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Introduction: Type 2 Diabetes Mellitus (T2DM) is increasing in epidemic proportions. In addition to the morbidity and mortality, for those treated with insulin, the physical, psychological, and financial tolls are often greater. Our real-world study evaluated a Low Carbohydrate Diet (LCD) in patients with T2DM on insulin with respect to glycemic control, insulin reduction, and weight loss.Materials and Methods: A prospective cohort study was conducted via an Electronic Medical Record search for patients attending the Virginia Commonwealth University Medical Weight Loss Program from 2014 to 2020 with Type 2 Diabetes Mellitus who initially presented on insulin. Data was extracted for 1 year after enrollment. The weight loss program focuses on a LCD.Results: Of 185 participants, the mean (± SD) age was 56.1 (9.9) years. Seventy percent were female and 63% were black. Eighty-five completed 12 months (45.9%), reduced their median (25–75% interquartile range, IQR) insulin dose from 69 to 0 units (0–18, p < 0.0001), HbA1c from 8 to 6.9% (6.2–7.8, p < 0.0001), and weight from 116 to 99 kg (85–120, p < 001). Eighty six percent who completed 12 months were able to reduce or discontinue insulin, with 70.6% completely discontinuing. Among all participants who completed 3, 6, or 12 months, 97.6% were able to reduce or eliminate insulin use.Conclusion: In patients with T2DM on a LCD, it is possible to reduce and even discontinue insulin use while facilitating weight loss and achieving glycemic control. A Low Carbohydrate Diet should be offered to all patients with diabetes, especially those using insulin.

Transcatheter aortic valve implantation has emerged as a therapeutic option for patients with symptomatic severe aortic stenosis who are inoperable, or at very high risk of open-heart surgery. Recently, we encountered a patient with aortic stenosis and Larsen syndrome, who had short stature, obesity, kyphoscoliosis, multiple musculoskeletal deformities, and severe restrictive lung disease. An open-heart surgery in such a patient involves substantial peri-operative risk. A successful transcaval aortic valve implantation was done under general anesthesia.

A 60-year-old man presented to the authors’ institution and underwent simultaneous surgery for severe aortic stenosis and left renal mass. Potential benefits of a combined cardiac and noncardiac procedure are discussed. The literature, however, is scarce on standards of management of patients with two coexisting life-threatening conditions.

BACKGROUND ST elevation myocardial infarction is an acute emergency, more than 50% of deaths due to STEMI occur within first 1 hour, mainly due to various arrhythmias. Various arrhythmia can complicate the course of STEMI. This study was done to access the incidence and pattern of arrhythmias complicating STEMI and the prognostic implications of these arrhythmias. MATERIALS AND METHODS 100 patients were included in the study that fulfilled the required criteria. They underwent detailed history taking and systemic examination. Patients were monitored through cardiac monitor and serial ECG recording were taken specially if any rhythm disturbances were observed and data was entered in a pretested proforma. RESULTS Among 100 patients, 60 were male and 40 were female. Commonest arrhythmias noticed in this study were sinus tachycardia (31%), followed by bundle branch block (30%), ventricular arrhythmia (25%) AV blocks (20%) sinus bradycardia (18%), supraventricular arrhythmia (4%) and AIVR in 1%. Mortality was more in patients with ventricular tachycardia and complete heart block. Majority of arrhythmias (76%) occur during first hour of hospitalization. CONCLUSION The commonest arrhythmia encountered were sinus tachycardia followed by bundle branch block (BBB), AV block and sinus bradycardia, AV block and sinus bradycardia were common with IWMI and ventricular arrhythmia and bundle branch block were common with AWMI.

With advancements in synthetic biology, the cost and the time needed for designing and synthesizing customized gene products have been steadily decreasing. Many research laboratories in academia as well as industry routinely create genetically engineered proteins as a part of their research activities. However, manipulation of protein sequences could result in unintentional production of toxic proteins. Therefore, being able to identify the toxicity of a protein before the synthesis would reduce the risk of potential hazards. Existing methods are too specific, which limits their application. Here, we extended general function prediction methods for predicting the toxicity of proteins. Protein function prediction methods have been actively studied in the bioinformatics community and have shown significant improvement over the last decade. We have previously developed successful function prediction methods, which were shown to be among top-performing methods in the community-wide functional annotation experiment, CAFA. Based on our function prediction method, we developed a neural network model, named NNTox, which uses predicted GO terms for a target protein to further predict the possibility of the protein being toxic. We have also developed a multi-label model, which can predict the specific toxicity type of the query sequence. Together, this work analyses the relationship between GO terms and protein toxicity and builds predictor models of protein toxicity.

