Cm In Circumference Research Articles

Diagnosis and surgical treatment of associated papillary lung adenocarcinoma to canine distemper: case report

Lung neoplasms in dogs have a multifactorial etiology, and animals aged 10 or older are the most affected, with no sexual or racial predisposition. Adenocarcinoma is the most common type of cancer and represent around 80% of the cases. The aim of this study was to describe a case of an 11-year-old dog of no defined breed (SRD) with papillary lung adenocarcinoma and canine distemper virus. Clinical examination revealed a body condition score (BCS: 5.0), normocardial, tachypneic, normothermic, mild dehydration (5 - 6%), hyporexia, hypocolored mucous membranes, normodipsia, normuria and normoquesia. Hematological tests (blood count, biochemistry) were carried out, initially showing leukocytosis and regenerative anemia. Imaging tests of the chest (x-ray) and computed tomography (CT) showed a nodule, with approximately 7cm in circumference in the ventral portion of the right caudal lung lobe. Treatment was by thoracotomy to excise the nodule. The excised material was sent for histopathological and immunohistochemical diagnosis, which confirmed the diagnosis of lung adenocarcinoma. Infection with the distemper virus was confirmed by the identification of the Lentz corpuscle, which was found in the blood sample during the differential leukocyte count, when the animal was returned for re-evaluation. The animal did not respond to treatment and died 48 hours after the diagnosis of distemper, in response to cardiorespiratory arrest, 12 days after the removal of the nodule. Infection with the distemper virus led to an unfavorable prognosis and made post-surgical treatment impossible, culminating in the animal's death.

Effect of Circuit Training on the Basis of Motor Skills (Speed) and Skill Abilitied (Dribbling) of School Football Players of Mumbai

Football is one of the well-known games across world. Football also known as Soccer or European Football in USA and Canada. There are certain rules and regulation for playing this game. Firstly, required two teams with sixteen players; 11 on field and 5 substitutes. This game using Spherical ball of 67-70 cm of circumference for playing. The game has to played in between of two goal post. And game started by kick off. There are some fundamental skills using for the game on field by the players like heading, dribbling, kicking, passing, defending, goal keeping etc. when ball crosses the goal line by team scored as goal. When both teams have scored equal goals means tie happened then there are methods to solved or break the tie by extra time, penalty shoot and sudden death. The purpose of study was to determine the effect of circuit training on speed and dribbling of school football players aged 14 to 16 years. A sample of Forty (n=40) school football players age ranged 14 to 16 years was identified as subjects from Arsenal football academy Mira road, area of suburban Mumbai. further they had been randomly divided into two identical corporations i.e. experimental and manipulate institution with same variety of topics. Experimental organization (circuit education institution (n=20)) and control group (non-circuit education institution (n=20)). The layout of the have a look at changed into Non- equivalent manage organization design. The experimental topics in conjunction with day these days lifestyles underwent a Circuit schooling programmed for 3 days in per week. The collected records changed into analysis with assist of ‘t’ test. The end result revealed that the effect of circuit schooling programmers helped to enhance velocity and dribbling talent of football gamers elderly 14 to 16 years. The findings finish that the circuit schooling turned into found beneficial to improve speed and dribbling of football players aged 14 to 16 years.

Assessing the Efficacy of Homoeopathic Medicine Gibberellic Acid 3X in Enhancing Yield Production in Neelam Mango Trees: A Comparative Pilot Study

