Search results for: subretinal bleed

Authors: Prachi Abhishek Dave, Abhishek Dave

Abstract:

Purpose: The purpose of this study is to elucidate the role of intravitreal injection Aflibercept in managing complex cases of Wet Age Related Macular Degeneration (ARMD) and the gratifying visual recovery experienced with a minimally invasive procedure. Methods: A 73-year-old gentleman presented with a drop in vision in the left eye for 25 days. On examination, his best corrected visual acuity (BCVA) in the Right eye (OD) was 6/60, and finger counting close to face in the Left eye (OS). On multimodal imaging, he was diagnosed to have a scarred Wet ARMD in OD and an active Wet ARMD with a large subretinal bleed secondary to Wet ARMD in OS. Treatment management options included monotherapy with an Injection Aflibercept or an intravitreal gas injection with tPA followed by Injection Aflibercept. Considering his one-eyed status, the patient decided to go for Aflibercept monotherapy. Results: After 3 monthly injections of injection Aflibercept, the subretinal bleed reduced, the subretinal fluid resolved, and his vision in OS improved to 6/9. He is on a regular follow-up and has not needed any further injections in OS and he maintains 6/9 vision. Conclusions: Conventional treatment guidelines for a large subretinal bleed dictate the use of gas followed by intravitreal Injection Aflibercept. However, gas has its own limitations of causing a rise in intraocular pressure and a transient loss of vision, which is particularly troublesome in one-eyed patients. Injection Aflibercept offers a much safer, less invasive, and elegant treatment option for such patients with equally good or even better visual outcomes.

Keywords: wet ARMD, subretinal bleed, intravitreal injections, aflibercept, EYELEA, intravitreal gas

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Authors: Man Chul Jeong, Hyoung Jin Lee, Sang Yoon Lee, Ji Hyun Park, Min Wook Chang, In-Seuck Jeung

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This study focus on the drag reduction effect of the base bleed at supersonic flow. Base bleed is the method which bleeds the gas on the tail of the flight vehicle and reduces the base drag, which occupies over 50% of the total drag in any flight speed. Thus base bleed can reduce the total drag significantly, and enhance the total flight range. Drag reduction ratio of the base bleed is strongly related to the mass flow rate of the bleeding gas. Thus selecting appropriate mass flow rate is important. However, since the flight vehicle has various flight speed, same mass flow rate of the base bleed can have different drag reduction effect during the flight. Thus, this study investigates the effect of the drag reduction depending on the flight speed by numerical analysis using STAR-CCM+. The analysis model is 155mm diameter projectile with boat-tailed shape base. Angle of the boat-tail is chosen previously for minimum drag coefficient. Numerical analysis is conducted for Mach 2 and Mach 3, with various mass flow rate, or the injection parameter I, of the bleeding gas and the temperature of the bleeding gas, is fixed to 300K. The results showed that I=0.025 has the minimum drag at Mach 2, and I=0.014 has the minimum drag at Mach 3. Thus as the Mach number is higher, the lower mass flow rate of the base bleed has more effect on drag reduction.

Keywords: base bleed, supersonic, drag reduction, recirculation

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Authors: T. Walczak, J. K. Grabski, P. Fritzkowski, M. Stopa

Abstract:

Objectives of the study are i) to perform numerical simulations that permit an analysis of the dynamics of subretinal fluid when an implant has induced scleral intussusception and ii) assess the impact of the physical parameters of the model on the flow rate. Computer simulations were created using finite element method (FEM) based on a model that takes into account the interaction of a viscous fluid (subretinal fluid) with a hyperelastic body (retina). The purpose of the calculation was to investigate the dependence of the flow rate of subretinal fluid through a hole in the retina on different factors such as viscosity of subretinal fluid, material parameters of the retina, and the offset of the implant from the retina’s hole. These simulations were performed for different speeds of eye movement that reflect the behavior of the eye when reading, REM, and saccadic movements. Similar to other works in the field of subretinal fluid flow, it was assumed stationary, single sided, forced fluid flow in the considered area simulating the subretinal space. Additionally, a hyperelastic material model of the retina and parameterized geometry of the considered model was adopted. The calculations also examined the influence the direction of the force of gravity due to the position of the patient’s head on the trend of outflow of fluid. The simulations revealed that fluid outflow from the retina becomes significant with eyeball movement speed of 100°/sec. This speed is greater than in the case of reading but is four times less than saccadic movement. The increase of viscosity of the fluid increased beneficial effect. Further, the simulation results suggest that moderate eye movement speed is optimal and that the conventional prescription of the avoidance of routine eye movement following retinal detachment surgery should be relaxed. Additionally, to verify numerical results, some calculations were repeated with use of meshless method (method of fundamental solutions), which is relatively fast and easy to implement. The paper has been supported by 02/21/DSPB/3477 grant.

Keywords: CFD simulations, FEM analysis, meshless method, retinal detachment

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Authors: Andriati Nadhilah Widyarini, Ezra Margareth

Abstract:

Introduction: Rhegmatogenous retinal detachment is a condition where there’s a break in the retina, which allows the vitreous to directly enter the subretinal space. Proliferative vitreoretinopathy (PVR) may develop due to this condition and can result in a new break, which could cause traction on the previously detached retina. Various methods of therapy can be done to treat this complication. Case: This case series involved 2 eyes of 2 patients who had total retinal detachment with advanced PVR. Pars plana vitrectomy was performed, and a 360-degree retinectomy procedure with perfluorocarbon liquid usage was done. This was followed by endo laser retinopexy to surround the border of retinectomy. 5000 cs silicone oil was used in 1 eye, whereas 12% of perfluoropropane gas was used in the other eye as a tamponade. These procedures were performed with meticulous attention to prevent any fluid from entering the subretinal space. Postoperative examination showed attachment of the retina and improvement of the patient’s visual acuity. Both eyes’ intraocular pressure was in the normal range. One eye developed retinal displacement, but no other complications occurred. Discussion: Rhegmatogenous retinal detachment with advanced PVR is a complex situation for vitreoretinal surgeons. PVR is characterized by the growth and migration of preretinal or subretinal membranes. PVR is the most common cause of retinal reattachment failure. A 360-degree retinectomy is an alternative surgical method to overcome this condition. Objectives of this procedure are releasing retinal traction caused by PVR, reducing the recurrence rate of PVR, and reattaching the retina to the pigment epithelial surface. Conclusion: 360-degree retinectomy provides satisfactory retinal reattachment and visual outcome improvement in rhegmatogenous retinal detachment with advanced PVR.

