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The COVID-19 pandemic has reshaped the way healthcare systems operate around the world. The major hurdles faced have been availability of personal protective equipment, intensive care unit beds, ventilators, treatments and medical personnel. Detroit, Michigan has been an epidemic ‘hotspot’ in the USA with Wayne County among the hardest hit counties in the nation. The Department of Neurology at Henry Ford Hospital, in the heart of Detroit, has responded effectively to the pandemic by altering many aspects of its operations. The rapid engagement of the department and enhanced utilisation of teleneurology were two of the pivotal elements in the successful response to the pandemic. In this review, we describe the transformation our department has undergone, as it relates to its infrastructure redesigning, coverage restructuring, redeployment strategies, medical education adaptations and novel research initiatives.

Purpose: Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). Methods: We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. Conclusion: Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke. [ABSTRACT FROM AUTHOR]

Abstract Ultra-wideband (UWB) technology is extensively used in indoor navigation, medical applications, and Internet of Things devices due to its low power consumption and resilience against multipath fading and losses. This paper examines a multiple-input multiple-output (MIMO), circularly polarized (CP) dielectric resonator antenna for UWB systems. Compact form factor, high gain, wideband response, improved port isolation, and high data rates are the major design goals. This arrangement consists of two identical DRAs with self-decoupled orthogonal orientations eliminating the need for extra decoupling structures while achieving an impressive maximum isolation of 43 dB. The corner-edge feeding mechanism of the extended feedline generates two orthogonal E-fields, facilitating circular polarization. Additionally, a printed hook-shaped stub integrated with the ground plane enhances CP performance across the two operating bands without altering the DR structure. Fabrication and testing exhibit an impressive 133 $$\%$$ % impedance bandwidth (2.5–14 GHz) with high port isolation. For a 3 dB axial ratio reference, the single-element design exhibits axial ratio bandwidths (ARBW) of 1.2 GHz (3.6–4.8 GHz) and 0.8 GHz (9.3–10.1 GHz). Remarkably, the MIMO configuration achieves a single ARBW of 0.5 GHz (3.9–4.4 GHz). Detailed investigations of MIMO performance parameters, including diversity gain, envelope correlation coefficient, channel capacity loss, and total active reflection coefficient, underscore the design’s efficacy, making it a good choice for UWB wireless applications.

Background The aim of this study was threefold. Firstly, it aimed to introduce and detail a novel method for chemically etching the bases of stainless-steel orthodontic brackets. Secondly, the study sought to investigate the structural alterations within the brackets’ microstructure following chemical etching compared to those with sandblasted bases, using electron microscopy analysis. Lastly, the study aimed to evaluate and compare the long-term durability and survivability of orthodontic brackets with chemically etched bases versus those with sandblasted bases, both bonded using the conventional acid etch technique with Transbond XT adhesive, over an 18-month follow-up period. Methods The study was a randomized clinical control trial with triple blinding and split-mouth study design and consisted of two groups. The brackets in the sandblasted group were prepared by sandblasting the intaglio surface of the base of the bracket with 50 µm SiO2 particles. Hydrofluoric acid was used to roughen the base in the acid-etched group. The bases of the brackets were viewed under an electron microscope to analyze the topographical changes. Results A total of 5,803 brackets (3,006 acid-etch, 2,797 sandblasted) in 310 patients were bonded, in a split-mouth design by the same operator. The patients were followed for 18 months. The failure rate of 2.59% and 2.7% was noted in an acid-etched and sandblasted group, respectively. There was a close approximation of curves in the Kaplan-Meier plot, and the survival distribution of the two groups in the log-rank (Mantel-Cox) test was insignificant; x2 = 0.062 (P value = 0.804). Conclusion Acid etching if the bases of the brackets can be used as an alternative to sandblasting furthermore acid etching can be performed on the chair side.

