Circulatory and Respiratory Physiology Commons^™

Lrp1 Protects Against Excessive Superior Mesenteric Artery Remodeling By Modulating Angiotensin Ii–Mediated Signaling, Jackie M. Zhang, Dianaly T. Au, Hisashi Sawada, Michael K. Franklin, Jessica J. Moorleghen, Deborah A. Howatt, Pengjun Wang, Brittany O. Aicher, Brian Hampton, Mary Migliorini, Fenge Ni, Adam E. Mullick, Mashhood M. Wani, Areck A. Ucuzian, Hong S. Lu, Selen C. Muratoglu, Alan Daugherty, Dudley K. Strickland

Saha Cardiovascular Research Center Faculty Publications

Vascular smooth muscle cells (vSMCs) exert a critical role in sensing and maintaining vascular integrity. These cells abundantly express the low-density lipoprotein receptor–related protein 1 (LRP1), a large endocytic signaling receptor that recognizes numerous ligands, including apolipoprotein E–rich lipoproteins, proteases, and protease-inhibitor complexes. We observed the spontaneous formation of aneurysms in the superior mesenteric artery (SMA) of both male and female mice in which LRP1 was genetically deleted in vSMCs (smLRP1–/– mice). Quantitative proteomics revealed elevated abundance of several proteins in smLRP1–/– mice that are known to be induced by angiotensin II–mediated (AngII-mediated) signaling, suggesting that this pathway was dysregulated. …

Macrophage Angiotensin-Converting Enzyme Reduces Atherosclerosis By Increasing Peroxisome Proliferator-Activated Receptor Α And Fundamentally Changing Lipid Metabolism, Duoyao Cao, Zakir Khan, Xiaomo Li, Suguru Saito, Ellen A. Bernstein, Aaron R. Victor, Faizan Ahmed, Aoi O. Hoshi, Luciana C. Veiras, Tomohiro Shibata, Mingtian Che, Lei Cai, Michifumi Yamashita, Ryan E. Temel, Jorge F. Giani, Daniel J. Luthringer, Ajit S. Divakaruni, Derick Okwan-Duodu, Kenneth E. Bernstein

Saha Cardiovascular Research Center Faculty Publications

Aims The metabolic failure of macrophages to adequately process lipid is central to the aetiology of atherosclerosis. Here, we examine the role of macrophage angiotensin-converting enzyme (ACE) in a mouse model of PCSK9-induced atherosclerosis.

Methods and results Atherosclerosis in mice was induced with AAV-PCSK9 and a high-fat diet. Animals with increased macrophage ACE (ACE 10/10 mice) have a marked reduction in atherosclerosis vs. WT mice. Macrophages from both the aorta and peritoneum of ACE 10/10 express increased PPARα and have a profoundly altered phenotype to process lipids characterized by higher levels of the surface scavenger receptor CD36, increased uptake of …

Use Of Cardiomems Hf Sensor In Management Of Nyha Class Iii Heart Failure, Trevor Andrunik, Anne Eady

Physician Assistant Capstones, 2020-current

Objective: Assess the ability of continuous pulmonary artery pressure monitoring via implantable CardioMEMs HF device to reduce hospitalization in New York Heart Association (NYHA) Class III heart failure patients over the age of 18. Design: Systematic literature review. Methods: Searches were conducted via PubMed and ClinicalTrials.gov using the single search term “CardioMEMs.” Inclusion criteria narrowed results to studies performed in the last 10 years, randomized control trials, cohort studies, and utilizing heart failure related hospitalization as the primary endpoint. Results: The current data unanimously asserts that the CardioMEMs HF device is effective at reducing heart failure related hospitalizations, with secondary …

Upper Gastrointestinal Bleeding During The Covid-19 Pandemic; Particularities Of Diagnosis And Therapy, Adrian Silaghi, Bogdan Severus Gaspar, Dragos Epistatu, Daniela Gabriela Bălan, Ioana Păunică, Anca Silvia Dumitriu, Stana Paunica, Bogdan Socea, Vlad Denis Constantin