Background: Pediatric surgery performed in a daycare unit has become the norm in the last few years. Children need special care in terms of psychological stress during the perioperative period 1 . There are many ways to reduce stress in children scheduled for surgery, including preoperative sedative premedication, induction of anesthesia in a familiar environment and “steal” induction in the mother’s arms 2,3 . It is important to consider parental satisfaction while delivering a healthcare service to children. Objective: To assess the overall parental satisfaction throughout the patient’s journey, including the preoperative, intraoperative and the postoperative periods. Setting: Daycare Unit, Department of Anesthesia, King Hamad University Hospital, Bahrain. Design: A Prospective Study. Method: Fifty parents were consented for the questionnaire-based study. Children of these parents were posted for different types of daycare surgery. The parents were asked to fill a form either in Arabic or English, before their children were discharged from the daycare ward. The parents were given an 11-point questionnaire 4 . Scoring these questions was based on their choice of 5 options including: (1) strongly agree, (2) agree, (3) neutral, (4) disagree and (5) strongly disagree. Fifty parents had been included in the study. Patient’s CPR numbers and telephone numbers of the parents were recorded. Questions 7 and 11 demanded individual answers rather than box-ticking. Result: “Strongly agree” and “agree” were taken as positive responses. The majority of parents answered positively to the questions asked. “Strongly disagree” and “disagree” were taken as negative responses. Neutral response was taken as a parent’s wish not to comment either positively or negatively. Conclusion: The majority of the parents were in positive agreement with the questions asked. The majority of the parents were satisfied that the PAC clinic gave them enough information about the anesthetic. The majority of parents were also satisfied with the amount of pain relief given in the recovery room and in the day-care ward. ______________________________________________________________________________ * Senior Registrar ** Director of Intensive Care and Consultant Anesthetist Associate Professor of Physiology and Critical Care, RCSI-MUB *** Senior Registrar Department of Anesthesia and ICU King Hamad University Hospital Kingdom of Bahrain Email: eamon.tierney@khuh.org.bh; aashishjain29@gmail.com INTRODUCTION In a questionnaire-based study conducted in the Royal Berkshire Hospital, it was concluded that parental satisfaction is an important outcome of quality of care delivered in the pediatric daycare unit 5 . The study also concluded that the nurses play a key role in maintaining a quality service and should therefore be involved in monitoring that service. Daycare surgery is increasingly popular because it reduces the length of stay in the hospital by facilitating admission and discharge on the same day. At least 70% of procedures in the pediatric age group are performed as day cases 6 . The increase in daycare surgery has become possible as a result of the availability of shorter-acting anesthetic agents and analgesics. In addition, the use of nerve blocks such as penile blocks and caudal blocks per-operatively has become more commonplace for pain management. Proper selection of patients is of the utmost importance for daycare surgery and one of the important categories of the patients in daycare surgeries is the pediatric age group. These patients are commonly posted for tonsillectomy, adenotonsillectomy, circumcision, undescended testes, inguinal herniotomy and other similar short duration surgeries with minimal blood loss. Children are vulnerable to separation anxiety and associated perioperative stress. In our hospital, we have a policy of child-friendly and parent-friendly management of the pediatric patient coming to theatre for surgery. The parent stays with the child until the child falls asleep. Anesthesia is always induced by inhalation to avoid placing a needle into a conscious child. When the child is transferred from theatre to the recovery room after surgery, the parent is called as quickly as possible to the recovery room to be with the child. In this manner, the child is awake without the presence of a parent for a minimum period of time. In addition, we place a large emphasis on good peri-operative analgesia in pediatric patients, with good intra-operative analgesia and with a rapid response to any complaint of pain expressed by the child in the recovery room. The aim of this study is to assess the overall parental satisfaction throughout the patient’s journey including the preoperative, intraoperative and the postoperative periods. METHOD The parents of 50 patients below 10 years of age posted for daycare surgery were included in the study. The children were anesthetized by anesthetic gas inhalation in the presence of one parent. The parent left the induction room immediately when the child fell asleep. At the end of surgery, the child was transferred to the recovery room. The parent was called to the recovery room as soon as the anesthetist and recovery nurse were satisfied that the child had recovered from the anesthetic. An eleven-point questionnaire was filled out by the parents just before their children were discharged from the daycare ward, see table 1. The questionnaire included the preoperative, intraoperative and postoperative periods. In response to each question, parents were requested to select one of the options on five-point score; the options were:  strongly agree  agree  neutral  disagree  strongly disagree Identifying data on the questionnaire forms were the patient’s Central Population Registration (CPR) number and the telephone number of their parents. RESULT Table 1: Parents’ Responses Numbers and Percentages Question Number Strongly Agree Agree Neutral Disagree Strongly Disagree Not Attempted 1 Was your visit to the pre admission Clinic helpful? 31 16 0 1 1 1 2 Are you satisfied that the doctor/anesthetist gave you enough information about the anesthetic for your child? 34 10 3 2 1 0 3 Did the doctor or anesthetist answer all your questions? 37 10 2 0 0 1 4 Did the doctor/anesthetist explain enough details about the anesthetic procedure? 31 13 2 3 0 1 5 Was it helpful for you to go to operating room with your child? 42 6 2 0 0 6 If yes, was it helpful for your child? 39 9 1 0 0 1 7 Why was it helpful for your child? Discussed below 8 Were you called early enough to be with the child as he/she woke up in the recovery room? 39 9 0 0 1 1 9 Were you satisfied with the 40 8 1 0 0 1 amount of pain relief given to your child in the recovery room? 10 Were you satisfied with the amount of pain relief given to your child in the ward? 42 7 0 0 0 1 11 Do you have any suggestions as to how we can improve the anesthetic and Pain relief services for children? Discussed below