Extreme rainfall events are occasional, and understanding their intensity and frequency is important for long-term planning and for public safety. The current study aims to investigate the stability of extreme precipitation events in different regions of Pakistan, their independence and the uniformity of their occurrence. A rainfall frequency analysis (RFA) was conducted based on information from 8 weather stations namely, the distribution and moments L of the annual maximum precipitation in Pakistan were investigated; Using goodness-of-fit criteria, the study determined the possible distribution of precipitation. Relatively Absolute Error (RAE) results are based on the most appropriate GUM distribution, revealed that the Sialkot, Multan, Faisalabad and DI Khan stations produce very low errors (0.266, 0.847, 0.075, 0.856, 1.671, 2.522, 3.659, 4.524). It was found that the most suitable distribution is LN distribution for Peshawar, Sibbi and Karachi Stations. The GEV distribution also performs well with small errors for various return periods (0.266, 0.847, 0.075, 0.856, 1.671, 2.522, 3.659, 4.524), corresponding to the return periods 2, 5, 25, 50, 100, 200, 500 and 1000 years. In contrast, P3 has the advantage of a return period of 10 years for all stations, as they all produce similar results for this particular return period. The current research provides valuable insights into estimating extreme rainfall at stations where rainfall data are available.

Conclusion: AADI demonstrates promising results in reducing IOP at 3 months compared to BGI, with comparable surgical outcomes and complication rates over the long term. Further studies with larger samples are warranted to validate these findings and assess cost-effectiveness, particularly in developing countries.

Upper gastrointestinal bleeding (UGIB), defined as blood loss originating from above the ligament of Treitz in the gastrointestinal tract, is the most common gastroenterological emergency.1 Acute forms of UGIB have an approximate in-patient mortality rate of 2-10 percent, despite advances in management options over the last three decades. Urgent endoscopy within 12 hours is the standard management for all patients presenting with UGIB, both as a diagnostic and therapeutic tool.1 Worldwide, most cases of UGIB are due to peptic ulcers, however, this trend differs in Pakistan, where variceal haemorrhage is the predominant cause most likely due to the high disease burden of hepatitis C in the country2. According to the national health survey conducted in 2009, there is limited data on the exact prevalence and incidence, but trends have shown a frequency of 4.7% (CI 4.6-4.8), and around 8 million affected people.3 The major viral epidemic continues to impact the country’s healthcare system, primarily due to resource constraints, overburdened government setups, and lack of public awareness.2 As such, there is an urgent need to cater to this healthcare detriment, especially the decompensated forms of the disease which contribute to most mortalities.4 Like other low-income countries, Pakistan does not have the luxury of emergent endoscopic services and facilities in the well-developed world as a primary care modality. No national data on mortality from UGIB in Pakistan, or numbers on acute cases managed without emergent endoscopy exist. A study by Rajan et al 5 demonstrates that a lack of emergent endoscopy is an independent predictor of mortality among patients with UGIB in similar low-income setups, with numbers rising up to 30%. Such trends indicate a significant gap in our literature that needs to be addressed, with more studies oriented around this health concern. We also require a higher number of emergent endoscopic services to be made readily available, especially at large government tertiary care centers which cater to most of these patients, especially given the epidemic of Hepatitis C.

Abstract Environmental heat stress in dairy cattle leads to poor health, reduced milk production and decreased reproductive efficiency. Multiple genes interact and coordinate the response to overcome the impact of heat stress. The present study identified heat shock regulated genes in the peripheral blood mononuclear cells (PBMC). Genome-wide expression patterns for cellular stress response were compared between two genetically distinct groups of cattle viz., Hariana (B. indicus) and Vrindavani (B. indicus X B. taurus). In addition to major heat shock response genes, oxidative stress and immune response genes were also found to be affected by heat stress. Heat shock proteins such as HSPH1, HSPB8, FKB4, DNAJ4 and SERPINH1 were up-regulated at higher fold change in Vrindavani compared to Hariana cattle. The oxidative stress response genes (HMOX1, BNIP3, RHOB and VEGFA) and immune response genes (FSOB, GADD45B and JUN) were up-regulated in Vrindavani whereas the same were down-regulated in Hariana cattle. The enrichment analysis of dysregulated genes revealed the biological functions and signaling pathways that were affected by heat stress. Overall, these results show distinct cellular responses to heat stress in two different genetic groups of cattle. This also highlight the long-term adaptation of B. indicus (Hariana) to tropical climate as compared to the crossbred (Vrindavani) with mixed genetic makeup (B. indicus X B. taurus).