Journal of Mind and Medical Sciences

SARS-COV 2 recently caused a global pandemic, with the first case being reported in Romania in February 2020. Important restrictive measures were imposed, so that the addressability of patients to medical services decreased. Upper gastrointestinal bleeding had more severe forms of evolution at the time of presentation, which required additional methods of diagnosis and treatment. This is a retrospective study performed on 268 patients, which aims to evaluate the type and effectiveness of different treatment methods for upper gastrointestinal bleeding during the COVID 19 pandemic. Severity assessment was performed by measuring the Rockall score and additional methods of diagnosis. The …

Fear Of Covid-19, Anxiety, Depression And Suicide Among Elderly Patients With Chronic Physical Or Mental Diseases, Vasiliki Holeva, Vasiliki Aliki Nikopoulou, Eleni Parlapani, Konstantinos Karkaletsis, Styliani Kokkoni, Dimitrios Nouvakis, Patroklos Theocharis, Ioannis Diakogiannis

Journal of Mind and Medical Sciences

Older age renders individuals vulnerable during public emergency crises. Considering that older adults are a highly heterogeneous and continuously growing demographic subgroup, this study aimed to assess the mental health impact of COVID-19 on two groups of older patients: a group of chronic physical disease and a group of chronic mental disease. A total of 102 patients completed the Fear of COVID-19 Scale, the Generalized Anxiety Disorder scale, the Brief Patient Health Questionnaire (PHQ-9) and several questions regarding demographic characteristics. Suicidality was assessed by the 9th item of the PHQ-9. According to the results, older chronic disease patients showed higher …

Healthy Exosomes And Their Effects On Diabetic Cardiomyocytes, Miguel A. Garza, Genaro A. Ramírez-Correa, Maria Lourdes Garza-Rodríguez, Andres J. Medina

MEDI 9331 Scholarly Activities Clinical Years

Extracellular Vesicles, and more specifically, exosomes, are essential for effective cell-to-cell communication in a wide variety of tissues. In the last couple of decades, these nanovesicles have been proven to be active participants and regulators in many disease processes; therefore, their therapeutic effects have been widely studied and proven in various cardiovascular diseases both, in vitro and in vivo. Thus, this study aims at assessing the effects of running healthy mice exosomes on cardiomyocyte and cardiac tissue samples obtained from diabetic mice. Here, we successfully extract exosomes from mice plasma and detect their presence through the use of anti-CD9 and …

Heart To Heart, Mom To Mom, Karis L. Tekwani

Journal of Patient-Centered Research and Reviews

This essay describes the human connection forged between two young moms, one the physician and one the patient, when their paths collided one night in the emergency department of a busy hospital. It describes a challenging and most memorable care experience in the career of a young emergency physician, the clinical outcome, and the patient’s appreciative follow-up message years later.

Cardiovascular Disease Awareness Program On Risk Factors For Cardiovascular Disease Among Adolescents In Selected Schools, In New Delhi, Komal Kumari

Manipal Journal of Nursing and Health Sciences

Introduction: Cardiovascular disease (CVD) is the main cause of mortality worldwide. The main risk factors include tobacco chewing/smoking, higher blood cholesterol, high blood pressure, physical inactivity, obesity, excessive alcohol use, age, sex, and heredity. Although CVDs commonly develop in middle age or later, risk factors are highly impacted by childhood practices that are continued into maturity. Knowledge gaps on CVD and its risk factors are major obstacles to effective prevention and treatment. Hence, a CVD awareness program was organized in order to educate adolescents about CVD and its risk factors. Objective: The objectives of the study were to identify students’ …

Sinus Pauses And Asystole As A Rare Presentation Of Thyrotoxic Crisis: A Case Report, Christian Akem Dimala, Charnjeet Sandhu, Oreoluwa Oladiran, Agnieszka Mochon, William Finneran Iii

Transformative Medicine

Introduction

Thyroid crisis is a rare and life-threatening endocrine emergency characterized by exaggerated clinical manifestations of hyperthyroidism with cardiovascular manifestations being the most severe. Rhythm disturbances, sinus tachycardia and atrial fibrillation, are the commonest cardiac manifestations of severe thyrotoxicosis; however, asystole remains a very atypical and uncommon presentation. We present a case of thyrotoxicosis due to Grave’s disease complicated by multiple episodes of asystole.