Keywords: RRD, retinectomy, pars plana, advanced PVR

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Authors: Amir Mukhtar, Habib Nasir

Abstract:

To achieve an enhanced range of large calibre artillery a base bleed unit equipped with ammonium perchlorate and hydroxyl-terminated polybutadiene (AP/HTPB) based composite propellant grain is installed at the bottom of a projectile which produces jet of hot gasses and reduces base drag during flight of the projectile. Upon leaving the muzzle at very high muzzle velocity, due to sudden pressure drop, the propellant grain gets quenched. Therefore, base-bleed unit is equipped with an igniter to ensure ignition as well as reignition of the propellant grain. Pyrotechnic compositions based on Zr/NH₄ClO₄ and Zr/KClO₄ mixtures have been studied for the effect of fuel/oxidizer ratio and oxidizer type on ballistic properties. Calorific values of mixtures were investigated by bomb calorimeter, the average burning rate was measured by fuse wire technique at ambient conditions, and high-pressure closed vessel was used to record pressure-time profile, maximum pressure achieved (Pmax), time to achieve Pmax and differential pressure (dP/dt). It was observed that the 30, 40, 50 and 60 wt.% of Zr has a very significant effect on ballistic properties of mixtures. Compositions with NH₄ClO₄ produced higher values of Pmax, dP/dt and Calorific value as compared to Zr/KClO₄ based mixtures. Composition containing KClO₄ comparatively produced higher burning rate and maximum burning rate was recorded at 8.30 mm/s with 60 wt.% Zr in Zr/KClO₄ pyrotechnic mixture. Zr/KClO₄ with 50 wt. % of Zr was tests fired in igniter assembly by electric initiation method. Igniter assembly was test fired several times and average burning time of 3.5 sec with igniter mass burning rate of 6.85 g/sec was recorded. Igniter was finally fired on static and dynamic level with base bleed unit which gave successful ignition to the base bleed grain and extended range was achieved with 155 mm artillery projectile.

Keywords: base bleed, closed vessel, igniter, zirconium

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Authors: Kalyan Koganti

Abstract:

Background: In India, platelet transfusions are given to large no. of patients suffering from dengue due to the fear of bleeding especially when the platelet counts are low. Though many patients do not bleed when the platelet count falls to less than 20,000, certain patients bleed even if the platelet counts are more than 20,000 without any comorbid condition (like gastrointestinal ulcer) in the past. This fear has led to huge amounts of unnecessary platelet transfusions which cause significant economic burden to low and middle-income countries like India and also sometimes these transfusions end with transfusion-related adverse reactions. Objective: To identify the role of Activated Partial Thromboplastin Time (APTT) in comparison with thrombocytoenia as an indicator to assess the real need of platelet transfusions. Method: A prospective study was conducted at a hospital in South India which included 176 admitted cases of dengue confirmed by immunochromatography. APTT was performed in all these patients along with platelet count. Cut off values of > 60 seconds for APTT and < 20,000 for platelet count were considered to assess the bleeding manifestations. Results: Among the total 176 patients, 56 patients had bleeding manifestations like malena, hematuria, bleeding gums etc. APTT > 60 seconds had a sensitivity and specificity of 93% and 90% respectively in identifying bleeding manifestations where as platelet count of < 20,000 had a sensitivity and specificity of 64% and 73% respectively. Conclusion: Elevated APTT levels can be considered as an indicator to assess the need of platelet transfusion in dengue. As there is a significant variation among patients who bleed with respect to platelet count, APTT can be considered to avoid unnecessary transfusions.

Keywords: activated partial thromboplastin time, dengue, platelet transfusion, thrombocytopenia

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Authors: Jeffey George, Varghese Thomas

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Background and Objectives: PHG is an important source of gastrointestinal bleeding in patients with portal hypertension. Aim: To assess the progression to severe portal hypertensive gastropathy(PHG) in patients with cirrhosis who were treated with maximum tolerated dose of propranalol, after variceal eradication to grade II or below. Methods: Cirrhotic patients(child A and B) presenting with upper gastrointestinal bleeding with endoscopic findings of mild or no PHG were followed up over 6 months after variceal eradication to assess the progression to severe PHG. Included patients were randomised to either maximum tolerated doses of propranalol (group A) or to no treatment (group B). Primary end point of the study were the development of gastrointestinal bleed, evidence of hepatic decompensation and death. Progression to severe PHG were compared between the two groups. Results: 56 patients (49 males) were enrolled (group A = 28, group B = 28). 8 patients were excluded from final analysis (gi bleed=5, encephalopathy=2,HCC=1 including 4 deaths).3 patients were lost to follow-up, and 1 developed intolerance to propranalol. Mean dose of propranalol used was 60 mg per day. Progression to severe PHG in the fundus over 6 months was 23.8% in group A versus 15.8 % in group B (p = 0.52). Severe PHG was noted in body in 14.3% in group A versus 21.1% in group B (p = 0.57). 23.8 % in group A had progression to severe PHG compared with 15.8 % in group B (p =0.52). There was no statistically significant difference in the progression of PHG between the two groups(p=0.43). Conclusion: In this short term study propranalol was found not to prevent the progression to severe portal hypertensive gastropathy in cirrhotic patients who had undergone endotherapy for esophageal varices.

Keywords: propranalol, portal hypertensive gastropathy, cirrhotic patients, gastroenterology

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Authors: Kinyas Aydin, Fatih Erguney, Tolga Ceper, Serap Ozay, Ipar N. Uzun, Sebnem Kemaloglu Dogan, Deniz Tunc

Abstract:

In order to meet high growth rates in baby diaper industry worldwide, the high-speed textile backsheet lamination lines have recently been introduced to the market for non-woven/film lamination applications. It is a process where two substrates are bonded to each other via hotmelt adhesive (HMA). Nonwoven (NW) lamination system basically consists of 4 components; polypropylene (PP) nonwoven, polyethylene (PE) film, HMA and applicator system. Each component has a substantial effect on the process efficiency of continuous line and final product properties. However, for a precise subject cover, we will be addressing only the main challenges and possible solutions in this paper. The NW is often produced by spunbond method (SSS or SMS configuration) and has a 10-12 gsm (g/m²) basis weight. The NW rolls can have a width and length up to 2.060 mm and 30.000 linear meters, respectively. The PE film is the 2ⁿᵈ component in TBS lamination, which is usually a 12-14 gsm blown or cast breathable film. HMA is a thermoplastic glue (mostly rubber based) that can be applied in a large range of viscosity ranges. The main HMA application technology in TBS lamination is the slot die application in which HMA is spread on the top of the NW along the whole width at high temperatures in the melt form. Then, the NW is passed over chiller rolls with a certain open time depending on the line speed. HMAs are applied at certain levels in order to provide a proper de-lamination strength in cross and machine directions to the entire structure. Current TBS lamination line speed and width can be as high as 800 m/min and 2100 mm, respectively. They also feature an automated web control tension system for winders and unwinders. In order to run a continuous trouble-free mass production campaign on the fast industrial TBS lines, rheological properties of HMAs and micro-properties of NWs can have adverse effects on the line efficiency and continuity. NW fiber orientation and fineness, as well as spun/melt blown composition fabric micro-level properties, are the significant factors to affect the degree of “HMA bleed through.” As a result of this problem, frequent line stops are observed to clean the glue that is being accumulated on the chiller rolls, which significantly reduces the line efficiency. HMA rheology is also important and to eliminate any bleed through the problem; one should have a good understanding of rheology driven potential complications. So, the applied viscosity/temperature should be optimized in accordance with the line speed, line width, NW characteristics and the required open time for a given HMA formulation. In this study, we will show practical aspects of potential preventative actions to minimize the HMA bleed through the problem, which may stem from both HMA rheological properties and NW spun melt/melt blown fiber characteristics.

