Supplementary Material Online Research Articles

Testing the Appropriateness of Diabetes Prevention and Care Information Given by the Online Conversational AI ChatGPT.

Commentary| June 15 2023 Testing the Appropriateness of Diabetes Prevention and Care Information Given by the Online Conversational AI ChatGPT Jison Hong 0000-0002-7192-5647 ; Jison Hong 1Department of Medicine, Division of Immunology & Rheumatology, Stanford University, Stanford CA Corresponding author: Jison Hong, jison@stanford.edu Search for other works by this author on: This Site PubMed Google Scholar Nicholas Takayuki Kikuta; Nicholas Takayuki Kikuta 1Department of Medicine, Division of Immunology & Rheumatology, Stanford University, Stanford CA Search for other works by this author on: This Site PubMed Google Scholar Anna Simos; Anna Simos 2Stanford Health Care, Stanford, CA Search for other works by this author on: This Site PubMed Google Scholar Sandra Tsai; Sandra Tsai 3Department of Medicine, Division of Primary Care and Population Health, Stanford University, Stanford, CA Search for other works by this author on: This Site PubMed Google Scholar Bryant Lin; Bryant Lin 3Department of Medicine, Division of Primary Care and Population Health, Stanford University, Stanford, CA Search for other works by this author on: This Site PubMed Google Scholar Fatima Rodriguez; Fatima Rodriguez 4Department of Medicine, Division of Cardiovascular Medicine, Stanford Prevention Research Center, Stanford University, Stanford, CA Search for other works by this author on: This Site PubMed Google Scholar Latha Palaniappan 0000-0002-1245-665X Latha Palaniappan 5Department of Medicine, Division of Cardiovascular Medicine, Epidemiology and Population Health, Stanford University, Stanford, CA Search for other works by this author on: This Site PubMed Google Scholar Corresponding author: Jison Hong, jison@stanford.edu Clin Diabetes cd230026 https://doi.org/10.2337/cd23-0026 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Citation Jison Hong, Nicholas Takayuki Kikuta, Anna Simos, Sandra Tsai, Bryant Lin, Fatima Rodriguez, Latha Palaniappan; Testing the Appropriateness of Diabetes Prevention and Care Information Given by the Online Conversational AI ChatGPT. Clin Diabetes 2023; cd230026. https://doi.org/10.2337/cd23-0026 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsClinical Diabetes Search Advanced Search This article contains supplementary material online at https://doi.org/10.2337/figshare.23278418. This content is only available via PDF. ©2023 by the American Diabetes Association2023Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/journals/pages/license. Article PDF first page preview Close Modal You do not currently have access to this content.

Timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome-an updated individual patient data meta-analysis.

The optimal timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome (NSTE-ACS) was subject of several randomized controlled trials (RCTs) since more than 20 years. American and European guidelines recommend an early invasive strategy <24 h for high-risk NSTE-ACS patients with a global registry of acute coronary events (GRACE) risk score >140 but without evidence for ongoing ischaemia or haemodynamic instability.1,2 However, scientific evidence supporting this recommendation is sparse. Butt et al.3 analysed the effect of the GRACE risk score on all-cause mortality in a post-hoc analysis of the very early versus deferred invasive evaluation using computerized tomography (VERDICT) trial. We combined the published VERDICT data with an existing database of our previous meta-analysis (Supplementary material online for further details, Table S1, Table S2, and Figure S1r).4 Consecutively, we updated our previous GRACE risk score subgroup analysis to synthetize up-to-date scientific evidence from the currently available data. The methodology is described in the Supplementary material online in detail. In short, we performed one-stage as well as two-stage meta-analyses. Both approaches led to the same result that an early invasive strategy does reduce the risk of all-cause mortality in patients with a GRACE risk score >140 but not in patients with a GRACE risk score ≤140 or the unselected population of NSTE-ACS patients (Figure 1). While some heterogeneity is present in the total population (I2 = 30%), it is absent in each subgroup stratum (I2 = 0%; Supplementary material online, Figure S2). The reported finding is driven by the addition of data from the VERDICT trial. Exclusion of this trial leads to a similar finding as reported in our previous meta-analysis (see Supplementary material online, Table S3 and Supplementary material online, Figure S3).4

Answer: Acute dyspnoea with an unusual mass in the right ventricle.

