirement Longitudinal Study (CHARLS) and joined the follow-up surveys in 2013 and 2015. Generalized estimating equations (GEE) was used to analyze the effects of caregiving transitions (transitioning into low-intensity or high-intensity caregivers versus the non-caregivers) and changes in social engagement on the depressive symptoms over time. Results: The results showed that old adults who transitioned into spousal caregiving over a 4-year period reported more depressive symptoms than those remained non-caregivers. Old adults who continued or increased social participation reported fewer depressive symptoms than those without social participation. Individuals who continued social participation during the transitions into high-intensity caregiving showed less severe elevated depressive symptoms than their counterparts who did not engage in social participation. Conclusion: The results highlighted that continuous social participation might be a protective factor for old adults against negative psychological outcomes during the transition to high-intensive caregiving.


Drought stress limits growth and yield of crops, particularly under smallholder production systems with minimal use of inputs and edaphic limitations such as nitrogen (N) deficiency. The development of genotypes adapted to these conditions through genetic improvement is an important strategy to address this limitation. The identification of morpho-physiological traits associated with drought resistance contributes to increasing the efficiency of breeding programs. A set of 36 bean genotypes belonging to the Middle American gene pool was evaluated. A greenhouse study using soil cylinders was conducted to determine root vigor traits  under drought stress. Two field trials were conducted to determinate grain yield, symbiotic nitrogen fixation (SNF) ability and other shoot traits under drought stress. Field data on grain yield and other shoot traits measured under drought were related with the greenhouse data on root traits under drought conditions to test the relationships between shoot traits and root traits. Response of root vigor to drought stress appeared to be related with ideotypes of water use (water savers and water spenders). The water spender ideotypes presented deeper root system, while the water saver ideotypes showed a relatively shallower root system. Increase in SNF ability under drought stress was associated with greater values of mean root diameter while greater acquisition of N from soil was associated with finer root system. We identified seven common bean lines  that showed greater root vigor under drought stress in the greenhouse and higher values of grain yield under drought stress in the field. These lines could serve as parents for improving drought resistance in common bean. Drought stress is one of the major abiotic constraints limiting agricultural productivity, particularly for smallholder systems. Drought affects different plant processes resulting in reduced gas exchange, crop growth and productivity  production, affecting around 60% of bean producing regions and generating losses in production from 10 to 100% . Several shoot and root traits improve resistance to drought . Better remobilization of photosynthates to the grains is essential for the success of high yielding genotypes under drought stress  determine genotypic differences in root vigor under drought stress and test the relationships between root vigor and grain yield and SNF ability; and (ii) identify a few promising genotypes that combine root vigor with greater values of SNF ability and grain yield under drought stress which could serve as parents in breeding programs aimed to improve drought resistance in common bean.Phaseolus coccineus ; one landrace of tepary bean (Phaseolus acutifolius) G 40001 from Veracruz-Mexico, and two interspecific lines between tepary bean and common bean (INB 841 and INB 827) developed from five cycles of congruity backcrossing of tepary with ICA Pijao ; five interspecific lines between elite line SER 16 and BFS  lines have been developed to improve adaptation to low soil fertility and drought. SER, SCR and RCB , SEN  and NCB  lines have been developed for improved adaptation to drought, disease resistance and commercial grain. ALB  lines were developed for improved adaptation to drought and aluminum toxicity in acidic soil.–3. The seeds were germinated in paper towels and uniform seedlings were selected for transplanting to transparent plastic cylinders, each of which was inserted into PVC sleeve-tubes. Plants were grown for 45 days in these plastic cylinders/PVC sleeve-tubes with an average maximum and minimum temperature of 34 and 21 °C. A randomized complete block design (RCB) with three replications was used. One level of water supply treatment was applied: progressive soil drying with no watering after 10 days of growth in order to simulate terminal drought stress conditions. The initial soil moisture was at 80% of field capacity. Plants received no water application and each cylinder was weighed at 2 day intervals to determine the decrease in soil moisture content until the time of plant harvest.A greenhouse study was conducted at the main experiment station of the International Center for Tropical Agriculture (CIAT) in Palmira, Colombia, using transparent plastic cylinders  filled with a Mollisol from Palmira, Colombia  and proportion of fine roots or proportion of roots (%) with diameter less than 0.5 mm, were estimated through image analysis using WinRHIZO software . Total root and shoot dry weight per plant were determined after the roots and shoots were dried in an oven at 60 °C for 48 h.Plants were harvested at 45 days after transplanting (35 days of withholding of water application to induce water-stress treatment) when the plants are at early pod development. The root traits were evaluated at this time since the greatest phenotypic differences between the genotypes were observed  were recorded for each plot. Leaf area was measured using a leaf area meter  and the leaf area index (LAI) was calculated as leaf area per unit land area. The stomatal conductance was measured with a portable leaf porometer (Decagon SC-1) on a fully expanded young leaf of one plant within each replication. The following attributes were determined according to Beebe et al. (Grain yield and other shoot traits such as: days to flowering (DF), days to physiological maturity (DPM), canopy biomass (CB), leaf area index (LAI), stomatal conductance (SC), seed number per area (SNA), pod number per area (PNA), harvest index (HI), pod harvest index (PHI), pod partitioning index (PPI), grain carbon isotope discrimination (CID-G), percentage of N derived from the atmosphere using grain tissue (%Ndfa-G), percentage of N derived from soil using grain tissue (%Ndfs-G) and total shoot and seed N content per unit area  PROC MIXED and PROC CORR (SAS Institute Inc. P < 0.05) between genotypes were observed in visual root growth rate under drought conditions. Water spender lines were superior in their visual root growth rate under drought conditions and these were considered as genotypes with high root vigor (Based on genotypic differences in grain carbon isotope discrimination (CID-G), leaf stomatal conductance, canopy biomass, and grain yield under drought stress, the lines resistant to drought conditions were classified into two groups, water savers  and water spenders   in total root length were observed under drought conditions  combined higher values of total root biomass with superior grain yield under drought stress . Five geP < 0.05) were observed in fine root proportion under drought stress conditions. Ten genotypes  developed fine roots under drought stress (acutifolius (G 40001) and its inter-specific progeny INB 841 presented a fine root system but with relatively low values of total root length and total root biomass under drought stress , total root length (r = 0.22*) and total root volume (r = 0.22*). Also a significant and positive correlation (r = 0.58***) was observed between total root length and fine root proportion (r = -0.27**) (A positive and significant correlation was observed between different root traits and grain yield under drought conditions . Grain yoportion . A negat-0.27**) . No corr-0.27**) .r = 0.43***); fine root proportion and %Ndfs (r = 0.46***); fine root proportion and shoot N uptake in kg ha–1 (r = 0.37***); and total root length and shoot N uptake in kg ha–1 (r = 0.39***). Seven lines  combined fine root system development  probably resulting from a deeper root system, higher canopy biomass production and improved partitioning of photosynthates to grain. A few lines of the water saver type combined higher water use efficiency (WUE) with a relatively shallower root system and better photosynthate partitioning under drought stress. Superior SNF ability under drought stress was related with superior presence of roots with greater values of mean root diameter. Superior N uptake from the soil was associated with a larger root system with more presence of fine roots. Seven lines  combined the shoot and root traits of water spending ideotype characterized by superior grain production and a vigorous and deeper root system under drought stress. Four genotypes  that were superior in their SNF ability under drought stress were also identified and these could serve as parents for further improvement of SNF ability and drought resistance of common bean.Click here for additional data file.


MindfulGarden (MG) is a digital device resembling a flat screen TV, with touchless sensors that react to voice and motion. In this study 13 long-term care home residents aged 74-100 exhibiting Behavioural and Psychological Symptoms of Dementia (BPSD) were randomized to treatment and control groups. On days 1-3 the treatment group received usual care plus exposure to MG during morning and evening care - events well documented to be problematic for residents and care staff; controls received usual care only. On day 4 both groups were exposed to MG with verbal cueing. A 26-item checklist was used to record frequency and types of disruptive BPSD exhibited; care duration was recorded in minutes. There was a trend toward reduction of BPSD and duration of care during morning care. Findings suggest that verbal cueing may be important for successful implementation of MG in calming residents with dementia during routine care.


