Liparis maguanensis, a new orchid species from Yunnan province of China, is described and illustrated based on morphological and molecular analysis. Morphologically, this new species is similar to L. viridiflora, but it can be distinguished from the latter by having one leaf, a loosely flowered, 11-30 cm inflorescence, and a 1-5 cm × 0.5-1.2 cm obovate-elliptic pseudobulb. Phylogenetic analysis based on nrITS and plastid matK DNA sequences data further supported that Liparis maguanensis is a distinct species.

Trait-based approaches offer valuable perspectives for vegetation classification, but functional traits struggle to capture resource allocation among competing plants, showing limitations across scales. This study aimed to introduce plant architecture to enhance trait-based vegetation classification. From 2021 to 2023, 32 plots of Coastal Dwarf Forests (CDF) and Coastal Normal Forests (NCDF) along China’s eastern coast were surveyed. Their community characteristics were quantified, and classification and clustering models assessed the advantages of plant architecture in distinguishing these communities. The results indicated plant architecture traits are more critical for distinguishing different community types than leaf-based functional traits. Additionally, plant architecture traits are effective in clustering plant associations within the same community type. This is because plant architecture traits are closely linked to habitat, phylogeny, and community structure, providing a comprehensive description of vegetation, while functional traits reflect only partial habitat information related to soil nutrients. Our findings underscore the importance of plant architecture in optimizing trait-based vegetation classification and suggest that variations in the plasticity of plant architecture traits may support the classification of CDF as a distinct vegetation unit.

not-yet-known not-yet-known not-yet-known unknown In the context of climate change, associated with increasingly frequent water deficit and heat waves, there is an urgent need to maintain the performance of soybean the most extensively grown legume before it declines. The objective of this study was to explore which plant traits improve soybean resilience to heat and/or water stress, with a focus on traits involved in plant architecture and nutrient uptake. For this purpose, two soybean genotypes, already shown to have contrasted root architecture were grown under controlled conditions in the high-throughput phenotyping platform 4PMI where either optimal condition, heat waves, water stress or both heat waves and water stresses were applied during the vegetative stage. Under stress conditions the two genotypes displayed contrasted architectural features traits such as root width, root angle branching or number of roots. By correlating architectural to functional traits, related to water, carbon allocation and nutrient absorption, we were able to explain the stress susceptibility level of the two genotypes. This cross analysis of plant ecophysiology and architectural traits under different stresses provides new information on the adaptation of soybean and can inform future crop design, particularly under changing climatic conditions.

Infective endocarditis (IE) continues to have high rates of adverse outcomes, despite recent advances in diagnosis and management. Although the use of computer tomography and nuclear imaging appears to be increasing, echocardiography, widely available in most centers, is the recommended initial modality of choice to diagnose and consequently guide the management of IE in a timely-dependent fashion. Echocardiographic imaging should be performed as soon as the IE diagnosis is suspected. Several factors may delay diagnosis, for example echocardiography findings may be negative early in the disease course. Thus, repeated echocardiography is recommended in patients with negative initial echocardiography if high suspicion for IE persists, in patients at high risk. However systematic echocardiographic screening should not be utilized as a common tool for fever, but only in the presence of a reasonable clinical suspicion of IE. It may increase the risk of false positive rates of patients requiring IE therapy or may exacerbate diagnostic uncertainty about subtle findings. Considering the complexity of the disease, the echocardiographic proper use should be increasingly time-efficient and focused on the correct identification of IE lesions and associated complications. The path to identify patients who need surgery passes through an echocardiographic skill ensuring the identification of the cardiac anatomical structures and their involvement on the destructive infective extension. We pointed out the role of echocardiography focused on the correct identification of IE distinctive lesions and the associated complications, as part of a diagnostic strategy, within an integrated multimodality imaging, managed by an “endocarditis team”.

IntroductionAngiomyofibroblastoma (AMFB) is a relatively recently described tumor in the expanding spectrum of benign mesenchymal tumors that predominantly arise in the lower genitalia of women. AMFB was first illustrated by Fletcher et al.1 as a benign soft tissue tumor of the vulvar region which should be distinguished from aggressive angiomyxoma in a series published in 1992. AMFB also occurs in men and can arise in the inguen, scrotum, spermatic cord, and bladder2. Only 23 cases of male AMF were reported in the English-language literature based on a review of PubMed data since 19923,4. In this article, we report a case of AMFB in a middle-aged male that arose in the para-vesical region. Salient histopathology, IHC, and genetic features contribute to the diagnosis of AFMB and surgical excision is curative. Our work has been documented according to the CARE guidelines.

A document by Eimear Loftus. Click on the document to view its contents.

