Abnormal Wall Research Articles

A Rapid Development of a Right Ventricular Aneurysm Postmyocardial Infarction

Myocardial infarctions may cause ventricular aneurysms. Ischemia-induced ventricular changes are more common in the left ventricle owing to the larger vascular supply, greater volume of myocardium, and increased intra-ventricular pressure. Ischemia-induced right ventricular free wall abnormalities are rare owing to the lower ventricular pressure. The authors describe the echocardiographic progression of a right ventricular ischemic aneurysm resulting from an ST-elevated myocardial infarction in a 71- year-old man. In this E-Challenge, the authors will review the echocardiographic findings and pathophysiology of ischemic aneurysms.

Approach To CT Findings In Non-Neoplastic Bowel Wall Abnormalities

Approach To CT Findings In Non-Neoplastic Bowel Wall Abnormalities

Kagami\u2013Ogata syndrome in a fetus presenting with polyhydramnios, malformations, and preterm delivery: a case report

BackgroundKagami–Ogata syndrome is also known as paternal uniparental disomy 14 and related disorders and is caused by abnormal genomic imprinting in the long arm of the chromosome 14q32.2 region. Its clinical manifestations include polyhydramnios in the fetal stage, respiratory insufficiency because of a small thorax, abdominal wall abnormalities, and peculiar facial features after birth.Case presentationA 38-year-old Japanese primigravida woman was referred to our hospital in the 19th week of pregnancy for suspected omphalocele. She had a history of hypothyroidism but was prescribed orally administered levothyroxine (50 μg/day) prior to conception and was euthyroid. Her ultrasound scan prior to visiting our hospital revealed fetal omphalocele, heavy for date, and polyhydramnios. The mother was advised to be admitted for observation from 28 weeks of gestation for threatened premature delivery. She required amniodrainage at 29 and 32 weeks of gestation. At 35 weeks of gestation, the fetal membrane prematurely ruptured and she gave birth after an emergency Cesarean section. The infant was a male child with a birth weight of 3188 g, and was suspected to have Kagami–Ogata syndrome after birth based on thoracic hypoplasia, swallowing function abnormalities, and peculiar facial features. A definitive diagnosis was established by performing genetic testing of the infant after obtaining informed written consent from both the parents; the results of the genetic testing revealed hypermethylated intergenic-differentially methylated region and maternally expressed gene 3-differentially methylated region in the corresponding chromosome 14 region. Both the parents were genetically tested after adequate genetic counseling, which revealed a de novo microdeletion in a differentially methylated region.ConclusionKagami–Ogata syndrome should have been suspected because of the presence of polyhydramnios and omphalocele during pregnancy. Respiratory insufficiency soon after birth, because of a small thorax, is expected in this disease and a diagnosis during pregnancy may have enabled appropriate care after birth.

Clinical study of Warfarin combined with Aspirin in the treatment of Kawasaki disease complicated with multiple medium and giant coronary artery aneurysms

Objective To investigate the safety and efficacy of Warfarin combined with Aspirin in the treatment of multiple medium and giant coronary artery aneurysms in Kawasaki disease(KD). Methods Clinical and follow-up data of 45 children diagnosed with KD complicated with multiple medium-sized and giant coronary artery aneurysms from April 2014 to December 2018 at Guangzhou Women and Children′s Medical Center were collected.These children were divided into 2 groups.A total of 31 cases received regular oral Warfarin combined with Aspirin called experimental group.There were 14 patients treated with oral Aspirin and Clopidogrel called control group.General information, laboratory examination, electrocardiogram, echocardiography, outcome and bleeding complications of the 2 groups were analyzed retrospectively. Results (1) In experimental group, there were 22 patients found thrombosis under echocardiography.The 10 patients′ thrombosis disappeared, 5 patients′ thrombosis reduced, and 2 patients′ increased after treatment.In control group, there were 5 cases found thrombosis.The 2 cases′ thrombosis reduced and 3 cases′ throm-bosis increased.The number of thrombosis in experimental group was significantly reduced, and the number of new thrombosis was less than that in control group (χ2=6.454, P<0.05). (2) The number of coronary artery aneurysms in experimental group increased slowly than that in control group [12.90%(4/31 cases)vs.14.28%(2/14 cases)]. (3) The number of coronary artery aneurysms in experimental group decreased rapidly than that in control group [23.91%(11/46 cases)vs.10.00%(1/10 cases)]. (4) The number of cases of tumor retraction in experimental group was more than that in control group [74.19%(23/31 cases)vs.42.85%(6/14 cases)]. (5) During the followed-up, there was no abnormality in the blood phosphokinase isozyme and troponin, no abnormality in the electrocardiogram and echocardiogram, no ventricular enlargement and abnormal ventricular wall movement, and the ejection fraction value was within the normal range.No active bleeding and no death occurred in the two groups. Conclusions Warfarin combined with Aspirin is very safe and effective in the treatment of KD coronary tumor, it can reduce thrombosis effectively.Compared with oral Aspirin and Clopidogrel, Warfarin combined with Aspirin can reduce the number of multiple medium-sized and large coronary artery aneurysms and reduce the diameter of coronary artery aneurysms. Key words: Warfarin; Aspirin; Kawasaki disease; Coronary artery aneurysm; Giant coronary artery aneurysm