Large vessel occlusion in patients on ECMO is challenging to appreciate clinically secondary to sedation or induced paralysis, thus placing more emphasis on neurovascular imaging. However, emergent CTA and CTP are both inaccurate and unreliable in ECMO patients due to altered circuitry and interference with normal physiologic hemodynamics. In this review, the utility of DSA is discussed in evaluating the altered hemodynamics of VA-ECMO circuits and patency of major vasculature. In addition, the potential use of TCD in ECMO patients is discussed. [ABSTRACT FROM AUTHOR]

Retroperitoneal liposarcomas are rare malignant tumours that often grow rapidly in size and become symptomatic late in the disease course, posing diagnostic and therapeutic challenges. Although abdominal imaging can reliably diagnose the tumour, definitive diagnosis is only possible through biopsy after surgical excision, which remains the primary treatment modality for these tumours. Long-term survival is primarily determined through histologic grade and post-resection tumour margins. We report the case of a 43-year-old male patient, seen at Dr Ruth KM Pfau Hospital Karachi, who underwent successful surgical excision for a well-differentiated retroperitoneal liposarcoma and had no radiographic evidence of local recurrence at both 3 and 12-month follow-ups. Keywords: Retroperitoneal liposarcoma, surgical excision, tumour recurrence, tumour grade.

This study addresses the issue of secure control design for cyber-physical systems (CPS) against denial of service (DoS) attacks. We take into account a continuous-time linear system with a convex quadratic performance measure and a sampled linear state feedback control. DoS attacks impose constraints on the CPS, where packets may be jammed between the sensor and controller by a malicious entity, potentially resulting in system instability and performance degradation. We assume that the attacker can perform DoS attacks with a limited time and frequency due to energy restrictions. We devise an efficient procedure using the linear matrix inequality approach to compute an upper bound on the performance degradation brought on by the DoS attack. We also propose a redesign of the controller to minimize this performance degradation. Finally, a simulation example illustrates the computation of the performance degradation under a bounded DoS attack and the design of a secure controller. Simulation results show that the designed controller effectively keeps the feedback loop’s performance and stability under attack.

The design of networked switched systems with event-based communication is attractive due to its potential to save bandwidth and energy. However, ensuring the stability and performance of networked systems with event-triggered communication and asynchronous switching is challenging due to their time-varying nature. This paper presents a novel sampled-data approach to design event-triggered asynchronous $\mathcal {H}_{\infty} $ filters for networked switched systems. Unlike most existing event-based filtering results, which either design the event-triggering scheme only or co-design the event-triggering condition and the filter, we consider that the event-triggering policy is predefined and synthesize the filter. We model the estimation error system as an event-triggered switched system with time delay and non-uniform sampling. By implementing a delay-dependent multiple Lyapunov method, we derive sufficient conditions to ensure the global asymptotic stability of the filtering error system and an $\mathcal {H}_{\infty} $ performance level. The efficacy of the proposed design technique and the superiority of the filter performance is illustrated by numerical examples and by comparing the performance with a recent result.

Objective: To evaluate if the jaw growth patterns are associated with third molar impactions. Design: Cross-sectional study. Study setting: Orthodontics Department, Islamic International Dental College & Hospital Islamabad, Jan to Jun 2018. Methods: We analysed the records of 300 mandibular and maxillary third molars with specific criteria. Orthopantomogram Xrays were used to identify impactions and were classified by Pell and Gregory (P&G) and Winter lines. In addition, lateral cephalograms were assessed for sagittal classes and vertical growth patterns. Results: Angles of impaction (Winter lines) of mandibular M3s were significantly associated with sagittal growth patterns(p=0.021), with most mesioangular impactions found in Classes I and II. High-angle subjects resulted in the highest impactions in the vertical growth patterns. High angle was followed by low angle and normal angle in mandibular M3s and normal angle and low angle in maxillary M3s. Levels of maxillary M3s (P&G) and vertical patterns showed a significant association (p=0.016), with the highest M3s at level C. The maximum number of impacted M3 coexisted with P&G Class- II and level B for both jaws. Conclusion: Significant associations were found between mandibular M3 angles, sagittal patterns, and levels of maxillary M3s and vertical patterns. Results conclude that facial growth patterns and M3 impactions are not completely independent and may help predict impaction status in adolescence and aid in orthodontic treatment.