Keywords: breathable, hotmelt, nonwoven, textile backsheet lamination, spun/melt blown

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Authors: Hameed Rukayat Opeyemi, Pericles Pilidis Pagone Emmanuele, Agbadede Roupa, Allison Isaiah

Abstract:

Climate change represents one of the single most challenging problems facing the world today. According to the National Oceanic and Administrative Association, Atmospheric temperature rose almost 25% since 1958, Artic sea ice has shrunk 40% since 1959 and global sea levels have risen more than 5.5cm since 1990. Power plants are the major culprits of GHG emission to the atmosphere. Several technologies have been proposed to reduce the amount of GHG emitted to the atmosphere from power plant, one of which is the less researched Advanced zero-emission power plant. The advanced zero emission power plants make use of mixed conductive membrane (MCM) reactor also known as oxygen transfer membrane (OTM) for oxygen transfer. The MCM employs membrane separation process. The membrane separation process was first introduced in 1899 when Walter Hermann Nernst investigated electric current between metals and solutions. He found that when a dense ceramic is heated, the current of oxygen molecules move through it. In the bid to curb the amount of GHG emitted to the atmosphere, the membrane separation process was applied to the field of power engineering in the low carbon cycle known as the Advanced zero emission power plant (AZEP cycle). The AZEP cycle was originally invented by Norsk Hydro, Norway and ABB Alstom power (now known as Demag Delaval Industrial turbomachinery AB), Sweden. The AZEP drew a lot of attention because its ability to capture ~100% CO2 and also boasts of about 30-50% cost reduction compared to other carbon abatement technologies, the penalty in efficiency is also not as much as its counterparts and crowns it with almost zero NOx emissions due to very low nitrogen concentrations in the working fluid. The advanced zero emission power plants differ from a conventional gas turbine in the sense that its combustor is substituted with the mixed conductive membrane (MCM-reactor). The MCM-reactor is made up of the combustor, low-temperature heat exchanger LTHX (referred to by some authors as air preheater the mixed conductive membrane responsible for oxygen transfer and the high-temperature heat exchanger and in some layouts, the bleed gas heat exchanger. Air is taken in by the compressor and compressed to a temperature of about 723 Kelvin and pressure of 2 Mega-Pascals. The membrane area needed for oxygen transfer is reduced by increasing the temperature of 90% of the air using the LTHX; the temperature is also increased to facilitate oxygen transfer through the membrane. The air stream enters the LTHX through the transition duct leading to inlet of the LTHX. The temperature of the air stream is then increased to about 1150 K depending on the design point specification of the plant and the efficiency of the heat exchanging system. The amount of oxygen transported through the membrane is directly proportional to the temperature of air going through the membrane. The AZEP cycle was developed using the Fortran software and economic analysis was conducted using excel and Matlab followed by optimization case study. The Simple bleed gas heat exchange layout (100 % CO2 capture), Bleed gas heat exchanger layout with flue gas turbine (100 % CO2 capture), Pre-expansion reheating layout (Sequential burning layout)–AZEP 85% (85% CO2 capture) and Pre-expansion reheating layout (Sequential burning layout) with flue gas turbine–AZEP 85% (85% CO2 capture). This paper discusses monte carlo risk analysis of four possible layouts of the AZEP cycle.

Keywords: gas turbine, global warming, green house gas, fossil fuel power plants

Procedia PDF Downloads 397

Authors: Hameed Rukayat Opeyemi, Pericles Pilidis, Pagone Emanuele

Abstract:

Climate change represents one of the single most challenging problems facing the world today. According to the National Oceanic and Administrative Association, Atmospheric temperature rose almost 25% since 1958, Artic sea ice has shrunk 40% since 1959 and global sea levels have risen more than 5.5 cm since 1990. Power plants are the major culprits of GHG emission to the atmosphere. Several technologies have been proposed to reduce the amount of GHG emitted to the atmosphere from power plant, one of which is the less researched Advanced zero emission power plant. The advanced zero emission power plants make use of mixed conductive membrane (MCM) reactor also known as oxygen transfer membrane (OTM) for oxygen transfer. The MCM employs membrane separation process. The membrane separation process was first introduced in 1899 when Walter Hermann Nernst investigated electric current between metals and solutions. He found that when a dense ceramic is heated, current of oxygen molecules move through it. In the bid to curb the amount of GHG emitted to the atmosphere, the membrane separation process was applied to the field of power engineering in the low carbon cycle known as the Advanced zero emission power plant (AZEP cycle). The AZEP cycle was originally invented by Norsk Hydro, Norway and ABB Alstom power (now known as Demag Delaval Industrial turbo machinery AB), Sweden. The AZEP drew a lot of attention because its ability to capture ~100% CO2 and also boasts of about 30-50 % cost reduction compared to other carbon abatement technologies, the penalty in efficiency is also not as much as its counterparts and crowns it with almost zero NOx emissions due to very low nitrogen concentrations in the working fluid. The advanced zero emission power plants differ from a conventional gas turbine in the sense that its combustor is substituted with the mixed conductive membrane (MCM-reactor). The MCM-reactor is made up of the combustor, low temperature heat exchanger LTHX (referred to by some authors as air pre-heater the mixed conductive membrane responsible for oxygen transfer and the high temperature heat exchanger and in some layouts, the bleed gas heat exchanger. Air is taken in by the compressor and compressed to a temperature of about 723 Kelvin and pressure of 2 Mega-Pascals. The membrane area needed for oxygen transfer is reduced by increasing the temperature of 90% of the air using the LTHX; the temperature is also increased to facilitate oxygen transfer through the membrane. The air stream enters the LTHX through the transition duct leading to inlet of the LTHX. The temperature of the air stream is then increased to about 1150 K depending on the design point specification of the plant and the efficiency of the heat exchanging system. The amount of oxygen transported through the membrane is directly proportional to the temperature of air going through the membrane. The AZEP cycle was developed using the Fortran software and economic analysis was conducted using excel and Matlab followed by optimization case study. This paper discusses techno-economic analysis of four possible layouts of the AZEP cycle. The Simple bleed gas heat exchange layout (100 % CO2 capture), Bleed gas heat exchanger layout with flue gas turbine (100 % CO2 capture), Pre-expansion reheating layout (Sequential burning layout) – AZEP 85 % (85 % CO2 capture) and Pre-expansion reheating layout (Sequential burning layout) with flue gas turbine– AZEP 85 % (85 % CO2 capture). This paper discusses Montecarlo risk analysis of four possible layouts of the AZEP cycle.

Keywords: gas turbine, global warming, green house gases, power plants

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Authors: Vanessa Roulet, Marc Turini, Juliane Hey, Stéphanie Bord-Romeu, Emilie Bonzom, Mahmoud Badawi, Mohammed-Amine Chakir, Valérie Simon, Vanessa Viotti, Jérémie Gautier, Françoise Le Boulaire, Catherine Coignard, Claire Vincent, Sandrine Greaume, Isabelle Voisin

Abstract:

Background: Beckman Coulter, Inc. has recently developed fully automated assays for the detection of HBsAg on a new immunoassay platform. The objective of this European multicenter study was to evaluate the performance of the ACCESS HBsAg and ACCESS HBsAg Confirmatory assays† on the recently CE-marked DxI 9000 ACCESS Immunoassay Analyzer. Methods: The clinical specificity of the ACCESS HBsAg and HBsAg Confirmatory assays was determined using HBsAg-negative samples from blood donors and hospitalized patients. The clinical sensitivity was determined using presumed HBsAg-positive samples. Sample HBsAg status was determined using a CE-marked HBsAg assay (Abbott ARCHITECT HBsAg Qualitative II, Roche Elecsys HBsAg II, or Abbott PRISM HBsAg assay) and a CE-marked HBsAg confirmatory assay (Abbott ARCHITECT HBsAg Qualitative II Confirmatory or Abbott PRISM HBsAg Confirmatory assay) according to manufacturer package inserts and pre-determined testing algorithms. False initial reactive rate was determined on fresh hospitalized patient samples. The sensitivity for the early detection of HBV infection was assessed internally on thirty (30) seroconversion panels. Results: Clinical specificity was 99.95% (95% CI, 99.86 – 99.99%) on 6047 blood donors and 99.71% (95%CI, 99.15 – 99.94%) on 1023 hospitalized patient samples. A total of six (6) samples were found false positive with the ACCESS HBsAg assay. None were confirmed for the presence of HBsAg with the ACCESS HBsAg Confirmatory assay. Clinical sensitivity on 455 HBsAg-positive samples was 100.00% (95% CI, 99.19 – 100.00%) for the ACCESS HBsAg assay alone and for the ACCESS HBsAg Confirmatory assay. The false initial reactive rate on 821 fresh hospitalized patient samples was 0.24% (95% CI, 0.03 – 0.87%). Results obtained on 30 seroconversion panels demonstrated that the ACCESS HBsAg assay had equivalent sensitivity performances compared to the Abbott ARCHITECT HBsAg Qualitative II assay with an average bleed difference since first reactive bleed of 0.13. All bleeds found reactive in ACCESS HBsAg assay were confirmed in ACCESS HBsAg Confirmatory assay. Conclusion: The newly developed ACCESS HBsAg and ACCESS HBsAg Confirmatory assays from Beckman Coulter have demonstrated high clinical sensitivity and specificity, equivalent to currently marketed HBsAg assays, as well as a low false initial reactive rate. †Pending achievement of CE compliance; not yet available for in vitro diagnostic use. 2023-11317 Beckman Coulter and the Beckman Coulter product and service marks mentioned herein are trademarks or registered trademarks of Beckman Coulter, Inc. in the United States and other countries. All other trademarks are the property of their respective owners.

Keywords: dxi 9000 access immunoassay analyzer, hbsag, hbv, hepatitis b surface antigen, hepatitis b virus, immunoassay

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Authors: Osagiede Efosa Kelvin

Abstract:

The Ebola virus disease (EVD); also Ebola hemorrhagic fever, is a disease of humans and other primates caused by Ebola viruses. Signs and symptoms typically start between two days and three weeks after contracting the virus as a fever, sore throat, muscle pain, and headaches. Then, vomiting, diarrhoea and rash usually follow, along with decreased function of the liver and kidneys. At this time, some people begin to bleed both internally and externally. The first death in Nigeria was reported on 25 July 2014: a Liberian-American with Ebola flew from Liberia to Nigeria and died in Lagos soon after arrival. As part of the effort to contain the disease, possible contacts were monitored –353 in Lagos and 451 in Port Harcourt On 22 September, the World Health Organisation reported a total of 20 cases, including eight deaths. The WHO's representative in Nigeria officially declared Nigeria Ebola-free on 20 October after no new active cases were reported in the follow-up contact. This paper looks at the Ebola Virus in general and the measures taken by Nigeria to combat its spread.

Keywords: Ebola virus, hemorrhagic fever, Nigeria, outbreak

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Authors: Dan W. Rhodes, Juliane Hey, Magali Karagueuzian, Florianne Martinez, Yael Sandowski, Vanessa Roulet, Mahmoud Badawi, Mohammed-Amine Chakir, Valérie Simon, Jérémie Gautier, Françoise Le Boulaire, Catherine Coignard, Claire Vincent, Sandrine Greaume, Isabelle Voisin

Abstract:

Background: Beckman Coulter, Inc. (BEC) has recently developed a fully automated second-generation anti-HCV test on a new immunoassay platform. The objective of this multicenter study conducted in Europe was to evaluate the performance of the ACCESS anti-HCV assay on the recently CE-marked DxI 9000 ACCESS Immunoassay Analyzer as an aid in the diagnosis of HCV (Hepatitis C Virus) infection and as a screening test for blood and plasma donors. Methods: The clinical specificity of the ACCESS anti-HCV assay was determined using HCV antibody-negative samples from blood donors and hospitalized patients. Sample antibody status was determined by a CE-marked anti-HCV assay (Abbott ARCHITECTTM anti-HCV assay or Abbott PRISM HCV assay) with an additional confirmation method (Immunoblot testing with INNO-LIATM HCV Score - Fujirebio), if necessary, according to pre-determined testing algorithms. The clinical sensitivity was determined using known HCV antibody-positive samples, identified positive by Immunoblot testing with INNO-LIATM HCV Score - Fujirebio. HCV RNA PCR or genotyping was available on all Immunoblot positive samples for further characterization. The false initial reactive rate was determined on fresh samples from blood donors and hospitalized patients. Thirty (30) commercially available seroconversion panels were tested to assess the sensitivity for early detection of HCV infection. The study was conducted from November 2019 to March 2022. Three (3) external sites and one (1) internal site participated. Results: Clinical specificity (95% CI) was 99.7% (99.6 – 99.8%) on 5852 blood donors and 99.0% (98.4 – 99.4%) on 1527 hospitalized patient samples. There were 15 discrepant samples (positive on ACCESS anti-HCV assay and negative on both ARCHITECT and Immunoblot) observed with hospitalized patient samples, and of note, additional HCV RNA PCR results showed five (5) samples had positive HCV RNA PCR results despite the absence of HCV antibody detection by ARCHITECT and Immunoblot, suggesting a better sensitivity of the ACCESS anti-HCV assay with these five samples compared to the ARCHITECT and Immunoblot anti-HCV assays. Clinical sensitivity (95% CI) on 510 well-characterized, known HCV antibody-positive samples was 100.0% (99.3 – 100.0%), including 353 samples with known HCV genotypes (1 to 6). The overall false initial reactive rate (95% CI) on 6630 patient samples was 0.02% (0.00 – 0.09%). Results obtained on 30 seroconversion panels demonstrated that the ACCESS anti-HCV assay had equivalent sensitivity performances, with an average bleed difference since the first reactive bleed below one (1), compared to the ARCHITECTTM anti-HCV assay. Conclusion: The newly developed ACCESS anti-HCV assay from BEC for use on the DxI 9000 ACCESS Immunoassay Analyzer demonstrated high clinical sensitivity and specificity, equivalent to currently marketed anti-HCV assays, as well as a low false initial reactive rate.

Keywords: DxI 9000 ACCESS Immunoassay Analyzer, HCV, HCV antibody, Hepatitis C virus, immunoassay

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Authors: Rômulo Eustáquio Martins de Souza, Paulo Alexandre Rodrigues de Vasconcelos Figueiredo

Abstract:

In recent years, there has been a surge in interest in applying artificial intelligence techniques, particularly machine learning algorithms. Machine learning is a data-analysis technique that automates the creation of analytical models, making it especially useful for designing complex situations. As a result, this technology aids in reducing human intervention while producing accurate results. This methodology is also extensively used in aerospace engineering since this is a field that encompasses several high-complexity operations, such as rocket propulsion. Rocket propulsion is a high-risk operation in which engine failure could result in the loss of life. As a result, it is critical to use computational methods capable of precisely representing the spacecraft's analytical model to guarantee its security and operation. Thus, this paper describes the use of machine learning algorithms for rocket propulsion to aid the realization that this technique is an efficient way to deal with challenging and restrictive aerospace engineering activities. The paper focuses on three machine-learning-aided rocket propulsion applications: set-point control of an expander-bleed rocket engine, supersonic retro-propulsion of a small-scale rocket, and leak detection and isolation on rocket engine data. This paper describes the data-driven methods used for each implementation in depth and presents the obtained results.