Case Presentation

A 65-year-old female recently diagnosed with Grave’s disease presented to the hospital with recurrent episodes of syncope. Her hospital course was significant for atrial fibrillation with subsequent progression to sinus pauses and asystole spontaneously …

Admission Pao2 And Mortality Among Pediatric Icu Patients And Critically Ill Subgroups, Cara Holton

Research Days

Watch recording of live presentation

Background and Objectives: Studies analyzing the association between hyperoxia and mortality in critically ill pediatric patients and those admitted after cardiac arrest are conflicting and limited by small sample sizes. The aim of this study is to evaluate the association between PaO2 on admission to the pediatric ICU and mortality in a heterogeneous, multicenter cohort and among subgroups of critically ill patients.

Methods/Design: A retrospective cohort study was conducted using data from Virtual Pediatric Systems (VPS) database. VPS is a clinical pediatric critical care database with over 135 participating hospitals in North America. All VPS …

Physician's Attitudes On Pulmonary Rehabilitation Following Covid-19: A Brief Perspective From A Developing Country, Ivan Cherrez-Ojeda, Emanuel Vanegas, Miguel Felix, María José Farfán Bajaña, Azza Sarfraz, Zouina Sarfraz, Genesis Camacho, Alanna Barrios-Ruiz, Jack Michel

Department of Paediatrics and Child Health

Despite the uncertainty about the follow up of COVID-19 survivors, there is a growing body of evidence supporting specific interventions including pulmonary rehabilitation, which may lead to a reduced hospital stay and improved overall respiratory function. The aim of this short report was to assess the attitudes toward pulmonary rehabilitation following COVID-19 among Ecuadorian physicians. A cross-sectional study was conducted, in which a 5-question survey was used to assess the level of agreement to specific statements with a 5-point Likert scale. Out of the 282 participants, 48.2% (n=136) were male, with a mean of 12.6 (SD=11.3) years of experience. More …

Oxygen Deprivation Masks For Training, Brittany M. Hanlon

Student Publications

Oxygen deprivation masks are being advertised towards athletes as a piece of fitness equipment that can simulate the effects of high altitude, as well as a respiratory muscle training device. Studies that investigated the claims as to whether ODMs increased VO2max and improved endurance were looked into. Experimental data did not find that the use of these masks increased VO2max, nor was there any supporting data to prove that it improved endurance. The function of ODMs as a training tool to increase respiratory muscle strength was also examined. There were contradicting results between the three different studies examined. One study …

Dpo: Diffuse Pulmonary Ossification - A Diagnostic Challenge, Gaetano Rea, Giuliana Giacobbe, Danila Caroppo, Silvia Iovine, Roberta Lieto, Marialuisa Bocchino, Tullio Valente, Angelantonio Maglio, Alessandro Vatrella

Translational Medicine @ UniSa

Diffuse pulmonary ossification (DPO) is a rare condition of DLD (diffuse lung disease) characterized by the presence of metaplastic ectopic bone in the lungs and is less frequent in patients without a clear background of lung diseases. DPO is characterized by very small calcific nodules, often with bone mature located in both lungs and often in peripheral areas of the lungs. Two patterns of DPO have been recognized dendriform and nodular. The dendriform type is less common and is characterized by a coral-like network of bone spiculae along the alveolar septa and is often related to interstitial fibrosis or chronic …

Breaks In Longitudinal Elastic Fibers Of Human Femoropopliteal Arteries, Elham Zamani

UNO Student Research and Creative Activity Fair

Breaks in Longitudinal Elastic Fibers of Human Femoropopliteal Arteries

Elham Zamani1, Majid Jadidi1

1 Department of Biomechanics, University of Nebraska Omaha, Omaha, NE

Introduction: Elastin is a major protein in the body with half-life >50 years. It is thought that elastic fibers are formed before the postnatal period. In the femoropopliteal artery (FPA), the main artery in the leg, longitudinal elastic fibers are present in External Elastic Lamina (EEL). Our team has studied more than 1000 cadaveric human FPA and has noticed that there are big breaks in their longitudinal elastic fibers in some subjects. Our goal in this work …

Imaging Techniques For Aortic Aneurysms And Dissections In Mice: Comparisons Of Ex Vivo, In Situ, And Ultrasound Approaches, Sohei Ito, Hong S. Lu, Alan Daugherty, Hisashi Sawada