In this article, a compact 4-port UWB (Ultra-Wide Band) MIMO (Multiple Input Multiple Output) antenna is proposed. A low profile FR-4 substrate is used as a dielectric material with the dimensions of 58 × 58 mm2 (0.52λ × 0.52λ) at 2.8 GHz and a standard thickness of 1.6 mm. The proposed design characterizes an impedance bandwidth starting from 2.8 to 12.1 GHz (124.1%). Each of the four elements of the proposed MIMO antenna configuration consists of a monopole antenna with PG (partial ground) that has a slot at its center. The corner of each patch (radiator) and ground slot are rounded for impedance matching. Each unit cell is in an orthogonal orientation, forming a quad-port MIMO antenna system. For reference, the partial ground of each unit cell is connected meticulously with the others. The simulated results of the proposed quad-port MIMO antenna design were configured and validated by fabrication and testing. The proposed Quad-port MIMO design has a 6.57 dBi peak gain and 97% radiation efficiency. The proposed design has good isolation below 15 dB in the lower frequency range and below 20 dB in the higher frequency range. The design has a measured ECC (Envelop Correlation Co-efficient) of 0.03 and DG (Diversity Gain) of 10 dB. The value of TARC (Total Active Reflection Coefficient) over the entire operating band is less than 10 dB. Moreover, the design maintained CCL (Channel Capacity Loss) < 0.4 bits/sec/Hz and MEG (Mean Effective Gain) < 3 dB. Based on the obtained results, the proposed design is suitable for the intended high data rate UWB wireless communication portable devices.

Accurate and fast detection of faults is one of the main concerns of power systems for their operation and productivity. In this paper, a robust dynamic fault detection filter is presented for a synchronous generator (SG) characterized by a highly non-linear model, having uncertainties and perturbations both in state and measurements. The filter is so designed that the residual signal is robust against model uncertainties, process disturbances on the one hand and sensitive to faults on the other hand. To this end, a so-called mixed $\mathscr {H}_{-}/\mathscr {H}_{\infty} $ optimization is used to design the filter. The norm-based threshold is design which guarantee no false alarm. The effectiveness of the proposed approach is demonstrated by introducing synchronous generators in IEEE 9 and IEEE 39 Bus system, and considering different types of faults.

A single negative metamaterial structure with hexagonal split-ring resonators (H-SRRs) is inserted within a two-port multiple-input multiple-output (MIMO) dielectric resonator antenna (DRA) in order to achieve a reduction of mutual coupling between closed multiple antenna elements. Between closed, tightly coupled, high-profile antenna elements, the single negative magnetic inclusions (H-SRRs) are embedded. By incorporating magnetic structures within antenna elements, the mutual coupling is significantly diminished. Mutual coupling reduction is attained by inserting an array of hexagonal split-ring resonators between the inter-spacing elements. An operative approach for the reduction of the mutual coupling between two × two MIMO DRAs initially operating at 5.2-GHz band is provided. To make the simulated design replica of the fabricated prototype, an air gap is introduced between the substrate, DRs, and H-SSRs. The addition of the air gap shifts the simulated results to 5.9 GHz, which closely resembles the measured values. The mutual coupling reduction is realized by integrating a meta-surface amid the two × two MIMO DRAs, which are settled in the H-plane. The meta-surface embraces an array of hexagonal split-ring resonator (H-SRR) cells that are unified along the E-plane. The H-SRR structure is designed to offer band-stop functionality within the antenna bandwidth. The proposed design has an overall dimension of 40 × 58.3 × 4.75 mm3 (1.5λ × 1.02λ × 0.079λ). By stacking the DRA with a one × three array of H-SRR unit cells, a 30 dB reduction in the mutual coupling level is attained without compromising on the antenna performance. The corresponding mutual impedance of the MIMO DRA is better than 30 dB over 5.9–6.1 GHz operating bandwidth. The proposed design has a DG of 10 db, ECC < 0.02, CCL < 0.02 bits/s/Hz, and an MEG of 0 dB. The overall design has a promising performance, which shows its suitability for the target wireless application.