Aims: Assess the influence of Gibberellic Acid 3X on yield production: Measure the effect of Gibberellic Acid 3X treatment on increasing the overall yield of Neelam mangoes, including the number of fruits, fruit weight, and fruit size, compared to the control group.
 Study Design: A Comparative Pilot Study.
 Place and Duration of Study: MNR Homoeopathic Medical College and Hospital premises with good sunlight and ventilation, Sangareddy, between February 2023 to August 2023.
 Methodology: The total sample size was taken as 6 Branches of 2 Trees. Three branches of a tree were divided into 3 groups. This is to ensure that the flowers of the mango tree will be receiving the same amount of water, nutrients, and sunlight. Gibberellic acid 3x was prepared according to rules and regulations of Homoeopathic Pharmacopoeia of India (HPI). Foliar application of medicine was done after the flowering of plant. The fruits are taken for analysis once they have matured.
 Results: The "Gibberellic Acid 3X - Alcoholic potency" group had the highest mean weight (563.94 grams) and circumference (18.106 cm), followed by the "Gibberellic Acid 3X - Water potency" group with slightly lower values (556.67 grams for weight and 17.771 cm for circumference). Additionally, the "Gibberellic Acid 3X - Alcoholic potency" group had the longest mean length (18.833 cm), followed by the "Gibberellic Acid 3X - Water potency" group (17.646 cm). Overall, the "Gibberellic Acid 3X - Alcoholic potency" group displayed the highest measurements in weight, circumference, and length among the three groups.
 Conclusion: In conclusion, this study provides evidence of the potential of homoeopathic medicine, specifically Gibberellic Acid 3X, as an effective alternative for addressing enhancing yield production in Neelam mango trees when applied via foliar spray method on flowers. It opens doors to exploring more sustainable and eco-friendly approaches to mango cultivation and warrants further investigation and application in agricultural practices.

Allometric Equations for Estimation of Below-ground Biomass of Two Dominants Shrub Species of Burkina Faso

Deforestation leads to a significant loss of carbon and contributes indirectly to climate change. This study was carried out in four types of formations in the Sudanian zone of Burkina Faso to assess the contribution of plant species to climate change mitigation. The below-ground biomass of two species (Piliostigma reticulatum and Guiera senegalensis) was determined by the direct method. Three classes of subjects were determined and a total of 80 shrubs of P. reticulatum and 90 shrubs of G. senegalensis were completely excavated. The results showed that P. reticulatum measures about 0.49 to 2.10 m in height, 3.58 to 25 cm in circumference at the base of the trunk and stores 0.18 to 3.68 tC/ha in the root biomass (respectively after 3 years and 15 years) for a 3x3m plantation. In the 15-year fallow dominated by G. senegalensis stands, 3.93 tC/ha are stored by the underground biomass of G. senegalensis shrubs. Model fit showed that there is a good correlation between circumference at the base of the trunk and below-ground biomass for P. reticulatum. For G. senegalensis, it is the total height of the foot that is most correlated with the below-ground biomass. These results provide information on the carbon sequestration potential of these two species, and can thus help in the decision-making process for climate change adaptation and/or mitigation policies.

A Participatory Inventory Project to Kick-Start the Creation of a Hospital Park: The Experience of the University of Verona (North-Eastern Italy)

The proximity and accessibility of a green space to places of care have recognized beneficial effects on healing processes. In this communication, we present the results of a pilot research action which has been focused on a neglected urban green area located near to a university hospital. The research action was conducted with a participatory approach, which mainly involved university students, to make the renovation project more inclusive and to create an opportunity for training on green and sustainability themes. The specific aims were: (i) to initiate the renovation of a green space of 18,000 square meters with potential benefits for users of both the hospital and the University of Verona (north-eastern Italy); (ii) to map and classify the greenery in the park; and (iii) to investigate the opinions and attitudes of the potential users of the green area. By performing digital identification and mapping, a detailed tree inventory of the green space was created. Results showed that five species accounted for more than 70% of the trees, with the majority being deciduous plants (59%) between 5 and 20 m tall (72.5%) and 20–200 cm in circumference (80.8%). Through interviews with the population, we highlighted a limited knowledge of the area but a consensus on the importance of the requalification. We highlight how the participatory methodology may represent a valuable tool for local policymakers to manage the city’s green spaces at various scales and implement greenery for the common well-being.

