Painless Presentation of a Deadly Disease:Type A Aortic Dissection Requiring the Bentall Procedure

Aortic dissection is a relatively uncommon, although catastrophic, disease which requires early and accurate diagnosis and treatment for patient survival. Aortic dissection can be difficult to diagnose due to the diverse symptom presentation, which can lead to later diagnosis, resulting in a higher mortality rate. Here we present a case of type A aortic dissection with a varied symptom presentation, highlighting the importance of early detection and the Bentall procedure for management of such cases. A 50-year-old man with no known medical history presented with bilateral lower extremity swelling and fatigue for 2 weeks. The patient denied any chest pain or dyspnoea. Vital signs showed blood pressure of 160/76 mmHg, pulse of 103 bpm, respiratory rate of 18, and temperature of 36.7°C. Laboratory findings indicated a BNP of 1901 pg/ml and troponin of 0.5 ng/ml. An initial diagnosis of decompensated heart failure was made, and IV Lasix was started. Subsequently, an echocardiogram indicated an EF of 50–55% and ascending dissection of the aorta. A CT angiogram of the chest and abdomen confirmed this diagnosis. This patient presented with unusual symptoms of aortic dissection without the typical presentation of chest pain. It is important to consider aortic dissection in a cardiac-related case as prompt imaging can help confirm the diagnosis. We explore the risks and benefits of the Bentall procedure for the management and early detection of aortic dissectio

A Rare Case of Elevated Osmolar Gap in Diabetic Ketoacidosis/Hyperosmolar Hyperglycaemic State in the Absence of Concomitant Toxic Alcohol Ingestion

The serum osmolar gap, defined as the difference between measured osmolality and calculated osmolarity, is a convenient method to screen for toxins in serum. In normal circumstances, the difference between the two is 6–10 mol/kg. Typical contributors to serum osmolarity are sodium bicarbonate, sodium chloride, glucose and urea. An elevated gap, defined as a difference >10 mol/kg, can occur if a sufficient quantity of an additional solute other than those mentioned above is present in the serum or there are inaccuracies in sodium measurement secondary to hyperlipidaemia and hyperproteinaemia. An elevated serum osmolar gap should thus prompt clinicians to check for toxic alcohol levels. Treatment with fomepizole should not be delayed if suspicion is high. Isolated diabetic ketoacidosis can occasionally present with an elevated osmolar gap in the absence of concomitant alcohol ingestion. This finding is attributed to the production of acetone and glycerol. We describe the case of a 62-year-old man presenting with diabetic ketoacidosis/hyperosmolar hyperglycaemic state and an elevated osmolar gap in the absence of toxic alcohol ingestion

Global, regional, and national burden of colorectal cancer and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Funding: F Carvalho and E Fernandes acknowledge support from Fundação para a Ciência e a Tecnologia, I.P. (FCT), in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of the Research Unit on Applied Molecular Biosciences UCIBIO and the project LA/P/0140/2020 of the Associate Laboratory Institute for Health and Bioeconomy i4HB; FCT/MCTES through the project UIDB/50006/2020. J Conde acknowledges the European Research Council Starting Grant (ERC-StG-2019-848325). V M Costa acknowledges the grant SFRH/BHD/110001/2015, received by Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006.proofepub_ahead_of_prin

The global burden of cancer attributable to risk factors, 2010-19 : a systematic analysis for the Global Burden of Disease Study 2019

Background Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally. Methods The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented. Findings Globally, in 2019, the risk factors included in this analysis accounted for 4.45 million (95% uncertainty interval 4.01-4.94) deaths and 105 million (95.0-116) DALYs for both sexes combined, representing 44.4% (41.3-48.4) of all cancer deaths and 42.0% (39.1-45.6) of all DALYs. There were 2.88 million (2.60-3.18) risk-attributable cancer deaths in males (50.6% [47.8-54.1] of all male cancer deaths) and 1.58 million (1.36-1.84) risk-attributable cancer deaths in females (36.3% [32.5-41.3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20.4% (12.6-28.4) and DALYs by 16.8% (8.8-25.0), with the greatest percentage increase in metabolic risks (34.7% [27.9-42.8] and 33.3% [25.8-42.0]). Interpretation The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.Peer reviewe

Naloxone induced pulmonary edema

Naloxone-induced noncardiogenic pulmonary edema is a rare but reported entity that can occur following naloxone use in the reversal of opioid overdose. Proposed mechanisms include an adrenergic crisis secondary to catecholamine surge which causes more volume shift to pulmonary vasculature, subsequently leading to pulmonary edema. It appears to be more common when higher doses of naloxone are used. We present a case of a patient with opioid overdose came with altered mental status developed early features of pulmonary edema following the administration of multiple doses of naloxone. She responded well with the administration of diuretics and oxygen supplementation. Her oxygen requirements improved and didn’t require mechanical ventilation

Heart broken. An unusual case of biventricular takotsubo cardiomyopathy complicated by STEMI and Left ventricular thrombi. A case report