Abstract Climate change is a multidimensional phenomenon, which has various effects on people's environmental and socioeconomic conditions. In the agricultural economy that is susceptible to natural changes, its impact is more profound. Therefore, climate change directly affects society in different ways, and society must pay a price. Climate change, especially the changes in annual temperature and rainfall, has attracted widespread attention worldwide. The variability of these factors or the magnitude of fluctuations varies according to location. Therefore, in the context of climate change, especially in countries dominated by rainfed agriculture, studying the trend of meteorological variables is essential to assess climate-induced variations and propose feasible adaptation approaches. Focusing on this fact is the main goal of this research study was to determine the rainfall trend and the accuracy of predicted temperature at three particular stations of Khyber Pakhtunkhwa (Kp) Province, Pakistan. For this purpose, rainfall and temperature data were provided by Pakistan Meteorological Department (PMD), Islamabad, for the period 1960–2020. Two types of nonparametric techniques, Sen’s slope estimate and the Mann–Kendall test, were applied to determine a trend in the average monthly and annual rainfall. The results of the annual rainfall trend analysis showed that Peshawar and Dera Ismail Khan stations showed a positive increasing trend, while the monthly rainfall trend showed a negative decreasing trend for all stations. The trend was statistically significant for Peshawar and Saidu Sharif stations. The accuracy of predicted and actual temperature and rainfall indicated that mostly over-forecast occurred at Saidu Sharif and Peshawar. Most of the precipitation and temperature records showed under forecast for Dera Ismail Khan, but some over-prediction has also occurred. Graphical abstract

Various applications of degenerate polynomials in different areas call for the thoughtful study and research, and many extensions and variants can be found in the literature. In this paper, we introduce partially degenerate Laguerre-Genocchi polynomials and investigate their properties and identities. Furthermore, we introduce a generalized form of partially degenerate Laguerre-Genocchi polynomials and derive some interesting properties and identities. The results obtained are of general character and can be reduced to yield formulas and identities for relatively simple polynomials and numbers.

In this article our main object to compute image formulas of generalized fractional hypergeometric operators, involving the product of multivariable Srivastava polynomial and multiindex Bessel function. The results obtained provide unification and an extension of known results given earlier by Agarwal and Nieto [1], Agarwal et al. [2] Mishra et al. [18], Saxena and Saigo [26], Suthar et al. [32]. We also consider certain special cases of derived results by specializing suitable value of the parameters.

A number of studies have highlighted physiological data from the first surge in critically unwell Covid-19 patients but there is a paucity of data describing emerging variants of SARS-CoV-2, such as B.1.1.7. We compared ventilatory parameters, biochemical and physiological data and mortality between the first and second COVID-19 surges in the United Kingdom, where distinct variants of SARS-CoV-2 were the dominant stain. We performed a retrospective cohort study investigating critically unwell patients admitted with COVID-19 across three tertiary regional ICUs in London, UK. Of 1782 adult ICU patients screened, 330 intubated and ventilated patients diagnosed with COVID-19 were included. In the second wave where B.1.1.7 variant was the dominant strain, patients were had increased severity of ARDS whilst compliance was greater (p

The production and consumption of plastics, which is indispensable in our modern life, has caused severe environmental impacts. Hence, academics and policymakers have been advocating the circularity of plastics. The role of businesses—particularly manufacturing companies—is pivotal to ensuring the circularity of plastics. This study, therefore, attempted to investigate whether chief executives of manufacturing companies based in the EU are keen on the uptake of recycled plastic and, furthermore, whether the uptake of recycled plastic is a worthwhile business strategy. This study found that the attitude, subjective norms and perceived behavioral control of chief executives positively shape their behavioral intention toward the circularity of plastics. Furthermore, the behavioral intentions of chief executives positively influence the uptake of recycled plastic in manufacturing companies, which could consequently improve business performance. This study suggests measures to increase the uptake of recycled plastic among businesses.