The study investigates effect of shape on gas bypassing and mixing of gas-fluidized Geldart A particles. A shallow Fluidized Bed (FB), configured at bench-scale, was used with Digital Image Analysis (DIA) for the investigation. The extent of scatter of tracer particles throughout the bed was assessed from DIA images of defluidized powder. A novel method, employed Jupyter notebook software, which directly determined Mixing Index from the images. Remarkably, Platelet-shaped China clay powder displayed the best mixing characteristics (Mixing Index: 0.79) with no significant bypassing. Angular shaped Quartz displayed moderate mixing (Mixing Index: 0.67), but high bypassing (Bypassing Index: 0.75). Contrary to conventional assumptions, spherical diatomite exhibited poor mixing (Mixing Index: 0.61) with the highest bypassing (Bypassing Index: 0.82). Platelet particles performed well even with fines removal or larger particles addition. Most likely, particle shape significantly influenced the number of available particle contact points, tracer migration, and tracer on particle binding.

Background : The gift of post-mortem tissue donation is critical to pediatric CNS research. As a “Center of Excellence” for the Gift from a Child Program, our institution has a well-established post-mortem tissue donation program. Our objective was to determine if differences exist between patients that participated in and those that declined research-based autopsy. Procedure: We performed a single-institution retrospective chart review of pediatric patients with CNS malignancies who died from their disease between 1/1/2021 and 12/31/2022. Individual clinical, demographic, and socioeconomic data were assessed. Population-level data were estimated using Zip Code Tabulation Areas. Descriptive statistics were used to compare categorical data. Results : Among the 23 patient families approached during the study time frame, 8/23 (35%) consented to participation. In the consented (C) vs. declined (D) group, there was a higher percentage of White, Non-Hispanic/Latino patients by self-reported race (C: 88% vs. D: 55%) and no patients who identified as Asian or Hispanic/Latino (C: 0% & 0% vs. D: 13% & 27%). Of all patients approached, 2 required interpreters (9%) and both families declined participation. The rate of private insurance was higher in the consented group (C: 75% vs D: 47%) compared to Medicaid as primary insurance in the declined group (C: 13% vs D: 53%). Conclusions : Future research should aim to understand and improve identified disparities to ensure research advancements benefit all children with CNS malignancies. One area we plan to address is improved communication with non-English speaking families by partnering with our interpreter services.