Is there a correlation between structural changes of the bladder wall and its dysfunction? A Prospective Study

The aim of the study was to evaluate the microscopic structure of the bladder wall in children with a neurogenic bladder to find a correlation between changes in the microscopic structure of the bladder wall and functional disorders. The study group consisted of 42 children who underwent bladder augmentation. Full-thickness fragments of the bladder wall were collected during operation, photographed for evaluation with a morphometric analysis. The proportion of muscle and connective tissue was determined. Results were correlated with the results of urodynamic tests. The analysis showed a progressive increase in connective/muscle tissue ratio with a decrease in the number of nerve trunks with a correlation between the connective/muscle tissue ratio and the deterioration of lower urinary tract in urodynamic investigations. Dysfunctions of the bladder are associated with histological abnormalities of the bladder wall, particularly increases in the amount of connective tissue and reduction of the number of nerve trunks. The increase in the percentage of the connective tissue correlates positively with deterioration of bladder function, reduced compliance of the bladder wall, and changes in the structure of the bladder wall and deterioration of the upper urinary tract.

Detection of arterial wall abnormalities via Bayesian model selection.

Patient-specific modelling of haemodynamics in arterial networks has so far relied on parameter estimation for inexpensive or small-scale models. We describe here a Bayesian uncertainty quantification framework which makes two major advances: an efficient parallel implementation, allowing parameter estimation for more complex forward models, and a system for practical model selection, allowing evidence-based comparison between distinct physical models. We demonstrate the proposed methodology by generating simulated noisy flow velocity data from a branching arterial tree model in which a structural defect is introduced at an unknown location; our approach is shown to accurately locate the abnormality and estimate its physical properties even in the presence of significant observational and systemic error. As the method readily admits real data, it shows great potential in patient-specific parameter fitting for haemodynamical flow models.

2728 An Unexpected Cause of a Gastric Ulcer

INTRODUCTION: Mucormycosis is a rare rhino-orbital-cerebral fungal infection. The GI tract is involved in approximately 7% of the patients; however, this incidence may not be exact since several cases have been diagnosed postmortem. Within the GI tract, the stomach is the most frequently compromised organ, followed by the colon. CASE DESCRIPTION/METHODS: 46-year old man presented to the ED with 1-week history of diffuse, crampy abdominal pain. His pain was associated with nausea, non-bloody vomiting, anorexia and watery non-bloody diarrhea for the past 3 days. His PMH is significant for HIV, well controlled on ART and DM complicated with gastroparesis. Laboratory results showed a CD4 of 540, normal WBC, A1C of 10.3% and negative infectious stool studies. The patient was admitted to the hospital and was placed on supportive treatment. Due to persistence of his symptoms, a CT of the abdomen was done showing gastric wall abnormalities (Figure 1). GI was consulted and a decision to perform an EGD was made. The EGD showed a large ulcerated irregular area in the stomach fundus (Figures 2 and 3). Biopsies were taken showing positive fungal stain compatible with mold from the order Mucorales. The patient was started on amphotericin B and then underwent a total gastrectomy with roux en Y reconstruction. Pathology results confirmed biopsy findings and culture was positive for Rhizopus species. DISCUSSION: Mucormycosis is an opportunistic infection that mainly occurs in immunocompromised states like DM, uncontrolled HIV infection and hematopoietic and solid organ transplant. GI invasion caused by Mucorales does not have a clearly understood mechanism; however, many authors propose that this starts after ingestion of fermented foods. Fungal hyphae can invade the blood vessels, leading to local ischemia, ulceration, infarction and necrosis of the affected tissue. Patients can present with nonspecific symptoms, which can delay the diagnosis, leading to mortality in 85% of the cases. EGD elucidates large ulcers that can be associated with emphysematous changes, as in our patient, but the diagnosis is made by fungal cultures of biopsies, since histopathological examination can be misleading. Treatment is based on amphotericin B or posaconazole, but surgical resection is necessary for cure. We report this case to increase awareness of mucormycosis as a cause of gastric ulceration in an immunosuppressed patient. Surgical treatment is encouraged, since delays are related to high mortality rates.