Published in May - 2021

Carotid Blow-Out Syndrome (CBS) is a life-threatening complication of head and neck cancer. We report the case of a patient who suffered a fatal haemorrhage whilst driving, review the law and role of healthcare professionals in preventing such events.

In this paper, we establish fractional integral and derivative formulas involving the generalized p-k-Mittag-Leffler function by using Marichev–Saigo–Maeda type fractional integral and derivative operators. We also consider some special cases of derived results by considering specific values of the parameters of the generalized p-k-Mittag-Leffler function to give the application of our main results. Keywords: Fractional calculus operators, Fox–Wright function, Fox H-function, Generalized p-k-Mittag-Leffler function, Mathematics Subject Classification: 26A33, 33C20, 33E12, 62E12

Abstract The Mathieu series appeared in the study of elasticity of solid bodies in the work of Émile Leonard Mathieu. Since then numerous authors have studied various problems arising from the Mathieu series in several diverse ways. In this line, our aim is to study the solution of fractional kinetic equations involving generalized Mathieu-type series. The generality of this series will help us to deduce results related to a fractional kinetic equation involving another form of Mathieu series. To obtain the solution, we use the Laplace transform technique. Besides, a graphical representation is given to observe the behavior of the obtained solutions.

A 31-year-old female was referred with a history of unexplained exertional breathlessness. The patient had normal resting lung function and a CT thorax showed no significant abnormality. Closer scrutiny of the flow-volume loop confirmed an elevated Empey's index. Cardiopulmonary exercise testing with continuous laryngoscopy was conducted to evaluate the upper airway response to exercise which confirmed loud biphasic wheeze. A bronchoscopy revealed no stenosis nor intraluminal narrowing, however, a contrast CT confirmed a right-sided aortic arch and aberrant left subclavian artery. Following multidisciplinary review, the patient opted for a surgical approach to treatment however despite initially reporting an improvement in symptoms and exercise capacity continued to suffer exertional wheeze two-years post-surgery. This clinical report describes a rare vascular cause of exertional wheeze but also provides a cautionary note in terms of providing a guarded prognosis for adults undergoing surgical intervention for tracheal compression arising from congenital vascular abnormalities. Keywords: Dyspnoea, Cough, Trachea, Wheeze, Bronchoscopy

Abstract— Robotic exploration typically involves navigation through unknown terrains. In this paper, collaborative strategy for coverage is presented, in which the concept of informed agents as a leader in a swarm has been introduced for autonomous coverage. The small population of robots in large swarms act as informed leaders, and help others to accomplish their tasks related to the exploration. These informed leaders receive information about the environment from external sources (e.g. humans, media etc.), and influence uninformed robots using their swarm behaviors. Multiple Swarm behaviors have been designed for swarm navigation, and dynamic selection of the informed leaders. This approach has been tested in simulation of homogeneous swarm, with and without informed leaders. The number of informed agents needed to guide the swarm effectively has been investigated as well. Experimental results showed that the introduction of informed agents improves the coverage task

Background and Objectives: Lung cancer is the most common cancer and cancer related cause of death worldwide. However, the association between sleep duration and incident lung cancer has not been investigated in a prospective cohort study. Methods: We prospectively examined the association between sleep duration and incident lung cancer in a cohort of 21,026 United States (US) male physicians. Self-reported sleep duration was ascertained during 2002 annual follow-up questionnaire. Incident lung cancer was ascertained through yearly follow-up questionnaires. Cox regression was used to estimate relative risk of incident lung cancer. Results: The average age at baseline was 68.3±8.8 yr. During a mean follow up of 7.5 (±2.2) yr, 150 cases of lung cancer occurred. Using 7 h of sleep as the reference group, multivariable adjusted hazard ratios (95%CI) for lung cancer were 1.18 (0.77-1.82), 1.0 (ref), and 0.97 (0.67-1.41) from lowest to the highest category of sleep duration (P for quadratic trend 0.697), respectively. In a secondary analysis, smoking status did not modify the sleep duration-lung cancer association (P=0.78). There was no evidence for an interaction between sleep duration and sleep apnea on the risk of lung cancer either (P=0.65). Conclusions: Our data failed to show a higher risk of lung cancer in association with altered sleep duration among US male physicians.