Schizotypy refers to a continuum of symptoms from subclinical manifestations in the general population to severe symptoms in schizophrenia spectrum disorders. Neuroimaging studies revealed significant relationships between schizotypy and cortical anatomy in the general population. However, it remains unclear whether these structural associations has a gender specificity.The present study used structural MRI data to investigate the relationship between subclinical schizotypy symptoms and cortical and subcortical morphometric measures in male and female samples of healthy individuals.et al. Schizophr Bull. 2004; 30 335-350) were calculated. Partial correlation analysis  was used to assess the associations between ROIs cortical thickness and total schizotypy or 4 factors scores including age and sex as covariates. The same analysis was performed for subcortical volumes including intracranial volume as additional covariate.164 right-handed healthy unmedicated individuals  underwent structural MRI at 3T Philips scanner. T1-weighted images were processed via FreeSurfer 6.0 to quantify cortical thickness for 34 regions-of-interest (ROIs) according to Desikan atlas and volumes for 7 subcortical structures at each hemisphere. Schizotypy levels were assessed using self-report Schizotypal Personality Questionnaire, total schizotypy score and 4 factors scores  and negative factor of schizotypy  (Image). No correlations survived correction for multiple comparisons in female sample. There were no differences in age, caudal middle frontal gyrus thickness, total schizotypy or negative factor of schizotypy scores between male and female subgroups.In male group we revealed a positive correlation between greater thickness of the left caudal middle frontal gyrus and higher total schizotypy  and levels of schizotypy is gender specific. We showed that total and negative schizotypy positively correlated with thicker DLPFC in male but not in female sample. The present data are inverse to findings of prefrontal cortical thinning observed in schizophrenia. Such correlations suggest that thicker cortex could be a potential compensatory mechanism or could reflect alterations in trajectory of cortical thickness reductions across the lifespan.The work was supported by RFBR grant 20-013-00748None Declared


It has also been associated with a variety of reproductive disorders and adverse pregnancy outcomes. Recent studies highlight the VitD role in regulating male and female reproductive health , 2. Matireatment . Supplemreatment .Liu et al. investigated the influence of thyroid autoimmunity (TAI) and VitD levels on early pregnancy outcomes in women of normal thyroid function who undergo in vitro fertilization (IVF). The study found low serum VitD in subjects with TAI with fewer good-quality embryos. Additionally, aging also reduced the chances of pregnancy. The paper provides clinical practice guidelines for managing infertility in patients with normal thyroid function. Future studies should explore the effectiveness of VitD interventions in patients with TAI-assisted reproductive techniques (ART).A perspective study authored by Liu et al. emphasizes the influence of TAI on serum and follicular fluid (FF) VitD levels and VitD receptor expression in granulosa cells (GCs) on laboratory results in infertile patients undergoing IVF or intracytoplasmic sperm injection (ICSI) treatment. The study found that TAI has a more detrimental effect on the maturation of good-quality embryos as compared to low VitD levels.Another prospective study by Wei-Jiun Li et al.: The original article describes that low VitD levels are a risk factor for Post partum heamorrhage (PPH), and low levels of VitD are associated with an increased likelihood of experiencing low haemoglobin levels before delivery. Therefore, the study recommends that VitD should be corrected during antenatal care to avoid PPH and its complications.A study conducted by Shan et al.: The original article declared that lower serum 25(OH)D levels were associated with higher risks of hyperandrogenemia (HA) in females with polycystic ovary syndrome (PCOS). The study identified increased BMI and age greater than 26 years as risk factors for PCOS women with VitD deficiency which should be considered for HA assessment and correction of VitD.Zhou et al.: This meta-analysis concludes that VitD supplementation improves the chemical pregnancy rate in infertile women with VitD deficiency; however, VitD supplementation does not improve the clinical pregnancy rate and all secondary outcomes. Further studies are needed to explore the role of VitD on other IVF outcomes, like fertilization rate and ongoing pregnancy rates.Li et al. reviews “nine randomized controlled trials (RCTs) for PCOS undergoing therapy with magnesium supplementation alone or in combination with other agents”. The study outcome indicated that magnesium supplementation in combination with other supplements may be a potential therapeutic option for improving metabolic disorders in PCOS patients.Another systematic review authored by Recent studies have found promising results in using VitD supplementation to improve oxidative stress, reproductive endocrine and metabolic parameters. VitD may positively affect fertility and metabolic health by influencing hormone levels and metabolic markers . HoweverFA initiated the write-up of the editorial. MB, AK, and RR completed the write-up. All authors revised the manuscript before final submission. All authors contributed to the article and approved the submitted version.


Current methods of storing explanted donor livers at 4°C in University of Wisconsin (UW) solution result in loss of graft function and ultimately leads to less-than-ideal outcomes post transplantation. Our lab has previously shown that supplementing UW solution with 35-kilodalton polyethylene glycol (PEG) has membrane stabilizing effects for cold stored primary rat hepatocytes in suspension. Expanding on past studies, we here investigate if PEG has the same beneficial effects in an adherent primary rat hepatocyte cold storage model. In addition, we investigated the extent of cold-induced apoptosis through treating cold-stored hepatocytes with pan caspase inhibitor emricasan. In parallel to storage at the current cold storage standard of 4°C, we investigated the effects of lowering the storage temperature to –4°C, at which the storage solution remains ice-free due to the supercooling phenomenon. We show the addition of 5% PEG to the storage medium significantly reduced the release of lactate dehydrogenase (LDH) in plated rat hepatocytes and a combinatorial treatment with emricasan maintains hepatocyte viability and morphology following recovery from cold storage. These results show that cold-stored hepatocytes undergo multiple mechanisms of cold-induced injury and that PEG and emricasan treatment in combination with supercooling may improve cell and organ preservation.


Teaching Point: An edematous ileocecal valve may mimic a residual intussusception after reduction. Differential diagnosis is important for therapeutic implications. A two-year-old boy was transferred to the emergency department from a regional hospital with intermittent episodes of intense abdominal pain. An intussusception was diagnosed by ultrasound whereafter hydrostatic reduction with single-contrast enema was attempted. The reduction was diagnosed incomplete , and theAbdominal ultrasound showed a small target sign in the transverse plane without presence of mesenterial fat, vessels or lymph nodes between the layers of the target sign . The widIleocolic intussusception is one of the most common pediatric abdominal emergencies. Fluoroscopic enema reduction (air- or water-soluble contrast) is the initial treatment of choice with a success rate of 80–95%, sonographic-guided hydrostatic saline enema reduction has been shown a good alternative. Operative reduction is the alternative in patients with complications or multiple failed reduction attempts .After fluoroscopic attempted reduction of an ileocolic intussusception, a persistent intraluminal filling defect may be seen in the cecum, posing a diagnostic dilemma in differentiating a residual or recurrent intussusception, a pathological lead point or a residual edematous ileocecal valve. Post-reduction sonography may solve this dilemma showing a ‘smaller’ donut/target sign  compared


Several endoscopic modalities are used to treat colonic diverticular bleeding (CDB), a predominant lower gastrointestinal bleeding typeA 49-year-old man presented with a chief complaint of bloody stools. Contrast-enhanced computed tomography revealed extravasation from the descending colonic diverticulum. We diagnosed him with CDB and performed emergency colonoscopy.When a descending colonic diverticulum was aspirated and inverted, a visible vessel was found. Active bleeding occurred due to suction stimulation, and the diverticulum was identified as the bleeding source . EndoscVideo 1 Endoscopic hemostasis of colonic diverticular bleeding by combining endoscopic band ligation and clipping.Endoscopic clipping was performed by placing a hemostatic clip  onto the responsible vessel within the diverticulum. The endoscope was removed, and an EBL device  was attached to its tip. It was then reinserted and directed toward the diverticulum marked with a clip. The diverticulum was aspirated with the clip into the EBL device and the elastic O-band was released . No rebClipping involves grasping the exposed blood vessel part, whereas EBL involves grasping the root of the blood vessel. Therefore, the novel EBL-C combination treatment provided a stronger and more reliable hemostatic effect than that of each treatment alone . The clThis is the first reported case describing the EBL-C method for hemostasis of CDB. The EBL-C method could be a simple alternative for CDB treatment with less risk of rebleeding compared with EBL or clipping alone, if confirmed in a large case series.Endoscopy_UCTN_Code_TTT_1AO_2AD


