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The objective of the study was to describe the complexity of diagnosis and evaluation of Zika-exposed pregnant women/fetuses and infants in a U.S. Congenital Zika Program. Pregnant women/fetuses and/or infants referred for clinical evaluation to the Congenital Zika Program at Children’s National (Washington, DC) from January 2016 to June 2018 were included. We recorded the timing of maternal Zika-virus (ZIKV) exposure and ZIKV laboratory testing results. Based on laboratory testing, cases were either confirmed, possible, or unlikely ZIKV infection. Prenatal and postnatal imaging by ultrasound and/or magnetic resonance imaging (MRI) were categorized as normal, nonspecific, or as findings of congenital Zika syndrome (CZS). Of 81 women–fetus/infant pairs evaluated, 72 (89%) had confirmed ZIKV exposure; 18% of women were symptomatic; only a minority presented for evaluation within the time frame for laboratory detection. Zika virus could only be confirmed in 29 (40%) cases, was possible in 26 (36%) cases, and was excluded in 17 (24%) cases. Five cases (7%) had prenatal ultrasound and MRI findings of CZS, but in only three was ZIKV confirmed by laboratory testing. Because of timing of exposure to presentation, ZIKV infection could not be excluded in many cases. Neuroimaging found CZS in 7% of cases, and in many patients, there were nonspecific imaging findings that warrant long-term follow-up. Overall, adherence to postnatal recommended follow-up evaluations was modest, representing a barrier to care. These challenges may be instructive to future pediatric multidisciplinary clinics for congenital infectious/noninfectious threats to pregnant women and their infants.

Left atrial appendage closure (LAAC) has evolved as a safe alternative to oral anticoagulation therapy for stroke prophylaxis. However, the presence of a patent foramen ovale (PFO) occluder device is considered a relative contraindication. Here we report a successful case of LAAC in the presence of a PFO occluder device. (Level of Difficulty: Beginner.), Graphical abstract

Cardiac troponin (cTn) is mainly used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of cardiology consultation on the clinical outcomes of patients admitted to medical intensive care unit (ICU) with elevated cTn is unclear.A retrospective analysis of medical ICU patients with elevated cTn without evidence of ACS between January 2013 through December 2018. Patients were stratified based on documentation of cardiology consultation. The primary outcome was 1-year mortality. Secondary outcomes were in-hospital and 30-day mortality, the length of stay (LOS), further cardiac testing, 30-day readmission rate, new prescription of cardiac medications, and the predictors of a cardiology consultation.Of 846 patients screened, 766 patients were included, of whom 63.2% had cardiology consultation. Cardiology consultation group had longer median LOS (7 vs. 5 days, P = 0.007), additional cardiac testing (90.3% vs. 67.7%, P 0.001), and more new cardiac medications (52.1% vs. 16.3%, P 0.001). No difference was noted in-hospital mortality (adjusted odds ratio [aOR], 0.6, 95% CI, 0.4-1.1, P = .117), 30-day mortality (aOR = 0.8, 95% CI, 0.5-1.4, P = .425), 1- year mortality (aOR, 1.4, 95% CI, 0.9-2.2, P = .193), or cardiac-specific 30-day readmission rate (aOR, 7.0, 95% CI, 0.7-14.9, P = .137). History of coronary artery disease (CAD) was the most independent predictor for a cardiology consult (aOR, 2.2, 95% CI, 1.3-3.8, P .001).Cardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.

Background There is limited data on the efficacy of direct oral anticoagulants (DOACs) for the treatment of left ventricular thrombus. Currently, vitamin K antagonists (VKAs) remain the preferred oral anticoagulant for left ventricular thrombus. In this retrospective study, we assessed the safety and efficacy of DOACs in comparison to VKAs in patients with a new diagnosis of left ventricular thrombus. Methods We retrospectively identified all patients admitted to the 5 Catholic Health Initiative Omaha hospitals with a diagnosis of left ventricular thrombus between January 2012 and March 2019 and were discharged on oral anticoagulants. Patients were stratified into 2 groups: VKAs or DOACs and followed for up to 1 year. We compared the outcomes of ischemic stroke, bleeding, and echocardiographic resolution of left ventricular thrombus between the 2 groups. Results A total of 99 patients were included in this study (mean age: 61 years, 29% females). Of these, 80 (81%) were discharged on VKAs and 19 (19%) on DOACs. Stroke within 1 year of diagnosis occurred in 2 patients in the VKA group and none in the DOAC group (P = 0.49). Bleeding events were observed in 5 patients (4 in the VKA group and 1 in the DOAC group; P = 0.96). Ninety patients had follow-up echocardiogram; resolution of left ventricular thrombus was similar between the 2 groups (VKAs vs DOACs: 81% vs 80%; P = 0.9). Conclusion In patients with left ventricular thrombus, DOACs and VKAs had similar rates of stroke and bleeding. These findings need confirmation in randomized clinical trials.

Cerebrovascular disease is the second leading cause of death in the United States in adults aged 65 years and older and is most commonly caused by atherosclerosis. More so, cryptogenic strokes account for one-third of all ischemic strokes. At the same time, iron deficiency anemia is prevalent worldwide and mostly affects females of childbearing age. Here we report a case of a 42-year-old female who presented with symptoms of acute ischemic stroke and was found to have severe iron deficiency anemia. After prompt investigation of other secondary causes, it was determined that her stroke was likely secondary to her iron deficiency anemia. Upon review of the literature, a few case reports showed an association between iron deficiency anemia and strokes in the adult population, but little evidence exists supporting a direct relationship between the two entities. In this case, we aim to evaluate the complex relationship between iron deficiency anemia and stroke and to define a new potential cause of ischemic stroke, which would have been considered earlier as cryptogenic. However, further studies in the future are warranted to validate our observation.