What is the most likely diagnosis? ... Chest computed tomography angiogram showed dense, bilateral pulmonary embolism compatible with cyanoacrylate remnants which is used to obliterate varices. Cyanoacrylate is a monomer, which polymerizes fast when in contact with blood to form a strong glue. There are already clues to the aetiology of the mass on transthoracic echocardiography (Figure 1 and see Supplementary material online, Videos S1–S4). A history of drug abuse is a risk factor for endocarditis of the tricuspid valve, but vegetations tend to be irregular shaped with myocardial like grey scale. Furthermore, they are typically attached on the low-pressure side of atrioventricular valves. A papillary fibroelastoma is mostly localized downstream and would display a well-demarcated border with digitations but will rarely exceed a size of 3 cm as seen in this case (Figure 1A and B and see Supplementary material online, Videos S1 and S2), making it less plausible.1 A thrombus is less likely because it is frequently multi-lobulated and hypoechogenic in the acute phase.

An unusual giant coronary artery aneurysm mimicking mediastinal mass.

A 55-year-old woman was admitted with complaints of recurrent chest pain for eight days. She had a history of intermittent chest tightness and pain for 5 years. Laboratory test showed increased hypersensitive cardiac troponin I of 0.14 μg/L. The ECG showed ST segment depression in leads V1, V2, V3, and V4. Acute non-ST segment elevation myocardial infarction was diagnosed. Echocardiography revealed a hypoechoic mass (8.9 × 7.0 cm) (asterisk, Panel A, see Supplementary material online, Video S1) in front of the right side of the heart. The right atrium (RA) and right ventricle (RV) were compressed and deformed. A cystic cavity (13 mm wide) can be observed in the mass (arrowhead, Panel B, see Supplementary material online, Video S2), which was connected to the dilated right coronary artery (RCA). Enhanced chest CT showed the obviously enhanced RCA entered into the mass (asterisk, Panels C and D), the distal of which was occlusive and dilated like ‘gallbladder’ (arrowhead, Panel C, D and E). Coronary artery aneurysm (CAA) was suspected. Coronary angiography showed abnormal neoplastic dilatation in the proximal segment of the RCA and complete occlusion in the middle segment (arrowhead, panel F, see Supplementary material online, Video S3). The left coronary artery provided collateral circulation to the RCA (see Supplementary material online, Video S4). The patient underwent resection of the mass. The giant mass was observed between RA and RV (panel G) with numerous thrombi inside (panels H and I). Coronary artery bypass surgery was performed successfully after CAA resection.

Double anterograde/retrograde approach for embolization of pulmonary arteriovenous malformation presenting with acute respiratory failure.

A 54-year-old male with multiple cardiovascular risk factors and past medical history of long-standing dyspnea was admitted for acute respiratory failure. Physical examination revealed near-normal blood pressure, sinus tachycardia, tachypnea, and reduced oxygen saturation (90%) with mild distal-limb cyanosis. On admission ECG, chest X-ray, transthoracic echocardiography, and laboratory tests were performed to exclude new-onset heart failure and/or an acute coronary syndrome. Then, he underwent pulmonary CT angiography seeking for pulmonary embolism that showed a voluminous pulmonary arterio-venous malformation (PAVM) with the feeding artery coming from the right pulmonary artery and venous drainage confluent into the right pulmonary vein (Panel 1A and C). A thrombophilic screening showed a heterozygous mutation for the methylenetetrahydrofolate reductase-1 gene and reduced serum-free protein S levels. The invasive left–right heart catheterization revealed mild-to-moderate pulmonary hypertension and moderate arterial desaturation (O2 saturation, 91%). Considering the large size of both the feeding artery and vein drainage (10 mm) and in order to reduce postprocedural embolization risk and recanalization rate,1,2 a contemporary percutaneous embolization of both PAVM branches (Panel 1C and D; Supplementary material online, Videos S1–3) with two Amplatzer Vascular Plug (AVP) II® 20 mm (Abbott, Plymouth, MN, USA) was planned using a double access technique, transfemoral trans-septal (retrograde) and transfemoral transpulmonary (anterograde) with a post-procedural improvement of arterial saturation (up to 99%). The patient was discharged with a marked clinical improvement (NYHA Class I) and complete exclusion of the PAVM at six months follow-up (Panel 1E and F).

