High versus low mean arterial pressures in hepatorenal syndrome: A randomized controlled pilot trial

There is controversy regarding the mean arterial pressure (MAP) goals that should be targeted in the treatment of hepatorenal syndrome (HRS.) We conducted a study to assess different MAP targets in HRS in the intensive care unit (ICU).

MATERIALS AND METHODS

This is a prospective randomized controlled pilot trial. ICU patients had target mean arterial pressure (MAP) ≥ 85 mmHg (control arm) or 65-70 mmHg (study arm). Urine output and serum creatinine were trended and recorded.

RESULTS

A total of 18 patients were enrolled. The day four urine output in the high and low MAP group was 1194 (SD = 1249) mL/24 h and 920 (SD = 812) mL/24 h, respectively. The difference in day four - day one urine output was -689 (SD = 1684) mL/24 h and 272 (SD = 582) mL/24 h for the high and low MAP groups. The difference in serum creatinine at day four - day one was -0.54 (SD = 0.63) mg/dL and - 0.77 (SD = 1.14) mg/dL in the high and low MAP groups, respectively.

CONCLUSION

In this study, we failed to prove non-inferiority between a low and high target MAP in patients with HRS.

TRIAL REGISTRATION

This trial was registered with and approved by the University of Louisville Internal Review Board and hospital research review committees (IRB # 14.1190). The trial was registered with ClinicalTrials.gov (ID # NCT02789150). The IRB committee roster 7/21/2014-2/26/2015 is registered with IORG (IORG # IORG0000147; OMB # 0990-0279) and is available at http://louisville.edu/research/humansubjects/about-the-irb/rosters/RosterEffective20140721thru20150226.pdf.

Lansoprazole-Induced Thrombocytopenia in a Critically Ill Patient: A Case Report

Introduction:

Proton pump inhibitors (PPIs) may rarely cause thrombocytopenia. To our knowledge, only one case of lansoprazole-induced thrombocytopenia has been reported previously.

Case:

We report a case of a 50-year-old South Asian male who was admitted to the intensive care unit (ICU) after cardiac arrest during general anesthesia for ureteroscopy. During ICU stay, his platelet count dropped from 315×10³/µL to 57×10³/µL after 5 days of initiation of lansoprazole for stress-ulcer prophylaxis. After excluding other causes of thrombocytopenia; lansoprazole was stopped and his platelets recovered over the next few days. Later exposure to lansoprazole resulted in another drop in his platelet count with subsequent recovery after discontinuation of lansoprazole. A review of his home medications showed that he had been taking pantoprazole prior to hospitalization.

Discussion:

Thrombocytopenia has been previously reported with different PPIs. In the previously reported lansoprazole-induced thrombocytopenia, the level of certainty was not high due to lack of re-exposure. In the present case, another exposure to lansoprazole, without intention of rechallenge, reproduced the same adverse drug reaction (ADR). Although platelet-reactive antibodies testing was not available to confirm causation in this case, the Naranjo score was 8 which indicated probable causation by lansoprazole. Despite probable lansoprazole-induced thrombocytopenia, our patient had been tolerating pantoprazole. This finding highlights the different effects of individual PPIs on platelet counts in the same patient.

Conclusion:

Lansoprazole may cause thrombocytopenia. However, patients who develop lansoprazole-induced thrombocytopenia may tolerate other PPIs.

Retention and transport processes of particulate and dissolved micropollutants in stormwater biofilters treating road runoff

Road runoff is contaminated by various micropollutants and may be treated using low impact development techniques, such as stormwater biofilters. Better understanding the processes, such as filtration, sorption and leaching, which affect pollutants in these systems is essential to reliably predicting treatment performance and optimizing system design. Field data from an in situ monitoring campaign, wherein dissolved and particulate concentrations of a wide range of micropollutants (trace metals, polycyclic aromatic hydrocarbons, bisphenol-A, alkylphenols and phthalates) were characterized in untreated road runoff and biofilter outlets for 19 rain events, are used to explore transport and retention processes. Although retention of the particulate phase of pollutants was generally quite effective, unusually high particle concentrations were observed at biofilter outlets for three winter events. Particle characterization in road runoff and outlet waters revealed that this degraded performance was due to poor filtration rather than particle erosion, which was attributed to the relative abundance of small (<10 μm) particles during this period, along with possible preferential flows. Dissolved pollutants were less effectively removed in general. To better understand this behavior, field results were combined with laboratory sorption and leaching tests. Dissolved concentrations of trace metals were shown to be influenced by organic carbon; leaching from road-originated particles may also influence their transport. Removal of the dissolved phase of organic micropollutants was limited by the contamination of the filter media, either before installation or during the first period of operation, due to emissions from construction materials.