Here we report the case of a previously healthy 8-year-old boy who presented with altered mental status, right facial droop and right-sided hemiplegia the day after playing in an inflatable bouncer. No head trauma was reported by the patient nor witnessed by the parents. Urgent magnetic resonance imaging (MRI) demonstrated acute ischemic infarction in the left pons; computed tomographic angiography excluded arterial dissection but identified a small hyperdense filling defect in the basilar artery, later confirmed to be a calcification at the origin of a perforating artery. Pediatric National Institutes of Health (PedNIH) Stroke Scale score was 15. Infectious, inflammatory, hypercoagulable and additional vascular causes were excluded. Although the cause of the calcification remains obscure, we speculate that, similarly to mineralizing microangiopathy, a minor trauma led to stroke in this child. To our knowledge, mineralizing microangiopathy, the well-described entity affecting perforating arteries of the anterior circulation in young children leading to basal ganglia stroke following minor head traumas has not been described in the posterior circulation or in previously healthy school-age children.

Prenatal viral infection can lead to a spectrum of neurodevelopmental disabilities or fetal demise. These can include microencephaly, global developmental delay, intellectual disability, refractory epilepsy, deafness, retinal defects, and cortical-visual impairment. Each of these clinical conditions can occur on a semi-quantitative to continuous spectrum, from mild to severe disease, and often as a collective of phenotypes. Such serious outcomes result from viruses’ overlapping neuropathology and hosts’ common neuronal and gene regulatory response to infections. The etiology of variability in clinical outcomes is not yet clear, but it may be related to viral, host, vector, and/or environmental risk and protective factors that likely interact in multiple ways. In this perspective of the literature, we work toward understanding the causes of phenotypic variability after prenatal viral infections by highlighting key aspects of the viral lifecycle that can affect human disease, with special attention to the 2015 Zika pandemic. Therefore, this work offers important insights into how viral infections and environmental teratogens affect the prenatal brain, toward our ultimate goal of preventing neurodevelopmental disabilities.

The use of intravenous (IV) oxytocin has been commonly associated with the development of nausea, vomiting, headache, flushing, and hypotension. To date, only a few previously published studies have linked the administration of IV oxytocin, in high doses exceeding 15 mU/min, with the development of acute pulmonary edema. In this article, we aim to report the rare occurrence of acute pulmonary edema following administration of IV oxytocin at a small dose of 2 mU/min, in a 20-year-old pregnant female, to allow its recognition and prompt treatment by the clinician caring for the patient.

This study investigated the sources of black carbon (BC) at two contrasting urban environments in Helsinki, Finland; residential area and street canyon. The sources of BC were explored by using positive matrix factorization (PMF) for the organic and refractory black carbon (rBC) mass spectra collected with a soot particle aerosol mass spectrometer (SP-AMS). Two sites had different local BC sources; the largest fraction of BC originated from biomass burning at the residential site (38 %) and from the vehicular emissions at the street canyon (57 %). Also, the mass size distribution of BC diverged at the sites as BC from traffic was found at the particle size of ~100–150 nm whereas BC from biomass combustion was detected at ~300 nm. At both sites, a large fraction of BC was associated with urban background or long-range transported BC indicated by the high oxidation state of organics related to those PMF factors. The results from the PMF analysis were compared with the source apportionment from the aethalometer model calculated with two pair of absorption Ångström values. It was found that several PMF factors can be attributed to wood combustion and fossil fuel fraction of BC provided by the aethalometer model. In general, the aethalometer model showed less variation between the sources within a day than PMF being less responsive to the fast changes in the BC sources at the site. The results of this study increase understanding of the limitations and validity of the BC source apportionment methods in different environments. Moreover, this study advances the current knowledge of BC sources and especially the contribution of residential combustion in urban areas.

Purpose To determine whether arthroscopic osteochondroplasty demonstrated effectiveness in a pragmatic femoroacetabular impingement patient population embedded within FIRST (the Femoroacetabular Impingement RandomiSed controlled Trial). Methods All cohort patients were not randomized and were followed prospectively with a follow-up assessment protocol identical to that in FIRST. The primary outcome was hip pain using a 100-point visual analog scale. Secondary outcomes included hip function (Hip Outcome Score, International Hip Outcome Tool-12), health utility (EuroQol 5 Dimensions), and health-related quality of life (Short Form-12) at 12 months, as well as operatively and nonoperatively treated hip complications at 24 months. We performed multivariable regressions to compare these outcomes between 3 groups of patients: (1) those randomized to lavage in FIRST, (2) those randomized to osteochondroplasty in FIRST, and (3) those who received osteochondroplasty as part of the cohort study. Results All groups had improvements across all questionnaire outcomes from baseline to 12 months, with no significant differences. There were significantly more reoperations in the lavage trial group compared with those in the embedded cohort (adjusted odds ratio [aOR] 3.08; 95% confidence interval [CI] 1.23-7.73; P = .016). There were significantly more nonoperatively treated hip complications in the lavage trial group and in the osteochondroplasty trial group when compared with those in the embedded cohort (aOR 3.81; 95% CI 1.19-12.17; P = .024 and aOR 4.55; 95% CI 1.43-14.42; P = .010, respectively). Conclusions Hip arthroscopic osteochondroplasty and lavage led to improvement in hip pain, function, and health-related quality of life at 12 months across both randomized controlled trial (RCT) and cohort patients. The pragmatic cohort receiving osteochondroplasty had (1) significantly fewer complications than RCT patients, (2) significantly less reoperations than RCT patients randomized to arthroscopic lavage, and (3) fewer, although nonsignificant, reoperations than RCT osteochondroplasty patients. Level of Evidence II, therapeutic.

Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus that was identified in December 2019. The impact of COVID-19 virus on Acquired Immunodeficiency syndrome (AIDS) patients has been reported with variable outcome. We reported a patient that was immunosuppressed by AIDS disease and chemotherapy for cancer who contracted SARS-CoV-2 infection and had a mild disease. We did literature review for the cases published that had human immunodeficiency virus (HIV) infection and COVID-19 disease and analyzed the characteristics and outcomes of the reported cases. Our review yielded three case reports and four case series for patients with HIV infection and COVID-19 disease. The majority of patients had mild disease, and some had critical disease or death. Those who had severe disease usually had other comorbidities. The findings from the case reports and case series indicate that the risk of death or severe disease from COVID-19 in HIV positive patients was lower than observed in the general population, which may indicate a possible protective effect of uncontrolled HIV in preventing the complications associated with the massive inflammatory response.

Background:Femoroacetabular impingement (FAI) is a condition known to cause hip pain in young adults.Purpose:To evaluate the efficacy of the surgical correction of FAI via arthroscopic osteochondroplasty with or without labral repair compared with arthroscopic lavage of the hip joint with or without labral repair.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 220 male and female participants aged 18 to 50 years with nonarthritic FAI suitable for surgical treatment were recruited for the trial at 10 clinical centers in Canada, Finland, and Denmark between October 2012 and November 2017, of whom 214 were included in the final analysis. In the osteochondroplasty group, cam- and/or pincer-type lesions were resected using fluoroscopic guidance. In the lavage group, the joint was washed out with 3 L of normal saline. Surgeons were instructed to repair the labrum in both groups if it was mechanically unstable once probed, showing visible displacement or chondrolabral separation. The primary outcome was patient-reported pain (using the 100-point visual analog scale [VAS]) at 12 months. Secondary outcomes included hip function (Hip Outcome Score [HOS] and International Hip Outcome Tool), physical and mental health (12-Item Short Form Health Survey), and health utility (EuroQol–5 Dimensions) at 12 months as well as any reoperations and other hip-related adverse events at 24 months.Results:At 12 months, there was no difference in pain (VAS) between the groups (mean difference [MD], 0.11 [95% CI, –7.22 to 7.45]; P = .98). Also, 88.3% (189/214) of participants had a labral tear, of which 60.3% were repaired. For the secondary outcomes, there were no significant differences between treatment groups, with the exception of the HOS activities of daily living domain in which lavage showed significant improvement compared with osteochondroplasty (MD, –5.03 [95% CI, −10.40 to −0.03]; P = .049). By 24 months, there were significantly fewer reoperations reported in the osteochondroplasty group (8/105) than the lavage group (19/104) (odds ratio, 0.37 [95% CI, 0.15-0.89]; P = .026). The primary reasons for a reoperation included hip pain (15/27; 55.6%) and a reinjury of the labrum (11/27; 40.7%).Conclusion:Both the osteochondroplasty and the lavage groups with or without labral repair for FAI had significantly improved pain or function significantly at 1 year. By 2 years, the reoperation rate was significantly lower in the osteochondroplasty group.Registration:NCT01623843 ( ClinicalTrials.gov identifier)

Objective Although the standard treatment of infective endocarditis (IE) is antimicrobial therapy, surgical intervention is required in some cases. However, the optimal timing of surgery remains unclear. Hence, we conducted a population-based analysis using the National Inpatient Sample (NIS) database to assess the outcomes of early versus late surgery in patients with native valve IE. Methods We queried the NIS database for all hospitalized patients between 2006 and 2016 with a primary diagnosis of IE who had cardiac surgery. We stratified surgery as early ≤7 or late >7 days of admission. Multivariable logistic regression models were used to assess in-hospital mortality and postoperative complications. Length of stay (LOS) and total hospital cost (HC) were evaluated using multivariable log-normal regression models. Results A total of 13 056 patients (57.6% in the early group and 42.4% in the late group) were included. The in-hospital mortality rate in the early group was 5.0% compared to 5.4% in the late intervention group (adjusted odds ratio, 1.20, 95% confidence interval [CI] 0.79-1.81). Overall median LOS was reduced in the early group by 48.2% (95% CI, 46.5%-49.9%, 12.4 days in the early group and 25.9 days in late group), as well as HC which was reduced in the early group by 28.3% (95% CI, 26.0%-30.6%). Conclusion Among patients with native valve IE who needed cardiac surgery, the time of surgical intervention did not affect the in-hospital mortality. However, early surgery was associated with significantly shorter LOS and lower HC.

Background Acquired thrombocytopenia (aTP) is associated with a high frequency of bleeding and ischemic complications in patients undergoing percutaneous coronary intervention (PCI). Herein, we report a meta-analysis evaluating the adverse effects of aTP on cardiovascular outcomes and mortality post-PCI. Methods A literature search was performed using PubMed, Embase, Cochrane and, clinicaltrials.gov from the inception of these databases through October 2019. Patients were divided into two groups: 1) No Thrombocytopenia (nTP) and 2) Acquired Thrombocytopenia (aTP) after PCI. Primary endpoints were in-hospital, 30-day and all-cause mortality rates at the longest follow-up. The main summary estimate was random effects Risk ratio (RR) with 95% confidence intervals (CIs). Results Seven studies involving 57,247 participants were included. There was significantly increased in-hospital all-cause mortality (HR 10.73 [6.82–16.88]), MACE (HR 2.96 [2.24–3.94]), major bleeding (HR 4.78 [3.54–6.47]), and target vessel revascularization (TVR) (HR 7.53 [2.8–20.2]), in the aTP group compared to the nTP group. Similarly, aTP group had a statistically significant increased incidence of 30-day all-cause mortality (HR 6.08), MACE (HR 2.77), post-PCI MI (HR 1.98), TVR (HR 5.2), and major bleeding (HR 12.73). Outcomes at longest follow-up showed increased incidence of all-cause mortality (HR 3.98 [1.53–10.33]) and MACE (HR 1.24 [0.99–1.54]) in aTP group, while there was no significant difference for post-PCI MI (HR 0.94 [0.37–2.39]) and TVR (HR 0.96 [0.69–1.32]) between both groups. Conclusions Acquired Thrombocytopenia after PCI is associated with increased morbidity, mortality, adverse bleeding events and the need for in-hospital and 30- day TVR.

Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism. Bradycardia is a well-known cardiac manifestation for myxedema coma; however, not all bradycardia with hypothyroidism are sinus bradycardia. Sick sinus syndrome is a group of arrhythmias caused by the malfunction of the natural pacemaker of the heart. Tachy-Brady syndrome is considered to be a type of sick sinus syndrome, where the heart alternates between tachycardia and bradycardia, and it is usually treated with pacemaker implantation along with rate slowing medical therapy. Here we report a case of an 83-year-old female who presented with myxedema coma and atrial fibrillation with tachycardia and intermittent slow ventricular response. We attempt to review the relationship between these two diseases and conclude that appropriate diagnosis of myxedema coma, may be beneficial in reducing the need for pacemaker implantation.

Background Electroencephalography at hospital presentation may offer important insights regarding prognosis that can inform understanding of cerebral malaria (CM) pathophysiology and potentially guide patient selection and risk stratification for future clinical trials. Electroencephalogram (EEG) findings in children with CM in Uganda and Malawi were compared and associations between admission EEG findings and outcome across this diverse population were assessed. Demographic, clinical and admission EEG data from Ugandan and Malawian children admitted from 2009 to 2012 with CM were gathered, and survivors assessed for neurological abnormalities at discharge. Results 281 children were enrolled (Uganda n = 122, Malawi n = 159). The Malawian population was comprised only of retinopathy positive children (versus 72.5% retinopathy positive in Uganda) and were older (4.2 versus 3.7 years; p = 0.046), had a higher HIV prevalence (9.0 versus 2.8%; p = 0.042), and worse hyperlactataemia (7.4 versus 5.2 mmol/L; p

Sarcoidosis is a systemic disease with heterogeneous clinical manifestations that is characterized histologically by the presence of noncaseating granulomas in the affected organs. It can be a diagnostic challenge, especially when mimicking malignancy or fungal infections. Previous case reports of sarcoidosis presenting with multiple masses are highly suggestive of infectious or malignant etiology. In this case, our patient presented with enlarged lymph node and was found to have innumerable nodules in the mediastinum, lungs, and liver. Azygos vein enlargement was also seen on radiological imaging, and malignancy was highly suspected; hence, an extensive workup was conducted, including laboratory, radiology and biopsy evaluation, which were diagnostic of sarcoidosis. Our case showed the importance of correlation of the history, physical examination, radiological and histopathologic studies in confirming the diagnosis and the need to rule out other serious infections and malignancies, especially with azygous vein enlargement, which can sometimes be missed in chest radiograph.

Background Congenital Zika infection can result in a spectrum of neurological abnormalities in the newborn. Newborns exposed to Zika virus in utero often have neuroimaging as part of their clinical evaluation. Methods Through the Congenital Zika Program at Children's National Health System in Washington DC, we performed fetal or neonatal neuroimaging, including magnetic resonance imaging and ultrasound, on over 70 fetuses or neonates with intrauterine Zika exposure. Novel findings on neonatal brain magnetic resonance imaging were observed in two instances. Results Gadolinium-contrast magnetic resonance imaging showed enhancement of multiple cranial nerves at three days of age on one infant. Another infant underwent magnetic resonance imaging at 16 days of age and was shown to have a chronic ischemic cerebral infarction. This infant had previously normal fetal magnetic resonance imaging. Conclusion Cranial nerve enhancement and cerebral infarction may be among the expanding list of neurological findings in congenital Zika infection. Postnatal brain magnetic resonance imaging should be considered for newborns exposed to Zika virus in utero .

Nonbacterial thrombotic endocarditis (NBTE) is illustrated by thrombi deposition on normal heart valves without the presence of bacteremia. It typically occurs in the setting of chronic debilitating diseases such as cancer or autoimmune disease. The pathogenesis involves an endothelial injury in the presence of a hypercoagulable state secondary to the effects of circulatory cytokines, which triggers platelet deposition. It usually forms on the upstream atrial surface of the mitral and tricuspid valves and the ventricular surface of the pulmonic and aortic valves and occurs most commonly in the fourth to eighth decades of life with no specific gender predisposition. These vegetations have a distinct morphology that varies from infective endocarditis (IE). Cerebrovascular lesions due to NBTE have a distinctive pattern of multiple, widely distributed small and large strokes on brain magnetic resonance imaging (MRI). We present a case of a 78-year-old man who was initially diagnosed as pneumonia and IE; he underwent a trans-esophageal echocardiogram (TEE), which revealed Libman-Sacks findings that have changed his diagnosis to lung cancer. We aim to highlight the characteristic TEE findings of NBTE to help clinicians search for underlying etiologies, including malignancies if NBTE is suspected.

We present the design of a online course that focuses on container-based virtualization as part of the DevOps toolchain. In addition, we outline the professional background of participants taking the course, and describe how this affects perceived previous knowledge of DevOps. We found out that the self-evaluated conceptual understanding of DevOps topics is nearly equal regardless of the participants professional identity (e.g., student or developer). However, there are significant differences in how much participants have used tools like Docker before. We conclude that there is a clear need for lifelong learning among software engineering professionals as (future) developers often struggle in operations related skills such as command line or networking.