Left internal thoracic artery bypass graft.

A 77-year-old man presented with chest discomfort on exertion for several weeks. Thirty-one years prior, he had performed on-pump coronary artery bypass grafting (CABG) using the pedicled left internal thoracic artery (LITA) to left anterior descending artery (LAD) and saphenous vein grafts (SVGs). The SVGs to the left circumflex artery had already occluded and to the right coronary artery (RCA) had previously required percutaneous coronary intervention (PCI). Although an electrocardiogram showed no remarkable change and echocardiography showed findings of known old posterior myocardial infarction, single-photon emission computed tomography demonstrated new inferior myocardial ischemia. Coronary angiography showed occlusion of all native coronary artery and severe stenosis of the residual SVG to RCA. On the other hand, the 31-year-old LITA graft revealed excellent patency (Panel and Supplementary material online, Video). Since the 1980s, the LITA for LAD grafting has been a cornerstone of CABG surgery.1 The European Society of Cardiology guideline recommends grafting with internal thoracic artery to the LAD as Class I.2 Furthermore, LITA graft had better patency than SVG for 20 years post-operatively.3 This case showed the over 30 years patency of LITA graft, although the use of a pump or the harvesting method might affect patency. This case indicated that it is precisely in patients less than 50 years of age scheduled for CABG that LITA to the LAD should be utilized.

Answer: Uncommon masquerader of inferior STEMI.

Correct answer: 2. Aortic Dissection JR-4 guide into aortic root with non-selective shot suggest aortic dissection—filling the right coronary artery therefore in the false lumen (see Supplementary material online, Video S1 and Figure 1B, arrow indicates right coronary artery). Acute Type A aortic dissection is then confirmed with pigtail aortogram where the true lumen is shown and filling the left main artery (see Supplementary material online, Video S2 and Figure 1C, arrow indicates dissection flap). Glyceryl trinitrate infusion was started with gradual titration for his hypertension. Patient was transferred to a cardiothoracic centre but unfortunately arrested on the computed tomography table before he could be operated. ... Myocardial infarction resulted from functional coronary artery occlusion where the dissection flap occluded the ostium of right coronary artery in this case. Invasive aortography remains a valuable tool for rapid and accurate diagnosis of aortic dissection particularly in patients presenting with ST-elevation myocardial infarction.

Question: Uncommon masquerader of inferior STEMI.

A 54-year-old man brought into the emergency department with acute onset of chest pain. He had background history of hypertension. Physical examination was notable for an elevated blood pressure of 165/85 mmHg. His chest was clear to auscultation and his heart sound did not reveal any murmur. His electrocardiograph showed inferior ST Elevation Myocardial Infarction (STEMI) as shown in Figure 1A. Patient was transferred urgently to the catheterization laboratory for coronary angiography. Ultrasound guided vascular access was obtained in the right femoral artery. JL-4 catheter was used but noted to be catching in the ascending aorta. JR-4 guide into aortic root with non-selective shot is shown in Figure 1B (see Supplementary material online, Video S1). A pigtail aortogram was performed as shown in Figure 1C (see Supplementary material online, Video S2). ... Supplementary material is available at European Heart Journal: Acute Cardiovascular Care online.

Post-traumatic acute aortic regurgitation due to cusp rupture in non-calcific bicuspid valve treated with ballon-expandable transcatheter heart valve.