Title: Papillary muscle free strain- promising parameter to predict sudden cardiac death in hypertrophic cardiomyopathy?Author:Dr Aslannif Roslan (MBBS, MRCP)Institut Jantung Negara,50400 Kuala Lumpur,MalaysiaE-mail: [email protected] author:Dr Aslannif Roslan (MBBS, MRCP)Institut Jantung Negara,50400 Kuala Lumpur,MalaysiaE-mail:[email protected] Cardiomyopathy (HCM) generally have a good prognosis. In the long follow-up study over 5 decades annual overall HCM-related mortality was 1.3%/y (0.7% first decade to 1.8% in second and third decades). The sudden cardiac death (SCD) mortality rate was also low (0.1%/y first decade to 0.44% in second and third decades)1. SCD is the most feared HCM complication and the only effective treatment for this is Implantable Cardioverter Defibrillator (ICD) that is responsible for >10-fold decrease in HCM related mortality2. In 2014,the European Society of Cardiology (ESC) come out with risk score comprising 7 variables but this risk score have low sensitivity3,4. This led to the search for additional risk factors such as percentage of late gadolinium enhancement (LGE) in the left ventricle, presence of apical aneurysm and left ventricle ejection fraction <50% .The American Society of Cardiology/American Heart Association (ACC/AHA) incorporate this for their guidelines in 20205.Eventhough this guidelines have high sensitivity, it have low ability to identify low risk patients which can lead to inappropriate ICD implantation4. The ongoing challenge is to identify the small yet significant group of patients who are at risk of sudden cardiac death, heart failure, and death resulting from heart failure.Neither the 2014 nor the 2020 SCD risk calculators/predictors, nor even the latest 2022 ESC guidelines, have incorporated the relatively new echocardiography technique of speckle-tracking strain measurements. This technique is non-doppler oriented, angle independent and have been shown to be highly reproducible with high sensitivity and specificity6. These techniques can measure Global longitudinal strain (GLS), left atrial reservoir (LArS), conduit (LAcS) and booster (LAbS) strain and right ventricle global (RVGLS) and free wall strain (RVFWS). The most studied of these is Global Longitudinal Strain (GLS) and a recent study showed GLS have the highest accuracy to predict fatal arrhythmia and accurate ICD indication compare to all the other echocardiographic parameters that was previously considered important like diastolic left atrial (LA) diameter, left ventricular wall thickness and ejection fraction7.This is consistent with another study of large cohort of 427 HCM patients showing independent association between GLS and all cause mortality, heart transplantation, aborted SCD, and appropriate ICD therapy8. Furthermore, the latest meta-analysis of 13 studies with 2441 HCM patients showed significant correlation between impaired GLS and major adverse cardiovascular outcomes (MACE). The same correlation was also found with LA strain. A recent meta-analysis in 2023 shows significant association between all aspect of LA strain (reservoir, conduit and booster) with MACE as well as development of new atrial fibrillation (AF)9. This is not only true with echocardiography derived strain. In a Cardiac MRI (CMR) strain study published in 2024, the combination of left ventricle circumferential strain and left atrial reservoir strain model shows high diagnostic value of SCD with staggeringly high area under the curve (AUC) of 0.9510. All of these studies show how powerful is strain study in HCM SCD prognosis and it is natural to then look at papillary muscle (PM) strain as this structure is frequently abnormal in HCM11.It is widely known that papillary muscle abnormalities are part of HCM phenotypes, in addition to elongated mitral valve leaflets and hypertrophied muscle with excessive contractility (the sine qua non of HCM)11. Abnormal papillary muscle morphology is independently associated with increase left ventricular outflow tract (LVOT) obstruction with anteroapically displaced PM and double bifid PM patients having higher resting LVOT gradients than control independent of septal thickness, use of rate control medications and resting heart rate12. The variations of papillary muscle abnormalities are anterior and apical displacement of the PM usually involving ALPM, bifid PM characterized by the presence of more than one muscle head (If both PM involved it is called double bifid morphology), accessory PM that extend from the LV apex and inserted to basal myocardium without insertion into the mitral leaflets and anomalous insertion of the PM itself12,13,14.In HCM, the PM are frequently hypertrophied, with a mass measuring roughly twice the healthy controls. HCM patients also tend to have larger number of PM (2.5 muscles vs 2.1 in control) with half of the patients demonstrating multiple (3 or 4) PM15.In this issue of Echocardiography Atilla Koyuncu et al look at 79 patients with HCM that were divided into low/intermediate-risk (n=57, ESC risk score <6 points) and high risk (n=22, ESC risk score ≥6 points) groups based on the ESC risk calculator. Their mean follow-up duration is 6.2 years. They specifically look for PM abnormalities and measured anterolateral papillary muscle (ALPM) and posteromedial papillary muscle (PMPM) free strain in addition to other conventional 2-dimensional echocardiographic parameters and GLS. They enrolled all HCM phenotypic groups with or without obstruction and they exclude patients with hypertension, valvular heart diseases, hepatic/renal failure or inflammatory diseases. Of note, they did not perform left atrium (LA) or right ventricle (RV) strain. Papillary muscle strain is a relatively new tool and the measurements of ALPM strain is done in apical 4 chamber view and measurement for PMPM strain is done in apical 3 chamber view. The majority of patients have sigmoid or reverse curvature phenotype (70.9%). Interestingly 5 patients (6.3%) had anteriorly displaced papillary muscles, 7(8.8%) had bifid ALPM, 5(6.3%) had bifid PMPM and 2 patients have both bifid ALPM and PMPM (double bifid morphology).They found that the high SCD-risk group had greater wall thickness, interventricular septum thickness, posterior wall thickness and left ventricle mass index and lower GLS, ALPM (-16.88 ± 4.41% vs. -14.34 ± 3.68%, p = .028) and PMPM (-18.48 ± 6.31% vs. -15.28 ± 6.88%, p = .042) free strain. Furthermore, the SCD risk score was positively correlated with GLS, ALPM (r=0.658, p<0.001) and PMPM (r=0.600, p<0.001) strain. Also important is the fact that patient who have papillary muscle abnormalities had significantly worse ALPM and PMPM free strain. Finally, in multivariate analysis, LVMI, presence of syncope, worse GLS and ALPM-free strain were predictors of death. In terms of PM free strain value in normal healthy populations, one study done in 2016 shows between -32.5% to -48% for ALPM and -34.5% to -39.5% for PMPM but for the moment at least there are no guidelines for normal values16.What is the relevance of this paper for our understanding of HCM? It introduces an additional parameter that is easy to measure and reproducible alongside GLS and LA strain, aiding in the prediction of SCD. Although the technique is new and the sample size is limited, further studies with larger populations are necessary to establish its predictive value for SCD, similar to GLS. As strain measurements are generally robust and reproducible, papillary muscle strain has the potential to replace traditional parameters like left atrial dimension, wall thickness, and ejection fraction. Moreover, this paper highlights the importance of considering papillary muscle involvement in HCM, drawing attention to abnormalities such as bifid papillary muscles and anterior displacement during strain measurement. Ultimately, by integrating papillary muscle free strain with GLS, RV, and LA strain, we can enhance our ability to predict sudden cardiac death and ensure more appropriate ICD implantation. For clinicians focused on managing HCM, these are exciting times, and this paper provides valuable insights into the field.Maurizi N, Olivotto I, Maron M, et al. Lifetime clinical course of hypertrophic cardiomyopathy: Outcome of the historical Florence cohort over five decades. JACC Adv. 2023;2(4). doi:10.1016/j.jacadv.2023.100337Maron MS, Rowin EJ, Maron BJ. The paradigm of sudden death prevention in hypertrophic cardiomyopathy. Am J Cardiol. 2024;212S:S64-S76. doi:10.1016/j.amjcard.2023.10.076Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al. 2022 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2022;26:ehac262. doi:10.1093/eurheartj/ehac262Monda E, Limongelli G. Integrated sudden cardiac death risk prediction model for patients with hypertrophic cardiomyopathy. Circulation. 2023;147(4):281-283. doi:10.1161/CIRCULATIONAHA.122.063019Ommen SR, Mital S, Burke MA, et al. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2020;142:e558–e631. doi:10.1161/CIR.0000000000000937Shirani J, Pick R, Roberts WC, Maron BJ. Morphology and significance of the left ventricular collagen network in young patients with hypertrophic cardiomyopathy and sudden cardiac death. J Am Coll Cardiol. 2000;35(1):36-44. doi:10.1016/s0735-1097(99)00492-1Nikoo MH, Zarrabi M, Moaref A, Razeghian-Jahromi I. Global longitudinal strain may be the one that appropriately identifies candidates for ICD implantation. Cardiol Res Pract. 2024;2024:2214072. doi:10.1155/2024/2214072Hiemstra YL, Debonnaire P, Bootsma M, et al. Global longitudinal strain and left atrial volume index provide incremental prognostic value in patients with hypertrophic cardiomyopathy. Circ Cardiovasc Imaging. 2017;10(7): e005706. doi:10.1161/CIRCIMAGING.116.005706Hussain K, Nso N, Tsourdinis G, et al. A systematic review and meta-analysis of left atrial strain in hypertrophic cardiomyopathy and its prognostic utility. Curr Probl Cardiol. 2024;49(1 Pt C):102146. doi:10.1016/j.cpcardiol.2023.102146Zhu X, Shi Y, Lian J, et al. Left atrial and left ventricular strain in feature-tracking cardiac magnetic resonance for predicting patients at high risk of sudden cardiac death in hypertrophic cardiomyopathy. Quant Imaging Med Surg. 2024;14(5):3544-3556. doi:10.21037/qims-23-1615Sherrid MV, Adams DH. The mitral valve in hypertrophic cardiomyopathy: Other side of the outflow tract. J Am Coll Cardiol. 2020;76(19):2248-2251. doi:10.1016/j.jacc.2020.09.580Kwon DH, Setser RM, Thamilarasan M, et al. Abnormal papillary muscle morphology is independently associated with increased left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. Heart. 2008;94(10):1295-1301. doi:10.1136/hrt.2007.118018Klues HG, Maron BJ, Dollar AL, Roberts WC. Diversity of structural mitral valve alterations in hypertrophic cardiomyopathy. Circulation. 1992;85(5):1651-1660. doi:10.1161/01.cir.85.5.1651Gruner C, Chan RH, Crean A, et al. Significance of left ventricular apical-basal muscle bundle identified by cardiovascular magnetic resonance imaging in patients with hypertrophic cardiomyopathy. Eur Heart J. 2014;Rajiah P, Fulton NL, Bolen M. Magnetic resonance imaging of the papillary muscles of the left ventricle: Normal anatomy, variants, and abnormalities. Insights Imaging. 2019;10(1):83. doi:10.1186/s13244-019-0761-3Kılıcgedik A, Kahveci G, Gurbuz AS, et al. Papillary muscle free strain in patients with severe degenerative and functional mitral regurgitation. Arq Bras Cardiol. 2017;108(4):339-346. doi:10.5935/abc.20170035