Persistent hypoxemia during veno-venous extracorporeal membrane oxygenation (VV-ECMO) for supporting acute respiratory distress syndrome (ARDS) patients is a clinical challenge for intensive care medical providers. Prone positioning is an effective strategy to treat persistent hypoxemia; however, placing a patient in a prone position is resource intensive with significant risks to the patient. We present a patient with severe ARDS receiving VV-ECMO who underwent verticalization therapy and subsequently recovered pulmonary function. Veno-venous extracorporeal membrane oxygenation therapy (VV-ECMO) is a modality to support patients with acute respiratory distress syndrome (ARDS) when traditional positive pressure ventilation has failed. The institution of VV-ECMO allows the patient to maintain end-organ oxygenation while clinicians prescribe an appropriate lung protective strategy. In patients with inadequate oxygenation despite optimizing the extracorporeal membrane oxygenation (ECMO) settings, prone positioning (PP) has been proposed to improve oxygenation through improved lung mechanics and gas exchange ,2.PP is logistically difficult and associated with pressure sore development with potential for severe complications such as inadvertent decannulation or extubation . VerticaWe present the first reported case of VT to improve oxygenation in a VV-ECMO patient with severe ARDS resulting in a successful outcome.2) woman with no significant past medical history other than attention deficit disorder and anxiety presented to an outside hospital (OSH) with worsening respiratory status. She had been initially treated for influenza as an outpatient, yet her respiratory status declined over seven days at the OSH, requiring mechanical ventilation. She was transferred from the OSH via ambulance for further management and to evaluate the need for ECMO.A 31-year-old 160-pound 5'7"  of the chest showed severe multifocal consolidation with right upper lung necrotizing lesions  for 45 to 60 degree-VT. The patient underwent VT twice daily for thirty minutes per session. The hemodynamic profile during VT was stable, with blood pressures of 140/80 mmHg and heart rates of 100 beats per minute on average during VT sessions.The decisions regarding the duration and degree of VT were based on patient tolerance. Due to deconditioning, achieving more than 60 degrees of VT was limited by her lower extremity weakness. Similarly, sessions longer than 30 minutes were not tolerated due to leg muscle fatigue. During VT sessions, the degree of sedation utilizing infusions of propofol and fentanyl was targeted to a Richmond Agitation-Sedation Scale (RASS) score of zero to negative one, indicating that the patient was alert and calm .The patient sustained an oxygen saturation above 90 percent for approximately three hours after each VT without changes to the ventilator or ECMO settings. VT sessions continued two to three times daily for one month. As the patient's pulmonary status improved, she was successfully weaned from ECMO and decannulated approximately seven weeks post-cannulation. The patient was discharged from the intensive care unit two weeks later to a long-term acute care hospital. Her chest radiograph two months post-discharge demonstrated a resolution of pneumonia (see Figure Refractory hypoxemia is a treatment problem in patients with severe ARDS who require VV-ECMO. PP has been advocated successfully in VV-ECMO patients to improve oxygenation ,2. GianiGiven the potential risk for position-related pressure sores or more severe complications such as inadvertent decannulation or extubation, alternatives to PP could be a useful therapeutic option for intensivists caring for ARDS patients . VerticaThe mechanism for improving oxygenation in VT likely involves improved pulmonary mechanics and improvements in matching ventilation and perfusion. The major risk of VT would be a negative impact on hemodynamics due to worsening preload. Our patient demonstrated a slight reduction in blood pressure and an increased heart rate during VT sessions, yet hemodynamics were stable, and no interventions were necessary for blood pressure management.VT has not been previously reported for refractory hypoxemia in the setting of ARDS requiring VV-ECMO. We report the first case in the literature of VT to achieve improvement in arterial oxygenation in this setting.Managing refractory tissue hypoxemia during VV-ECMO therapy for ARDS patients is a clinical challenge for intensive care physicians. Previously reported proposed changes in patient positioning, such as PP, are effective yet logistically challenging and associated with risks and complications. VT is potentially an effective yet technically less demanding alternative to PP in the setting of VV-ECMO for ARDS patients.


The pineal lesion affecting melatonin is a rare cause of central precocious puberty by decreasing the inhibition of hypothalamic–pituitary–gonadal axis. Germ cell tumor secreting human chorionic gonadotropin is a rare cause of peripheral puberty.A 5.8-year-old male presented facial hair and phallic growth, deepened voice, and accelerated growth velocity for 6 months. The elevated human chorionic gonadotropin level with undetectable gonadotropin levels indicated peripheral precocious puberty. Brain imaging revealed a pineal mass and further pathology indicated the diagnosis of teratoma. During chemoradiotherapy with operation, the elevated human chorionic gonadotropin level reduced to normal range, while the levels of gonadotropins and testosterone increased. Subsequently, progressing precocious puberty was arrested with gonadotrophin-releasing hormone analog therapy. Previous cases of transition from peripheral precocious puberty to central precocious puberty were reviewed. The transitions were caused by the suddenly reduced feedback inhibition of sex steroid hormones on gonadotropin releasing hormone and gonadotropins.For patients with human chorionic gonadotropin-secreting tumors, gonadotropin levels increase prior to sex steroid decrease, seems a sign of melatonin-related central PP related to melatonin. Central nervous system neoplasm is considered as one of the important etiologies of precocious puberty (PP). The neoplasm in proximity to the hypothalamic-pituitary region or intracranial radiotherapy focused on this region  may actiA 5.8-year-old boy was admitted to our hospital with a 6-month of facial hair and phallic growth, deepen voice and accelerate growth velocity. The Tanner stage was II for genital development and II-III for pubic hair. Both side testicular volumes were 4 mLby Prader. Family history of PP was denied. The serum sex hormone profile indicated prepubertal levels of gonadotropins with basal LH < 0.1IU/L  and basal FSH < below 0.1 IU/L , and pubertal testosterone level . His height reached 129 cm  with a high serum insulin like growth factor-1 level (+ 3.5 standard deviation scores) in National-specific charts . Other aWe systematically searched PubMed database with “central PP” and “peripheral PP” from inception through July 1st, 2022. No language restrictions were imposed. A hand search through reference lists of relevant primary and review articles was also performed for completeness. Each of the two review authors (HC and C-Y M) independently screened articles for inclusion based on title and abstract and reviewed relevant articles as full text. Disagreement during the review process was resolved by consensus through involvement of a third review author (L-Y Z). A total of 25 original articles involving 51 patients with the transition from peripheral to central PP were reviewed and summarized (16–41) (Table Transition from peripheral PP to central PP is rare, which means activating GnRH or inhibiting gonadotropin inhibitory hormone after a period of overexposure to steroids. This transition has been reported in patients with Leydig cell tumors –24, adreIn the present study, we describe a young boy with a pineal germ cell tumor and peripheral PP who later developed central PP. Initial peripheral PP of the patient due to serum hCG, which binds to the LH receptor and then acts on the testicular Leydig cell to excessively promote testosterone synthesis. The elevated hCG level in serum and CSF inidicated the diagnosis of iGCT. The residual in pineal lesion after induction chemotherapy indicated the diagnosis of mixed iGCT and following histological results indicated the teratoma component. During the initial 2 courses of chemotherapy, although the hCG level returned to normal range, the patient’s LH and FSH levels increased synchronously with the stably elevated testosterone. Compared to previous cases where patients’ central PP commonly developed after months or even years of peripheral PP regression, the abnormal change in gonadotropin and sex steroid hormone of this patient suggested a probable mechanism different from loss of negative feedback to the gonadotropins Fig. . In our Clinicians caring for young patients with pineal hCG-secreting tumors should be alert to the secondary central PP, although most hCG-induced peripheral PP would regress after the tumor was eliminated. Gonadotropin levels increasing prior to sex steroid suppression may be a a sign of melatonin-related central PP. It is highly recommended to assess the function of hypothalamic–pituitary–gonadal axis by testing hormones during the treatment period of pineal hCG-secreting tumors.


Proximal metal stent migration during or after endoscopic ultrasound-guided hepaticogastrostomy  scan revealed dilatation and infection of the cystic bile duct in left lobe of the liver , and heAfter tract dilation, we tried to place a 6-mm fully covered self-expandable metal stent (SEMS). However, the edge of SEMS on the gastric side migrated into the abdominal cavity. After unsuccessful attempts to retrieve the stent endoscopically via the puncture site, surgical intervention was deemed necessary. We placed two guidewires orally from the gastric fistula into the abdominal cavity so that surgeons could find the gastric fistula  and retSurgical salvage intervention for a migrated metal stent during endoscopic ultrasound-guided hepaticogastrostomy.Video 1Endoscopy_UCTN_Code_CPL_1AL_2AD


Correction to: Internal and Emergency Medicine 10.1007/s11739-023-03203-0In the original article under the section NAFLD and metabolic dysfunctions the word "painful" was incorrectly written as "painless".Also, the small gramatical error "are" changed to "is" under the section Conclusions and future perspectives.The original article has been corrected.