Keywords: data analysis, modeling, machine learning, aerospace, rocket propulsion

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Authors: Lina Liang, Kai Xu, Jing Zhang

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Purpose: Age-related macular degeneration (AMD) is a major leading cause of visual impairment and blindness with no cure currently established. Cell replacement is discussed as a potential therapy for AMD. Besides intravitreal injection and subretinal injection, intravenous administration has been explored as an alternative route. This study is to observe the effect of BSYJ, a traditional Chinese medicine on the homing and differentiation of mesenchymal stem cells transplanted via tail vein injection in an age-related macular degeneration mouse model. Methods: Four-week-old C57BL/6J mice were injected with 40 mg/kg NaIO₃ to induce age-related macular degeneration model. At the second day after NaIO₃ injection, 1×10⁷ GFP labeled bone marrow-derived mesenchymal stem cells (GFP-MSCs) were transplanted via tali vein injection into the experimental mice. Then the mice were randomly divided into two groups, gavaged with either BSYJ solution (BSYJ group, n=12) or distilled water (DW group, n=12). 12 age-matched healthy C57BL/6J mice were fed regularly as normal control. At day 7, day 14, and day 28 after treatment, retina flat mounting was used to detect the homing of mesenchymal stem cells at the retina. Double-labeling immunofluorescence was used to determine the differentiation of mesenchymal stem cells. Results: At 7, 14, 28 days after treatment, the numbers of GFP-MSCs detected by retina flatmount were 10.2 ± 2.5, 14.5 ± 3.4 and 18.7 ± 5.8, respectively in the distilled water group, while 15.7 ± 3.8, 32.3 ± 3.5 and 77.3 ± 6.4 in BSYJ group, the differences between the two groups were significant (p < 0.05). At 28 days after treatment, it was shown by double staining immunofluorescence that there were more GFP positive cells in the retina of BSYJ group than that of the DW group, but none of the cells expressed RPE specific genes such as RPE65 and CRALBP, or photoreceptor genes such as recoverin and rhodopsin either in BSYJ group or DW group. However, GFAP positive cells were found among the cells labeled with GFP, and the double labeling cells were much more in the BSYJ group than the distilled water group. Conclusion: BSYJ could promote homing of mesenchymal stem cells at the retina of age-related macular degeneration model mice induced by NaIO₃, and the differentiation towards to glial cells. Acknowledgement: National Natural Foundation of China (No: 81473736, 81674033,81973912).

Keywords: BSYJ, differentiation, homing, mesenchymal stem cells

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Authors: Norimichi Nagano, Yoshio Hirano, Tsutomu Yasukawa

Abstract:

Mesenchymal stem cells are thought to confer neuroprotection, facilitate tissue regeneration and exert their effects on retinal degenerative diseases, however, adverse events such as proliferative vitreoretinopathy and preretinal membrane disease associated with cell suspension transplantation have also been reported. We have recently developed human (allogeneic) adipose tissue-derived mesenchymal stem cell (adMSC) sheets through our proprietary sheet transformation technique, which could potentially mitigate these adverse events. To clarify the properties of our adMSC sheets named PAL-222, we performed in vitro studies such as viability testing, cytokine secretions by ELISA, immunohistochemical study, and migration assay. The viability of the cells exceeded 70%. Vascular Endothelial Growth Factor (VEGF) and Pigment Epithelium-Derived Factor (PEDF), which are quite important cytokines for the retinal area, were observed. PAL-222 expressed type I collagen, a strength marker, type IV collagen, a marker of the basement membrane, and elastin, an elasticity marker. Finally, the migration assay was performed and showed negative, which means that PAL-222 is stably kept in the topical area and does not come to pieces. Next, to evaluate the efficacy in vivo, we transplanted PAL-222 into the subretinal space of the eye of Royal College of Surgeons rats with congenital retinal degeneration and assessed it for three weeks after transplantation. We confirmed that PAL-222 suppressed the decrease in the thickness of the outer nuclear layer, which means that the photoreceptor protective effect treated with PAL-222 was significantly higher than that in the sham group. (p < 0.01). This finding demonstrates that PAL-222 showed their retinoprotective effect in a model of congenital retinal degeneration. As the study suggested the efficacy of PAL-222 in both in vitro and in vivo studies, we are presently engaged in clinical trials of PAL-222 for myopic chorioretinal atrophy, which is one of the retinal degenerative diseases, for the purpose of regenerative medicine.

Keywords: cell sheet, clinical trial, mesenchymal stem cell, myopic chorioretinal atrophy

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Authors: Dinoo Kirthinanda, Sujani Wijeratne

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Pseudohyperkalaemia is a common benign in vitro phenomenon caused by the release of potassium ions (K+) from cells during specimen processing. Analysis of haemolysed blood samples for predominantly intracellular electrolytes may lead to re-investigation and potentially harmful interventions. We report a case of a 52-year male with myeloproliferative disease manifested as Polycythaemia Rubra Vera, Hypertension and hypertensive nephropathy with stage 3 chronic kidney disease admitted to Neuro-intensive care unit (NICU) with an intra-cerebral haemorrhage secondary to hypertensive bleed. His initial blood investigations showed hyperkalemia with serum K+ 6.2 mmol/L yet the bedside arterial blood gas analysis yielded K+ of 4.6 mmol/L. The patient was however given hyperkalemia regime twice based on venous electrolyte analysis. The discrepancy between the bedside electrolyte analysis using arterial blood and venous blood prompted further evaluation. The 12 lead Electrocardiogram showed U waves and sinus bradycardia corresponding to the serum K+ of 2.8 mmol/L on arterial blood gas analysis. Immediate K+ replacement ensured the patient did not develop life-threatening cardiac complications. Pseudohyperkalaemia may pose diagnostic challenges in the absence of detectable haemolysis and should be suspected in susceptible patients with normal Electrocardiogram and Glomerular Filtration Rate to avoid potentially life-threatening interventions. When in doubt, rapid analysis of arterial blood gas may be useful for accurate quantification of potassium.

Keywords: patient safety, pseudohyperkalaemia, haemolysis, myeloproliferative disorder

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Authors: Saba Amreen Syeda, Summaiah Asim, Syeda, Hafsa, Essam Quraishi

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Mantle Cell Lymphoma (MCL) is a relatively uncommon type of lymphoma that comprises approximately 7 percent of non hodgkin's lymphomas (NHL), Classic MCL presents mostly in lymph nodes and occasionally in extranodal sites. About 26 % of MCL is present primarily in the Gastrointestinal tract. While both the upper GI tract and the lower GI tract could be involved, it is rare to present with concurrent upper and lower GI involvement with MCL. We present the case of a 51-year-old Asian Indian male that presented to our clinic with complaints of chronic diarrhea for the last one year, progressively worsening over the past three months. The Patient also reported black stool as well as bright red blood per rectum. Patient reported severe fatigue on minimal exertion. On a physical exam, the patient was noted to have matted lymphadenopathy in the neck. Patient was noted to be anemic with a hemoglobin to be 8 g/dl. Esophagogastroduodenoscopy and colonoscopy was performed. EGD showed a large 4 cm ulcer in the gastric antrum with thick heaped up edges. There was bleeding on contact. Colonoscopy showed a large 35 mm multilobulated polyp in the ascending colon, which was biopsied. The patient was also noted to have nodular proctitis in the mid rectum. This was localized and extended to about 5 cm. This area was biopsied as well. Biopsies from the stomach, colon, as well as the rectum, returned with findings of mantle cell lymphoma on pathology. Lymphoid cells in the biopsy were stained strongly positive for CD 20, cyclin D1, and CD 5. There was the absence of stain for CD 3 and CD 10. The IHC stain for CD 23 was negative. Biopsies from neck LAD were obtained and were also positive for MCL. The patient was referred to oncology for staging and treatment.