The study of species environmental niches underpins numerous questions in ecology and evolutionary and has increasing relevance in a rapidly changing world. Environmental niches, characterized from observations of organisms, inform about a species’ specialization in multivariate environment space and help assess their exposure and sensitivity to a changing climate. Environmental niches are also the central concept behind the species distribution models (SDMs) which assess and predict the geographic variation in environmental suitability. Despite the clear role of past evolutionary processes in driving contemporary biodiversity distribution, the assessment of multivariate or n-dimensional (where n is the number of environmental axes) niches in a phylogenetic framework has remained limited and constrained by restrictive assumptions. This hampers important existing and emerging applications, such as assessments of niche conservatism, estimates of species’ adaptive potential under changing climates, and prediction of niches in less-studied parts of the tree of life. Here we introduce a framework that extends SDMs to estimate n-dimensional environmental niches jointly with underlying evolutionary processes. Specifically, we fit the relationship between niche distance and phylogenetic distance as a latent Gaussian Process across all species in a clade. We demonstrate mathematically how the parameters of the Gaussian Process can be linked to existing traditional evolutionary models. Simulations indicate that the approach successfully recovers evolutionary parameters. Applied to two clades of hummingbirds, the presented joint framework uncovers the relationships among species’ niches in phylogenetic space and supports the quantification and hypothesis testing of niche evolution. A key advantage of the presented framework is its joint estimation of the evolutionary process alongside niches directly from species observations with uncertainty propagated to evolutionary model parameters. The proposed approach has the potential to increase the robustness of inference about niche evolution and improve understanding of how the processes of niche formation and evolution interact.