Objective: Describe the major discrepancies between the clinical and postmortem findings in critically ill cancer patients admitted to the medical intensive care unit (MICU). Materials and Methods: Retrospectively review of the medical records of all cancer patients who were admitted to the MICU and underwent postmortem examination over 6 year period. The records were reviewed for demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, clinical cause of death, and postmortem findings. Results: There were 70 patients who had complete medical records. Mean age was 54.7 years (standard deviation (SD) ±14.8 years). Twenty-six patients had hematopoeitic stem cell transplantation (group I), 21 patients had hematological malignancies (group II), and 23 patients had solid malignancies (group III). The APACHE II score on admission to the MICU was 24.2 ± 8.0. Sixty-seven patients were mechanically ventilated, and the MICU stay was (mean ± SD) 9.0 ± 11.6 days. Major discrepancies between the clinical and postmortem diagnoses (Goldman classes I and II) were detected in 15 patients (21%). The most common missed diagnoses were aspergillosis, pulmonary embolism, and cancer recurrence. There were no differences between groups regarding the rate of major discrepancies. Conclusion: Despite the advances in the diagnosis and treatment of critically ill cancer patients, autopsies continue to show major discrepancies between the clinical and postmortem diagnoses. Autopsy is still useful in this patient population.

Introduction: Chronic pain remains an important public health problem as it continues to increase healthcare-related cost. Comorbidities like obesity have been associated with efficacy of spinal cord stimulator (SCS) therapy and worse outcomes. The goal of this study is to investigate the trends of obesity amongst hospitalized patients with SCS therapy as well as healthcare utilization outcomes., Methods: Using the International Classification of Diseases (ICD) ninth and tenth procedure and diagnosis code, we investigated the National Inpatient Sample (NIS) for patients with SCS implants between 2011 and 2015. Patients received a diagnosis of obesity based on the following categories: class I, II and III obesity. Age, gender, and comorbid conditions of patients with obesity were matched 1:1 on propensity score to those without obesity diagnosis. Our primary outcome was defined as trend of obesity diagnosis. Our secondary outcome, healthcare utilization, included in-hospital cost, length of stay, and discharge location., Results: Between 2011 and 2015, a total of 3893 patients with SCS implants were identified (average age 56 ± 15 years, 58% female, 0.70 ± 1.1 Charlson Comorbidity Index, CCI). Of this cohort, 640 patients were identified as obese. The proportion of patients with obesity diagnosis increased significantly from 13.75% in 2011 to 19.36% in 2015 (p < 0.001). After 1:1 matching on propensity score, 597 patients with obesity were successfully matched to 597 patients without obesity. The total hospital cost for SCS patients with obesity (median $104,845, IQR $74,648-144,292) was not significantly different from patients without obesity diagnosis (median $111,092, IQR $68,990-145,459) (p = 0.161)., Conclusions: The data from our study suggests that there is an increasing rate of obesity diagnosis amongst patients with SCS therapy. However, there was no difference in healthcare utilization between patients with and without obesity. Additional studies may provide more insight into our findings.