Imaging diagnostics in large vessel vasculitis

Imaging procedures have become an important diagnostic tool in vasculitis. In large vessel vasculitides, such as giant-cell arteritis (GCA) and Takayasu arteritis, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can depict specific abnormalities of the arterial wall. Aclinically suspected diagnosis can be confirmed by imaging if performed by atrained specialist using appropriate equipment, without histological investigations. Ultrasound, MRI and CT show ahomogeneous, concentric thickening of the arterial wall and PET can detect increased glucose metabolism of the arterial wall. Ultrasound is the method of choice, especially in predominantly cranial GCA. Imaging should be performed before or within the first few days of glucocorticoid treatment as the PET findings of all arteries as well as ultrasound and MRI findings in temporal arteries normalize quickly with treatment. Aplanned imaging examination must not delay initiation of glucocorticoid treatment.

Adhesive and non-adhesive internal hernia: clinical relevance and multi-detector CT images

Internal hernia (IH)-related surgical acute abdomen is not well understood because of the rarity of cases and underdiagnosis. This study was performed to further understand the clinicopathological features and multi-detector computed tomography (MDCT) findings of IH in cases confirmed by surgery. In all, 51 patients with a definite diagnosis of IH confirmed during surgical exploration from Feb. 2012 to Feb. 2018 in our hospital were included in this research. Medical records, including MDCT images and intra-operative findings, were collected retrospectively. In all, 39 and 12 cases were categorized as adhesive IH (76.5%) and non-adhesive IH (23.5%), respectively. Among the patients with adhesive IH, 73% had a history of abdominal or pelvic surgery. Additionally, the mesentery was the most common component of adhesive bands (64.1%). Congenital peritoneal abnormalities and gastrointestinal reconstruction were the main causes of non-adhesive IH.As a specific sign, the fat notch sign was much more common in adhesive IH than in non-adhesive IH (P = 0.023). Bowel wall thickening (P = 0.041), abnormal bowel wall enhancement (P = 0.006) and twisted bowels with the vessel swirl sign (P = 0.004) were indicators of bowel necrosis. Among all of the cases of IH, 34 (66.7%) were complicated by bowel necrosis, and 1 patient died. In conclusion, non-adhesive IH has different clinicopathological features and MDCT findings from those of adhesive IH. MDCT is a useful tool with high sensitivity for confirming IH and may help to guide the early treatment of IH.

Mechanical Abnormalities of the Airway Wall in Adult Mice After Intrauterine Growth Restriction.

Developmental abnormalities of airways may impact susceptibility to asthma in later life. We used a maternal hypoxia-induced mouse model of intrauterine growth restriction (IUGR) to examine changes in mechanical properties of the airway wall. Pregnant BALB/c mice were housed under hypoxic conditions (10.5% O2) from gestational day (GD) 11 to GD 17.5 (IUGR; term, GD 21). Following hypoxic exposure, mice were returned to a normoxic environment (21% O2). A control group of pregnant mice were housed under normoxic conditions throughout pregnancy. At 8 weeks postnatal age, offspring were euthanized and a tracheasectomy performed. Tracheal segments were studied in organ baths to measure active airway smooth muscle (ASM) stress to carbachol and assess passive mechanical properties (stiffness) from stress-strain curves. In a separate group of anesthetized offspring, the forced oscillation technique was used to examine airway mechanics from relative changes in airway conductance during slow inflation and deflation between 0 and 20 cmH2O transrespiratory pressure. From predicted radius-pressure loops, storage and loss moduli and hysteresivity were calculated. IUGR offspring were lighter at birth (p < 0.05) and remained lighter at 8 weeks of age (p < 0.05) compared with Controls. Maximal stress was reduced in male IUGR offspring compared with Controls (p < 0.05), but not in females. Sensitivity to contractile agonist was not affected by IUGR or sex. Compared with the Control group, airways from IUGR animals were stiffer in vitro (p < 0.05). In vivo, airway hysteresivity (p < 0.05) was increased in the IUGR group, but there was no difference in storage or loss moduli between groups. In summary, the effects of IUGR persist to the mature airway wall, where there are clear abnormalities to ASM contractile properties and passive wall mechanics. We propose that mechanical abnormalities of the airway wall acquired through disrupted fetal growth impact susceptibility to disease.