not-yet-known not-yet-known not-yet-known unknown A variable gain amplifier (VGA) is an essential building block used in the automatic gain control (AGC) loop to provide a continuous, adjustable gain for the signal strength. To maintain the stability and consistency of the AGC loop, it is necessary to ensure that the gain of the VGA has an accurate dB-linear characteristic. This tutorial provides a detailed overview of the development of dB-linear VGAs based on differential pair structures over recent years. We categorise various VGA cells based on differential pair structures, analyse their operating principles, and explain the key features of each topology. Based on observation and extraction of the dB-linear implementation schemes used by these VGAs, we summarise three basic methods for achieving dB-linear gain control. We also discuss specific methods for realising the exponential function, using a true exponential and a mathematical approximation, and present the different types of approximation functions adopted in the works described here. Considerations in regard to the tuning range, gain error, bandwidth, linearity, process-temperature robustness, and circuit simplicity are also discussed. Finally, we draw comparisons and give perspectives for future dB-linear VGAs.

In the rapidly evolving landscape of energy storage technologies, sodium-ion batteries (SIBs) have emerged as promising alternatives to conventional lithium-ion batteries. SIBs exhibit moderate to high specific energy ranging from approximately 70 to 170 Wh/kg, ensuring suitability for diverse applications. Furthermore, with their abundance of raw materials and potential for lower costs, sodium-ion batteries are attracting significant interest from researchers, manufacturers, and investors. This heightened interest is evidenced by the exponential growth in the number of patents filed for SIBs over the past decade, totalling 131,026 patents. This surge in patent filings underscores the growth pattern of SIBs as promising alternatives in the energy storage landscape. In this dynamic environment, securing and maintaining a robust patent portfolio is imperative for companies and innovators to establish a competitive edge, enabling them to capitalize on the increasing market demand. This article examines the strategies involved in building, protecting, and managing a robust patent portfolio as well as provides intellectual property challenges and patent filing opportunities in SIB technologies.

not-yet-known not-yet-known not-yet-known unknown A tandem Diels–Alder reaction / aza-Claisen rearrangement / decarboxylation strategy of N-allenamides with 3-alkoxycarbonyl-2-pyrones has been developed for the efficient synthesis of diarylmethanes with moderate to good yields. The reac-tion exhibits good functional group tolerance and can be applied to late-stage modifications of known drug molecules. Mechanistic studies indicate that the ester group at the 3-position of 2-pyrones is essential, and the initial Diels–Alder reaction between the 2-pyrones with the proximal C=C bond of the N-allenamides is crucial for the success of the reaction.

A document by Amneet Sandhu. Click on the document to view its contents.

This report describes the identification of C7-T1 discospondylitis on myelography and confirmed on postmortem computed tomography and necropsy in a 4-year-old Standardbred gelding as the consequence of jugular vein catheterization and secondary septic thrombophlebitis. Staphylococcus aureus was isolated from both sites. Diagnosis was complicated by non-specific signs of pain and the acute presentation of the gelding. Clinical signs included cervical pain, low head carriage, fever, and ataxia. Antimicrobial therapy and multimodal pain management were initiated but were unsuccessful. Spread of infection from septic thrombophlebitis has uncommonly been reported in horses, and this is the first reported case of secondary discospondylitis in this species.