Objective: To examine the effect of age on procedural and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions. Methods: Literature search was conducted across PubMed, Google Scholar and Web of science, databases till March 2019. Results: Seven studies including 7671 patients with an overall follow-up period of 1.5 to 5 years were included in our review. A total of 6299/1372 patients were included in non-elderly and elderly groups, respectively, with mean age and 67%/61% male patients. CTO-PCI was similarly successful in younger and older patients (82.8%, n = 5070 vs. 78.1%, n = 1010). The incidence of short-term outcomes was low across the studies and comparable between the two groups (all-cause mortality: 0.4% younger vs. 0.85% elderly, cerebrovascular accidents: 0.3% vs. 0.4%, major adverse cardiovascular events (MACE): 1.53% vs. 3.72% and major bleeding: 0.57% vs. 2.18%). Long-term outcomes including all-cause mortality (8.89% vs. 29.5%), cardiac mortality (3.72% vs. 15%) and MACE (24.9% vs. 40%) occurred with a higher incidence in elderly patients. When results were segregated according to the success of CTO-PCI, reduced clinical events were noted with successful revascularization in either age group. Conclusion: Compared with the younger age group, CTO-PCI in elderly patients is safe and feasible with a comparable incidence of short-term outcomes. In either population, the incidence of long-term outcomes including survival remains a concern but when successful, CTO-PCI may be associated with improvement in terms of multiple patient-important clinical end-points.

Rheumatoid vasculitis (RV) occurs in patients with long-standing rheumatoid arthritis (RA) or high levels of immunological factors and can result in devastating cardiovascular (CV) events. Here we report a case of a 38-year-old male who presented with hypertensive emergency and intracerebral hemorrhage (ICH). In the literature, a few observational studies have indicated the association of RA with hypertension; however, little evidence exists supporting a direct relationship between RA and ICH. In this case, we attempted to evaluate the complex relationship between all of these factors and found that early detection and treatment of RA may be beneficial in reducing ICH; however, large studies in the future are warranted to validate our observation.

This paper introduces a hybrid system for vehicle access control using RFID and automatic license plate recognition (ALPR) technologies. RFID technology is proven to provide an effective solution to different tracking and localization problems. However, the technology has its shortcomings in tracking objects/users without a tag. As such, we propose to complement this technology with ALPR to control the access of different types of vehicles to the area of Makkah (Saudi Arabia) during Pilgrimage seasons. This limited area can easily get congested with the huge number of vehicles attempting access. Before the start of the season, vehicles authorized to access the region are assigned passive RFID tags specifying their allowed schedule of entry. Violating vehicles that do not have RFID tags are detected and identified using ALPR. The developed system was tested over two pilgrimage seasons. The experiments showed that the developed RFID system was able to identify all passing vehicles with speeds up to 100 km/h, while the ALPR system achieved 94 % recognition accuracy of vehicles not equipped with RFID tags.

Background: Pediatric stroke is a rare but important cause of mortality and morbidity in this population. Endovascular therapy up to 24 hours after symptoms onset is beneficial in adults LVO acute ischemic stroke (AIS), but no safety or efficacy data of this approach is available for patients Methods and Results: We present three pediatric AIS cases (age 15-17) treated at GUH and WVU with endovascular techniques using extended time-window with selection based on perfusion criteria. Case 1 : 17 year old patient with history of Ebstein’s anomaly presented the day after a cardiac catheterization procedure with right hemiparesis and aphasia (NIHSS = 22). CTP identified left proximal ICA occlusion (ASPECTS score 7). Using the Penumbra device successful clot retrieval was achieved at 9:19 hours from onset. She was found to have a venous clot and right-to-left shunt from an atrial septal defect. 3 months mRS was 1. Case 2 : 17 y.o. female with 2 weeks history of intermittent right arm numbness presented with left hemiparesis and hemi-sensory loss (NIHSS 12). ER arrival time was 18:43 hours from the onset of sensory symptoms. CTP demonstrated complete right M1 occlusion secondary to right sub-clavian thrombus (ASPECTS score 8). Using the Solitaire stent retriever, recanalization was obtained at 20:05 hours after clinical onset. 3 months mRS was 1. Case 3 : 15 y.o female with Down syndrome, recently started on BCP woke up with right hemiparesis and aphasia (NIHSS = 22). MR perfusion demonstrated a distal M1/M2 clot with a large mismatch in the left MCA territory. Using a stent retriever device complete recanalization was obtained at 14:46 hours from the last time she was well. On the day of discharge her NIHSS was 7. Complete recanalization (TICI 3) was obtained in all three patients. No complications were observed during or following the procedure. NIHSS before and after the procedure improved by 11-to-17 points. Conclusions: A controlled study regarding endovascular approach in pediatric stroke is unlikely to occur. Therefore, case series must be reported in order to understand the safety of this approach. Strict patient selection and a team approach involving multiple pediatric and adult expertise are needed for a pediatric AIS response that includes endovascular intervention.

Radiation induces complicated vascular occlusions due to scarring, adventitial fibrosis, elastic degeneration, and accelerated atherosclerosis. Such occlusions were typically treated by vascular surgery bypassing the stenosis. However, minimally invasive percutaneous transluminal angioplasty (PTA)

Cardiac troponin (T) is used to diagnose acute coronary syndrome. However, T can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of routine cardiology consultation on the clinical outcomes of critically ill patients with elevated T is unclear

Randomized controlled trials have reported 10% to 23% prevalence of anemia in patients undergoing percutaneous coronary interventions (PCI). Current clinical guidelines fail to offer recommendations for its concurrent management in such patients. We conducted meta-analysis to review impact of

Chiropractic therapy (CPT) is a popular physical therapy. Cerebrovascular accidents were reported with neck manipulation (NM), mainly due to vertebral artery dissection. However, it is unclear whether NM could be associated with internal carotid artery atherosclerosis (ICAAS). We present a case of

Contrast induced Nephropathy (CIN) has been associated with morbidity and mortality. Oxidative stress play a major role in development of CIN. Increased Red cell Distribution Width(RDW) has been associated with an inflammatory state and poor outcomes in coronary artery disease (CAD) patients.