AIM AND OBJECTIVE: The aim of this study was to determine the effectiveness and results of repair of Organic Tricuspid Valve disease. INTRODUCTION : since tricuspid valve disease most often found in association with other valve disease. Isolated tricuspid valve disease is ra re. Pattern of involvement of tricuspid valve disease shows functional (75%) and primary (organic) in (25%). Surgical repair of organic tricuspid valve disease often fails because of abnormal valve. This usually leads to limited options. This study examine s our experience of tricuspid valve repair with autologous pericardium for organic tricuspid valve disease. MATERIAL AND METHODS : From Jan 2014 to May 2015, 22 patients underwent repairs for organic tricuspid valve disease. The patient aged 15 to 65 years and all were in New York Heart Association (NYHA) class of III or IV. All patients presented with severe tricuspid disease coexisting with other cardiac pathology, usually left - sided heart valve disease. Repair techniques included Commisurotomy, division o f secondary chordae, Glutaraldehyde treated autologous pericardial patch augmentation of tricuspid valve leaflets, anterior papillary muscle advancement etc with or without ring/suture annuloplasty. Follow - up duration was 3 to 18 months. RESULTS : No deaths or late reoperations occurred. All patients demonstrated clinical improvements on follow up. Echocardiographic studies before hospital discharge showed less than mild tricuspid regurgitation in all patients except one. CONCLUSIONS : Large majorit y of organic tricuspid valve regurgitation is repairable with acceptable early results. Tricuspid stenosis and mixed tricuspid valve disease are more challenging. In the latter group, it is a judgment call whether to accept a suboptimal result or replace t he valve

Epidural analgesia is widely used in cardiothoracic surgery. Most of the complications associated with epidural analgesia are related to the insertion techniques of epidural catheter. A 68-year-old obese patient posted for coronary artery bypass grafting surgery developed headache followed by seizures after insertion of the thoracic epidural catheter. Magnetic resonance imaging revealed air in the basal cisterns and in the left frontal region. The patient was managed conservatively and the symptoms subsided after 24 h. Later, the patient underwent coronary angioplasty.