Myocarditis and Central Retinal Vein Occlusion as Initial Presenting Symptoms of Systemic Lupus Erythematosus, A Case ReportAuthorsMehrdad Jafari Fesharakia, MD aNegar Raissi Dehkordi, MD b, Zahra Zakeri, MDc, Emadoddin Hosseinjani, MDd,, Nastaran Raissi Dehkordi, MD eaAssistant Professor of CardiologyDepartment of Cardiology, School of MedicineCardiovascular Research CenterShahid Labbafinezhad HospitalEmail: [email protected] Research CenterShahid Labbafinezhad HospitalShahid Beheshti University of Medical SciencesEmail: [email protected] Professor of RheumatologyDepartment of Adult Rheumatology, School of MedicineShahid Labbafinezhad HospitalShahid Beheshti University of Medical SciencesEmail: [email protected] Professor of CardiologyDepartment of Cardiology, School of MedicineCardiovascular Research CenterShahid Labbafinezhad HospitalEmail: [email protected] bCardiovascular Research CenterShahid Labbafinezhad HospitalShahid Beheshti University of Medical SciencesEmail: [email protected] for correspondenceNastaran Raissi Dehkordi, MDDepartment of Cardiology, School of Medicine, Cardiovascular Research CenterShahid Labbafinezhad HospitalShahid Beheshti University of Medical [email protected] number: +989128077485Key Clinical MessageSystemic lupus erythematosus may present with atypical symptoms, including central retinal vein occlusion, myocarditis, and deep vein thrombosis, highlighting the need for a comprehensive diagnostic approach. Early diagnosis and prompt treatment help mitigate disease morbidity and mortality, and emphasize the importance of heightened clinical suspicion in complex presentations.AbstractBackground: This article presents the case of a patient diagnosed with systemic lupus erythematosus (SLE) who exhibited a rare and atypical combination of initial symptoms, including acute visual loss, myocarditis, and deep vein thrombosis. This case underscores the significance of reporting such manifestations, contributing to a deeper understanding of the diverse clinical presentations of SLE.Case Presentation: A 35-year-old patient with a history of pulmonary embolism (PTE) and deep vein thrombosis (DVT) presented with acute visual loss, myocarditis, and DVT as the initial symptoms of SLE. The patient’s medical history also included epilepsy treated with Sodium Valproate. Physical examination revealed a malar rash, unilateral lower extremity edema, and complete vision loss in the right eye. Laboratory investigations showed elevated cardiac troponin levels and markedly increased D-dimer levels. Doppler sonography confirmed the diagnosis of DVT, revealing echogenic non-compressible popliteal veins and altered femoral vein diameters. Echocardiography demonstrated mild to moderate systolic dysfunction and severe hypokinesia in specific cardiac walls.Conclusions: This case highlights the rare and unusual nature of the patient’s presentation, combining central retinal vein occlusion, myocarditis, and DVT as initial symptoms of SLE. It emphasizes the importance of considering SLE in patients with seemingly unrelated symptoms and the need for prompt recognition and management. Early intervention in multi-organ system involvement of SLE can significantly enhance patient outcomes.KeywordsSystemic lupus erythematosus; Deep Vein Thrombosis; Lupus Myocarditis; Central Retinal Vein OcclusionIntroductionSystemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by immune complex deposition and autoantibody production, occurring predominantly in reproductive-age female patients (1). Multiple organ systems may be involved in patients with SLE, including skin, musculoskeletal system, kidneys, heart, and lungs (2). While ocular involvement may be a common manifestation of SLE, retinal vein occlusion is an uncommon occurrence in severe vaso-occlusive retinopathy related to SLE. This condition can appear as occlusion in major vessels, such as the central retinal vessels and the cilioretinal artery, or as extensive microembolization in small vessels. The most severe form of retinopathy in SLE can result in extensive damage to the retina and significant visual impairment (3) SLE can also lead to myocarditis, an inflammation of the heart muscle caused by immune complex deposition. Myocarditis in SLE can range from asymptomatic to severe heart failure, depending on the extent of inflammation and damage to the heart muscle (4). Deep vein thrombosis (DVT) is another known complication of SLE, caused by an increased risk of blood clots associated with the disease (5).This case report highlights the unique presentation of systemic lupus erythematosus (SLE) in a patient who presented with central retinal vein occlusion, deep vein thrombosis, and myocarditis as the initial symptoms. While each of these manifestations has been previously reported in SLE patients, the occurrence of all three simultaneously is extremely rare. This case highlights the importance of considering the possibility of SLE in patients presenting with seemingly unrelated symptoms, as prompt recognition and treatment can prevent further complications and improve outcomes. It also underscores the need for clinicians to be aware of the wide spectrum of multi-organ system involvement in SLE and to consider the possibility of the disease in the differential diagnosis of patients presenting with unusual symptoms.Case History/ExaminationA 35-year-old patient presented to the emergency department complaining of blurred vision starting two days ago, which had turned into complete visual loss in the right eye the next morning, in addition to swelling in the right leg, and a history of flu-like symptoms last week. The patient had a history of PTE and DVT following leg trauma two years ago and a history of epilepsy with unknown etiology which was under treatment with Sodium Valproate. According to the family history, the patient’s sister had passed away at the age of 20 due to SLE-related complications. However, it is unclear whether her morbidity was caused by antiphospholipid syndrome (APS), lupus nephritis, or other factors.Physical exam findings included a malar rash across the nose and cheeks, and unilateral edema of the right lower extremity. Ophthalmologic examination of visual acuity showed no light perception in the right eye, suggestive of occlusion in the central retinal vein. Additional physical exam findings were negative for oral or nasal ulcers, joint pain and swelling, pleural or pericardial rub, and lymphadenopathy.MethodsInitial blood investigations showed a white blood cell count of 7.8 × 10^3/μl with 59% neutrophil predominance and 38% lymphocytes, hemoglobin of 6.6 g/dl, and platelet count of 110 × 10^3/μl. The patient’s creatinine levels were within normal range (1.1 mg/dL) and his urine analysis did not show proteinuria. Cardiac troponin level was 8.1 ng/ml and D-dimer level was significantly increased (8000), while ECG showed normal sinus rate and rhythm with no ST or T changes (Figure 1). Doppler sonography of the right lower extremity showed echogenic non-compressible popliteal vein with increased diameter, suggestive of DVT. Follow-up venous Doppler sonography confirmed the initial diagnosis, and showed decreased diameter in common femoral vein (CFV) and distal part of superficial femoral vein (SFV), suggestive of acute DVT in distal SFV and popliteal vein, and chronic DVT