Pattern and severity of transverse sinus stenosis in patients with pulsatile tinnitus associated with sigmoid sinus wall anomalies

Describe the location and severity of transverse sinus stenosis (TSS) in a consecutive series of patients with intraoperatively confirmed sigmoid sinus wall abnormalities (SSWA). A retrospective review of imaging studies from patients undergoing sinus wall reconstruction for pulsatile tinnitus associated with SSWA "was performed." Qualitative and quantitative analyses of the TSS, including the side, type, location, extent, and severity, were performed and compared with normal controls and historical controls with idiopathic intracranial hypertension (IIH). Twenty-six of 36 subjects had adequate imaging data. The majority of subjects had some degree of bilateral TSS, and the majority of stenoses involved the distal transverse sinus. Subjects with diverticulum were significantly more likely than those with dehiscence to have ipsilateral distal TSS (16 of 16 vs. 4 of 10, P = 0.009). The mean minimum transverse sinus diameter, stenosis severity grade, and overall posterior venous sinus outflow were significantly worse in the subjects as compared to normal controls (P = 0.002), although not as severe as the comparable values in historical controls with IIH (P < 0.003). Subjects with SSWA have a high incidence of TSS, with patterns differing between those with dehiscence and diverticulum. Severity of TSS and overall posterior fossa venous outflow are worse as compared to normal controls but not as severe as in subjects with IIH. These findings have implications for the pathophysiology and management of SSWA. 4 Laryngoscope, 130:1028-1033, 2020.

Perspective: Something Old, Something New? Review of Wasting and Other Mortality in Asteroidea (Echinodermata)

Asteroids (Echinodermata) experience mass mortality events that have the potential to cause dramatic shifts in ecosystem structure. Asteroid wasting describes a suite of body wall abnormalities that can ultimately result in animal mortality. Wasting in Northeast Pacific asteroids has gained considerable recent scientific attention due to its geographic extent, number of species affected, and effects on overall population density in some affected regions. However, asteroid wasting has been observed for over a century in other regions and species. Asteroids are subject to physical injury and adverse environmental conditions, which may result in very similar external manifestations to wasting, making identification of causative processes sometimes problematic. Here we review asteroid health abnormalities reported in years prior to the 2013-present Northeast Pacific wasting mass mortality, and report two additional geographically disparate wasting events that occurred concomitantly with the recent wasting outbreak.

Minimally invasive repair of the severe pectus excavatum in an infant

Abstract Pectus excavatum is the most common congenital chest wall abnormality. Nuss et al., in 1998 described minimally invasive repair of pectus excavatum and this procedure is now the procedure of choice in many institutions for the surgical repair of pectus excavatum. However, since that time the optimal age and indications for surgical repair are still debate. Although there is no age limitation for the procedure, publications regarding the surgical management of infants with pectus deformities are few. We present a case of an 11-month-old girl with severe pectus excavatum who presented with a 3-day history of increasing dyspnea which was present since her birth. During her follow in pediatric intensive care unit she became apneic and underwent intubation. A chest tomography demonstrated pectus excavatum with right main stem bronchial compression and bilateral lower lobe pneumonia. She underwent minimally invasive repair of his pectus excavatum and was extubated on hospital day 10 and was discharged from the hospital on postoperative day 17.

Most exposed: the endothelium in chronic kidney disease.

Accumulating evidence indicates that the pathological changes of the endothelium may contribute to the development of cardiovascular complications in chronic kidney disease (CKD). Non-traditional risk factors related to CKD are associated with the incidence of cardiovascular disease, but their role in uraemic endothelial dysfunction has often been disregarded. In this context, soluble α-Klotho and vitamin D are of importance to maintain endothelial integrity, but their concentrations decline in CKD, thereby contributing to the dysfunction of the endothelial lining. These hormonal disturbances are accompanied by an increment of circulating fibroblast growth factor-23 and phosphate, both exacerbating endothelial toxicities. Furthermore, impaired renal function leads to an increment of inflammatory mediators, reactive oxygen species and uraemic toxins that further aggravate the endothelial abnormalities and in turn also inhibit the regeneration of disrupted endothelial lining. Here, we highlight the distinct endothelial alterations mediated by the abovementioned non-traditional risk factors as demonstrated in experimental studies and connect these to pathological changes in CKD patients, which are driven by endothelial disturbances, other than atherosclerosis. In addition, we describe therapeutic strategies that may promote restoration of endothelial abnormalities by modulating imbalanced mineral homoeostasis and attenuate the impact of uraemic retention molecules, inflammatory mediators and reactive oxygen species. A clinical perspective on endothelial dysfunction in CKD may translate into reduced structural and functional abnormalities of the vessel wall in CKD, and ultimately improved cardiovascular disease.