Saha Cardiovascular Research Center Faculty Publications

Aortic aneurysms and dissections are life-threatening conditions that have a high risk for lethal bleeding and organ malperfusion. Many studies have investigated the molecular basis of these diseases using mouse models. In mice, ex vivo, in situ, and ultrasound imaging are major approaches to evaluate aortic diameters, a common parameter to determine the severity of aortic aneurysms. However, accurate evaluations of aortic dimensions by these imaging approaches could be challenging due to pathological features of aortic aneurysms. Currently, there is no standardized mode to assess aortic dissections in mice. It is important to understand the characteristics of each approach for …

Risk Factors For Acute Respiratory Infections In Children Between 0 And 23 Months Of Age In A Peri-Urban District In Pakistan: A Matched Case–Control Study, Fatima Mir, Shabina Ariff, Maria Asif Bhura, Suhail Chanar, Aspara Ali, Muhammad Jawwad, A Hussain, Arjumand Rizvi, Muhammad Umer, Zahid Memon, Atif Habib, Sajid Bashir Soofi, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Acute respiratory infection (ARI) accounts for nearly 15% of all childhood mortality in South Asia, with children from rural areas at higher risk due to inaccessibility to healthcare facilities. We therefore aimed to identify risk factors associated with ARI in children under 2 years of age in rural Pakistan.
Methods: A retrospective 1:2 matched case-control study was conducted between October and December 2018 in Taluka Kotri, Jamshoro District of Pakistan. Cases were identified as children between 0 and 23 months of age with a history of fever, cough, sore throat, fast breathing, difficulty breathing, or chest indrawing in the …

Obstructive Sleep Apnea Education To The Rural Community, Brandi Harris

Doctor of Nursing Practice Projects

This project was executed to provide obstructive sleep apnea education to the men and women of the rural community. Many residents of rural communities remain undereducated and unaware of diseases and disorders in which they are subjected to or have increased risks for. Obstructive sleep apnea affects approximately twenty-two billion Americans. Of those affected, nearly eighty percent remain undiagnosed and untreated (Nagappa et al., 2015). Victims of the sleep disorder fail to acknowledge signs and symptoms of obstructive sleep apnea, many oblivious to the etiology, risk factors, symptoms, and pathophysiology of the disorder. Presenting education to residents of the rural …

Obstructive Sleep Apnea And Cardiovascular Disease, Evan Gagnon

Graduate Research Projects

No abstract provided.

The Effect Of Heparinoid As Systemic Prophylactic Anticoagulants On Covid-19 Patient Mortality And Its Safety Profiles: A Systematic Review And Meta-Analysis, Ariska Deffy Anggarany, Rani Sauriasari, Muhammad Alkaff, Famila Takhwifa, Hayatun Nufus, Diana Paramita

Pharmaceutical Sciences and Research

Coagulopathy is one of the complications of COVID-19 and is associated with a higher risk of mortality. However, evidence regarding the effectiveness and safety of anticoagulant therapy in various doses among COVID-19 patients is limited. This systematic review and meta-analysis aims to review and explore the effect of using heparinoids as a systemic anticoagulant at prophylactic doses on mortality in COVID-19 patients. Systematic searches were conducted of various databases (Pubmed, ScienceDirect, SpringerLink, Scopus, and ProQuest) covering the period 2019-2021. We assessed the quality of the articles using the STROBE checklist. Studies with a high risk of bias were excluded before …

An Assessment Of The Diagnostic Value In Syncope Workup: A Retrospective Study, Ashan T. Hatharasinghe, Kayvon Etebar, Ryan Wolsky, Hossein Akhondi, Napatkamon Ayutyanont

HCA Healthcare Journal of Medicine

Background

Patients with syncope often undergo costly testing, despite current guidelines and data supporting the contrary.

Objective

To determine the diagnostic value through positivity rate of electrocardiogram (EKG), computed tomography (CT) of the brain, magnetic resonance imaging (MRI) of the brain, transthoracic echocardiogram, nuclear and pharmacologic cardiac stress test, tilt table test and carotid ultrasound in patients diagnosed with syncope.