in CFV and proximal SFV. Echocardiography revealed mild to moderate systolic dysfunction, (EF:40-45%), severe hypokinesia in the base mid-inferior wall, posterior wall, and inferoseptal wall, in addition to mild diastolic dysfunction, and moderate mitral regurgitation.Considering the patient’s family history of SLE (in the patient’s sister), and DVT in the lower limb, comprehensive rheumatologic lab exams were requested for the patient. Complement levels including C3, C4, and complement CH50 were within normal range. Antinuclear antibody (ANA) was positive in two separate tests, in addition to two positive (>1/160) titers of anti-double-strand DNA (anti-dsDNA). Anti-Cardiolipin Ab (IgG) (ELISA), Anti Cardiolipin Ab (IgM) (ELISA), B2 Glycoprotein Ab (lgG) were negative, while Anti-beta2-glycoprotein I Ab (IgM and IgG) levels were increased. P.ANCA (Anti-MPO), C.ANCA (Anti-PR3) were negative. A summary of the patient’s rheumatologic lab results is shown in Table 1. Coagulation tests for Protein C, S, Antithrombin III, and Factor V Leiden were within normal limits.Due to elevated Troponin levels, the patient was admitted to the cardiac care unit with a possible diagnosis of acute coronary syndrome and DVT. A coronary angiogram was obtained, which showed normal coronary arteries. Based on the patient’s family history of SLE, presenting symptoms, and three positive laboratory findings (ANA, anti-dsDNA, Anti-beta2-glycoprotein I Ab), a diagnosis of SLE was reached. Additionally, the diagnosis of APS was suspected due to an episode of thrombosis and positive Anti-beta2-glycoprotein I Abs. After ruling out coronary artery disease, a diagnosis of lupus myocarditis was reached, on the basis of clinical findings, laboratory tests (elevated levels of cardiac troponin and anti-dsDNA) and imaging tests (echocardiogram).Treatment was initiated with high-dose corticosteroids, anticoagulant agents, and hydroxychloroquine. Workup for ACS and DVT was initiated, including Warfarin 5 mg once daily for anticoagulation, and the patient’s INR level was controlled in a range of 3.0-4.0 due to recurring episodes of DVT. An MRI was requested, which did not show any signs of vasculitis and ruled out the need to administer cytotoxic therapies. Regular consultations with cardiology, rheumatology, ophthalmology, and nephrology specialists were conducted to follow the patient’s condition.Conclusion and ResultsThe patient’s visual acuity remained unchanged, and he was discharged with instructions for continued medical treatment and weekly follow-up visits with instructions to report any vision deterioration.DiscussionMultiple organ systems may be involved in SLE, including cutaneous, musculoskeletal, renal, cardiac, hematopoietic, and ocular (6). Affecting up to one third of the patients, ocular manifestations are a common finding in SLE patients. Although the most common ocular finding is keratoconjunctivitis sicca, more serious complications such as optic neuritis and occlusive vasculitis may occur, leading to potential visual loss (3,7). Cardiac manifestations may include pericarditis, myocarditis, Libman-Sacks endocarditis, and coronary artery disease (8). Although lupus myocarditis remains a rare manifestation of SLE and occurs in 5-10% of patients (8,9), the potentially life-threatening complications of lupus myocarditis, including heart failure, arrhythmias, and sudden cardiac death (10) underscore the need for prompt diagnosis and management. Although ocular and cardiac manifestation may be prevalent in SLE patients, a combination of central retinal vein occlusion, myocarditis, and DVT manifesting as the initial symptoms in the same patient is an extremely rare finding, and to the best of our knowledge, has not been reported in the literature. Although this case report presents a rare and unusual presentation of SLE, there are several limitations that need to be acknowledged. Firstly, this is a single case report an d may not be representative of the general patient population. Secondly, a diagnosis of APS requires positive laboratory criteria on two occasions taken at least 12 weeks apart, and thus long-term follow-up is required, in which the patient is asked to stop taking anticoagulation medication for a week, and is tested for APS laboratory criteria in order for us to reach a definite diagnosis of APS. Thirdly, the patient’s incomplete family history might include confounding information, which is unfortunately not available.In conclusion, the primary take-away lessons from this case report are the need for thorough and comprehensive evaluation of patients presenting with atypical symptoms, and the importance of interdisciplinary collaboration in diagnosing and managing complex medical cases.Consent for publicationSigned informed consent was obtained from the patient regarding the use of patient information for the purposes of writing a case report publication.Competing interestsThe authors declare that they have no competing interests.FundingThis work did not receive any funding from private or public sources.AcknowledgementsNot applicable.FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.DisclosureThe authors declare that there are no conflicts of interest.Author ContributionsM.J.F: Conceptualized the study with N.R.D., wrote the manuscript and provided final approval.Ne.R.D: Participated in drafting and writing the manuscript and collected patient data.Z.Z: Critically revised the manuscript.E.H.: Critically revised the manuscript.Na.R.D: Co-conceived the study, participated in drafting and writing the manuscript and critically revised the content.All authors provided final approval of the study.Figure LegendFigure 1. ECG obtained upon admission showed normal sinus rate and rhythm.References1. Moulton VR, Suarez-Fueyo A, Meidan E, Li H, Mizui M, Tsokos GC. Pathogenesis of Human Systemic Lupus Erythematosus: A Cellular Perspective. Trends Mol Med. 2017 Jul;23(7):615–35.2. Fanouriakis A, Tziolos N, Bertsias G, Boumpas DT. Update οn the diagnosis and management of systemic lupus erythematosus. Ann Rheum Dis. 2021 Jan;80(1):14–25.3. Silpa-archa S, Lee JJ, Foster CS. Ocular manifestations in systemic lupus erythematosus. Br J Ophthalmol. 2016 Jan;100(1):135–41.4. Raval JJ, Ruiz CR, Heywood J, Weiner JJ. SLE strikes the heart! A rare presentation of SLE myocarditis presenting as cardiogenic shock. BMC Cardiovasc Disord. 2021 Jun 13;21(1):294.5. Al-Homood IA. Thrombosis in systemic lupus erythematosus: a review article. ISRN Rheumatol. 2012 Jul 30;2012:428269.6. García-Carrasco M, Pinto CM, Poblano JCS, Morales IE, Cervera R, Anaya JM. Systemic lupus erythematosus. El Rosario University Press; 2013.7. Palejwala NV, Walia HS, Yeh S. Ocular manifestations of systemic lupus erythematosus: a review of the literature. Autoimmune Dis. 2012 Jul 2;2012:290898.8. Wang TKM, Chan N, Khayata M, Flanagan P, Grimm RA, Griffin BP, et al. Abstract 13131: Cardiovascular Manifestations and Outcomes in Systemic Lupus Erythematosus: The Cleveland Clinic Contemporary Experience. Circulation. 2020 Nov 17;142(Suppl_3):A13131–A13131.9. Al-Nokhatha SA, Khogali HI, Al Shehhi MA, Jassim IT. Myocarditis as a lupus challenge: two case reports. J Med Case Rep. 2019 Nov 20;13(1):343.10. Al-Akchar M, Shams P, Kiel J. Acute Myocarditis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.