The inferior vena cava draining to the left atrium is a rare congenital anomaly. Patients usually present with hypoxia and dyspnoea. This condition is usually diagnosed by echocardiography and sometimes by CT scan. Here we report two cases that presented with normal saturation and their surgical management. It is very rare for the inferior vena cava (IVC) to empty into the left atrium (LA) when the normal atrial configuration (situs solitus) is present . It can The first case is a six-year-old male child who was incidentally diagnosed with ostium secundum atrial septal defect (OSASD). Physical examination revealed a resting saturation of 99% in room air and a systolic murmur. His electrocardiogram (ECG) and chest radiograph were normal. A transthoracic echocardiogram revealed a 17 x 20mm OSASD with IVC draining into LA  using an oblique autologous pericardial patch. The patient tolerated the procedure well and was discharged a few days later, asymptomatic and with normal oxygen saturation. Echocardiography on a one-month follow-up showed unobstructed SVC and IVC draining into RA Figure .The second case involves a four-year-old female child who was also incidentally diagnosed with ostium secundum atrial septal defect (OSASD). Physical examination revealed a resting saturation of 99% in room air and a systolic murmur. ECG and chest radiographs were normal. A transthoracic echocardiogram revealed a 20 mm posterior OSASD with IVC draining into LA Figure .Left-sided superior vena cava draining into the coronary sinus was also noted. Intraoperatively all margins of the interatrial septum were well formed. It was noticed that the IVC was opening into the LA and IAS was malaligned. The IVC was then baffled into the RA using an oblique autologous pericardial patch. The patient tolerated the procedure well and was discharged three days later, asymptomatic and with normal oxygen saturation. Echocardiography taken at the one-month follow-up showed unobstructed SVC and IVC draining into RA.Gardner originally identified the unusual congenital vascular condition known as abnormal IVC draining into the left atrium in 1955 . Most paWe present two rare cases of IVC draining into LA presenting with normal saturation. Normal saturation thus doesn’t rule out anomalous systemic venous drainage. CT angiography is useful but not necessary to make a diagnosis. Surgery can be planned if the echocardiography is convincing enough. Utmost care should be taken while closing an OSASD and anomalous opening of the IVC into the LA should be ruled out in every case by identifying the opening of the IVC into the RA.


A major tenet of environmental cleaning is to focus on high-touch surfaces (HTS). HTS in the patient’s proximity have high rates of contamination, yet cleaning compliance of HTS remains low particularly when the patient is present. This quality improvement (QI) project aimed to use stakeholder input to modify a HTS cleaning checklist.Figure 1).This pilot project used a Plan-Do-Check-Act cycle to modify and evaluate a daily cleaning checklist across acute and long-term care settings at one Midwestern VA Hospital  and b. extent of surface cleaning .Two pre-intervention focus groups  were conducted to understand stakeholder perspectives and barriers to daily cleaning to inform modifications to the cleaning checklist. Participants viewed the graphic and discussed patients’ and EMS’s possible notions upon EMS entering the patient room. The groups were then asked how these insights could be addressed during the cleaning process. Recurrent themes of stakeholder’s perceived barriers to cleaning are depicted in Pre- and post-intervention observations of daily cleaning compliance of 10 HTS showed a significant improvement of 38%  to 72%  (p = 0.011).Two EMS interviews were conducted post-intervention to evaluate checklist usability. Emergent themes were discomfort with cleaning any surface near the patient while the patient was in the bed and with the use of the modified cleaning pattern due to discordance with previous training and practicesGraphic ExerciseCleaning Pattern Mental ModelModified ChecklistModified ChecklistCurrent checklists do not address contextual factors of navigating the environment surrounding patients in bed. HTS cleaning rates may be improved by modifying checklists based on input from local stakeholders. Future research is needed to evaluate modified cleaning processes to facilitate daily cleaning of occupied patient rooms.All Authors: No reported disclosures


Lichen planus is a chronic inflammatory disorder affecting skin and mucosal surfaces. There are multiple variants of lichen planus described in the literature. We report a case of inverse lichen planus in a healthy 50-year-old male who presented to our dermatology clinic with multiple violaceous to hyperpigmented patches affecting both axillae and groin for three months. A skin biopsy confirmed the diagnosis of lichen planus. The patient subsequently developed nail dystrophy affecting his fingernails consistent with nail lichen planus. Early recognition and treatment of nail lichen planus is important to prevent irreversible scarring. Lichen planus is an idiopathic inflammatory skin disorder that typically presents with pruritic, polygonal, violaceous papules and plaques on flexor surfaces of forearms, wrists, genitalia and oral mucosa . There aInverse lichen planus is a rare variant of lichen planus that presents with pink to violaceous patches and plaques affecting axillae, groin and inframammary areas . HyperpiNail lichen planus has been reported in up to 15% of patients with lichen planus .A 50-year-old male presented to the clinic with a three-month history of itchy rash over both axillae and groin. No other skin, mucosal, scalp, or nail involvement at initial presentation. He had no past medical history and no systemic symptoms. Physical examination revealed multiple violaceous to hyperpigmented patches, with no secondary changes.A punch biopsy was taken from the left axilla revealed band-like lymphocytic infiltrates at the dermo-epidermal junction with hyperkeratosis, hypergranulosis and necrotic keratinocytes (Civatte bodies) visible at the lower epidermis Figure .The patient was started on tacrolimus 0.1% ointment twice daily for two months which resulted in improvement of the lesions with only post-inflammatory hyperpigmentation Figures -3. One yInverse lichen planus is a rare variant of lichen planus with unusual morphological presentation affecting the axillae, inguinal folds and inframammary areas . Sites oThere can be an overlap between inverse lichen planus and lichen planus pigmentosus. Lichen planus pigmentosus typically presents as hyperpigmented macules and patches affecting sun-exposed sites . In our The literature review showed only a few reported cases of Inverse lichen planus -12. NoneNail lichen planus is an inflammatory process that affects the nail unit . TreatmeLichen planus is a chronic inflammatory papulosquamous disorder. Inverse lichen planus is a rare variant affecting intertriginous areas. Treatment of nail lichen planus can be challenging and early intervention should be considered to prevent irreversible nail damage.


Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30% of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challenging due to atrial scarring leading to heterogeneous P-wave morphology.A 74-year-old male with a history of prior catheter ablation for atrial fibrillation presented with palpitations and subacute symptoms of heart failure. The patient’s ECG revealed narrow complex tachycardia with more P waves than QRS complexes. The differential diagnosis included typical flutter, atypical flutter, and focal atrial tachycardias with 2:1 conduction block. P waves were positive in V1 and across all precordial leads . This favors atypical flutter originating from the left atrium over typical cavotricuspid isthmus-dependent right atrial flutter. Transthoracic echocardiogram showed a reduced ejection fraction due to tachycardia-mediated cardiomyopathy. The patient underwent a repeat electrophysiology study and ablation, which confirmed the presence of an atypical flutter circuit using the mitral annulus, known as perimitral flutter. Repeat catheter ablation resulted in maintenance of sinus rhythm. At follow-up, his ejection fraction recovered.Recognizing ECG findings suggestive of atypical flutter impacts initial emergency department decisions and triage as atypical flutter post-atrial fibrillation ablation is frequently resistant to rate-controlling medications and often requires cardiology and/or electrophysiology consultation if available. Catheter ablation with pulmonary vein isolation is increasingly used in the management of paroxysmal atrial fibrillation (AF). Post-ablation late atrial tachycardias are common, occurring in up to 30% of patients.A 74-year-old male with a history of symptomatic drug-refractory paroxysmal AF treated with a catheter ablation with pulmonary vein isolation 14 years prior and a second catheter ablation two years prior, presented to the emergency department (ED) with three months of progressive shortness of breath and palpitations. Upon presentation, he was afebrile, his heart rate was 137 beats per minute, respiratory rate was 18 breaths per minute, blood pressure was 106/76 millimeters of mercury, and oxygen saturation was 90% on room air. Cardiovascular examination revealed tachycardia with normal heart sounds and no murmurs, rubs or gallops. Jugular venous pressure was elevated. Pulmonary exam was negative for rales, and there was no lower extremity edema.The ECG  revealedCPC-EM CapsuleWhat do we already know about this clinical entity?Late atrial arrhythmias after atrial fibrillation ablation occur in up to 30% of post-ablation patients. However, the diagnosis remains challenging due to heterogeneous P wave morphology.What makes this presentation of disease reportable?This case highlights the electrocardiogram (ECG) findings suggestive of atypical flutter in a patient with prior catheter ablation.What is the major learning point?The absence of precordial transition favors atypical flutter originating in the left atrium in the post-ablation patient, among other ECG findings.How might this improve emergency medicine practice?Atypical flutter is often resistant to control medications. Symptomatic patients presenting with atypical flutter warrant early consultation or referral to cardiac electrophysiology.A transthoracic echocardiogram (TTE) revealed a severely reduced ejection fraction of 20% without valvular disease or wall motion abnormalities. The patient was started on amiodarone and underwent direct current cardioversion. An electrophysiology study revealed perimitral isthmus flutter. Delayed atrial arrhythmias post-AF ablation present a challenge as the degree of atrial scarring and location of prior radiofrequency ablation sites result in variable P-wave morphology. Most post-ablation arrhythmias are caused by either macroreentry or localized microreentrant atrial tachycardias (circuits <3 centimeters in diameter), and true focal AT due to an ectopic focus is less common.5Typical atrial flutter is defined as a macroreentrant circuit (most often counterclockwise) around the tricuspid annulus, using the CTI.3Atypical atrial flutter refers to macroreentrant tachycardias that are not CTI-dependent. Atypical flutter circuits can originate in the left or right atrium, usually around an atrial scar in patients with structural heart disease.However, an electrophysiology study is needed to map the exact reentrant circuit. Flutter wave polarity in the inferior leads does not separate typical from atypical flutter but rather indicates that the macroreentrant circuit initially activated the superior right atrium with subsequent superior to inferior right atrial activation.A notable feature in 5Distinguishing LA atypical flutter from an arrhythmia originating in the right atrium impacts clinical management as atypical flutter is often resistant to rate-controlling and antiarrhythmic medications and frequently requires repeat catheter ablation.5Late post-ablation arrhythmias are increasingly common as the number of catheter ablation procedures performed for AF increases. The presence of upright P waves across all precordial leads favors atypical flutter from the left atrium over typical CTI dependent right atrial flutter. Once recognized, atypical flutter, including perimitral flutter, is often resistant to rate and rhythm controlling medications. Patients with atrial fibrillation or typical flutter who are asymptomatic once rate controlled or who spontaneously convert in the emergency department are often appropriate for outpatient follow-up with primary care, with cardiology follow-up based on symptoms and clinical course. Symptomatic patients presenting to the ED with atypical flutter warrant early consultation or referral to cardiac electrophysiology for definitive diagnosis and management.


Heteroresistance is a phenotype in which a clinically susceptible bacterial isolate contains less susceptible subpopulations. Unexpectedly high levels of treatment failure for cefiderocol, a novel antibiotic designed to treat multidrug-resistant infections, have been attributed to this phenomenon.To determine prevalence of cefiderocol heteroresistance amongst clinical isolates at a North London tertiary care centre and study the population dynamics upon exposure to the antibiotic.n = 146) were screened for cefiderocol susceptibility by standard disc diffusion and Etest assays. Isolates were classified based on EUCAST breakpoints for cefiderocol susceptibility. Heteroresistance was confirmed by performing modified-population analysis profile (mPAP) assay in iron-depleted Mueller Hinton II agar. MIC values were determined by broth microdilution (BMD) assay as per EUCAST guidelines. The heteroresistant isolates and their corresponding less susceptible subpopulations were serially passaged in media with sub-inhibitory concentrations of cefiderocol as well as in cefiderocol-free medium. The changes in frequency and/or susceptibility in the heteroresistant subpopulation were detected using mPAP.Gram-negative clinical isolates  and twenty-two resistant (15.06%) isolates were identified. Cefiderocol susceptibility of the heteroresistant isolates after five passages in cefiderocol-free medium partially reverted to that of the parent population. However, this phenomenon was not observed in the cohort that was first passaged in cefiderocol-containing medium before passages in cefiderocol-free medium. When heteroresistant populations were passaged in cefiderocol-containing media at 0.25× MIC values, no MIC changes were observed after five serial passages; however, the proportion of less susceptible subpopulations increased by 1.2 logThe prevalence of heteroresistance to cefiderocol was around 7% amongst clinical isolates. The heteroresistant phenotypes were unstable unless exposed to cefiderocol. Such exposure may also increase the MIC and/or frequency of less susceptible cells within the heteroresistant population. This amplification can continue even after removal of antibiotic pressure. Developing methods for detecting heteroresistance to cefiderocol in clinical laboratories is essential. Clinicians need to take this phenomenon into account when planning treatment regimens to optimize the effectiveness of this invaluable addition to the antimicrobial armamentarium.


Chromoendoscopy is mainly used in gastrointestinal endoscopy to enhance the visibility of mucosal abnormalities in the digestive tract, by applying stains to the mucosa during endoscopy. The most commonly used stain in chromoendoscopy is indigo carmine, which can highlight subtle changes when sprayed onto the mucosa. Indigo carmine staining is also expected to be useful for the diagnosis of biliary diseases on peroral cholangioscopy (POCS). However, because the bile duct lumen is usually filled with bile or saline during POCS, it is difficult to spray the indigo carmine. In addition, the safety of spraying indigo carmine in the bile duct is unclear.This report presents the first case demonstrating the usefulness of virtual indigo carmine chromoendoscopy (VIC) on POCS using a “cycle-consistent adversarial network” (CycleGAN), an artificial intelligence technology which can convert white-light images to VIC images. VIC makes it easier to recognize the margins and surface irregularities of malignant lesions on POCS. A 74-year-old man was admitted to our hospital with jaundice. Computed tomography showed wall thickening at the distal bile duct. Endoscopic retrograde cholangiopancreatography showed a main lesion at the distal bile duct extending into the left hepatic duct . We theVideo 1 Virtual indigo carmine chromoendoscopy (VIC) on peroral cholangioscopy using a “cycle-consistent adversarial network” (CycleGAN), an artificial intelligence technology which can convert white-light images to VIC images.Endoscopy_UCTN_Code_CCL_1AZ_2AI


Aortic knuckle calcification is a condition where there is deposit of calcium in aortic valve causing reduced blood flow through the same. The condition usually presents in old age as a complication of rheumatic heart disease or Infective Endocarditis. Risk factors include old age, raised blood pressure and coronary heart disease. A 60-year-old female came with chief complaints of breathing difficulty for one month (grade 2 dyspnea) along with chest pain for two days. There was a history of rheumatic fever five years ago and was treated with a ten days course of penicillin. On examination, her blood pressure was found to be 150/100mmHg. Chest X-ray was taken and it showed aortic knuckle calcification. The patient was started on anti-hypertensive drugs and rheumatic fever prophylaxis and was planned for surgical valve replacement after 3 months.


One-year follow-up revealed the absence of clinically relevant infection with patency of the graft and the absence of biochemical inflammatory markers.Infectious aortic disease is a challenging life-threatening disease in cardiovascular surgery. A 70-year-old man patient presented with an infected infrarenal aortic pseudoaneurysm and right iliac artery- left iliac vein fistula (arteriovenous fistula). He underwent total infected tissues excision, debridement,  Infectious pseudoaneurysms of the abdominal aorta are rarer than endograft infections. However, complications, including septicopyemia and rupture, are usually dramatic, resulting in high morbidity and mortality . This reA 70-year-old man was diagnosed with an impending rupture of an infected infrarenal abdominal aortic pseudoaneurysm with AVF Fig. . He presin situ reconstruction with a self-made pericardial graft was performed  for at least 6 months. CTA showed a patent abdominal aorta without pseudoaneurysm or any infection symptom after a 1-year follow-up (Fig. in situ reconstruction with prosthetic grafts or homograft replacement is a common therapeutic alternative [in situ reconstruction due to better patency. In situ reconstruction can achieve immediate limb revascularization, avoid groyne and axillary incisions and decrease long-term graft occlusion and amputation rates.Infected infrarenal aortic pseudoaneurysm with AVF is an infrequent but severe complication and is unlikely to improve with conservative treatment. Open surgical repair is the most established option for the definitive eradication of the native aortic infection. Extraanatomical or ernative , 3. Extrin situ reconstructions of the aorta using pericardiac graft with great omental coverage and AVF repair to prevent leakage.The most suitable graft material for repairing infected aorta remains controversial. Cryopreserved allografts or autologous deep femoral vein grafts are optimal alternatives with low risk of reinfection and better survival rates. However, the availability of allografts is the main limiting factor for usability , 5. HarvIn situ reconstruction with a self-made pericardial patch followed by prolonged antibiotic therapy was effective and safe for native aortic pseudoaneurysm with AVF.