Abdominal Aortic Aneurysm: A Case Report in Western Maharashtra, India

An arterial aneurysm is defined as a permanent localized dilatation of the vessel at least 150% compared to a relative normal adjacent diameter of that artery. Abdominal aortic aneurysm (AAA) is defined as localized enlargement of the abdominal aorta such that the diameter is greater than 3 cm. AAA is potentially life-threatening finding. AAA may be detected incidentally or at the time of rupture. We reported a case of fusiform type of abdominal aortic aneurysm in a donated cadaver which was found during the routine dissection of a 76-year-old male died of acute myocardial infarction in western Maharashtra. The dimensions were measured by using both manual and verniers caliper method. The dimensions were 7 cm in length, 3.5cm in width, 11 cm in circumference, unruptured and positioned below the renal arteries, just above the aortic bifurcation. Owing to the vital role of aorta in the abdomen, we believe that the knowledge of this vascular pathology will be enlightening the field of medicine.

Improving the appearance of Kuini (Mangifera odorata) using carbon bagging during the preharvest stage

Kuini (Mangifera odorata) is one of the important indigenous fruits that can be found in Malaysia. This fruit belongs to the same genus as the mango and is known for its strong and pungent smells. Usually, this rare fruit is eaten fresh, semi-cooked in local delicacy, or is used to produce other products such as juice or functional drink. Naturally, Kuini has green colour skin even after the fruit has fully ripened. This study was conducted to evaluate the effects of carbon bagging during the preharvest stage on fruit quality and skin colour changes. Fruits were tagged after the setting stage and bagged with a carbon bag after reaching approximately 16 cm in circumference. Regular white bags were used as control. Results have shown a significant difference in skin colour (L, a*, b*, chroma and hue) where fruits bagged using carbon paper bag exuded a yellowish hue as compared to the control. However, for the chemical content of the fruits, there are no significant differences between fruits bagged using carbon paper bag and white colour bag in terms of total soluble solid (TSS), pH and titratable acidity. In short, the use of carbon bags during the preharvest stage can change fruit skin colour without compromising the fruit quality.

PHYTOSSOCIOLOGICAL ASSESSMENT OF A NATURAL REGENERATION SITE IN THE SOUTHEAST ATLANTIC FOREST BIOME

On some portions of the biodiversity Atlantic Forest bioversity hotspot, land abandonment has regenerated back to forest. However, the composition and structure of these areas are not well known. Thus, the aim of this study was to inventory a 45 years old natural regeneration forest site in a small farm (68 ha) in the Southeast portion of Atlantic Forest Biome in Brazil. In November 2019 all regenerating individuals (<15 cm of circumference at ground level and> 50 cm of height) and adults (>15 cm of circumference at breast height) were counted, identified, classified in ecological groups, dispersal and conservation status, and measured in 0.34 ha. We calculated Importance Value (VI) for all species. Of the 2720 individuals sampled, 435 were adults and 2285 regenerating individuals. Families with greatest species richness were Fabaceae, Myrtaceae and Euphorbiaceae. The majority of species and individuals were non-pioneer and zoochorous. Most of the regenerants belong to the specie Guarea kunthiana and were non-pioneer species, wich might indicate an advanced stage of forest succession. Additionally, high VI species were mostly non-pionners.

Atlantic Forest recovery after long-term eucalyptus plantations: The role of zoochoric and shade-tolerant tree species on carbon stock

Currently, about a third of the world’s forest areas that have been deforested are regrowing. These second-growth forests (SGF) promote carbon stocks and tree species richness recovery (co-benefits recovery), which is central to mitigating the negative impact of climate change and loss of biodiversity. In Brazil’s Atlantic Forest, second-growth forests that are regrowing after long-term land use can recover diversity and carbon and can have important carbon-tree diversity co-benefits. Thus, we evaluate the recovery of tree species richness and above-ground carbon stock (AGC) in SGF that are regrowing after a long-period of eucalyptus plantations. For this we sampled 43 SGF with stand ages varying from 1−32 years after eucalyptus plantations cutting and three reference old-growth forests (OGF). We considered all individuals with more than 15 cm of circumference at breast height in one 20 × 50 m plot by patch. We identified all tree species, which were categorized into functional attributes, such as zoochoric and non-zoochoric, pioneer and shade-tolerant, and fleshy and dry fruits species. There were marked differences in species richness and AGC between OGF and SGF, but SGFs were not different between then. However, in 32 years these second-growth forests recovered ∼38% of species richness and ∼14% of carbon stock of old-growth forests. In addition, there was a carbon-biodiversity co-benefits mainly between zoochoric and shade-tolerant species richness. These results showed that these second-growth forests could naturally recover biodiversity and AGC. Possibly, this is due to the connectivity provided by land-use for eucalyptus plantations that induces favorable conditions for the recruitment of zoochoric and shade-tolerant species and thus for the recovery of biodiversity and AGC after eucalyptus cutting. Thus, this second-growth forest management can contribute to Atlantic Forest biodiversity conservation and carbon stock initiatives.