Fabry disease in cardiology practice: Literature review and expert point of view

Fabry disease is an X-linked progressive multisystemic genetic sphingolipidosis caused by deficient activity of lysosomal α-galactosidase A. Men aged>30 years and women aged>40 years most often present with unexplained left ventricular hypertrophy, usually concentric and non-obstructive, but sometimes mimicking sarcomeric hypertrophic cardiomyopathy, particularly when isolated, as in the cardiac or late-onset variant of the disease. In hypertrophic cardiomyopathy cohorts, up to 1% of patients have been diagnosed with Fabry disease. Frequent cardiac symptoms include chronotropic incompetence, severe conduction disturbances and arrhythmias, heart failure and sudden death, and cardiovascular complications are currently the leading cause of death at a mean age of 55 years in men and 66 years in women. Complementary to screening for extracardiac manifestations, the initial cardiac evaluation should include long-duration electrocardiogram recordings, echocardiography and late gadolinium and T1 mapping magnetic resonance imaging. Abnormalities of a non-hypertrophied inferolateral wall at the base of the left ventricle (thinning, decreased strain, midwall fibrosis) and low native T1 signal on magnetic resonance imaging are evocative. Aggressive cardiac management may include the control of cardiovascular risk factors, anticoagulation, permanent cardiac pacing and/or an implantable cardioverter defibrillator device, while antiarrhythmics and beta-blockers should be used with caution. Specific therapy should be initiated at the earliest stage, when the first structural or functional cardiac abnormalities are detected, and should include enzyme replacement therapy (available since 2001) or chaperone therapy (available since 2016) (the use of which is limited to patients with Fabry disease and an amenable α-galactosidase A [GLA] gene mutation).

Fat embolism in right internal jugular vein: incidental ultrasound finding during internal jugular vein cannulation

BackgroundWe report a case study of fat embolism seen on ultrasound at right internal jugular vein during central venous cannulation in a patient diagnosed with fat embolism syndrome. This case demonstrates the importance of ultrasound for evaluation of trauma cases with suspicion of fat embolism.Case presentationA 23-year-old trauma patient with closed fracture of left femoral shaft and left humerus presented to our emergency department (ED). 11 h after admission to ED, patient became confused, hypoxic and hypotensive. He was then intubated for respiratory failure and mechanically ventilated. Transesophageal ultrasound revealed hyperdynamic heart, dilated right ventricle with no regional wall abnormalities and no major aorta injuries. Whole-body computed tomography was normal. During central venous cannulation of right internal jugular vein (IJV), we found free floating mobile hyperechoic spots, located at the anterior part of the vein. A diagnosis of fat embolism syndrome later was made based on the clinical presentation of long bone fractures and fat globulin in the blood. Despite aggressive fluid resuscitation, patient was a non-responder and needed vasopressor infusion for persistent shock. Blood aspirated during cannulation from the IJV revealed a fat globule. Patient underwent uneventful orthopedic procedures and was discharged well on day 5 of admission.ConclusionsPoint-of-care ultrasound findings of fat embolism in central vein can facilitate and increase the suspicion of fat embolism syndrome.

Early detection of lower GI tract tumors by dedicated assessment of the colon on routine computed tomography (CT) imaging: An observational study.