Keywords: mantle cell lymphoma, GI bleed, diarrhea, gastric ulcer, colon polyp

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Authors: Weaam Aldeeban, Majd Aljamali, Lama A. Youssef

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Background & Objective: Warfarin is considered a problematic drug due to its narrow therapeutic window and wide inter-individual response variations, which are attributed to demographic, environmental, and genetic factors, particularly single nucleotide polymorphism (SNPs) in the genes encoding VKORC1 and CYP2C9 involved in warfarin's mechanism of action and metabolism, respectively. CYP2C9*2rs1799853 and CYP2C9*3rs1057910 alleles are linked to reduced enzyme activity, as carriers of either or both alleles are classified as moderate or slow metabolizers, and therefore exhibit higher sensitivity of warfarin compared with wild type (CYP2C9*1*1). Our study aimed to assess the frequency of *1, *2, and *3 alleles in the CYP2C9 gene in a cohort of Syrian patients receiving a maintenance dose of warfarin for different indications, the impact of genotypes on warfarin dosing, and the frequency of adverse effects (i.e., bleedings). Subjects & Methods: This retrospective cohort study encompassed 94 patients treated with warfarin. Patients’ genotypes were identified by sequencing the polymerase chain reaction (PCR) specific products of the gene encoding CYP2C9, and the effects on warfarin therapeutic outcomes were investigated. Results: Sequencing revealed that 43.6% of the study population has the *2 and/or *3 SNPs. The mean weekly maintenance dose of warfarin was 37.42 ± 15.5 mg for patients with the wild-type allele (CYP2C9*1*1), whereas patients with one or both variants (*2 and/or *3) demanded a significantly lower dose (28.59 ±11.58 mg) of warfarin, (P= 0.015). A higher percentage (40.7%) of patients with allele *2 and/or *3 experienced hemorrhagic accidents compared with only 17.9% of patients with the wild type *1*1, (P = 0.04). Conclusions: Our study proves an association between *2 and *3 genotypes and higher sensitivity to warfarin and a tendency to bleed, which necessitates lowering the dose. These findings emphasize the significance of CYP2C9 genotyping prior to commencing warfarin therapy in order to achieve optimal and faster dose control and to ensure effectiveness and safety.

Keywords: warfarin, CYP2C9, polymorphisms, Syrian, hemorrhage

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Authors: Ahmed E. Hodaib, Muhammed A. Hashem

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High-speed transportation has become a growing concern. To increase high-speed efficiencies and minimize power consumption of a vehicle, we need to eliminate the friction with the ground and minimize the aerodynamic drag acting on the vehicle. Due to the complexity and high power requirements of electromagnetic levitation, we make use of the air in front of the capsule, that produces the majority of the drag, to compress it in two phases and inject a proportion of it through small nozzles to make a high-pressure air cushion to levitate the capsule. The tube is partially-evacuated so that the air pressure is optimized for maximum compressor effectiveness, optimum tube size, and minimum vacuum pump power consumption. The total relative mass flow rate of the tube air is divided into two fractions. One is by-passed to flow over the capsule body, ensuring that no chocked flow takes place. The other fraction is sucked by the compressor where it is diffused to decrease the Mach number (around 0.8) to be suitable for the compressor inlet. The air is then compressed and intercooled, then split. One fraction is expanded through a tail nozzle to contribute to generating thrust. The other is compressed again. Bleed from the two compressors is used to maintain a constant air pressure in an air tank. The air tank is used to supply air for levitation. Dividing the total mass flow rate increases the achievable speed (Kantrowitz limit), and compressing it decreases the blockage of the capsule. As a result, the aerodynamic drag on the capsule decreases. As the tube pressure decreases, the drag decreases and the capsule power requirements decrease, however, the vacuum pump consumes more power. That’s why Design optimization techniques are to be used to get the optimum values for all the design variables given specific design inputs. Aerodynamic shape optimization, Capsule and tube sizing, compressor design, diffuser and nozzle expander design and the effect of the air bearing on the aerodynamics of the capsule are to be considered. The variations of the variables are to be studied for the change of the capsule velocity and air pressure.

Keywords: tube-capsule, hyperloop, aerodynamic design optimization, air compressor, air bearing

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Authors: Girija Jha

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This paper investigates the need of cotton to integrate sustainability. The methodology used in the paper is to do secondary research to find out the various environmental implications of cotton as textile material across its life cycle and try to look at ways and possibilities of minimizing its ecological footprint. Cotton is called ‘The Fabric of Our Lives’. History is replete with examples where this fabric used to be more than a fabric of lives. It used to be a miracle fabric, a symbol India’s pride and social Movement of Swaraj, Gandhijee’s clarion call to self reliance. Cotton is grown in more than 90 countries across the globe on 2.5 percent of the world's arable land in countries like China, India, United States, etc. accounting for almost three fourth of global production. But cotton as a raw material has come under the scanner of sustainability experts because of myriad reasons a few have been discussed here. It may take more than 20,000 liters of water to produce 1kg of cotton. Cotton harvest is primarily done from irrigated land which leads to Salinization and depletion of local water reservoirs, e.g., Drying up of Aral Sea. Cotton is cultivated on 2.4% of total world’s crop land but accounts for 24% usage of insecticide and shares the blame of 11% usage of pesticides leading to health hazards and having an alarmingly dangerous impact on the ecosystem. One of the possible solutions to these problems as proposed was GM, Genetically Modified cotton crop. However, use of GM cotton is still debatable and has many ethical issues. The practice of mass production and increasing consumerism and especially fast fashion has been major culprits to disrupt this delicate balance. Disposable fashion or fast fashion is on the rise and cotton being one of the major choices adds on to the problem. Denims – made of cotton and have a strong fashion statement and the washes being an integral part of their creation they share a lot of blame. These are just a few problems listed. Today Sustainability is the need of the hour and it is inevitable to incorporate have major changes in the way we cultivate and process cotton to make it a sustainable choice. The answer lies in adopting minimalism and boycotting fast fashion, in using Khadi, in saying no to washed denims and using selvedge denims or using better methods of finishing the washed out fabric so that the environment does not bleed blue. Truly, the answer lies in integrating state of art technology with age old sustainable practices so that the synergy of the two may help us come out of the vicious circle.