Methods

This is a retrospective study of 10,036 adults presenting to the emergency department or hospitalized with a primary diagnosis of syncope at 8 acute care facilities in the southwest United States from January 1, 2019, to December 31, 2019. …

Mental Health Or Cardiac Health. Is There A Reason To Choose? Cardiac Arrhythmias Induced By Atomoxetine And Methylphenidate, Gabriel Cismaru, Viorel Lupu

Journal of Mind and Medical Sciences

The current treatment of Attention Deficit Disorder and Attention Deficit with Hyperactivity consists mainly in the administration of Straterra (Atomoxetine) Concerta and Ritalin (Methylphenidate). The FDA warned that the products might increase systolic, diastolic blood pressure, and lead to ventricular arrhythmias. Arrhythmic events and sudden cardiac death were described in adults with preexistent heart disease. However, studies on children have failed to demonstrate a clear association between the arrhythmic events and these drugs, as demonstrated in adults. What should the attitude of the pediatric psychiatrist be towards the administration of these products? What examination should be made by the psychiatrist …

Therapeutic Efficacy Of Mesenchymal Stem Cells For Cardiovascular Diseases, Dragana Radoje Miloradovic, Dragica Radoje Pavlovic, Miodrag Bozidar Stojkovic, Sanja Bratislav Bojic, Vladislav Bogdan Volarevic, Marina Milosav Gazdic Jankovic, Biljana Tomislav Ljujic

Journal of Mind and Medical Sciences

Despite the improvements in pharmacological and surgical treatments, cardiovascular diseases (CVDs) are the number one cause of death worldwide. During the last two decades, the search for new therapies has been revolutionized with the growing knowledge of stem cell biology. Due to their huge differentiation capacity and paracrine effects, mesenchymal stem cells (MSCs) are a promising tool for the treatment of CVDs. The encouraging outcomes of preclinical studies using MSCs as a treatment for diseased myocardium have set the scene for worldwide clinical trials. In this review, we overview either complete or ongoing clinical trials using MSCs for the therapy …

No Effect Of Hypercholesterolemia On Elastase-Induced Experimental Abdominal Aortic Aneurysm Progression, Toru Ikezoe, Takahiro Shoji, Jia Guo, Fanru Shen, Hong S. Lu, Alan Daugherty, Masao Nunokawa, Hiroshi Kubota, Masaaki Miyata, Baohui Xu, Ronald L. Dalman

Saha Cardiovascular Research Center Faculty Publications

Objective: Epidemiological studies link hyperlipidemia with increased risk for abdominal aortic aneurysms (AAAs). However, the influence of lipid-lowering drugs statins on prevalence and progression of clinical and experimental AAAs varies between reports, engendering controversy on the association of hyperlipidemia with AAA disease. This study investigated the impact of hypercholesterolemia on elastase-induced experimental AAAs in mice. Methods: Both spontaneous (targeted deletion of apolipoprotein E) and induced mouse hypercholesterolemia models were employed. In male wild type (WT) C57BL/6J mice, hypercholesterolemia was induced via intraperitoneal injection of an adeno-associated virus (AAV) encoding a gain-of-function proprotein convertase subtilisin/kexin type 9 mutation (PCSK9) followed by …

Covid-19 Deliveries: Maternal Features And Neonatal Outcomes, Viviana Zlochiver, Blair Tilkens, Ana Cristina Perez Moreno, Fatima Aziz, M. Fuad Jan

Journal of Patient-Centered Research and Reviews

Integrated, data-driven criteria are necessary to evaluate delivery outcomes in pregnancies affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the ongoing COVID-19 pandemic. This study analyzed maternal demographics, clinical characteristics, treatments, and delivery outcomes of 85 ethnically diverse, adult pregnant women who tested positive for SARS-CoV-2 at the time of delivery. Median maternal and gestational ages were 27 years (interquartile range [IQR]: 23–31) and 39 weeks (IQR: 37.3–40.0), respectively. Of the 85 SARS-CoV-2–positive participants, 67 (79%) had no COVID-19 symptoms at the time of routine COVID-19 admission testing, 14 (16%) reported mild COVID-19 symptoms, and 4 (5%) presented …

Incidental Finding Of Anomalous Pulmonary Venous Return Of The Left Upper Lobe, A Rare Anatomical Variation, Anika Dutta, Loren Zuiderveld