A 65-year-old male truck driver was admitted to the emergency department after a road crush with consequent polytrauma. Patient’s past medical and cardiovascular history were unremarkable. Physical examination showed neck haematoma with multiple contusions, abolished right vesicular murmur, bone deformities. Whole-body CT scan documented multiple bone fractures, right hemothorax and pneumothorax, mediastinal haematoma, bilateral pulmonary contusions and rib fractures, dissection not limiting flow of right subclavian artery, left vertebral artery and both internal carotid arteries with associated pseudoaneurysms. Emergency chest drainage was performed and the patient was intubated because of worsening dyspnoea. Transthoracic echocardiography documented massive aortic insufficiency due to cusp rupture (Panels A and B and Supplementary material online, Videos S1 and S2) in the context of aortic bicuspidia (Sievers Type 1) and pulmonary hypertension with signs of right ventricular dysfunction. Because of patient’s extremely critical condition with hemodynamic instability and pulmonary congestion and concomitant prohibitive surgical risk for urgent aortic valve replacement, off-label transcatheter aortic valve replacement was planned.

Hypertrophic cardiomyopathy and left ventricular non-compaction cardiomyopathy: two in one.

A 22-year-old asymptomatic Caucasian woman was referred because of an elevated NT-pro-BNP level (1225 ng/L, normal <125 ng/L) and a positive family history of unclear cardiomyopathy. Her electrocardiogram showed sinus rhythm, left axis deviation with signs of left ventricular (LV) hypertrophy, and repolarization abnormalities (Panel A). The transthoracic echocardiography revealed an asymmetrical LV hypertrophy without signs of left ventricular outflow tract obstruction at rest or under provocative Valsalva manoeuvre (Supplementary material online, Video S1). Imaging with cardiovascular magnetic resonance (CMR) confirmed asymmetrical LV hypertrophy with a maximum wall thickness of 18 mm. CMR also showed biventricular prominent trabeculation with multiple anterior, septal and inferior deep recesses (Panel B, Supplementary material online, Video S2) and a maximum ratio of non-compacted to compacted myocardium of 2.6 (Supplementary material online, Image). Biventricular volumes and global ejection fraction were normal with a mild hypokinesia of the hypertrophied LV segments. Late Gadolinium Enhancement and post-contrast T1 mapping demonstrated focal patchy fibrosis in the hypertrophied segments and at both right ventricular insertion points (Panel C, D).

Minimally invasive videoscope-assisted cardiac surgery for paroxysmal atrial tachycardia originating from right atrial appendage.

A 35-year-old female complained about palpitations for over 2 years and was admitted to department of cardiology. The 12-lead electrocardiogram (ECG) and 24 h Holter monitoring revealed the paroxysmal supra-ventricular tachycardia (Panel A). No structural abnormalities or impaired ventricular function were detected by transthoracic echocardiography, transoesophageal echocardiography, or multi-slice computed tomography. The tachycardia was not terminated after transcatheter radiofrequency ablation in the base and middle of right atrial appendage (RAA). Electro-anatomical three-dimensional mapping system (Carto) demonstrated that the earliest endocardial breakthrough was on the apex of RAA (Panels B and C, Supplementary material online, Video S1) and confirmed the diagnosis of the paroxysmal atrial tachycardia (PAT). Considering the high risk of RAA rupture by ablation, the patient was transferred to the department of cardiovascular surgery for ligation of RAA under videoscope-assisted cardiac surgery. During the surgery, a thin-walled cyst-like structure was found deriving from the RAA (Panels D–G, star). Not surprisingly, the rhythm immediately returned to sinus right after test clamping the cyst by a right-angle clamp (Panel D, Supplementary material online, Video S2). Finally, the left atrial appendage clip (E-clip) was deployed (Panels E–G) to isolate the structure. The postoperative ECG indicated sinus rhythm with the rate of 75 beats per minute (Panel H).