Introduction: Co-morbid depression has been associated with poor outcomes following spine surgery and worsening of low back pain symptoms leading to failed back surgery syndrome (FBSS). Given the increasing focus of healthcare utilization and value-based care, it is essential to understand the demographic and economic data surrounding co-morbid depression amongst patients with FBSS., Methods: Our study investigated the NIS database for FBSS patients who had co-morbid depression (ICD-9 CM codes 300.4, 301.12, 309.0, 309.1, 311; ICD-10 M96.1) between 2011 and 2015 across 44 states. We obtained demographic and economic data such as age, sex, ethnicity, location, number of in-patient procedures, hospital length of stay, cost of hospital stay, and frequency of routine discharge dispositions. The NIS database represents approximately a 20% sample of discharges from hospitals in the United States. These data are weighted to provide national estimates for the total United States population. National administrative databases (NADs) like National Inpatient Sample (NIS) are a common source of data for spine procedures. This database is appealing to investigators because of ease of data access and large patient sample. The NIS database is a de-identified database that consists of a collection of billing and diagnostic codes used by participating hospitals with the goal of quality control, population monitoring, and tracking procedures. The NIS does not require institutional review board (IRB) approval or exempt determination., Results: Between 2011 and 2015, a total number of 115,976 patients with FBSS were identified. Of these patients, about 23,425 had co-morbid depression. The rate of co-morbid depression in 2015 was 23% with the lowest reported rate being 20% in 2011. Females and Caucasians had consistently higher rates of co-morbid depression compared to males and other ethnic groups respectively. The average length of stay for patients with co-morbid depression fluctuated between 2011 and 2015, with the highest reported at 4.81 days in 2015. The number of procedures increased steadily from 2011 to 2015 with a dip in 2013. The highest number of procedures was reported as 3.94 in 2015. The mean total hospital charges remained stable over time with the largest change being the decrease from 2011 (mean $93,939; 95% CI $80,064-$107,815) to 2012 (mean 82,603; 95% CI $75,127-$90,079). Additionally, patients with FBSS and co-morbid depression were more often discharged home than home with healthcare or to another healthcare facility., Conclusions: The occurrence of co-morbid depression in hospitalized patients with FBSS increased from 20% in 2011 to 23% in 2015. While direct hospital costs and length of stay remained relatively stable, the number of inpatient procedures performed trended upwards. The exact etiology for this increase in depression prevalence is unknown; additional studies are needed to shed further insight.

Background: The left ventricular outflow tract (LVOT) is a composite of adjoining structures; therefore, a circular or elliptical shape at one point may not represent its entire structure. The purpose of this study was to evaluate the presence of heterogeneity in the LVOT., Methods: Patients with normal valvular and ventricular function undergoing elective coronary revascularization surgery were included in the study. Intraoperative R-wave gated 3-dimensional (3D) transesophageal echocardiographic imaging of the LVOT was performed at end-systole, with the midesophageal long axis as the reference view. Acquired data were analyzed with the Philips Q-Lab software with multiplanar reformatting in the sagittal (minor axis), transverse (major axis), and coronal (cross-sectional area by planimetry) views of the LVOT. These measurements were made on the left ventricular side or proximal LVOT, aortic side, or distal LVOT and mid-LVOT., Results: Fifty patients were included in the study. The LVOT minor (sagittal) axis dimension did not differ across the mid-LVOT, proximal LVOT, and distal LVOT (P = .11). The major axis diameter of LVOT differed among the 3 regions of the LVOT (P < .001). A difference in major axis diameter was observed between the proximal and the distal LVOT (median difference of 0.39 cm; Bonferroni-adjusted 95% confidence interval [CI] of the difference = 0.31-0.48 cm; Bonferroni-adjusted P < .001). Planimetry of the LVOT area differed significantly (P < .001) between the regions analyzed, and we found a difference between the distal and the proximal LVOT (median difference = 0.65 cm, Bonferroni-adjusted 95% CI of the difference = 0.44-0.88 cm, Bonferroni-adjusted P < .001). The LVOT area calculated from minor axis diameter differed significantly from the area obtained by planimetry (P < .001)., Conclusions: There was heterogeneity in the major axis diameter and cross-sectional area for the different regions of the LVOT. The distal LVOT (aortic side) was more circular, whereas the proximal LVOT (left ventricular side) was more elliptical in shape. This change in shape from circular to elliptical was accounted for by a difference in the major axis diameter from proximal to distal LVOT and a relatively similar minor axis diameter. Although the clinical significance of this finding is unknown, the assumption of a uniform structure of LVOT is incorrect. Three-dimensional imaging may be useful for assessing the LVOT shape and size at a specific region of interest.