Distal His bundle pacing in a patient with surgically corrected complex Ebstein anomaly and symptomatic second-degree atrioventricular block: a case report

Background: Ebstein's anomaly occurs when there is an apical displacement of the tricuspid valve with septal and posterior valve leaflets tethering. This condition often occurs in association with other congenital, structural, or conduction system diseases, including intracardiac shunts, valvular lesions, arrhythmias, accessory conduction pathways, and first-degree atrioventricular (AV) block. We present for the first time a case of a patient with Ebstein's anomaly who presented with second-degree Mobitz II AV block and was successfully treated with conduction system pacing (CSP) due to her young age and the likelihood of a long-term high percentage of pacing. Case summary: We present a case of a 42-year-old lady with a background of complex congenital heart disease, including severe pulmonary stenosis, Ebstein anomaly, and atrial septal defect (ASD). She required complex surgical intervention, including tricuspid valve (TV) repair and subsequently replacement, ASD closure, and pulmonary balloon valvuloplasty. She presented to our hospital with symptomatic second-degree Mobitz II AV block (dizziness, shortness of breath, and exercise intolerance) and right bundle branch block (RBBB) on her baseline ECG. Her echocardiogram showed dilated right ventricle (RV) and left ventricle (LV) with low normal LV systolic function. Due to her young age and the likelihood of a long-term high percentage of RV pacing, we opted for CSP after a detailed discussion and patient consent. The distal HIS position is the preferred pacing strategy at our centre. We could not cross the TV with the standard Medtronic C315 HIS catheter, so we had to use the deflectable C304 HIS catheter. Mapping and pacing of the distal HIS bundle were achieved by Medtronic Selectsecure 3830, 69cm lead. HIS bundle pacing led to the correction of both second-degree Mobitz II AV block and pre-existing RBBB. The implantation was uneventful, and the patient was discharged home the next day without any acute complications. Discussion: Distal HIS pacing is feasible in patients with surgically treated complex Ebstein anomaly and heart block. This approach can normalize the QRS complex with a high probability of preserving or improving LV function.</p

Ethical investing and capital structure

We test the relevance of the trade-off, pecking order, and market timing theories of capital structure from the point of view of a stock's religious orientation. Using a unique sample of Islamic stocks, we discover the leverage speed of adjustment (SOA) to be faster compared to that in the literature on conventional stocks, consistent with trade-off theory. We hypothesize that this result is due to the risk-sharing principal of Islamic investments that substantially reduces market imperfections. The inclusion of variables belonging to other theories of capital structure does not change the SOA, implying the importance of the trade-off theory

New artificial intelligence based tire size identification for fast and safe inflating cycle

Motor vehicle accidents are one of the main killers on the road. Modern vehicles have several safety features to improve the stability and controllability. The tire condition is critical to the proper function of the designed safety features. Under or over inflated tires adversely affects the stability of vehicles. It is generally the vehicle’s user responsibility to ensure the tire inflation pressure is set and maintained to the required value using a tire inflator. In the tire inflator operation, the vehicle’s user sets the desired value and the machine has to complete the task. During the inflation process, the pressure sensor does not read instantaneous static pressure to ensure the target value is reached. Hence, the inflator is designed to stop repetitively for pressure reading and avoid over inflation. This makes the inflation process slow, especially for large tires.This paper presents a novel approach using artificial neural network based technique to identify the tire size. Once the tire size is correctly identified, an optimized inflation cycle can be computed to improve performance, speed and accuracy of the inflation process. The developed neural network model was successfully simulated and tested for predicting tire size from the given sets of in put parameters. The test results are analyzed and discussed in this paper

Recommendations for Management of Diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD Consensus

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith.Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The ADA/EASD consensus recommendations emphasize the importance of patient factors and co-morbidities when choosing diabetes medications including the presence of co-morbidities, atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), chronic kidney disease (CKD), hypoglycaemia risk, weight issues and costs.Structured education and pre-Ramadan counselling are key components to successful management of patients with diabetes. These should cover important aspects like glycaemic targets, self-monitoring of blood glucose (SMBG), diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The Decision Cycle in figure 1 adapted for the specific situation of Ramadan provides an aid for such an assessment.Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycaemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. [1]Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes.Hypoglycaemia is a common concern during Ramadan fasting. To prevent hypoglycaemic and hyperglycaemic events, we recommend the adoption of diabetes self-management education and support (DSMES) principles.The use of the emerging technology and continuous glucose monitoring (CGM) during Ramadan could help to recognize hypoglycaemic and hyperglycaemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier. </p

Cardio-renal-metabolic disease in primary care setting

In the primary care setting providers have more tools available than ever before to impact positively obesity, diabetes, and their complications, such as renal and cardiac diseases. It is important to recognise what is available for treatment taking into account diabetes heterogeneity. For those who develop type 2 diabetes (T2DM), effective treatments are available that for the first time have shown a benefit in reducing mortality and macrovascular complications, in addition to the well-established benefits of glucose control in reducing microvascular complications. Some of the newer medications for treating hyperglycaemia have also a positive impact in reducing heart failure (HF). Technological advances have also contributed to improving the quality of care in patients with diabetes. The use of technology, such as continuous glucose monitoring systems (CGM), has improved significantly glucose and glycated haemoglobin A1c (HbA1c) values, while limiting the frequency of hypoglycaemia. Other technological support derives from the use of predictive algorithms that need to be refined to help predict those subjects who are at great risk of developing the disease and/or its complications, or who may require care by other specialists. In this review we also provide recommendations for the optimal use of the new medications; sodium-glucose co-transporter-2 inhibitors (SGLT2i) and Glucagon-like peptide-receptor agonists 1 (GLP1RA) in the primary care setting considering the relevance of these drugs for the management of T2DM also in its early stage.</p