Inflammatory infiltration of the cardiac conduction system in acute lymphocytic myocarditis.

A 53-year-old man with prior history of bone marrow transplant after acute myeloblastic leukaemia was admitted in the acute cardiac care unit due to suspected acute myocarditis. At admission, his electrocardiogram (ECG) showed right bundle branch block and left anterior fascicular block (Panel A). Previously, he had been assessed regularly in a dedicated cardio-oncology clinic, with normal ECG and transthoracic echocardiography (see Supplementary material online, Videos S1 and S2). Despite high-dose pulses of methylprednisolone, he developed both complete atrio-ventricular (AV) block and progressive left ventricular systolic dysfunction (see Supplementary material online, Videos S3 and S4), leading to cardiogenic shock requiring temporary transvenous pacing and mechanical circulatory support with VA-ECMO. However, he died on day 9 due to multiorgan failure. Gross examination of the heart (Panel B) was normal, but histopathology and immunohistochemistry showed significant infiltration of the ventricular myocardium (Panel C), AV node (Panel D) left anterior fascicle (Panel E), and right bundle branch (Panel F) by mononuclear CD3 + T cells, consistent with the diagnosis of lymphocytic myocarditis. High-definition images S1-S8 are included in the Supplementary material online.

Hybrid repair of a giant left subclavian artery aneurysm and arch coarctation in a patient with Larsen syndrome.

A 34-year-old male was admitted to our emergency department with progressively aggravated hoarseness and sudden onset of chest and neck pain. General examination was remarkable for severe scoliosis (Panel A) and a blood pressure gradient of >20 mmHg between upper and lower extremities. Computed tomography angiography (CTA) revealed a giant left subclavian artery (LSA) aneurysm (55 × 47 mm, asterisk), aortic arch coarctation, and severely tortuous descending aorta. In addition, an isolated left vertebral artery (ILVA) arose from the arch (Panel B-C). Whole-exome sequencing analysis identified p.Gly488Ser mutation in FLNB, indicating a diagnosis of Larsen syndrome. Considering the patient’s refusal of open surgery and the acutely worsening symptoms due to the pending rupture of the LSA aneurysm, a less-invasive hybrid approach was accepted as reasonable by interdisciplinary consensus. First, through the right femoral artery, a 20 F sheath (W.L. Gore and Associates, Newark, Del) was advanced across the arch coarctation, facilitating the delivery of the aortic stent. Then, a Gore cTAG stent was implanted at the arch distal to the innominate artery orifice, followed by a balloon-expandable Cheatham-Platinum stent (NuMED, Hopkinton, USA) deploying at the coarctation segment. Second, the membrane of the cTAG stent was penetrated with an aspiration biopsy needle through the left common carotid artery (LCCA). The fenestration was then expanded by balloons and LCCA was stented with a 120 × 40 mm covered endograft (Panel D–F; Supplementary material online, Video S1). After the endovascular procedures, the ILVA was anastomosed end-to-side to LCCA. Finally, the distal outlet of LSA aneurysm was ligated, and a bypass from LCCA to distal LSA was performed with a 6 mm Gore-Tex prosthetic graft (Panel G). Completion angiography (Panel H; Supplementary material online, Video S2) and postoperative CTA (Panel I) confirmed exclusion of the aneurysm and patency of all the supra-arch vessels. The postoperative course was uneventful and the patient was discharged on the 4th day after surgery.

Popeye's sign and transthyretin amyloidosis.