Characterization of the physicochemical properties of sweet pepper (Capsicum annuum) cultivated in Korhogo in the North of Côte d’Ivoire

Sweet peppers are consumed less in Korhogo, in the north of Côte d'Ivoire, than other hotter peppers. In addition, the sweet pepper is underexploited, it encounters problems of conservation, distribution. This study is a valorization of the sweet pepper. The physical properties are: 5.8-6.93 cm for length, 14.21-15.03 cm for circumference, 34.28-42.65 g for weight, 91.19-91.80 % for humidity, 0.49-0.61 % for ash content. The contents of biochemical elements are: 5.42-5.54 for the pH, 2.92 meq / 100 g on average for the titratable acidity, 177.45-254.57 mg / 100g for reducing sugars, 3,42-4.29 % for total sugars, 0.36 % on average for lipids, 0.73-1 % for proteins, 2.03-3 % for fibers, 6.62-6.93 % for total carbohydrates, 32.64-34.7 Kcal / 100 g for energy value. The amounts of vitamin C, polyphenols, flavonoids, tannins are respectively: 26.67-51.25 mg / 100 g; 116.16-131.28 mg / 100 g; 1.97-4.43 mg / 100 g; 14.74-19.12 mg / 100 g. The contents of anti-nutritional compounds are 363-388.67 mg / 100 g for oxalates, 20.08-22.20 mg / 100 g for phytates. Sweet pepper contains 0.14 % DM on average phosphorus, 0.33-0.37 % DM for potassium, 0.30-0.31 % DM for calcium, 0.167-0.174 % DM for magnesium, 2.76 -3.80 ppm copper, 7.5-7.92 ppm iron, 0.59-0.69 ppm manganese, 16.24-16.34 ppm zinc, 6.46-20.15 ppm sodium. Processed before consumption, Sweet pepper constitutes a significant source of food fibre, natural antioxidant, and mineral elements for local population.

Interface Pressures Derived from a Tubular Elastic Bandage.

Objective: We sought to clarify the interface pressure (IP) when using a tubular elastic bandage (TEB) and examine the possibility for TEBs to provide IPs comparable to those provided by anti-thrombotic stockings.Materials and Methods: In 40 healthy patients, IPs were measured at the level of calf at its maximum diameter (C) and transition of the medial gastrocnemius muscle into the Achilles tendon (B1) while a single or double layer of TEBs (17.5 cm in circumference) were applied with the patient in a supine position.Results: Including both the C and B1 levels, circumferences and IPs showed a good correlation (single layer; r=0.72, double layer; r=0.75). The IP obtained with a single layer of TEB at the C level (median, 17 mmHg [range, 12–23 mmHg]) was higher than that at the B1 level (14 mmHg [11–18 mmHg], p<0.001). When double-layer TEB was used, the IP at B1 level increased to 18 (14–23) mmHg (p<0.001 vs. single layer).Conclusion: Considering the characteristics of TEBs and using a single or double layer appropriately, creating a pressure profile mimicking that of an anti-thrombotic stocking seemed to be feasible when using a TEB.

Assessment of D-Shaped Annulus of Mitral Valve in Patients with Severe MR Using Semi-Automated 4-Dimensional Analysis: Implications for Transcatheter Interventions.