Increased uptake is associated with aneurysm expansion and adverse clinical events. The effect of endovascular aneurysm repair (EVAR) on aortic disease activity and sodium [18F]fluoride uptake is unknown. This study aimed to compare aortic sodium [18F]fluoride uptake before and after treatment with EVAR.In patients with abdominal aortic aneurysms, sodium [18F]fluoride positron emission tomography-computed tomography angiography was performed in patients with an infrarenal abdominal aortic aneurysm undergoing EVAR according to current guideline-directed size treatment thresholds. Regional aortic sodium [18F]fluoride uptake was assessed using aortic microcalcification activity (AMA): a summary measure of mean aortic sodium [18F]fluoride uptake.In a preliminary proof-of-concept cohort study, preoperative and post-operative sodium [18F]fluoride uptake was markedly reduced in the suprarenal , neck  and body of the aneurysm  while it remained unchanged in the thoracic aorta .Ten participants were recruited (76±6 years) with a mean aortic diameter of 57±2 mm at time of EVAR. Mean time from EVAR to repeat scan was 62±21 months. Prior to EVAR, there was higher abdominal aortic AMA when compared with the thoracic aorta . Following EVAR, sodium [18F]fluoride uptake is a promising non-invasive surrogate measure of aneurysm disease activity.EVAR is associated with a reduction in AMA within the stented aortic segment. This suggests that EVAR can modify aortic disease activity and aortic sodium [ Endovascular aneurysm repair durability is limited by the development of endoleaks and this necessitates the use of life-long postoperative surveillance programmes.In abdominal aortic aneurysms, sodium [18F]fluoride uptake on positron emission tomography.This study demonstrates that endovascular aneurysm repair leads to a reduction in microcalcification activity in the abdominal aorta which can be detected as a reduction in aortic sodium fluoride is a positron emission tomography (PET) radiotracer which binds to the deposited hydroxyapatite crystals and can detect aortic microcalcification. In the Sodium [18F]Fluoride Imaging of Abdominal Aortic Aneurysms (SoFIA3 study (NCT02229006), aortic sodium [18F]fluoride uptake specifically localised to abdominal aortic aneurysms and was associated with more rapid aneurysm expansion. This was independent of age, sex, baseline diameter, body mass index, blood pressure, smoking, renal function or peripheral arterial disease. During follow-up, aneurysms with the highest sodium [18F]fluoride uptake expanded more rapidly and patients were most likely to require elective abdominal aortic aneurysm repair (because they reached the threshold of 55 mm) or to have experienced aneurysm rupture.Aortic aneurysm formation is characterised by medial wall atrophy and degeneration which may be triggered by an initial inflammatory response.18F]fluoride PET-CT is a non-invasive marker of aortic aneurysm disease activity which predicts disease progression and clinical outcomes, we hypothesised that aortic sodium [18F]fluoride uptake would be reduced after successful EVAR implantation. In an exploratory proof-of-concept study, we undertook repeated sodium [18F]fluoride PET-CT in participants of the SoFIA3 study who had undergone EVAR.Given that sodium [18F]Fluoride Imaging in Abdominal Aortic Aneurysms study (NCT02229006). Participants had an asymptomatic abdominal aortic aneurysm and were under ultrasound-based surveillance. Patients who had undergone successful elective EVAR were invited for recruitment into the PET-EVAR Study (Predicting Endoleaks Following Endovascular Aortic Aneurysm Repair Using Sodium [18F]Fluoride).The study population consisted of patients recruited into the Sodium fluoride intravenously, and 60 min later they were imaged on a hybrid 128–slice PET-CT scanner . A low-dose attenuation correction CT scan was performed , followed by acquisition of PET data at 10 min intervals in three or four bed positions to cover the thoracic and abdominal aorta. A contrast-enhanced aortic CT angiogram  was performed on the same scanner immediately after PET acquisition. This was preceded by a non-contrast CT aortic calcium score at the second visit. Static PET-CT images were reconstructed with correction applied for attenuation, dead-time, scatter and random coincidences, using an optimised iterative reconstruction algorithm .At each of the two study visits, participants underwent a clinical assessment prior to imaging. Patients were then administered a target dose of 125 MBq of sodium fluoride uptake within the abdominal aorta. This reduction was prominent in the regions of the abdominal aorta covered by the stent graft and was not apparent in the thoracic aorta. This suggests that EVAR protects the aortic aneurysm from rupture by providing a physical barrier and by reducing aortic aneurysm disease activity within the aortic wall itself.EVAR is associated with shrinkage of the abdominal aortic aneurysm sac: a key morphological indicator of procedural success.18F]fluoride uptake correlates with progression of coronary calcification18F]fluoride uptake and aneurysm disease activity.Calcification is a marker of disease burden and disease progression in coronary artery disease. Coronary sodium Ffluoride18F]fluoro-2-deoxyglucose, where patients whose aneurysm diameter increased, had demonstrated lower radiotracer uptake on baseline PET-CT 9 months previously.18F]fluoride, detects microcalcification, which is increasingly becoming a specific and reliable marker of disease activity within the aorta. Sodium [18F]fluoride uptake quantifies microcalcification within the aortic media of patients with thoracic aortopathy18F]fluoride uptakes in the cohort occurred in a patient with a type 2 endoleak and sac enlargement. Although the small cohort size is insufficient to draw definitive conclusions, it does provide promising preliminary data to suggest that high aortic sodium [18F]fluoride uptake may reflect disease activity. As an indicator of reduced aneurysm metabolic activity, suppression of uptake could confirm or predict treatment efficacy of EVAR and may have a role in a select group of patients who demonstrate sac expansion on routine screening.An increase in aneurysm diameter and a change in radiotracer uptake over time has previously been observed using 2-[18F]fluoride binding. Irrespective of the mechanism, our findings highlight the potential of PET to provide an imaging biomarker of treatment efficacy in abdominal aortic aneurysm disease, especially for EVAR but potentially also for other future treatment interventions. Conversely, failure to suppress aortic sodium [18F]fluoride uptake may herald the development of complications and endoleaks not yet visible on CT. Speculatively, it could guide baseline patient selection for EVAR if intense uptake at baseline heralds likely future treatment failure, and is the subject of an ongoing prospective study (NCT04577716).The reduction in AMA we observed following EVAR suggests insertion of the stent graft can decrease aneurysm disease activity. The mechanism of such reduced disease activity has not been addressed by our study, but this could plausibly include reducing biomechanical stress within the aortic wall, preventing the build-up of further luminal thrombus or inflammatory mediators or providing a physical barrier to luminal blood pressure which could otherwise exacerbate aneurysmal dilatation. In turn, these processes could lead to a reduction or cessation in further degeneration in the aortic media which leads to reduced deposition of hydroxyapatite crystals and a reduction in surface area for sodium fluoride uptake has shown excellent levels of agreement with conventional PET quantification methods,This is a small single centre proof-of-concept study, with the small sample size a result of recruitment of only those patients from the original SoFIA18F]fluoride uptake localises to the diseased regions of abdominal aortic aneurysm disease and predicts development of aortic macrocalcification. Successful EVAR is associated with a marked reduction in aortic sodium [18F]fluoride uptake and microcalcification activity which is most prominent in the stented regions of the aorta. Although it requires future prospective validation and evaluation, this technique holds promise as a marker of aneurysm disease activity and treatment efficacy and may have clinical implications in personalised EVAR surveillance.In conclusion, aortic sodium [