A 76-year-old man with a history of cervical open-door laminoplasty for ossification of the posterior longitudinal ligament presented to our hospital with a symptom of exertional dyspnoea. A 12-lead electrocardiogram revealed I-degree atrioventricular block (PQ interval 262 ms), left axis deviation, and complete right bundle branch block (Panel A). A transthoracic echocardiogram indicated left ventricular hypertrophy with a maximum wall thickness of 17 mm and a left ventricular ejection fraction of 61% (Panel B1). Strain echocardiogram using speckled tracking showed marked diminution of global longitudinal strain with apical sparing (Panel B2). Physical examination found subconjunctival hemorrhage in right eye, several purpuric lesions in upper extremities, and a large bulge on his left upper arm when he flexed his arm, so-called Popeye’s sign, indicating a hallmark of biceps tendon rupture (see Supplementary material online, Video S1; Panel C; arrow). A monoclonal component was not detected by serum and urine immune-electrophoresis and free light chain assays. 99mTc-labelled bone scintigraphy showed grade 3 myocardial uptake (Panel D). Eventually, endomyocardial biopsy and genetic sequencing analysis of the transthyretin gene confirmed the patient as a wild-type transthyretin amyloidosis (Panel E). Popeye’s sign is uncommon, but pivotal to diagnose transthyretin amyloidosis.

Complete primary aortic ascending thrombosis resolution after dabigatran therapy.

A 36-year-old man visited hospital with chest pain and shortness of breath since a few days. There was no medical history. Due to troponin elevation 0.07 µg/L (normal <0.04 µg/L), a triple rule out computed tomography (CT) was performed and showed an extensive thrombosis starting from the aortic arch across to the brachiocephalic artery, measuring 25 × 35 mm, irregular, polylobular, in the ascending aortic lumen, 5 cm below the aortic arch, and bilateral pulmonary embolism (Panels A and B). No clue for dissection or other wall pathologies were found, normal size of the ascending aorta, no sign of intramural haematoma, no hypercoagulable disease in the medical history, or blood investigations. Aortic ascending thrombus in a non-aneurysmal aorta is an extremely rare event and has potentially very severe complications, with a life-threatening risk of myocardial infarction and cerebral embolization. After 2 weeks of intravenous heparin administration, the CT follow-up showed no change of the thrombus size and we decided to prescribe dabigatran 150 mg b.i.d. The patient felt very well and therefore he refused surgical resection, despite of heart team consensus. After 8 weeks, we find the thrombus getting smaller in the suprasternal echocardiographic view compared with the first imaging (Video still image E and see Supplementary material online, Video S1). After 3 months, there was a complete resolution in the suprasternal echocardiographic view (Video still image F and see Supplementary material online, Video S2). The use of dabigatran leads to complete resolution and prevented the recurrence of the disease during 2-year follow-up (Panels C and D).

Serial histopathologic assessment of fulminant myocarditis after the first mRNA COVID-19 vaccine dose.

A 77-year-old man with hypertension presented to the emergency department with fever and cardiogenic shock 8 days after receiving the first dose of the BNT16B2b2 mRNA COVID-19 vaccine (Pfizer-BioNTech). Nucleic acid amplification via polymerase chain reaction with a nasopharyngeal swab sample was negative for SARS-CoV-2. Electrocardiography showed atrial fibrillation with poor R progression and ST depressions in the precordial leads (Panel A). Chest radiography showed cardiomegaly and pulmonary congestion (Panel B). Echocardiography revealed severe left ventricular (LV) dysfunction (LV ejection fraction, 24%) (Panel C; Supplementary material online, Video S1). Laboratory tests showed marked elevation of troponin I (>50 ng/mL) and NT-proBNP levels (59 239 pg/mL). Coronary angiography identified no significant stenosis. Histopathologic analysis of endomyocardial biopsy specimens showed infiltration of numerous CD3-positive lymphocytes with myocyte degeneration and myocytolysis (Panel D). Tests for parvovirus, influenza virus, and other viruses were all...

