Migration of sternal wires into vital structures is a rare but potentially life-threatening complication. While a few cases have been reported, the sternal wires were broken in those cases. To our knowledge, this is the first report of multiple, non-broken migrated sternal wires stabbing vascular grafts. A 65-year-old woman with a long history of treatment for extended aortic pathology, which included replacement of the aortic root (Bentall procedure, coronary artery reconstruction with Piehler technique), aortic arch and thoracoabdominal aorta, as well as thoracic endovascular repair (TEVAR), underwent mitral valve replacement due to severe mitral regurgitation under third median sternotomy. The postoperative course was uneventful, and she was followed as an outpatient. Two years after the surgery, she complained of anterior chest discomfort. Computed tomography (CT) revealed hemorrhaging around the vascular grafts in the mediastinum and migration of several non-broken sternal wires into the vascular grafts. We suspected graft injury due to the sternal wires, and open repair by reopening the sternotomy incision was performed. During redo sternotomy, massive bleeding occurred, so cardiopulmonary bypass was urgently established via femoral cannulation, and her body temperature was brought down. After careful dissection, tearing of the grafts at both the ascending aorta and left coronary artery was found under circulatory arrest with moderate hypothermia. Polypropylene sutures were placed to control bleeding.

Increasing evidence indicates that hypertension and hypertensive end organ damage are not only mediated by hemodynamic injury but that inflammation plays an important role in the pathophysiology and contributes to the deleterious consequences of this disease. The complement system is an ancient part of innate immunity comprising multiple serum proteins and cellular receptors that protect the host from a hostile microbial environment and maintain tissue and cell integrity through the elimination of altered or dead cells. As an important effector arm of innate immunity, it plays also central roles in the regulation of adaptive immunity. Innate and adaptive immune responses have been identified as crucial players in the pathogenesis of arterial hypertension and hypertensive end organ damage. Thus, complement activation may drive the pathology of hypertension and hypertensive injury through its impact on innate and adaptive immune responses aside from direct effects on the vasculature. Indeed, recent experimental data strongly support a role for complement in all stages of arterial hypertension and hypertensive end organ damage. The remarkably similar clinical and histopathological features of malignant nephrosclerosis and atypical hemolytic uremic syndrome, which is driven by complement activation, suggest also a role for complement also in the development of malignant nephrosclerosis. We herein review the role of complement proteins in hypertension and hypertensive end organ damage.

We use recent plot-level panel data from Tanzanian smallholder farmers to investigate maize yield responses to inorganic fertilizer under variable soil carbon conditions. Unlike many prior studies which consider total carbon measurements, we focus on active soil carbon, which is the component that most influences key soil functions, such as nutrient cycling and availability. Active soil organic carbon is found to strongly influence maize yield response to nitrogen fertilizer. These results highlight important sources of variation in the returns to fertilizer investments across plots and smallholder farmers in the region. When farmgate prices for maize and fertilizer are incorporated into calculations of economic returns, we find that the profitability of fertilizer use is strongly dependent upon farmgate price ratio assumptions: under our most optimistic agronomic response estimates, 71% of farmer plots have an average value-cost ratio (AVCR) greater than 1.5 at a maize-nitrogen price ratio of 0.15. That share drops to 30% at a price ratio of 0.12 and 2% at a price ratio of 0.09. Our findings provide insights into the intertwined biophysical and economic underpinnings of low levels of fertilizer use in Tanzania and elsewhere in the region. Raising active carbon stocks in smallholder systems may be a strategic priority in many areas for incentivizing greater use of inorganic fertilizer, reversing land degradation, and achieving sustainable agricultural intensification.

As the global population continues to shift into cities, urban hydrologic systems are becoming increasingly important drivers of overall water quality. Engineered waterways and impervious surfaces strongly influence baseline flow, peak flow, and the transport of pollutants in the urban environment. Between May 2016 -- May 2019, we systematically measured water temperature, pH, dissolved oxygen, biochemical oxygen demand, and the concentrations of nitrate-N, ammonia-N, and orthophosphate in the South Platte River in the Denver metropolitan area, Colorado, USA. We found that the overall water quality of the river decreased through the study area. In addition, there appear to be several hotspots with consistently poor water quality. While it is beyond the scope of this paper to determine the specific sources of the hotspots, it seems likely that wastewater treatment facilities contribute to elevated pollution levels. We also found that water quality was strongly influenced by season. Decreased natural flows during the late fall and winter lead to higher concentrations of nutrients and lower dissolved oxygen levels. Most of the samples collected in this study had nutrient levels that were out of compliance with state regulations for nitrogen and phosphorus concentrations while dissolved oxygen and temperature levels were better than threshold values. Urban hydrologic systems are complex and improving water-quality may be difficult. However, tightening of water-quality standards could result in positive changes to this system.