Journal of Patient-Centered Research and Reviews

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital abnormality in which 1 to 3 of the pulmonary veins connect to the right atrium rather than the left atrium. In this synthesis of the literature on PAPVR of the left upper lobe, we attempt to illustrate this clinical entity using a case detected incidentally on chest computed tomography, explain the anatomical aspects of this anomaly, and summarize the reported incidence and etiology of left-sided PAPVR. Lastly, differential diagnoses, clinical relevance, and management of left-sided PAPVR are presented. The identification of this variant is important, as it may have serious …

Effect Of Metformin On The High-Density Lipoprotein Proteome In Youth With Type 1 Diabetes, Evgenia Gourgari, Kristen J. Nadeau, Laura Pyle, Martin P. Playford, Junfeng Ma, Nehal N. Mehta, Alan T. Remaley, Scott M. Gordon

Saha Cardiovascular Research Center Faculty Publications

Background: Youth with type 1 diabetes (T1D) have normal or elevated High-Density Lipoprotein Cholesterol (HDL-C), however, the function of HDL, partly mediated by the HDL proteome, may be impaired. Metformin can be used as an adjunct therapy in youth with T1D, but its effects on the HDL proteome are unknown.

Objective: To determine the effect of metformin on the HDL proteome.

Subjects: Youth (12-20 years old) with T1D who had a BMI > 90th percentile, HbA1c > 8.0% and Tanner stage 5.

Methods: Double-blinded, placebo-controlled randomized sub-study. We examined the effects of metformin (n = 25) or placebo (n = …

Effects Of Endogenous Angiotensin Ii On Abdominal Aortic Aneurysms And Atherosclerosis In Angiotensin Ii-Infused Mice, Masayoshi Kukida, Hisashi Sawada, Satoko Ohno-Urabe, Deborah A. Howatt, Jessica J. Moorleghen, Marko Poglitsch, Alan Daugherty, Hong S. Lu

Saha Cardiovascular Research Center Faculty Publications

No abstract provided.

D-Dimer Levels And Acute Pulmonary Embolism Development In Covid-19 Patients, Vural Ahmet, Kahraman Ahmet Nedim

Journal of Mind and Medical Sciences

Objective. To identify those who develop pulmonary embolism with Ddimer levels by evaluating pulmonary CT angiographies of patients who are followed up with suspicion of coronavirus disease 2019 (COVID-19). Methods. Patients who were followed up in a community hospital with suspicion of COVID-19 and underwent Pulmonary CT angiography examination were evaluated. Clinical and demographic parameters and DDimer values for patients with and without pulmonary embolism were evaluated in the pulmonary CT angiogram. Results. During the COVID-19 pandemic, Thorax CT examination was performed in our center for suspicion or follow-up of COVID-19 infection in 3396 patients. Pulmonary CT angiography was applied …

Mechanisms Of Synthetic Cannabinoids On Cardiovascular Health, Madeleine A. Nelson

Honors Thesis

Cannabinoids encompass natural cannabis and synthetic cannabinoids. While the synthetic cannabinoids interact with the same endogenous system as cannabis, their effects are quite different and poorly understood. In addition to psychological effects that trigger their use, these substances are linked to cardiovascular morbidity. To assess the cardiovascular effect of synthetic cannabinoids, we first tested the hypothesis that intravenous administration of a synthetic cannabinoid would increase blood pressure in conscious rats. Second, we tested the hypothesis that the sympathetic nervous system is involved by injecting a ganglion blocker to see if the cardiovascular response from synthetic cannabinoids would be blocked. Third, …

Methamphetamine Associated Cardiomyopathy In Pregnancy: The Distinctions And The Implications, Ashan Hatharasinghe, Hossein Akhondi

HCA Healthcare Journal of Medicine

Introduction

Methamphetamine associated cardiomyopathy (MAC) and peripartum cardiomyopathy (PPCM) are both rare obstetric conditions. Literature regarding methamphetamine associated cardiomyopathy in the obstetric population is limited, and it can be difficult to make the distinction between the two given the similarities in clinical presentation. However similar, there are significant distinctions in the pathophysiology of these two that can help clinicians with the management process.

Clinical Findings and Outcomes

This case involves a 35-year-old Hispanic G6P5005 at 37 weeks gestation presenting with acute respiratory failure secondary to acute decompensated heart failure with reduced ejection fraction and superimposed preeclampsia leading to urgent cesarean …