143 Effect of corpus luteum on recovery rate, quality, and in vitro developmental competence of oocytes in Bos indicus dairy cows

Assisted reproductive technologies have modernized the dairy industry for the rapid multiplication of superior genetic traits. However, the exploitation of genetics through in vitro embryo production in farm animals has been struggling during the last 3 decades. The presence or absence of a corpus luteum (CL) on ovaries from which cumulus-oocyte complexes were recovered has been shown to affect the quality of oocytes and in vitro embryo production outcome in Bos taurus cows. Similar information is lacking in Bos indicus cows. Therefore, the objectives of the present study were to determine the effect of presence or absence of a CL on recovery rate, quality, and in vitro developmental competence of oocytes in Bos indicus dairy cows. This study was conducted from December 2017 to April 2018. The ovaries were harvested from a local abattoir (Bos indicus; 5- to 8-year-old cows having mixed parity with clinically normal reproductive tracts). These ovaries (n=750) were divided into 2 groups [(1) CYCLIC (n=318) and (2) ACYCLIC (n=432)] based on the presence or absence of mature CL having follicles on either left or right ovaries of slaughtered cows. Blood samples from the jugular vein were collected at slaughter. Serum concentrations of progesterone of CYCLIC and ACYCLIC cows were measured using radioimmunoassay. Mean number of recovered oocytes per ovary and serum concentration of progesterone were compared using PROC TTEST model. However, quality, maturation, cleavage, 8-cell, 16-cell, and morula rates were analysed by PROC FREQ model of Chi-squared. All the data was analysed using SAS (SAS Institute Inc., Cary, NC, USA). Results revealed that the mean serum concentrations of progesterone (4.21±0.4v. 0.5±0.2ng mL−1; P&lt;0.05) were higher in CYCLIC as compared with ACYCLIC cows, respectively. The mean number of oocytes recovered per ovary (6.5±4.5v. 4.0±4.4; P&lt;0.05) was higher in CYCLIC than in ACYCLIC cows. The oocytes with grade I+II quality (55.3v. 47.6%; P&lt;0.05) were higher, whereas oocytes with grade III+IV quality (44.5v. 52.4%; P&lt;0.05) were lower, in CYCLIC as compared with ACYCLIC cows, respectively. Furthermore, cleavage rate (70.9v. 52.8%; P&lt;0.05) was higher in CYCLIC than in ACYCLIC cows, respectively. Similarly, the 8-cell (38.5v. 20.8%; P&lt;0.05) and 16-cell (20.0v. 10.9%; P&lt;0.05) stage embryos were greater in CYCLIC as compared with ACYCLIC cows, respectively. In conclusion, the presence of CL has a beneficial effect on recovery rate, quality, and in vitro embryo production outcomes in Bos indicus dairy cows. It is implied that for ovum pickup, cyclic cows should be preferred.

142 Effect of follicular size on oocyte recovery rate, quality, and in vitro developmental competency following maturation, fertilization, and culturing in Bos indicus cows

Applied reproductive technologies include AI, multiple ovulation and embryo transfer, IVF, cloning, ovum pickup, and zygote intra-fallopian tube transfer in farm animals. Modern commercialized dairy farming is ever more relying on in vitro embryo production for maximal utilisation of superior genetics of female animals. Follicular size influenced the quality of the oocytes and their in vitro developmental competence in Bos taurus cows. However, this information is lacking in Bos indicus cows. Therefore, the objectives of the present study were to determine the effect of follicular size on recovery rate, quality, and in vitro developmental competence of the oocytes in Bos indicus cows. The ovaries (n=508) of 5- to 8-years-old Bos indicus cows, body condition score 2.75±0.25, having mixed parity and clinically normal reproductive tracts, were collected. These follicles on the ovaries were divided into 2 groups based on their size: (1) &lt;6mm diameter and (2) ≥6mm diameter. The data on recovery; quality; maturation; cleavage rates; 4-cell, 8-cell, and 16-cell stages; and morula rate were analysed by Chi-squared test using SPSS version 20 software (IBM Corp., Armonk, NY, USA, 2016) system for windows. Results revealed that oocytes with grade I+II quality (68.4v. 42.1%; P&lt;0.05) were higher, whereas grade III+IV quality (31.6v. 57.5%; P&lt;0.05) were lower, in ≥6mm as compared with &lt;6mm groups, respectively. Moreover, the 4-cell (34.5v. 18.7%), 8-cell (15.4v. 7.7%), 16-cell (8.7v. 2.2%) stages and morula rate (4.5v. 0.3%) were higher (P&lt;0.05) in ≥6mm as compared with &lt;6mm groups, respectively. However, the maturation and cleavage rates did not differ (P&gt;0.05) between both groups. It is concluded that oocytes having follicle size ≥6mm have better quality in terms of morphological grades and in vitro developmental competence in Bos indicus cows. It is implied that for maximum production of embryos through ovum pickup, the most appropriate follicular size for aspiration is ≥6 mm.