Various causes of Recurrent Acute pancreatitis have been identified in the past. This report presents a novel case of “recurrent” acute pancreatitis in the setting of superior mesenteric artery syndrome (SMAS). Thus, highlighting SMAS as a rare yet possible cause of recurrent pancreatitis facilitating early diagnosis and prompt treatment.

Drug reaction with eosinophilia and systemic symptoms is a quite unusual condition related to drug reaction. A case report of sulfasalazine-induced liver failure is described. The patient was submitted to liver transplantation. Liver transplantation is an option when DRESS is associated with acute liver failure, but the prognosis remains poor.

The new corona virus has become a global health concern.Voice has the potential to provide an easily obtained, non-invasive way to monitor physiological changes throughout the body. For health care providers with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS and MERS, as well as sepsis and ARDS, the application of acoustical voice analysis should serve as a foundation for optimized supportive care to ensure the best possible chance for survival.

Enterolithiasis or formation of gastrointestinal concretions is an uncommon medical condition that develops in the setting of intestinal stasis due to various pathologies. Its prevalence ranges upto 10% and can present in different clinical picture to challenge a clinician.

Cardiac computed tomography (CT) is increasingly used to plan transcatheter structural heart interventions, however, intra-operative guidance relies on trans-esophageal echocardiography (TEE) and fluoroscopy. This study sought to develop the methods of stepwise CT multi-planar reconstruction manipulation to mimic TEE thus bridging the gap between preoperative planning and intra-operative guidance tools. This CT manipulation successfully reproduces similar configurations as TEE views in mid-esophageal left ventricle (LV) views, transgastric LV 2-chamber views for mitral apparatus, and other miscellaneous views. Stepwise cardiac CT manipulation to mimic TEE is the final piece of the puzzle in the mental co-registration of these three crucial imaging modalities. With it, we are enabled to foresee the TEE images and fluoroscopy projections in a preoperative rehearsal thus improving the intra-operative accuracy of interventions.

Ortner's syndrome is a really rare complication that manifest by hoarseness of voice. It is usually due to left recurrent laryngeal nerve compression. Cardiac causes of Ortner's syndrome are rarely encountered and it is usually due to left atrial enlargement as a complication of valvular lesions affecting mitral valve but other rare causes include ascending aortic aneurysm or pulmonary artery aneurysm. Hereby, we present the 3rd case in the literature to report Ortner's syndrome due to pulmonary artery aneurysm in a 38-year old female patient with previous history of bilharziasis.

His bundle pacing (HBP) offers physiologic pacing by placing the pacing lead directly to the His bundle. We present a case in which a HBP lead, implanted at the fragile membranous septum, resulted in a persistent restrictive peri-membranous ventricular septal defect (VSD). This complication of HBP has not been reported before but brings new insights in the discussion regarding the optimal position of a pacing lead in the ventricular septum. The fragility of the membranous septum and low rate of spontaneous closure of membranous VSD, might favor lead placement in the muscular septum when aiming for physiologic pacing.

Theories attempting to explain species coexistence in plant communities have argued in favor of species’ capacities to occupy a multidimensional niche with spatial, temporal and biotic axes. We used the concept of hydrological niche segregation to learn how ecological niches are structured both spatially and temporally and whether small scale humidity gradients between adjacent niches are the main factor explaining water partitioning among tree species in a highly water-limited semiarid forest ecosystem. By combining geophysical methods, isotopic ecology, plant ecophysiology and anatomical measurements, we show how coexisting pine and oak species share, use and temporally switch between diverse spatially distinct niches by employing a set of functionally coupled plant traits in response to changing environmental signals. We identified four geospatial niches that turned into nine, when considering the temporal dynamics of the wetting/drying cycles in the substrate and the particular plant species adaptations to garner, transfer, store and use water. Under water scarcity, pine and oak exhibited water use segregation from different niches, yet under maximum drought when oak trees crossed physiological thresholds, niche overlap occurred. The identification of niches and mechanistic understanding of when and how species use them will help unify theories of plant coexistence and competition.