Editorial on the Research TopicCase reports in general cardiovascular medicine: 2022In this 2022 Topic and Case Reports, an international collection of case reports is presented that aims to contribute to the advancement of understanding of personalized approaches to the prognosis, diagnosis, and treatment of cardiovascular disease. This editorial features the collection of Case reports published in Frontiers in Cardiovascular Medicine  in 2022. In total 33 papers are published in this Research Topic. Case reports of the contributions in this special issue highlight unique cases that present with an unexpected diagnosis, treatment outcome, or clinical course. Hereby, reports on this issue can not only describe the cases' clinical presentation, diagnostic process, and treatment but also provide important experience and treatment strategies to manage patients with similar conditions. Following are the Case Reports that are published in the General Cardiovascular Medicine Section of the year 2022 .–Amiodarone-Induced Multi-Systemic Toxicity Involving the Liver, Lungs, Thyroid, and Eyes: A Case Report .Amiodarone is a widely used anti-arrhythmia drug despite its side effects on various organs. However, cases of simultaneous toxicity of different organs in one patient have been rarely reported. This report describes an original case that multi-systemic amiodarone organ toxicity occurred in high-risk patients. This study provides important information for the diagnosis and treatment of amiodarone toxicity that could be useful for both physicians and researchers, as well as guideline makers in amiodarone administration.–The Diagnostic Challenge of Eosinophilic Granulomatosis With Polyangiitis Presenting as Acute Eosinophilic Myocarditis: Case Report and Literature Review .Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease that is typically associated with infection and drug factors. It commonly affects multiple organs in the body and manifests with various discomforting symptoms. EGPA-associated eosinophilic myocarditis is rare but can lead to death if left untreated. This report describes a case with this rare disease cured by timely treatment with systemic and oral corticosteroids. The description in this report provides critical clinical features and therapy strategies that can be useful for physicians to identify and treatment of this disease.–Case Report: Intravascular Ultrasound-guided Intervention for Anastomosis Stenosis of the Left Main Coronary Artery Post-Cabrol Technique .This study reports a case of acute myocardial infarction that is successfully treated with intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI). This is the first report that combined PVCI with virtual IVUS. The observations in this paper provide important information for physicians about how to evaluate plaque composition and conduct PCI in patients with chronic inflammatory diseases like Behçet's disease.–Aortic Coarctation Associated With Hypertrophic Cardiomyopathy in a Woman With Hypertension and Syncope: A Case Report With 8-Year Follow-Up .Coarctation of the aorta (CoA) and hypertrophic cardiomyopathy (HCM) are two irrelevant cardiovascular diseases . This re–Case report: Myocarditis following COVID-19 protein subunit vaccination .This study reports a case of myocarditis following ZF2001 vaccination in a female patient. This report describes the patient's clinical symptoms and immunohistochemical characteristics of heart sections. Though some patients with myocarditis following COVID-19 vaccination were vaccinated types of vaccines have been reported. Limited knowledge has been known about the association between vaccination and myocarditis in subunit vaccines against COVID-19. The report here suggests that physicians should consider the potential link between vaccination and myocarditis in clinical diagnosis. Also, investigating the specific mechanism underlying myocarditis after vaccination should be significant to guild the development of a new generation of subunit vaccines.–Case report: Aggressive progression of acute heart failure due to juvenile tuberculosis-associated Takayasu arteritis with aortic stenosis and thrombosis .Takayasu arteritis (TA) is a chronic granulomatous vasculitis of unknown pathophysiological mechanisms. The report describes a case of tuberculosis-associated TA who fail to survive after surgery. In this paper, the authors share their clinical experience in the diagnosis of TA and what they could learn from the case. The information provides in this paper can offer important knowledge for physicians to timely diagnose TA at an early stage with few typical features.–Case report: Changes in the levels of stress hormones during Takotsubo syndrome . Inverted Takotsubo Syndrome With HELLP Syndrome: A Case Report .Takotsubo syndrome is a sudden, transient, acute episode of left ventricular dysfunction, usually triggered by physical or emotional stress . These t–Decisive diagnostic clue for infectious abdominal aortic aneurysm caused by Arthrobacter russicus in a diabetic elderly woman with renal dysfunction: A case report and literature review .Arthrobacter russicus that is successfully treated with a combination of surgery and long-term antimicrobial therapy. Arthrobacter russicus is identified as a potential causative microorganism by using 16S rRNA sequencing. This paper indicates that a molecular diagnosis is important for identifying the causative microorganism, in particular in cases of Gram staining and tissue culture-negative IAA.Infectious aortic aneurysm (IAA) is a rare but serious infectious inflammatory disease of the aortic wall with high mortality. This report describes a case of IAA caused by –Disrupting arrhythmia in a professional male wrestler athlete after rapid weight loss and high-intensity training—Case report .It is well-known that physical exercise can induce physiological cardiac adaptions and benefit cardiovascular health , 4. Howe–Myocardial infarction with non-obstructive coronary arteries in a patient double-seropositive for anti-glomerular basement membrane and anti-neutrophil cytoplasmic antibodies: A case report .Anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) and anti-glomerular basement membrane (GBM) disease are rare diseases with high mortality. This report describes a myocardial infarction with non-obstructive coronary arteries (MINOCA) patient with double seropositive for anti-ANCA and anti-GBM antibodies. Limited cases have been reported of anti-GBM disease patients with cardiovascular complications. These observations provide important information for physicians that endothelial injury or systemic inflammation patients with double-positive disease might be at higher risk to develop MINOCA. Further in-depth investigations to understand the clear causality and mechanism are required in the future.–Case Report: Danon Disease: Six Family Members and Literature Review .Danon disease is a rare X-linked dominant genetic disorder characterized clinically by hypertrophic cardiomyopathy, skeletal muscle weakness, and intellectual disability . This re–Case report: Pulmonary arterial hypertension in ENG-related hereditary hemorrhagic telangiectasia .The etiology of pulmonary arterial hypertension (PAH) can stem from various factors and is often multifactorial. It is crucial to implement standardized diagnostic procedures, investigate potential causes, and identify risk factors early on to enhance patient prognosis. In this paper, the authors report a case of hereditary hemorrhagic telangiectasia (HHT) combined with PAH. The clinical presentation, diagnostic process, and treatment of this rare case report provide useful information for physicians to diagnose HHT combined PAH patients. Further studies to better the pathogenesis of PAH in HHT should be of contribution to the timely and accurate diagnosis of this disease.–Case Report: An Unusual Case of Pheochromocytoma .This report describes a female patient with acquired long QT syndrome, which is a rare complication of pheochromocytoma. Limited to the rarity and nonspecific clinical manifestations, diagnosis of pheochromocytoma is difficult. This study provides a successful diagnosis procedure of pheochromocytoma in this reported case and can offer important points for physicians to identify rare causes of common symptoms.–Case Report: Family Curse: An SCN5A Mutation, c.611C>A, p.A204E Associated With a Family History of Dilated Cardiomyopathy and Arrhythmia .SCN5A mutation with various dilated cardiomyopathy (DCM) associated gene mutations result in multiple phenotypes in a 3-generation family. By analyzing clinical data and genetic testing, this report suggests that a combination of SCN5A and PRKAG2 mutation can lead to DCM plus multifocal ectopic Purkinje-related premature contractions and PRKAG2 syndrome. This study discusses the possible causality between gene variants and observed clinical phenotype and indicates that gene diagnosis can offer early intervention to help physicians to improve diagnoses of DCM.This study reports that –Case report: From monkeypox pharyngitis to myopericarditis and atypical skin lesions .In this report, the authors describe a case of myopericarditis which is caused by human monkeypox, which is an endemic disease, infection followed by the onset of atypical skin lesions. This paper presents the clinical presentation, and diagnostic experience of this patient and provides antiviral treatment recommendations for physicians.–Case report: Conquer a complex variant: Coronary-pulmonary artery fistulas, atrial septal defect and bicuspid pulmonary valve, under beating heart surgery .This report describes a rare patient with two coronary artery to pulmonary artery fistula (CPAF) from two branches of the left anterior descending coronary to the main pulmonary artery, coexisting with a bicuspid pulmonary valve and atrial septal defect and treated by on-pump beating-heart surgery (OPBHS). This study discusses the potential origin and reason of this case as well as the clinical advantages of OPBHS. This report is a very complex case that has not yet been previously reported in the literature. This study offers important information for surgeries to treat CPAFs by OPBHS for patients with low surgical risk.–Case report: Coronavirus Disease 2019 (COVID-19) modified RNA vaccination-induced Adult-Onset Still’s Disease with fulminant myocarditis as initial presentation .Several types of vaccines against the coronavirus disease 2019 (COVID-19). In this paper, the authors report a case of an elderly female who is diagnosed with post-vaccination about Adult-Onset Still's Disease after receiving a modified mRNA vaccine (BNT162b2). Adult-Onset Still's Disease is a rare autoinflammatory disease and potentially life-threatening. The report here describes the clinical presentation and diagnosis of this rare Adult-Onset Still's Disease following mRNA vaccines can provide important knowledge for physicians about this disease.–Case report: Sudden cardiorespiratory collapse in a healthy male after coronavirus disease 2019 vaccination at a vaccination center .This paper reports a case of sudden cardiorespiratory collapse in a healthy young male after receiving the Oxford-AstraZeneca (ChAdOx1 nCoV-19) COVID-19 vaccination. This report addresses the importance of careful medical attention by healthcare providers to avoid possible severe adverse events following COVID-19 vaccination which could be certainly useful for healthcare policymakers, and physicians.–Multisystem immune-related adverse events due to toripalimab: Two cases-based review .Immune checkpoint inhibitors (ICIs) significantly prolong survival in patients with advanced cancer. However, immune-mediated adverse events (irAEs) caused by ICIs pose a major threat to patients' lives. In this paper, the authors report 2 patients with advanced tumors suffering from severe multisystem irAEs following treated with toripalimab (anti-PD-1). This report also reviews the Case reports regarding multisystem irAEs based on myocarditis induced by PD-1 inhibitors. Early detection and diagnosis of multisystem inflammation are critical for the management of patients treated with ICIs. This study can provide important experience and critical information for physicians to manage patients undergoing ICIs treatment.–A case report and review of literature: Tuberculous pericarditis with pericardial effusion as the only clinical manifestation .Tuberculosis (TB) remains a serious public health problem worldwide. In this paper, the authors report a case of a patient with Tuberculous pericarditis (TBP) who is admitted to the hospital with massive pericardial effusion. This patient is examined as negative with all routine laboratory tests for the pericardial effusion of unknown origin. This report provides experience and information for physicians to diagnose and treat percardial effuion patients, in particular to those demonstrated as non-TB causes negative.–Case report: A novel surgical technique for rapid valve-in-ring implantation into the native aortic annulus during left ventricular assist device implantation .Left ventricular assist device (LVAD) implantation is an excellent option for treating end-stage heart failure patients . This re–Case report: Severe dry cough associated with superior vena cava syndrome—Caused recurrent chylothorax (Wan).This case reports a patient with uremia who suffered from severe dry cough. This patient is finally diagnosed with superior vena cava and treated by percutaneous balloon dilatation. Chronic coughs, which may be caused by many diseases, are very common syndrome in the respiratory department outpatient clinic. This paper reports a severe dry cough case caused by superior vena cave occlusion-induced recurrent chylothorax can provide information for physicians to diagnose recurring severe cough patients.–Multimodal Imaging for Total Anomalous Systemic Venous Drainage Diagnosis and Preoperative Planning: A Case Report and Literature Review .Total anomalous systemic venous drainage (TASVD) is a rare congenital heart disease . In this–Massive pleural effusion following high-power and short-duration radiofrequency ablation for treatment of atrial fibrillation: A case report and review of the literature .Radiofrequency catheter ablation (RFCA) is a non-pharmacological treatment for drug-refractory atrial fibrillations. Postpericardial injury syndrome (PPIS) is defined as pericarditis or pericardial effusion during myocardial infarction or cardiac intervention. It is widely recognized as a common complication of cardiac surgery, with an incidence ranging from 3% to 30%. Different from previously reported PPIS which is most characterized by pericardial effusion, this report describes a case of PPIS that presents pleural effusion as a main feature after the operation. This case report also systematically reviews the clinical characteristics of PPIS. The study in this paper provides useful reference information for physicians to timely diagnose a patient with massive pleural effusion alone following RFCA.–Case report: Delayed cardiac rupture with congenital absence of pericardium after blunt trauma .As a rare disease with no specific symptoms and signs, the clinical diagnosis of congenital absence of pericardium (CAP) is very difficult. In this paper, the authors report a case of a patient with CAP and present some atypical features which are different from previously reported literature. The clinical presentation and diagnostic process of this patient should be useful to physicians in the diagnosis and treatment of CAP.–Case report: Reducing the duration of positive-pressure ventilation for large mediastinal masses .This report describes two high-risk patients with large mediastinal tumors (MMs) during general anesthesia undergoing tumorectomy by thoracotomy. The perioperative management of patients with large MMs is challenging. This study suggests that patients with large MM should receive positive-pressure ventilation following muscle relaxants given, but that cardiothoracic surgeons should immediately transect the sternum to relieve compression. This study provides important information and experiences for physicians to manage patients with large MMs.–Case report: Metastatic myxoid liposarcoma arising from the right atrium extends as cardiac tamponade—A rare case of atrial oncology . Right atrial cardiac lipoma with distinctive imaging characteristics. A rare case report and literature review .Cardiac lipomas is rare primary cardiac tumors, many of them do not exhibit obvious features and are difficult to identify. These two reports describe patients presenting a lipomas in the right atrium. In these papers, the authors share their experimence in the diagnosis and treatment of cardiac lipomas can provide useful information for physicians.–Successful simultaneous stenting of a pulmonary artery and vein in pulmonary vascular stenosis due to silicosis. Case report and literature review .via clinical symptom presentation and literature review.This report describes a successful stenting of a pulmonary artery and vein in a silicosis-caused pulmonary vascular stenosis patient. In this paper, the authors provide interventional procedure recommendations for this pulmonary vascular stenosis for physicians –An adult female patient with single atrium and single ventricle undergoing appendectomy: A case report .This paper reports an adult female patient with a single atrium and single ventricle undergoing appendectomy. Single atrium and single ventricle is a rare heart disease with very few patients surviving into adulthood. This report describes their associated surgical findings and can share useful experiences for physicians to diagnose patients with similar conditions.–Acute myocardial infarction after inactivated COVID-19 vaccination: a case report and literature review .Many types of vaccines have been developed to restrain the pandemic of COVID-19. This study reports an acute myocardial infarction case following post-COVID-19 vaccination and discusses the potential pathogenesis mechanisms. This study provides clinical experience and recommendations for physicians to manage patients with similar conditions.–Case report: Aortoesophageal fistula—an extremely rare but life-threatening cardiovascular cause of hematemesis .In this paper, the authors report a hematemesis patient with underlying diagnosed esophageal cancer who presents typical aortoesophageal fistula (AEF) clinical features. This report highlights the clinical features and diagnosis process of this extremely rare but life-threatening disease. This paper also provides recommendations for physicians to timely diagnose AEF.In conclusion, the high-quality clinical case contributions presented in this Research Topic have significantly boosted knowledge, diagnosis, and treatment of cardiovascular disease in complex cases.