Field performance of two biofiltration systems treating micropollutants from road runoff

The treatment efficiency of a vegetative filter strip and a biofiltration swale treating heavily loaded road runoff are evaluated. Concentrations measured in water drained from the two systems are compared to those in untreated road runoff collected from a reference catchment for a wide range of contaminants including organic carbon, nutrients (N and P), trace metals, and organic micropollutants (polycyclic aromatic hydrocarbons (PAH), total petroleum hydrocarbons (TPH), alkylphenols, bisphenol-A, phthalates), in both total and dissolved phases. Predominantly particulate pollutants, including Pb, Zn and PAH, were very efficiently removed (around 90%) for most events. However, poor particulate removal was observed during a winter period. Relatively few pollutants were significantly removed in the dissolved phase and observed concentration reductions tended to be lower than those of suspended solids and associated pollutants; as such, lower removals were observed for total concentrations of moderately particulate micropollutants, including bisphenol-A, alkylphenols and phthalates. In addition, some pollutants appear to be emitted from various biofilter components (filter media, drainage and lining materials), as low or negative concentration removals were observed during the first months of operation of the biofiltration swale.

Secondary intraocular lens implantation with absence of capsular support: Scleral versus iris fixation

PURPOSE

To assess the outcomes of iris fixated (IF) posterior chamber (PC) intraocular lens (IOL) versus scleral-fixated (SF) PC IOL implantation, and compare them with the results reviewed from the literature.

SETTING

The study took place in the ophthalmology department of the Eye and Ear Hospital (Lebanon).

DESIGN

This is a retrospective institutional study that collected the records of patients admitted for secondary IOL implantation between January 2007 and December 2016.

METHODS

A total of 28 eyes that underwent PC IOL fixation were included, 13 of which underwent trans-scleral PC IOL fixation and 15 of which underwent iris PC IOL fixation. Data were analyzed over a period of 3 years.

RESULTS

Of the 28 patients, 18 (64.3%) were male and 10 (35.7%) were female (mean age at intervention 36.78±23.47 [standard deviation, SD] years). There were no significant intergroup differences with regard to baseline values and demographic characteristics. Trauma was the most common etiology for posterior capsule insufficiency (82.1%). The mean preoperative baseline BCVA was 0.58±0.27 logMAR for SF and 0.27±0.20 logMAR for IF (P=0.07). Both groups had significant improvement in vision during the follow up period. No significant differences were noted regarding early or late postoperative complications between the two groups.

CONCLUSION

SF and IF techniques for PC IOL have similar outcomes and result in a significant improvement in BCVA. When compared to AC (anterior chamber) IOL, both techniques seem to yield fewer complications.

Prostate sparing cystectomy for bladder cancer: A two-center study

PURPOSE

To assess long-term functional and oncologic outcomes of prostate sparing cystectomy (PSC) as a sexuality-preserving alternative to radical cystectomy in a selected group of bladder cancer (BC) patients.

MATERIALS AND METHODS

Between 1995 and 2014, 185 BC patients underwent PSC according to one of two standardized procedures at two centers. All patients had received extensive evaluation to rule out prostate cancer and BC at the bladder neck and prostatic urethra (PU), including prostate specific antigen blood analysis, transrectal ultrasound and/or prostate biopsies, PU biopsies and/or PU frozen section analysis. All patients received an orthotopic ileal neobladder. Overall survival (OS) was assessed by Kaplan-Meier estimates. Cumulative incidence of cancer specific mortality, any recurrence and loco-regional recurrence were calculated using competing-risk methods. Finally, functional outcomes (voiding, continence and erectile function) were evaluated.

RESULTS

185 patients (cTa-3N0M0) with a mean age of 57 years (SD: 9) were included. Median follow-up was 7.5 years (IQR: 5.6-10.8). Five-year OS was 71% and 5-year cumulative incidence of recurrence was 31%. Twenty patients (10.8%) had a loco-regional recurrence, two recurrences were in the PU. During follow-up, prostate cancer was detected in six patients (3.2%). Erectile function was preserved in 86.1% of patients, complete daytime and nighttime continence in 95.6% and 70.2%, respectively.

CONCLUSION

This two-center study shows that in men with BC in whom the prostate and PU were proven free of malignancy, PSC would represent a valid treatment option with excellent functional outcome. Oncologic outcomes were comparable to what is known from radical cystoprostatectomy series.

Continuous infusion of furosemide versus intermittent boluses in acute decompensated heart failure: Effect on thoracic fluid content

INTRODUCTION

The administration of loop diuretics in the management of acute decompensated heart failure (ADHF) whether IV boluses or continuous infusion is still controversial. We intended to evaluate differences between the two administration routes on the thoracic fluid content (TFC) and the renal functions.