The development of transcatheter mitral valve replacement therapies requires accurate post-processing analysis tools to provide D-shaped mitral annulus dimensions from 3-dimensional (3D) data. The agreement between two semi-automated, software packages to process 3D transesophageal echocardiography (TEE) data for the measurement of the mitral valve annulus dimensions was evaluated. 3DTEE data of patients with moderate–severe mitral regurgitation (MR) were postprocessed with semi-automated, vendor-independent (VI) software and vendor-specific (VS) software. Both post-processing software provided key measurements for the selection of transcatheter valve prosthesis size: annulus area, annulus circumference and the septal-to-lateral distance of the annulus. The intertrigonal distance was provided only by the VS software. The inter- and intra-observer agreements were assessed with Bland–Altman analysis. Of 105 patients (63.8 ± 11 years, 66% male) with MR, 28 had secondary MR, 45 fibroelastic deficiency, and 32 Barlow’s disease. Using VS software, the dimensions for the overall population were 16.1 ± 4.6 cm2 for annulus area, for circumference 14.4 ± 1.9 cm, intertrigonal distance 3.4 ± 0.5 cm and septal-to-lateral distance 3.8 ± 0.6 cm. Similar dimensions were obtained using VI software: 15.7 ± 4.6 cm2 for annulus area, 14.5 ± 2.0 cm for circumference, and 4.1 ± 0.6 cm for septal-to-lateral distance. The inter- and intra-observer agreement for both software programs was excellent. In conclusion, current post-processing software programs for 3DTEE data of the mitral valve annulus provide good reproducibility of key measurements to select the transcatheter prosthesis size.

Autologous esophageal mucosa with polyglycolic acid transplantation and temporary stent implantation for the prevention of esophageal stenosis after circumferential endoscopic submucosal dissection.

Autologous esophageal mucosa with polyglycolic acid transplantation and temporary stent implantation for the prevention of esophageal stenosis after circumferential endoscopic submucosal dissection.

Florística e fitossociologia de um fragmento de Cerrado lato sensu, Gurupi, TO

O objetivo deste trabalho foi avaliar a composição florística e fitossociológica de um fragmento de Cerrado lato sensu. Foi realizado um censo na área de estudo, de 6,7 ha, com limite de inclusão de 15 cm de circunferência a 1,30 m acima do solo. Amostrou-se um total de 15.434 indivíduos, pertencentes a 78 espécies, 72 gêneros e 33 famílias. Foi realizada análise de densidade, dominância e valor de cobertura, encontrando-se densidade total de 2.303,58 ind ha-1 e área basal de 94,303 m² ha-1. As espécies com maiores valores de cobertura, em ordem decrescente, foram: Myrcia splendens, Astronium fraxinifolium, Magonia pubescens, Qualea parviflora, Protium heptaphyllum, Curatella americana, Vatairea macrocarpa, Tachigali aurea, Byrsonima stipulacea e Machaerium brasiliense, que representaram 53% do total dos indivíduos da área. As espécies do gênero Qualea apresentaram dominância, representando 11% do total de indivíduos. O padrão de distribuição dos indivíduos foi no formato de “J” invertido, mas Astronium fraxinifolium, Magonia pubescens e Tachigali aurea apresentaram menor número de indivíduo nas classes iniciais. O índice de diversidade de Shannon e equabilidade de Pielou indicaram a existência de alta riqueza e diversidade de espécies, quando se comparou a área estudada com fragmentos de Cerrado nas proximidades.

Estrutura da comunidade e diversidade de espécies arbóreas em uma floresta subtropical no sul do Brasil

Abstract: Local and regional environmental variations lead to different species composition, creating transitional areas. An example is the Araucaria and Seasonal forest in southern Brazil. Our objectives were (1) to describe the tree community structure and composition of a subtropical forest in southern Brazil and (2) to compare the floristic relationships between two forest typologies (Araucaria and Seasonal forest) in order to characterize the study area and the distribution patterns of tree species. We conducted a survey at Chapecó National Forest (in southern Brazil) in an area of 1.2 ha, where all individuals ≥ 30 cm of circumference at breast height were sampled. Community structure was described using the traditional phytosociological parameters. The floristic relationships were obtained by comparing our results with compiled data from other scientific papers through cluster analyses using an unweighted average linkage method, based on Jaccard similarity coefficient. We sampled 809 individuals belonging to 61 species and 28 families. The richest family was Fabaceae and Coussarea contracta (Walp.) Müll.Arg. was the most abundant species. Taxonomic diversity was 3.06 and the evenness was 0.74. The floristic similarity revealed that species composition of our study area is more similar to Seasonal forest. Species composition is related to environmental factors such as great thermal amplitude and seasonality. This subtropical forest is well structured, highly diverse and extremely important for the local and regional biodiversity conservation.