Takotsubo cardiomyopathy (TCM) is a rare occurrence in patients with troponin-positive acute coronary syndrome (ACS). It usually manifests as transient apical ballooning of the left ventricle with concomitant occurrence of right ventricular involvement in only one-third of cases. Biventricular TCM is associated with more hemodynamic instability as compared to left sided alone. Depressed ventricular systolic function and localized ventricular dyskinesis can facilitate clot formation in ventricular cavity. We present a case of 80-year-old man who presented to the ED for evaluation of hypotension. An electrocardiogram suggested acute anterior wall myocardial infarction. He underwent emergent coronary angiography and was found to have mid to apical akinesis and basal hyperkinesis with normal left coronaries and chronic total right coronary artery occlusion with excellent collaterals from left. A transthoracic echocardiography (TTE) revealed left ventricular ejection fraction 25–30% and akinesis of left and right ventricle except in the basal region. TTE with definity showed sessile thrombus. In our patient, sepsis was the most important triggering factor given initial presentation of hypotension with leukocytosis. Broad spectrum antibiotics including vancomycin and Zosyn were started considering a combination of septic and cardiogenic shock. Repeat EKG showed resolution of ST-T segment elevation but our patient remained hemodynamically unstable even with two pressure support and, ultimately, died 72 hours after admission. Herein, we emphasize on the importance right ventricular involvement and its relation to hemodynamic instability. This case highlights the importance of anticipating hemodynamic instability and clot formation in patients with biventricular Takotsubo cardiomyopathy

The great invasion, a case of lung mass invading the heart through the pulmonary veins

The heart is a rare site of metastatic lesions of malignancies. Cardiac metastasis may go unrecognized till autopsy, and about half of all newly diagnosed lung cancer patients have metastasis to another organ. Due to the absence of early symptoms, the clinical diagnosis of cardiac metastasis is challenging. Even when they are symptomatic, these symptoms may be masked by the clinical features of primary cancer. Noncardiac neoplasms may spread to the heart through lymphatic or hematogenous dissemination, local extension, or a transvenous route. Here, we report a case of a 56-year-old male with lung mass extending from the right upper lobe to the left atrium was associated with mass effect on superior vena cava and left brachiocephalic vein

Significant Enhancement of the Dielectric Constant through the Doping of CeO2 into HfO2 by Atomic Layer Deposition

Films of CeO2 were deposited by atomic layer deposition (ALD) using a Ce(mmp)(4) [mmp=1-methoxy-2-methyl-2-propanolate] precursor and H2O reactant. The growth characteristics and film properties of ALD CeO2 were investigated. The ALD CeO2 process produced highly pure, stoichiometric films with polycrystalline cubic phases. Using the ALD CeO2 process, the effects of Ce doping into an HfO2 gate dielectric were systematically investigated. Regardless of Ce/(Ce+Hf) composition, all ALD CexHf1-xO2 films exhibited constant growth rates of approximately 1.3 angstrom/cycle, which is essentially identical to the ALD HfO2 growth rates. After high-temperature vacuum annealing at 900 degrees C, it was verified, based on X-ray diffraction and high-resolution cross-sectional transmission electron microscopy results, that all samples with various Ce/(Ce+Hf) compositions were transformed from nanocrystalline to stabilized cubic or tetragonal HfO2 phases. In addition, the dielectric constant of the CexHf1-xO2 films significantly increased, depending on the Ce doping content. The maximum dielectric constant value was found to be nearly 39 for the Ce/(Ce+Hf) concentration of similar to 11%

Novel metal gates for high ? applications

The development of gate systems suitable for high ? dielectrics is critical to the advancement of complementary metal-oxide-semiconductor (CMOS) devices. Both the effective work function and material stability are key parameters to these systems. A systematic study of metal gates of the composition HfxSi1-x (0.25 ? x ? 1) is demonstrated here, including XPS, XRD and four point probe measurements. The effective work function of each material is evaluated and it is shown that it can be tuned from 4.5 to less than 4.0?eV. Suitable work functions for n-channel metal-oxide-semiconductor applications (4.05?±?0.2?eV) were achieved using hafnium rich compositions; however, XPS and diffraction measurements confirmed that these materials demonstrated a high propensity to oxidise, causing the reduction of the underlying oxides, making them unsuitable for commercial application

Prevalence, years lived with disability, and trends in anaemia burden by severity and cause, 1990–2021: findings from the Global Burden of Disease Study 2021

Background: Anaemia is a major health problem worldwide. Global estimates of anaemia burden are crucial for developing appropriate interventions to meet current international targets for disease mitigation. We describe the prevalence, years lived with disability, and trends of anaemia and its underlying causes in 204 countries and territories. Methods: We estimated population-level distributions of haemoglobin concentration by age and sex for each location from 1990 to 2021. We then calculated anaemia burden by severity and associated years lived with disability (YLDs). With data on prevalence of the causes of anaemia and associated cause-specific shifts in haemoglobin concentrations, we modelled the proportion of anaemia attributed to 37 underlying causes for all locations, years, and demographics in the Global Burden of Disease Study 2021. Findings: In 2021, the global prevalence of anaemia across all ages was 24·3% (95% uncertainty interval [UI] 23·9–24·7), corresponding to 1·92 billion (1·89–1·95) prevalent cases, compared with a prevalence of 28·2% (27·8–28·5) and 1·50 billion (1·48–1·52) prevalent cases in 1990. Large variations were observed in anaemia burden by age, sex, and geography, with children younger than 5 years, women, and countries in sub-Saharan Africa and south Asia being particularly affected. Anaemia caused 52·0 million (35·1–75·1) YLDs in 2021, and the YLD rate due to anaemia declined with increasing Socio-demographic Index. The most common causes of anaemia YLDs in 2021 were dietary iron deficiency (cause-specific anaemia YLD rate per 100 000 population: 422·4 [95% UI 286·1–612·9]), haemoglobinopathies and haemolytic anaemias (89·0 [58·2–123·7]), and other neglected tropical diseases (36·3 [24·4–52·8]), collectively accounting for 84·7% (84·1–85·2) of anaemia YLDs. Interpretation: Anaemia remains a substantial global health challenge, with persistent disparities according to age, sex, and geography. Estimates of cause-specific anaemia burden can be used to design locally relevant health interventions aimed at improving anaemia management and prevention. Funding: Bill & Melinda Gates Foundation