Percutaneous intervention in coronary chronic total occlusion (CTO) is generally faced with lots of difficulties and requires special equipment and skills. Among tools that can be utilized during CTO intervention is mechanical atherectomy devices. We systematically searched Pubmed, MEDLINE

Importance The evolution of fetal brain injury by Zika virus (ZIKV) infection is not well described. Objectives To perform longitudinal neuroimaging of fetuses and infants exposed to in utero maternal ZIKV infection using concomitant magnetic resonance imaging (MRI) and ultrasonography (US), as well as to determine the duration of viremia in pregnant women with ZIKV infection and whether the duration of viremia correlated with fetal and/or infant brain abnormalities. Design, Setting, and Participants A cohort of 82 pregnant women with clinical criteria for probable ZIKV infection in Barranquilla, Colombia, and Washington, DC, were enrolled from June 15, 2016, through June 27, 2017, with Colombian women identified by community recruitment and physician referral and travel-related cases of American women recruited from a Congenital Zika Program. Interventions and Exposures Women received 1 or more MRI and US examinations during the second and/or third trimesters. Postnatally, infants underwent brain MRI and cranial US. Blood samples were tested for ZIKV. Main Outcomes and Measures The neuroimaging studies were evaluated for brain injury and cerebral biometry. Results Of the 82 women, 80 were from Colombia and 2 were from the United States. In 3 of 82 cases (4%), fetal MRI demonstrated abnormalities consistent with congenital ZIKV infection. Two cases had heterotopias and malformations in cortical development and 1 case had a parietal encephalocele, Chiari II malformation, and microcephaly. In 1 case, US results remained normal despite fetal abnormalities detected on MRI. Prolonged maternal polymerase chain reaction positivity was present in 1 case. Of the remaining 79 cases with normal results of prenatal imaging, postnatal brain MRI was acquired in 53 infants and demonstrated mild abnormalities in 7 (13%). Fifty-seven infants underwent postnatal cranial US, which detected changes of lenticulostriate vasculopathy, choroid plexus cysts, germinolytic/subependymal cysts, and/or calcification in 21 infants (37%). Conclusions and Relevance In a cohort of pregnant women with ZIKV infection, prenatal US examination appeared to detect all but 1 abnormal fetal case. Postnatal neuroimaging in infants who had normal prenatal imaging revealed new mild abnormalities. For most patients, prenatal and postnatal US may identify ZIKV-related brain injury.

Holoprosencephaly is a spectrum of congenital defects of forebrain development characterized by incomplete separation of the cerebral hemispheres. In vivo diagnosis can be established with prenatal brain imaging and disease severity correlates with extent of abnormally developed brain tissue. Advances in magnetic resonance imaging (MRI) over the past 25 years and their application to the fetus have enabled diagnosis of holoprosencephaly in utero. Here, we report on the prenatal diagnosis of holoprosencephaly using MRI as part of a diagnostic and management evaluation at a tertiary and quaternary referral center. Using an advanced MRI protocol and a 1.5-Tesla magnet, we show radiographic data diagnostic for the holoprosencephaly spectrum, including alobar, semilobar, lobar, middle interhemispheric, and septopreoptic variant. Accurate prenatal evaluation is important because the severity of imaging findings correlates with postnatal morbidity and mortality in holoprosencephaly. Therefore, this work has implications for the evaluation, diagnosis, management, and genetic counseling that families can receive during a pregnancy.

Background Congenital Zika syndrome (CZS) is seen in 5–12% of newborns from Zika virus (ZIKV)-infected pregnancies and includes severe neurologic abnormalities. However, the majority of ZIKV-exposed newborns do not have CZS. The risk for neurodevelopmental impairment for infants without CZS following in utero ZIKV is not well known. The objective was to determine whether infants without CZS exposed to ZIKV in utero, have normal neurodevelopment. Methods We performed a longitudinal study of neurodevelopment in Colombia for infants exposed to ZIKV in utero who had a normal fetal brain MRI (Mulkey et al, JAMA Peds 2019) and normal head circumference at birth. Infant development was assessed by the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) and the Alberta Infant Motor Scale (AIMS) between 6 and 18 months of age. In-person training was done by a neurologist. The AIMS were video-recorded and scored centrally. Interrater reliability for the novel method of video-based AIMS was determined. WIDEA and AIMS scores were converted to Z-scores compared with normative samples. We also compared development between infants with normal and nonspecific findings on cranial ultrasound (US). Results Seventy-two non-CZS infants had neurodevelopmental tests; 40 were at a mean (SD) of 5.7 (0.9) months and 66 were at 13.5 (3.2) months of age. Thirty-four had two assessments. The total WIDEA, social cognition, and mobility domain scores became more abnormal with postnatal age (figure). The AIMS scores were similar to the normative sample. Three infants had an AIMS score < 2 SD’s below the norm. On cranial US, 19 infants (26%) had a nonspecific finding (lenticulostriate vasculopathy, choroid plexus cysts, subependymal cysts, and/or calcification). Infants with a US finding had a lower WIDEA mobility score than infants with normal US (P = .054). There was a trend toward lower AIMS scores in infants with US findings compared with infants with normal US (P = .26). AIMS Interrater agreement on video-based scoring was good (ICC = 0.73, 95% CI 0.42, 0.87). Conclusion ZIKV-exposed infants without CZS are at risk for neurodevelopmental delay. Nonspecific cranial US findings may represent mild ZIKV-related injury. Long-term neurodevelopmental follow-up is important for all ZIKV-exposed infants. Disclosures All Authors: No reported Disclosures.