Impact of Tree Growth Rate on the Mechanical Properties of Douglas Fir Lumber in Belgium

In the context of questioning the relevance of making Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco) silviculture more dynamic in Wallonia, we evaluated the influence of growth rate on the potential of Douglas-fir lumber for structural uses. Therefore, six trees 120 to 180 cm in circumference at 1.5 m were felled in 11 stands whose age varied from 40 to 69 years (mean circumference of the trees ≈150 cm; initial planting density from ≈2200 to 4400 seedlings/ha). In total, 706 boards (38 × 100 mm² and 70 × 180 mm² in cross section) were cut from these trees, whose average ring width ranged between 3 and 7 mm. The density of the wood (ρ) always appeared compatible with the mechanical class C30, regardless of the growth rate of the trees from which the lumber originated. The modulus of elasticity (E) and the modulus of rupture (fm) displayed by the 38 × 100 mm² boards cut from corewood were respectively 30% and 41% lower than those observed in outerwood. The latter did not seem affected by growth rate: E and fm characteristic values remained compatible with structural use, regardless of the mean ring width. Growth rate considerably affects the characteristic values of these mechanical properties when boards are made from corewood. Juvenile growth should therefore be limited.

ESTRUTURA DA COMUNIDADE ARBÓREA E CARACTERÍSTICAS EDÁFICAS DE UM FRAGMENTO URBANO

No Brasil há diversos municípios com fragmentos florestais inseridos no perímetro urbano sob ameaça de degradação. A Mata do Desamparo (Araguari - MG) é uma importante formação florestal que protege nascentes existentes em um parque urbano. O objetivo desse estudo foi realizar o levantamento fitossociológico da vegetação arbórea do gradiente florestal e realizar análises de solo. Foram plotadas 25 parcelas de 20 x 20 m, dispostas em quatro blocos e amostrados todos os indivíduos arbóreos com circunferência a 1,30 m ≥ 15 cm e também coletadas amostras de solo a 0-20 cm de profundidade para análises químicas, umidade do solo e o desnível do terreno. Para averiguar se as propriedades químicas, umidade do solo e o desnível influenciaram na distribuição das espécies vegetais do fragmento florestal foi realizada a análise de correspondência canônica (CCA). A comunidade apresentou elevada riqueza (94 espécies) e número de indivíduos (1760) muito elevado em relação a outras florestas da região e adensamentos de espécies de borda e comuns de áreas abertas mesmo na região mais interiorana da floresta, o que indica que existem impactos antrópicos sobre a comunidade arbórea. A CCA demonstrou a heterogeneidade ambiental com a formação de três grupos, um formado pelas parcelas próximas ao leito do rio com maior umidade do solo e menor desnível, outro formado por parcelas com grande desnível, com predominância de espécies generalistas consideradas uma floresta estacional semidecidual e outro fortemente correlacionado com alumínio. Assim, este fragmento florestal pode ser considerado um importante relicto urbano com grande riqueza de espécies, no entanto, impactos passados influenciaram a estrutura da comunidade arbórea, que está em um estágio intermediário de sucessão.

Satellite Images Combined with Field Data Reveal Negative Changes in the Distribution of Babassu Palms after Clearing off Amazonian Forests.