Keywords: cotton, sustainability, denim, Khadi

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Authors: John Yahng, Hansraj Riteesh Bookun

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Objective: This was a retrospective cross-sectional study evaluating the safety of discharge on the first postoperative day following carotid surgery - principally carotid endarterectomy. Methods: Between January 2010 to October 2017, 252 patients with mean age of 72 years, underwent carotid surgery by seven surgeons. Their medical records were consulted and their operative as well as complication timelines were databased. Descriptive statistics were used to analyse pooled responses and our indicator variables. The statistical package used was STATA 13. Results: There were 183 males (73%) and the comorbid burden was as follows: ischaemic heart disease (54%), diabetes (38%), hypertension (92%), stage 4 kidney impairment (5%) and current or ex-smoking (77%). The main indications were transient ischaemic attacks (42%), stroke (31%), asymptomatic carotid disease (16%) and amaurosis fugax (8%). 247 carotid endarterectomies (109 with patch arterioplasty, 88 with eversion and transection technique, 50 with endarterectomy only) were performed. 2 carotid bypasses, 1 embolectomy, 1 thrombectomy with patch arterioplasty and 1 excision of a carotid body tumour were also performed. 92% of the cases were performed under general anaesthesia. A shunt was used in 29% of cases. The mean length of stay was 5.1 ± 3.7days with the range of 2 to 22 days. No patient was discharged on day 1. The mean time from admission to surgery was 1.4 ± 2.8 days, ranging from 0 to 19 days. The mean time from surgery to discharge was 2.7 ± 2.0 days with the of range 0 to 14 days. 36 complications were encountered over this period, with 12 failed repairs (5 major strokes, 2 minor strokes, 3 transient ischaemic attacks, 1 cerebral bleed, 1 occluded graft), 11 bleeding episodes requiring a return to the operating theatre, 5 adverse cardiac events, 3 cranial nerve injuries, 2 respiratory complications, 2 wound complications and 1 acute kidney injury. There were no deaths. 17 complications occurred on postoperative day 0, 11 on postoperative day 1, 6 on postoperative day 2 and 2 on postoperative day 3. 78% of all complications happened before the second postoperative day. Out of the complications which occurred on the second or third postoperative day, 4 (1.6%) were bleeding episodes, 1 (0.4%) failed repair , 1 respiratory complication (0.4%) and 1 wound complication (0.4%). Conclusion: Although it has been common practice to discharge patients on the second postoperative day following carotid endarterectomy, we find here that discharge on the first operative day is safe. The overall complication rate is low and most complications are captured before the second postoperative day. We suggest that patients having an uneventful first 24 hours post surgery be discharged on the first day. This should reduce hospital length of stay and the health economic burden.

Keywords: carotid, complication, discharge, surgery

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Authors: Daniel Thompson, Muhammad Peerbux, Sophie Cerutti, Hansraj Riteesh Bookun

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Patients with carotid stenosis, which may be asymptomatic or symptomatic in the form of transient ischaemic attack (TIA), amaurosis fugax, or stroke, often require an endarterectomy to reduce stroke risk. Risks of this procedure include stroke, death, myocardial infarction, and cranial nerve damage. Carotid endarterectomy is most commonly performed under general anaesthetic, however, it can also be undertaken with a regional anaesthetic approach. Our tertiary centre generally performs carotid endarterectomy under regional anaesthetic. Our major tertiary hospital mostly utilises regional anaesthesia for carotid endarterectomy. We completed a cross-sectional analysis of all cases of carotid endarterectomy performed under regional anaesthesia across a 10-year period between January 2010 to March 2020 at our institution. 350 patients were included in this descriptive analysis, and demographic details for patients, indications for surgery, procedural details, length of surgery, and complications were collected. Data was cross tabulated and presented in frequency tables to describe these categorical variables. 263 of the 350 patients in the analysis were male, with a mean age of 71 ± 9. 172 patients had a history of ischaemic heart disease, 104 had diabetes mellitus, 318 had hypertension, and 17 patients had chronic kidney disease greater than Stage 3. 13.1% (46 patients) were current smokers, and the majority (63%) were ex-smokers. Most commonly, carotid endarterectomy was performed conventionally with patch arterioplasty 96% of the time (337 patients). The most common indication was TIA and stroke in 64% of patients, 18.9% were classified as asymptomatic, and 13.7% had amaurosis fugax. There were few general complications, with 9 wound complications/infections, 7 postoperative haematomas requiring return to theatre, 3 myocardial infarctions, 3 arrhythmias, 1 exacerbation of congestive heart failure, 1 chest infection, and 1 urinary tract infection. Specific complications to carotid endarterectomy included 3 strokes, 1 postoperative TIA, and 1 cerebral bleed. There were no deaths in our cohort. This analysis of a large cohort of patients from a major tertiary centre who underwent carotid endarterectomy under regional anaesthesia indicates the safety of such an approach for these patients. Regional anaesthesia holds the promise of less general respiratory and cardiac events compared to general anaesthesia, and in this vulnerable patient group, calls for comparative research between local and general anaesthesia in carotid surgery.

Keywords: anaesthesia, carotid endarterectomy, stroke, carotid stenosis

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Authors: Zhao Jiashen, Serene Goh, Jerry Goo, Anthony Li, Lim Woan Wui, Paul Drakeford, Chen Qing Yan

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Introduction: Emergency laparotomy (EL) is one of the most common surgeries done in Singapore to treat acute abdominal pathologies. A significant proportion of these surgeries are performed in the geriatric population (65 years and older), who tend to have the highest postoperative morbidity, mortality, and highest utilization of intensive care resources. Frailty, the state of vulnerability to adverse outcomes from an accumulation of physiological deficits, has been shown to be associated with poorer outcomes after surgery and remains a strong driver of healthcare utilization and costs. To date, there is little understanding of the impact it has on emergency laparotomy outcomes. The objective of this study is to examine the impact of frailty on postoperative morbidity, mortality, and length of stay after EL. Methods: A retrospective study was conducted in two tertiary centres in Singapore, Tan Tock Seng Hospital and Khoo Teck Puat Hospital the period from January to December 2019. Patients aged 65 years and above who underwent emergency laparotomy for intestinal obstruction, perforated viscus, bowel ischaemia, adhesiolysis, gastrointestinal bleed, or another suspected acute abdomen were included. Laparotomies performed for trauma, cholecystectomy, appendectomy, vascular surgery, and non-GI surgery were excluded. The Clinical Frailty Score (CFS) developed by the Canadian Study of Health and Aging (CSHA) was used. A score of 1 to 4 was defined as non-frail and 5 to 7 as frail. We compared the clinical outcomes of elderly patients in the frail and non-frail groups. Results: There were 233 elderly patients who underwent EL during the study period. Up to 26.2% of patients were frail. Patients who were frail (CFS 5-9) tend to be older, 79 ± 7 vs 79 ± 5 years of age, p <0.01. Gender distribution was equal in both groups. Indication for emergency laparotomies, time from diagnosis to surgery, and presence of consultant surgeons and anaesthetists in the operating theatre were comparable (p>0.05). Patients in the frail group were more likely to receive postoperative geriatric assessment than in the non-frail group, 49.2% vs. 27.9% (p<0.01). The postoperative complications were comparable (p>0.05). The length of stay in the critical care unit was longer for the frail patients, 2 (IQR 1-6.5) versus 1 (IQR 0-4) days, p<0.01. Frailty was found to be an independent predictor of 90-day mortality but not age, OR 2.9 (1.1-7.4), p=0.03. Conclusion: Up to one-fourth of the elderly who underwent EL were frail. Patients who were frail were associated with a longer length of stay in the critical care unit and a 90-day mortality rate of more than three times that of their non-frail counterparts. PPOSSUM was a better predictor of 90-day mortality in the non-frail group than in the frail group. As frailty scoring was a significant predictor of 90-day mortality, its integration into acute surgical units to facilitate shared decision-making and discharge planning should be considered.