Assessing topological congruence among concatenation-based phylogenomic approaches in empirical datasets

Assessing the effect of methodological decisions on the resulting hypotheses is critical in phylogenetics. Recent studies have focused on evaluating how model selection, orthology definition and confounding factors affect phylogenomic results. Here, we compare the results of three concatenated phylogenetic methods (Maximum Likelihood, ML; Bayesian Inference, BI; Maximum Parsimony, MP) in 157 empirical phylogenomic datasets. The resulting trees were very similar, with 96.7% of all nodes shared between BI and ML (90.6% for ML-MP and 89.1% for BI-MP). Differing nodes were predominantly those of lower support. The main conclusions of most of the studies agreed for the three phylogenetic methods and the discordance involved nodes considered as recalcitrant problems in systematics. The differences between methods were proportionally larger in datasets that analyze the relationships at higher taxonomic levels (particularly phyla and kingdoms), and independent of the number of characters included in the datasets. Note: a spanish version of this article is available in the Supplementary material (Supplementary material online).

Prediction of high-performance computing input/output variability and its application to optimization for system configurations

Performance variability is an important measure for a reliable high performance computing (HPC) system. Performance variability is affected by complicated interactions between numerous factors, such as CPU frequency, the number of input/output (IO) threads, and the IO scheduler. In this paper, we focus on HPC IO variability. The prediction of HPC variability is a challenging problem in the engineering of HPC systems and there is little statistical work on this problem to date. Although there are many methods available in the computer experiment literature, the applicability of existing methods to HPC performance variability needs investigation, especially, when the objective is to predict performance variability both in interpolation and extrapolation settings. A data analytic framework is developed to model data collected from large-scale experiments. Various promising methods are used to build predictive models for the variability of HPC systems. We evaluate the performance of the methods by measuring prediction accuracy at previously unseen system configurations. We also discuss a methodology for optimizing system configurations that uses the estimated variability map. The findings from method comparisons and developed tool sets in this paper yield new insights into existing statistical methods and can be beneficial for the practice of HPC variability management. This paper has supplementary materials online.

Cross-border Entrepreneurial Education, Development and Knowledge and Technology Transfer: Experiences with the Cambridge–Riga Venture Camp Programme—A Reflective Report

Over a 6-year period, a collaboration has been developed between a group in Cambridge, UK, and two Latvian Universities, Stockholm School of Economics in Riga and other organisations, including Riga City Council, supported by the British Embassy Riga and the Latvian Embassy in London, enabling structured processes to be developed to identify aspiring entrepreneurs based in Latvia and Estonia and provide education, coaching, mentoring and encouragement first in the home territory, leading to an intense whole-week development venture camp in Cambridge for selected candidates. The programme was extended to provide ongoing business development support for a number of entrepreneurial companies with global potential, and the developing venture camp activities attracted, supported and helped accelerate the evolution in Riga of an innovative ecosystem providing leadership in the Baltics. Practical examples of cross-border knowledge and technology transfers have been recorded as part of the Cambridge–Riga Venture Camp process. This report presents the development, content and outcomes of this innovative project aimed at supporting the emergence of entrepreneurial and innovative capabilities of Latvian delegates to the project. Detailed appendices including data and narrative based survey of outcomes and assessments containing structured feedback from delegates participating in the 2020 Cambridge-Riga Venture Camp are available as the Supplementary material online. This is an interim report, since the activity is ongoing and continuously developing.

Thrombus in giant right atrial appendage aneurysm.

A 57-year-old female with no abnormal disease history presented to our clinic for persistence shortness of breath over 1 year. On admission, the physical examination revealed a heart rate 89 beats/min with sinus rhythm, hepatojugular reflux syndrome, hepatomegaly, and peripheral oedema. No cardiac murmur can be noticed. Chest X-ray revealed a pronounced bulge of the right heart margin (Panel A, arrow), with normal pulmonary vascular markings. Transoesophageal echocardiography detected a giant echolucent mass with intra-cavity thrombus (Panel B, arrowhead, 6.02 cm × 3.70 cm; Supplementary material online, Video S1). Computerized tomography angiography (CTA) confirmed a giant aneurysm with intra-cavity thrombus arising from the right atrial appendage, compressing the right ventricle (Panels C and D, 8.30 cm × 6.53 cm in short-axis, arrowhead, and asterisk). The patient received surgical intervention under cardiopulmonary bypass. After median sternotomy, the intra-cavity thrombus, which was then removed, could...