When the Amazonian rain forest is cut to create pasture, some of the original vegetal species survive clearing, even expressing their ability to invade agro-systems. It is true of the babassu palm, which can be considered, paradoxically, a natural resource by the "Interstate Movement of Babassu Fruit Breaker Women" or as native weed by land owners-farmers. To manage potential conflict of land uses, we study here the current density of this palm tree in different habitats, based on a combination of field data and remote sensing data. Firstly, we checked that the field survey methodology (i.e., counting free-trunk palm trees over 20 cm in circumference) provides density values compatible with those stemming from satellite images interpretation. We can see then that, a PA-Benfica Brazilian territory revealed an average density of the babassu lower in pastures (2.86 ind/ha) than in the dense forest (4.72 ind/ha) from which they originate and than in fallow land (4.31 ind/ha). We analyze in detail density data repartition in three habitats and we discuss results from the literature on the density of this palm tree versus its resilience at different developmental stages after forest clearing, depending on anthropogenic-or not-factors, including solar radiation, fire, weeding, clear cutting, burying fruit, and competition with forage grass. All these results can be exploited for the design of future management plans for the babassu palm and we think that the linked methodology and interdisciplinary approach can be extended to others palms and trees species in similar problematic issues.

A Case of Incomplete Pancreas Divisum with Anomalous Pancreatic Duct-Biliary Duct Junction with Type IV-A Choledochal Cyst Complicated by Cystolithiasis

A 36-year-old Vietnamese woman who suffered from migraines and anxiety presented to the ED with acute abdominal pain of 3 hrs located in the mid-epigastrium and right upper quadrant, described as sharp and severe. She had one episode of non-bloody vomiting associated with chills, was afebrile and tender to palpation in the mid-epigastrium. Lab analysis noted moderate leukocytosis (14,810 cells/mcL), mild elevations in both AST (53 U/L) and ALT (43 U/L), and normal values of alkaline phosphatase, total bilirubin, lipase and lactic acid. H. pylori serum IgG was negative. RUQ sonogram revealed a hydropic gallbladder with echogenic material and a 2.7cm shadowing stone within a 4.1cm dilated common bile duct. ERCP was performed the next day. During the procedure, the minor papilla appeared prominent with pancreatic fluid draining from the orifice. The common bile duct and to a lesser extent the common hepatic duct appeared dilated. The cystic duct also appeared mildly dilated. While injecting the distal CBD, contrast was seen filling the pancreatic duct to the body >15mm from the ampullary junction. The dorsal duct was noted to be in continuity and drained to the minor papilla. A sphincterotomy and dilation to 15mm with a CRE balloon on the sphincterotome was performed. A 10F x 7cm plastic pigtail biliary stent was placed with adequate drainage. A post-procedure MRCP revealed fusiform dilatation of the CBD with a filling defect within. The proximal portion of the left hepatic duct was also dilated measuring up to 1.4cm and corresponded to type IV A choledochal cyst by Todani classification. Two days later after receiving perioperative antibiotics she underwent resection of choledochal cyst and Roux-en-Y hepaticojejunostomy without complication. Pathology noted a gallbladder size 7.5cm in length by 5.5cm in circumference with an attached bile duct cyst 9cm in circumference by approximation. One irregular green brown calculus was found and measured 2.5 x 2.2 x 1.5cm. Microscopy of the bile duct revealed ulcerated choledochal cyst and a gallbladder with no significant histologic abnormality. A JP drain and right subcostal incision staples were removed 14 days later. Eight weeks after surgery she developed MEG pain with radiation to her back and severe sepsis. LAEs and lipase were normal and a HIDA scan was negative for obstruction of the hepatobiliary tree. She was treated with a 10-day course of antibiotics and received follow-up care with transplant surgery.Figure 1Figure 2Figure 3

A Simple, Effective, and Inexpensive Technique for Exposure of Papillary Muscles in Minimally Invasive Mitral Valve Repair: Wakka Technique

Obtaining excellent exposure of the papillary muscles is challenging in minimally invasive mitral valve repair. We have developed a simple and effective technique using a sterile paper ruler. The ruler is cut to the proper length (8 to 12 cm) depending on the valve size, then rolled and sutured. The rolled ruler, 7 to 11 cm in circumference, is placed inside the mitral leaflets. This technique provides excellent exposure of the papillary muscles without damaging the leaflets and prevents chordal injury during artificial chordal implantation.