Keywords: frailty elderly, emergency, laparotomy

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Authors: Neerja Gupta

Abstract:

Objective-Reconstruction of large cavities of the breast without contralateral symmetrisation Background- Reconstruction of breast includes a wide spectrum of procedures from displacement to regional and distant flaps. The pedicled Perforator flaps cover a wide spectrum of reconstruction surgery for all quadrants of the breast, especially in patients with comorbidities. These axial flaps singly or adjunct are based on a near constant perforator vessel, a ratio of 2:1 at its entry in a flap is good to maintain vascularity. The perforators of lateral chest wall viz LICAP, LTAP have overlapping perfurosomes without clear demarcation. LTAP is localized in the narrow zone between the lateral breast fold and anterior axillary line,2.5-3.8cm from the fold. MICAP are localized at 1-2 cm from sternum. Being 1-2mm in diameter, a Single perforator is good to maintain the flap. LICAP has a dominant perforator in 6th-11th spaces, while LTAP has higher placed dominant perforators in 4th and 5th spaces. Methodology-Six consecutive patients who underwent reconstruction of the breast with pedicled perforator flaps were retrospectively analysed. Selections of the flap was done based on the size and locations of the tumour, anticipated volume loss, willingness to undergo contralateral symmetrisation, cosmetic expectations, and finances available.3 patients underwent vertical LTAP, the distal limit of the flap being the inframammary crease. 3 patients underwent MICAP, oriented along the axis of rib, the distal limit being the anterior axillary line. Preoperative identification was done using a unidirectional hand held doppler. The flap was raised caudal to cranial, the pivot point of rotation being the vessel entry into the skin. The donor area is determined by the skin pinch. Flap harvest time was 20-25 minutes. Intra operative vascularity was assessed with dermal bleed. The patient immediate pre, post-operative and follow up pics were compared independently by two breast surgeons. Patients were given a breast Q questionnaire (licensed) for scoring. Results-The median age of six patients was 46. Each patient had a hospital stay of 24 hours. None of the patients was willing for contralateral symmetrisation. The specimen dimensions were from 8x6.8x4 cm to 19x16x9 cm. The breast volume reconstructed range was 30 percent to 45 percent. All wide excision had free margins on frozen. The mean flap dimensions were 12x5x4.5 cm. One LTAP underwent marginal necrosis and delayed wound healing due to seroma. Three patients were phyllodes, of which one was borderline, and 2 were benign on final histopathology. All other 3 patients were invasive ductal cancer and have completed their radiation. The median follow up is 7 months the satisfaction scores at median follow of 7 months are 90 for physical wellbeing and 85 for surgical results. Surgeons scored fair to good in Harvard score. Conclusion- Pedicled perforator flaps are a valuable option for 3/8th volume of breast defects. LTAP is preferred for tumours at the Central, upper, and outer quadrants of the breast and MICAP for the inner and lower quadrant. The vascularity of the flap is dependent on the angiosomalterritories; adequate venous and cavity drainage.

Keywords: breast, oncoplasty, pedicled, perforator

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Authors: Benjamin J. Kuo, Silvia D. Vaca, Joao Ricardo Nickenig Vissoci, Catherine A. Staton, Linda Xu, Michael Muhumuza, Hussein Ssenyonjo, John Mukasa, Joel Kiryabwire, Lydia Nanjula, Christine Muhumuza, Henry E. Rice, Gerald A. Grant, Michael M. Haglund

Abstract:

Background: Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The disparities in the injury incidence and outcome between LMICs and resource-rich settings have led to increased health outcomes research for TBIs and their associated risk factors in LMICs. While there have been increasing TBI studies in LMICs over the last decade, there is still a need for more robust prospective registries. In Uganda, a trauma registry implemented in 2004 at the Mulago National Referral Hospital (MNRH) showed that RTI is the major contributor (60%) of overall mortality in the casualty department. While the prior registry provides information on injury incidence and burden, it’s limited in scope and doesn’t follow patients longitudinally throughout their hospital stay nor does it focus specifically on TBIs. And although these retrospective analyses are helpful for benchmarking TBI outcomes, they make it hard to identify specific quality improvement initiatives. The relationship among epidemiology, patient risk factors, clinical care, and TBI outcomes are still relatively unknown at MNRH. Objective: The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to a single tertiary hospital in Uganda. Methods: Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June – 30 November 2016. Research Electronic Data Capture (REDCap) was used to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality. Results: 563 TBI patients were enrolled from 1 June – 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours. Conclusions: The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Keywords: care continuum, global neurosurgery, Kampala Uganda, LMIC, Mulago, prospective registry, traumatic brain injury

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Authors: Anisa Suraya Ab Razak, Izza Hayat

Abstract:

Introduction: The diagnosis and management of severe hyponatremia in neuropsychiatric patients present a significant challenge to physicians. Several factors contribute, including diagnostic shadowing and attributing abnormal behavior to intellectual disability or psychiatric conditions. Hyponatraemia is the commonest electrolyte abnormality in the inpatient population, ranging from mild/asymptomatic, moderate to severe levels with life-threatening symptoms such as seizures, coma and death. There are several documented fatal case reports in the literature of severe hyponatremia secondary to psychogenic polydipsia, often diagnosed only in autopsy. This paper presents a case study of acute severe hyponatremia in a neuropsychiatric patient with early diagnosis and admission to intensive care. Case study: A 21-year old Caucasian male with known epilepsy and learning disability was admitted from residential living with generalized tonic-clonic self-terminating seizures after refusing medications for several weeks. Evidence of superficial head injury was detected on physical examination. His laboratory data demonstrated mild hyponatremia (125 mmol/L). Computed tomography imaging of his brain demonstrated no acute bleed or space-occupying lesion. He exhibited abnormal behavior - restlessness, drinking water from bathroom taps, inability to engage, paranoia, and hypersexuality. No collateral history was available to establish his baseline behavior. He was loaded with intravenous sodium valproate and leveritircaetam. Three hours later, he developed vomiting and a generalized tonic-clonic seizure lasting forty seconds. He remained drowsy for several hours and regained minimal recovery of consciousness. A repeat set of blood tests demonstrated profound hyponatremia (117 mmol/L). Outcomes: He was referred to intensive care for peripheral intravenous infusion of 2.7% sodium chloride solution with two-hourly laboratory monitoring of sodium concentration. Laboratory monitoring identified dangerously rapid correction of serum sodium concentration, and hypertonic saline was switched to a 5% dextrose solution to reduce the risk of acute large-volume fluid shifts from the cerebral intracellular compartment to the extracellular compartment. He underwent urethral catheterization and produced 8 liters of urine over 24 hours. Serum sodium concentration remained stable after 24 hours of correction fluids. His GCS recovered to baseline after 48 hours with improvement in behavior -he engaged with healthcare professionals, understood the importance of taking medications, admitted to illicit drug use and drinking massive amounts of water. He was transferred from high-dependency care to ward level and was initiated on multiple trials of anti-epileptics before achieving seizure-free days two weeks after resolution of acute hyponatremia. Conclusion: Psychogenic polydipsia is often found in young patients with intellectual disability or psychiatric disorders. Patients drink large volumes of water daily ranging from ten to forty liters, resulting in acute severe hyponatremia with mortality rates as high as 20%. Poor outcomes are due to challenges faced by physicians in making an early diagnosis and treating acute hyponatremia safely. A low index of suspicion of water intoxication is required in this population, including patients with known epilepsy. Monitoring urine output proved to be clinically effective in aiding diagnosis. Early referral and admission to intensive care should be considered for safe correction of sodium concentration while minimizing risk of fatal complications e.g. central pontine myelinolysis.

Keywords: epilepsy, psychogenic polydipsia, seizure, severe hyponatremia

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