Exhaust emissions of 23 individual city buses at Euro III, Euro IV and EEV (Enhanced Environmentally Friendly Vehicle) emission levels were measured by the chasing method under real-world conditions at a depot area and on the normal route of bus line 24 in Helsinki. The buses represented different technologies from the viewpoint of engines, exhaust after-treatment systems (ATS) and fuels. Some of the EEV buses were fueled by diesel, diesel-electric, ethanol (RED95) and compressed natural gas (CNG). At the depot area the emission factors were in the range of 0.3-21 × 10(14) # (kg fuel)(-1), 6-40 g (kg fuel)(-1), 0.004-0.88 g (kg fuel)(-1), 0.004-0.56 g (kg fuel)(-1), 0.01-1.2 g (kg fuel)(-1), for particle number (EFN), nitrogen oxides (EFNOx), black carbon (EFBC), organics (EFOrg), and particle mass (EFPM1), respectively. The highest particulate emissions were observed from the Euro III and Euro IV buses and the lowest from the ethanol and CNG-fueled buses, which emitted BC only during acceleration. The organics emitted from the CNG-fueled buses were clearly less oxidized compared to the other bus types. The bus line experiments showed that lowest emissions were obtained from the ethanol-fueled buses whereas large variation existed between individual buses of the same type indicating that the operating conditions by drivers had large effect on the emissions.

The pathophysiology of restless legs syndrome (RLS) may be related to abnormalities in central dopamine pathways. Vitamin D may play a role in the pathophysiology of RLS by modulating the dopaminergic system. The aim of our study is to examine the possible link between RLS and vitamin D deficiency.The total number of subjects enrolled was 201, including 78 patients with RLS based on the International RLS Study Group (IRLSSG) diagnostic criteria and 123 controls. Serum 25-hydroxy vitamin D levels were measured in both groups. RLS severity was assessed in all cases using the IRLSSG symptom severity rating scale.Fifty-nine patients with RLS (75.6%) and 52 controls (42.3%) had a diagnosis of vitamin D deficiency,Our study identified an association between vitamin D deficiency and RLS. Consequently, vitamin D deficiency should be considered in the management of RLS. However, further studies are needed to evaluate the causality relationship between vitamin D level and RLS.

Critically ill patients are known to have a variety of electrolyte abnormalities. Lactic acidosis can frequently be seen secondary to shock states and is usually treated with aggressive volume resuscitation. Interestingly, hypophosphatemia is a potential cause of resistant lactic acidosis, which may not be as commonly identified or considered. We present a case of a 42-year-old man admitted twice over a span of 6 months with an elevated lactate level that did not resolve with volume resuscitation. It was ultimately determined that his lactic acidosis was due to hypophosphatemia after ruling out other potential causes. Phosphate replacement therapy resulted in the normalization of his lactate. In the literature, multiple theories have indicated the association of hypophosphatemia with lactic acidosis though no prior cases exist supporting a direct relationship. In this case, we set forth to evaluate the complicated relationship between all of these factors and to highlight the importance of early detection and treatment of hypophosphatemia, which may be beneficial in treating lactic acidosis.

This paper describes a system for tracking and identifying pilgrims in the Holy areas in Makkah, Saudi Arabia and the surroundings, during Hajj season (Pilgrimage) using the mobile phone. It utilizes an internet enabled 3.5 G mobile wireless network, as service providers have already covered the Holy area with such networks. The performance of the developed system is compared with a system that uses a Wireless Sensor Network and is interfaced to the internet through a gateway available from a service provider. The developed system uses a regular mobile phone equipped with a Global Positioning System (GPS) that is available with most pilgrims, while in the second system a small and light weight mobile sensor unit is given to each pilgrim to be fixed on his Hajj cloths. The sensor unit includes a GPS chip, a microcontroller, antennas, and a battery. A network of fixed master units is installed throughout the Holy area for receiving and forwarding data. In both systems, upon request or periodically, the mobile sensor unit or the mobile phone sends its User IDentification number, latitude, longitude, and a time stamp. A server maps the location information on a Google map or a similar geographical information system. If the internet connection is lost, the mobile unit stores the location information in its memory. Once the internet connection is restored, the mobile unit sends all stored location information and clears this information from the memory. Both systems can be used to track a specific pilgrim. Alternatively, any pilgrim can request emergency help. Identification of pilgrims can be achieved by a separate Near Field Communication (NFC) tags if the mobile phone is not NFC enabled. Pilot experiments were carried out successfully during the recent pilgrimage seasons.

The Department of Electrical Engineering plans to run one of its basic courses, Introduction to Electrical Systems and Computation (EE 206), in Active Collaborative Learning (ACL) format. We have surveyed and examined several alternatives and flavors of running ACL, in an attempt to customize a platform that best achieves the course objectives. Issues related to team formation, team management and team assessment were debated. A survey of similar courses in other leading universities was conducted. The authors had the opportunity to test parts of the proposal in their running courses during the phase of the new course development. The feedback and lessons learned were incorporated to make adjustment and fine tuning to the proposal. The course is divided into four modules: Introducing EE fields, Project I: Research Activity, Matlab, and Project II: Robotics. In drafting the pilot course material, we did every effort to provide the fine details so that instructors feel comfortable with the approach. A complete set of documents has been developed to run the course in a productive and engaging manner.