As one of the famous traditional Chinese herbal medicines, Fritillariae Cirrhosae Bulbus (FCB) is widely used in the prevention and treatment of respiratory diseases and has best curative effect among the known fritillarias medicinal. Due to the variety, complex sources, similar appearance and shape, it is difficult to distinguish FCB with high curative effect (h-FCB) from other common fritillarias (c-FCB) in the market. In this paper, a very simple chemiresistor is used to identify FCB from three commonly used fritillarias drugs. The sensors are fabricated by anisotropic electrically conductive Metal-organic framework (cMOF) thin film Cu3(HHTP)2 (Cu-HHTP[001] and Cu-HHTP[100]) as active materials owing to their ability to detect specific groups of volatile organic compounds (volatolomics) as the functional motifs of chemiresistor. As a result, the sensors show orientation-dependence identification ability to FCB. Cu-HHTP[001]-based sensor shows the highest response (344.17%) to 0.5 g h-FCB powder volatiles among its three other c-FCB which is much higher than Cu-HHTP[100] (135.50%). Ultimately, Cu-HHTP[001] can realize the identification of FCB with an accuracy of 97.2% in a simple and real-time manner.

With the growth of cloud computing and the popularity of electronic health records (EHR), more and more patients and hospitals are uploading EHR to the cloud for storage, retrieval and organization. Due to the privacy of EHR, cloud-based EHR systems need to protect data security and provide access control, and attribute-based encryption (ABE) is the appropriate technology. Nevertheless, traditional single-center ABE schemes do not conform to the collaborative scenario of electronic health care, and some of them do not support real-time attribute update. Consequently, this paper proposes a lightweight CP-ABE scheme for EHR over cloud based on blockchain and secure multi-party computation (LCBS). Firstly, we introduce the model of multi-authority and innovatively apply secure multi-party computation to initialize the system, which maintains normal system operation while the power is decentralized. Secondly, we designed a blockchain suitable for EHR systems to record the users’ key information, assisting multiple entities to verify the key at different stages and protecting the EHR from illegal acquisition. In addition, our scheme supports lightweight attribute update, which requires small amount of computational overhead to achieve instant attribute update. Finally, through formal security analysis and simulation experiments of the LCBS system, it is shown that our scheme guarantees data security and improves computing efficiency.