510 Background: We have previously reported that up to 48% of the early features of colorectal cancer (subtle wall thickening, pericolonic stranding, and small lymph nodes in the draining nodal station) were not identified on the original CT abdomen and pelvis (CTAP) reports. This resulted in a 36% decrease in five-year survival based on historical data. In this report, we assessed whether dedicated assessment of the colon on routine CT scans could lead to early detection of colorectal cancer. Methods: 210 CTAPs over a three-month period were screened from the emergency room records at a tertiary care hospital. 194 scans met eligibility. Exclusion criteria included: cases known to the evaluating radiologist and age ≤ 19 or &gt; 89 years. No study was excluded for suboptimal image quality. The original report was reviewed for abnormalities involving the colon, mesentery and bowel and was recorded. A blinded evaluation of the eligible case was then performed by a board-certified radiologist with attention specifically to the colon and the mesentery for the suspicious early features of CRC. The concordance and discordance was then tabulated. Discordant findings were re-evaluated to determine if the discordance was true. Results: 72/194 patients were male, median age 44.5 years (range 20 - 89). 55/194 patients (29.1%) included in the study were noted to have suspicious features. 26 had abnormal lymph nodes, 24 had abnormal colonic wall thickening and 16 had pericolonic stranding and/or wall edema. 45/55 studies were truly discordant from the original interpretation. These included one missed colorectal cancer (confirmed), one likely small bowel neuroendocrine tumor (no follow up), and one likely transitional cell carcinoma of the right renal pelvis (no follow up). Conclusions: Dedicated search of the colon and mesentery on CTAP can identify subtle findings, although their true relevance is being evaluated in a larger future study. Our observational data does indicate that there maybe a potential role for a focused evaluation of the colon and mesentery on routine CTAP in an attempt to potentially increase the rate of cancer detection especially in younger low-average risk patients.

Is “gallbladder length-to-width ratio” useful in diagnosing biliary atresia?

BackgroundThe accurate assessment of gallbladder shape and wall abnormalities by ultrasound (US) in diagnosing biliary atresia (BA) remains a subjective determination. The objective of this study was to examine the reliability of gallbladder length-to-width ratio (LTWR) by US measurement for diagnosis of BA. MethodsOne hundred infants with conjugated hyperbilirubinemia and unknown cause of jaundice who underwent transabdominal US from February 2009 to February 2017 were enrolled. The gallbladder classification and other detailed US findings were reviewed. ResultsThere were statistical differences in gallbladder lumen, classification, length, width and LTWR of gallbladder (all P < 0.05) between BA and non-BA groups. The gallbladder LTWR with a cutoff at 4.1 had the highest sensitivity of 71.7%, while the fibrotic cord thickness had the highest specificity of 95.9%. The combination of portal vein (PV) diameter > 4.4 mm, hepatic artery (HA) diameter > 1.2 mm, and gallbladder LTWR >4.1, provided much higher specificity (98%), odds ratio (11), and positive likelihood ratio (LR+) (10.6). ConclusionThe gallbladder LTWR by US could be a suggestive US parameter for BA screening. The triad of PV diameter, HA diameter, and gallbladder LTWR yielded the highest specificity, odds ratio, and LR+ for diagnosing BA. Level of evidenceLevel III study of diagnostic test.

Blocking β-1,6-glucan synthesis by deleting KRE6 and SKN1 attenuates the virulence of Candida albicans.

β-1,6-glucan is an important component of the fungal cell wall. The β-1,6-glucan synthase gene KRE6 was thought to be essential in the fungal pathogen Candida albicans because it could not be deleted in previous efforts. Also, the role of its homolog SKN1 was unclear because its deletion caused no defects. Here, we report the construction and characterization of kre6Δ/Δ, skn1Δ/Δ and kre6Δ/Δ skn1Δ/Δ mutants in C. albicans. While deleting KRE6 or SKN1 had no obvious phenotypic consequence, deleting both caused slow growth, cell separation failure, cell wall abnormalities, diminished hyphal growth, poor biofilm formation and loss of virulence in mice. Furthermore, the GPI-linked cell surface proteins Hwp1 and the invasin Als3 or Ssa1 were not detected in kre6Δ/Δ skn1Δ/Δ mutant. In GMM medium, RT-qPCR and western blotting revealed a constitutive expression of KRE6 and growth conditions-associated activation of SKN1. Like many hypha-specific genes, SKN1 is repressed by Nrg1, but its activation does not involve the transcription factor Efg1. Dysregulation of SKN1 reduces C. albicans ability to damage epithelial and endothelial cells and attenuates its virulence. Given the vital role of β-1,6-glucan synthesis in C. albicans physiology and virulence, Kre6 and Skn1 are worthy targets for developing antifungal agents.

Type 9 Dual Left Anterior Descending Artery or Triple Left Anterior Descending Artery Anomaly: A Rare Anomaly

A middle aged patient presented with acute coronary syndrome. Echocardiography showed regional wall abnormality in the left anterior descending artery territory with reduced left ventricular dysfunction. Coronary angiogram showed early division, suggestive of a rare case of dual LAD.