Aim Kelp forests worldwide are important marine ecosystems that foster high primary to secondary productivity and multiple ecosystem services. These ecosystems are increasingly under threat from extreme storms, changing ocean temperatures, harvesting, and greater herbivore pressure at regional and global scales, necessitating urgent documentation of their historical to present day distributions. Species range shifts to higher latitudes have already been documented in some species that dominate subtidal habitats within Europe. Very little is known about kelp forest ecosystems in Ireland, where rocky coastlines are dominated by Laminaria hyperborea. In order to rectify this substantial knowledge gap, we compiled historical records from an array of sources to present historical distribution, kelp and kelp forest recording effort over time, and present rational for the monitoring of kelp habitats to better understand ecosystem resilience. Location Ireland (Northern Ireland and Éire). Methods Herbaria, literature from the Linnaean society dating back to late 1700s, journal articles, government reports, and online databases were scoured for information on L. hyperborea. Information about kelp ecosystems was solicited from dive clubs and citizen science groups that are active along Ireland’s coastlines. Results Data were used to create distribution maps, analyse methodology and technology used to record L. hyperborea presence and kelp ecosystems within Ireland. We discuss the recent surge in studies on Irish kelp ecosystems and fauna associated with kelp ecosystems that may be used as indicators of ecosystem health and suggest methodologies for continued monitoring. Main Conclusions While there has been a steady increase in recording effort of the dominant subtidal kelp forest species, L. hyperborea, only recently have studies begun to address other important eco-evolutionary processes at work in kelp forests including connectivity among kelp populations in Ireland. Further monitoring, using suggested methodologies, is required to better understand the resilience of kelp ecosystems in Ireland.

The COVID-19 outbreak is a global pandemic with rapid community spread. Patients with multi-morbidities are particularly vulnerable during this time. The number of cases soared in early February 2020, and Singapore declared escalation of the Disease Outbreak Response System Condition (DORSCON) level to Orange. Multiple measures have been taken to combat the spread of this highly contagious infection. Despite our medical manpower being diverted to the wards, our hospital aims to maintain nearly full operations at the clinic, balancing against concern about the spread of the virus and exposing healthcare workers to potential risks. We describe the measures taken in a tertiary hospital in Singapore to mitigate the risk of infection in the outpatient setting while ensuring that continuing clinical care of patients with chronic diseases is not compromised.

There is a vast number of biomaterials ranging from drug-eluting stents, coated implants, drug delivery devices and artificial organs, among others, that have been developed in recent years. However, translation of many of these biomaterials to clinic is often plagued by biocompatibility challenges. This review focuses on strategies implemented in some of the recently developed biomaterials -- particularly for soft and hard tissue regeneration, organ manufacturing and disease remediation -- to overcome potential foreign body response to the incorporation of the biomaterials in the host.

Starting from December 2019 the novel SARS-Cov-2 has spread all over the world, being recognized as the causing agent of COVID-19. Since nowadays no specific drug therapies neither vaccines are available for the treatment of COVID-19, drug repositioning may offer a strategy to efficiently control the clinical course of the disease and the spread of the outbreak. In this paper we aim to describe the main pharmacological properties, including data on mechanism of action, safety concerns and drug-drug interactions, of drugs currently administered in patients with COVID-19, focusing on antivirals and drugs with immune-modulatory and/or anti-inflammatory properties. Where available, data from clinical trials involving patients with COVID-19 were reported. A large number of clinical studies have been registered worldwide and several drugs were repurposed to face the new health emergency of COVID-19. For many of these drugs, including lopinavir/ritonavir, remdesivir, favipiravir, chloroquine and tocilizumab, clinical evidence from literature and real life settings support their favorable efficacy and safety profile in improving patients’ clinical conditions. Even though drug repurposing is necessary, it requires caution. Indeed, too many drugs that are currently tested in patients with COVID-19 have peculiar safety profiles. While waiting for the results of clinical studies demonstrating the efficacy of drugs able to reduce symptoms and complications of COVID-19, the best therapeutic path to pursue is the development of an effective vaccine able to prevent this infection.

The mechanisms by which herbivores induce plant defenses are well studied. However, how specialized herbivores suppress plant resistance is still poorly understood. Here, we discovered a rice (Oryza sativa) leucine-rich repeat receptor-like kinase, OsLRR-RLK2, which is induced upon attack by gravid females of a specialist piercing-sucking herbivore, the brown planthopper (BPH, Nilaparvata lugens). Silencing OsLRR-RLK2 decreases the constitutive activity of mitogen-activated protein kinase (OsMPK6) and alters BPH-induced transcript levels of several defense-related WRKY transcription factors. Moreover, silencing OsLRR-RLK2 reduces BPH-induction of jasmonic acid and ethylene but promotes the biosynthesis of both elicited salicylic acid and H2O2; silencing also enhances the production of volatiles emitted from rice plants infested with gravid BPH females. These changes decrease BPH preference and performance in the glasshouse and the field. Our study identifies OsLRR-RLK2 as a major susceptibility factor of rice against BPH. It is likely to be employed by BPH to suppress host plant defenses for its own benefit via signaling crosstalk and/or changing the plant’s defense-related signaling profile.

The occurrence of hepatoblastoma is infrequent in children older than 5 years. Therefore, clinicians need to consider hepatoblastoma even in school-aged children or adolescents.