METHODS

Sixty patients with ADHF admitted to the critical care medicine department (Cairo University, Egypt) were initially enrolled in the study. Twenty patients were excluded due to EF > 40%, myocardial infarction within 30 days, and baseline serum creatinine level > 4.0 mg/dL. Furosemide (120 mg/day) was given to the remaining 40 pts who continued the study after 1:1 randomization to either continuous infusion (group-I, 20 pts) or three equal intermittent daily doses (group-II, 20 pts). Subsequent dose titration was allowed after 24 h, but not earlier, according to patient's response. No other diuretic medications were allowed. All patients were daily evaluated for NYHA class, urine output, TFC, body weight, serum K+, and renal chemistry.

RESULTS

The median age (Q1-Q3) was 54.5 (43.8-63.8) years old with 24 (60%) males. Apart from TFC which was significantly higher in group-I, the admission demographic, clinical, laboratory and co-morbid conditions were similar in both groups. There was statistically insignificant tendency for increased urine output during the 1st and 2nd days in group-I compared to group-II (p = .08). The body weight was decreased during the 1st day by 2 (1.5-2.5) kg in group-I compared to 1.5 (1-2) kg in group-II, (p = .03). These changes became insignificant during the 2nd day (p = .4). The decrease of TFC was significantly higher in group-I than in group-II [10 (6.3-14.5) vs 7 (3.3-9.8) kΩ-1 during the first day and 8 (6-11) vs 6 (3.3-8.5) kΩ-1 during the second day in groups-I&II respectively, P = .02 for both]. There was similar NYHA class improvement in both groups (p = .7). The serum creatinine was increased by 0.2 (0.1-0.5) vs 0 (-0.1 to 0.2) mg% and the CrCl was decreased by 7.4 (4.5-12.3) vs 3.1 (0.2-8.8) ml/min in groups-I&II respectively (p = .009 and .02 respectively).

CONCLUSIONS

We concluded that continuous furosemide infusion in ADHF might cause greater weight loss and more decrease in TFC with no symptomatic improvement and possibly with more nephrotoxic effect.

Importance of Local and Regional Scales in Shaping Mycobacterial Abundance in Freshwater Lakes

Biogeographical studies considering the entire bacterial community may underestimate mechanisms of bacterial assemblages at lower taxonomic levels. In this context, the study aimed to identify factors affecting the spatial and temporal dynamic of the Mycobacterium, a genus widespread in aquatic ecosystems. Nontuberculous mycobacteria (NTM) density variations were quantified in the water column of freshwater lakes at the regional scale (annual monitoring of 49 lakes in the Paris area) and at the local scale (2-year monthly monitoring in Créteil Lake) by real-time quantitative PCR targeting the atpE gene. At the regional scale, mycobacteria densities in water samples ranged from 6.7 × 10³ to 1.9 × 10⁸ genome units per liter. Density variations were primarily explained by water pH, labile iron, and dispersal processes through the connection of the lakes to a river. In Créteil Lake, no spatial variation of mycobacterial densities was noticed over the 2-year monthly survey, except after large rainfall events. Indeed, storm sewer effluents locally and temporarily increased NTM densities in the water column. The temporal dynamic of the NTM densities in Créteil Lake was associated with suspended solid concentrations. No clear seasonal variation was noticed despite a shift in NTM densities observed over the 2012-2013 winter. Temporal NTM densities fluctuations were well predicted by the neutral community model, suggesting a random balance between loss and gain of mycobacterial taxa within Créteil Lake. This study highlights the importance of considering multiple spatial scales for understanding the spatio-temporal dynamic of bacterial populations in natural environments.

Monitoring joint quality: Taguchi approach and structure investigation

Purpose

This paper aims to monitor, evaluate and adjust the joint quality of dissimilar friction stir welded AA2024-T3 and AA7075-T6 Al alloys.

Design/methodology/approach

Taguchi analysis for design of experiments and ANOVA analysis were applied. Tensile test, visual inspection and macro and microstructure investigations were carried out at each welding condition. In addition, the grain size of stir zone and the value of heat input were measured.

Findings

Using Taguchi analysis, the optimum values of tool rotary speed, welding speed and axial load were 1,200 rpm, 100 mm/min and 1,300 kg, respectively, yielding the maximum tensile strength of the joints of 427 MPa. ANOVA analysis indicated that the most significant parameter on the joint strength is the tool rotary speed, followed by welding speed and axial load, with contributions of 67, 27 and 2 per cent, respectively. Best mixing between Al alloys in the stir zone with no defects was observed at moderate speeds because of proper heat input and grain size, resulting in high strength.

Originality/value

A relation between structure characteristics of the joint, the process parameters and the joint strength was established to control the joint quality.