The object of this work is a building situated in the ancient citadel of Damascus: tower 8 which has been affected by devastating earthquakes and subjected to a consolidation process thanks to the Syrian–Italian Cooperation Project. The aim of this research is to investigate the dynamic characteristics of this consolidated structure. Hence, a mixed procedure of experimental measurements and analytical analysis has been chosen. Considering the geotectonic environment and the historical importance, ambient noise measurements are preferred as being a non-destructive technique and the most suitable for the study purpose. The dynamic characteristics of tower 8 are analyzed experimentally and analytically on the basis of ambient noise measurements, which have been performed on the ground and floors of the tower. With spectral analysis of ambient noise records, the predominant frequencies, amplification factors, and damping ratios have been determined. The experimental and analytical results have allowed verifying the efficiency of the consolidation interventions in tower 8.

Background. Chlorhexidine is used for disinfection of skin and mucosae in medicine and dentistry. Prolonged exposure may lead to contact sensitization and allergic contact dermatitis or stomatitis. Objectives. The purpose of this study was to analyse the sources of chlorhexidine exposure and sensitization, and to obtain data on the prevalence of sensitization and chlorhexidine-related contact allergy. Patients and methods. From 1999, patch testing was performed with chlorhexidine digluconate (0.5% aq.) on 7610 general dermatology patients with suspected contact allergy at the Turku University Hospital Dermatology Department. The medical records were reviewed concerning the patients' exposure to chlorhexidine. Results. A positive patch reaction to chlorhexidine was seen in 36 patients (0.47%). Current dermatitis or stomatitis caused by chlorhexidine-containing topical medicaments was seen in 5 patients. Chlorhexidine sensitization contributed to the current dermatitis in 11 patients. A history of earlier exposure to chlorhexidine-containing products was recalled by only 16 sensitized patients, whereas no exposure was revealed in 4 cases. Conclusions. Chlorhexidine-containing corticosteroid creams, skin disinfectants and oral hygiene products are principal sources of chlorhexidine contact sensitization. Exposure to chlorhexidine in cosmetics may lead to delayed improvement of eczema in sensitized patients, emphasizing the importance of identifying the potential cosmetic sources.

Background: Detailed descriptions of meniscus and articular cartilage lesions associated with anterior cruciate ligament injury have not been presented in the literature. Our goal was to determine the associations between patient sex, age, and surgical delay and the frequency and location of meniscus and articular cartilage lesions seen at the time of the anterior cruciate ligament reconstruction. Methods: Data were obtained retrospectively from a database of 1209 consecutive patients undergoing anterior cruciate ligament reconstruction between 1988 and 2002. All knee cartilage, meniscus, and ligament injuries were documented on anatomic maps at the time of surgery, and the data were analyzed. Results: Meniscus injuries were identified in 722 (65%) of the 1104 patients who met the criteria for inclusion in the study. Female patients were less likely to have a meniscus injury than male patients were (56% compared with 71%), and male patients were more likely to have combined medial and lateral meniscus injuries than female patients were (20% compared with 11%). Patients with a surgical delay of less than three months were less likely to have a medial meniscus injury (8% compared with 19%). Femoral articular cartilage injuries were identified in 472 patients (43%). Patients who were twenty-five years of age or older were more likely to have multiple cartilage lesions throughout the knee (7.7% compared with 1.3%) and to have more isolated medial femoral condyle lesions (24.2% compared with 13.3%). Patients with a surgical delay of more than one year were more likely to have a lesion (60% compared with 47% for all others), and a surgical delay of more than one year resulted in a greater proportion of large and grade-3 lesions of the lateral femoral condyle. Female patients had a greater proportion of grade-1 lesions of the medial femoral condyle (29% compared with 16%), whereas male patients had a greater proportion of grade-3 and 4 lesions of the medial femoral condyle (49% compared with 35%). In patients who were thirty-five years of age or older, meniscus injuries were more frequent and were located more frequently on the medial side; femoral articular cartilage lesions were also located more frequently on the medial side. Conclusions: Increased age, male sex, and increased surgical delay all increase the frequency and severity of injuries of the meniscus and/or articular cartilage after an anterior cruciate ligament tear. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

This paper derives the multi-hop capacity of OFDM-based MIMO-multiplexing relaying systems. MIMO-multiplexing relaying presents a spectrally efficient means of realizing mesh supports in wireless networks operating over licensed bands by providing separate links for access and mesh relaying services on the same broadband radio channel. We show that for an NtimesN MIMO-multiplexing relaying system with amplification factor alpha at relay nodes, R-hops relaying degrade the capacity by at most -Nlog2(alpha2R/ (1 + Sigma r=1 R alpha2rNr)) + RNlog2(N) bits/sec/Hz. Therefore, greater capacity loss is experienced in MIMO-multiplexing relaying involving high order MIMO systems. We also illustrate that the capacity loss is independent of the OFDM configurations employed; thus network operators could employ higher OFDM configurations to compensate for data rate loss in access services when some of the MIMO-multiplexing links are dedicated to mesh relay. This pioneering analysis provides useful guidelines for network operators planning to employ MIMO-multiplexing option for mesh relay supports.

We launched a new intervention study called REPRINTS in which senior volunteers engaged in reading picture books to children. Sixty-nine volunteers and 72 participants in a control group, all aged 60 years and over, living in three urban locations, participated in a baseline health checkup in June 2004. After completion of a three-month training seminar, volunteers visited public elementary schools and kindergartens in groups of 6 to 10 for an 18 month period. They were assessed again by a follow-up health checkup in March 2006. At the follow-up, social network scores (frequency of contact with grandchildren and others around the neighborhood) and self-rated health improved or was maintained at a significantly higher rate for the 37 individuals volunteering most intensively as compared to those who did not volunteer or volunteered minimally. In conclusion, through intensively being engaged in the intergenerational volunteer programs during 21 months, self-rated health and social networks were more likely ...