Sustained viral suppression in HIV is essential to minimize drug resistance, reduce secondary transmission and improve health outcomes necessary to achieve the UNAIDS 95-95-95 strategy. There is dearth of information on viral suppression among adults in Nigeria. Identifying correlates of sustained viral suppression will inform treatment guidelines especially for people at risk and provide recommendations to policy makers.We collected sociodemographic and HIV-related data from a cross-section of 730 HIV-positive adults receiving antiretroviral therapy from six secondary health facilities in northern Nigeria, between October 2021 and February 2022. Sustained viral suppression was defined according to the Nigerian National Guideline for HIV Prevention, Treatment and Care as a viral load below the detection threshold of less than 20 copies of HIV RNA/ml. Proportion of participants with sustained viral suppression was estimated and a multivariable analysis used to identify independent correlates of sustained viral suppression.The sustained viral suppression rate among HIV-positive adults on ART was 35.7% . Being married  and having secondary education  were significantly associated with sustained viral suppression. Respondents on treatment for 5-10 years  and those taking two or more pills  were more likely to have sustained viral suppression. Previous treatment for opportunistic infection  significantly decreased the likelihood of sustained viral suppression.Sustained viral suppression rates among HIV-positive adults on ART in the six facilities were suboptimal. While being married, taking two or more ART pills and being on treatment for 5-10 years increased the likelihood of having a suppressed viral load, being educated up to secondary level and previous treatment for opportunistic infection decreased the odds of having sustained viral suppression. There is a need to improve viral load monitoring and direct viral suppression interventions towards at risk population.All Authors: No reported disclosures