Use of jejunal serosal patch and pyloric exclusion in the management of complex duodenal injury

BACKGROUND

Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma.

TECHNIQUE

The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.

Review on Fatigue of Additive Manufactured Metallic Alloys: Microstructure, Performance, Enhancement, and Assessment Methods

Additive manufacturing (AM), which is a process of building objects in a layer-upon-layer fashion from designed models, has received unprecedented attention from research and industry because it offers outstanding merits of flexibility, customization, reduced buy-to-fly ratio, and cost-effectiveness. However, the fatigue performance of safety-critical industrial components fabricated by AM is still far below that obtained from conventional methods. This review discusses the microstructural heterogeneities, randomly dispersed defects, poor surface quality, and complex residual stress generated during the AM process that can negatively impact the fatigue performance of as-printed parts. The difference in microstructural origin of fatigue failure between conventionally manufactured and printed metals is reviewed with particular attention to the effects of the trans-scale microstructures on AM fatigue failure mechanisms. Various methods for mitigating the fatigue issue, including pre-process, inter-process, and post-process treatments, are illustrated. Empirical, semi-empirical, and microstructure-sensitive models are presented to predict fatigue strength and lifetime. Summary and outlooks for future development of the fatigue performance of AM materials are provided.

The electron density: a fidelity witness for quantum computation

There is currently no combination of quantum hardware and algorithms that can provide an advantage over conventional calculations of molecules or materials. However, if or when such a point is reached, new strategies will be needed to verify predictions made using quantum devices. We propose that the electron density, obtained through experimental or computational means, can serve as a robust benchmark for validating the accuracy of quantum computation of chemistry. An initial exploration into topological features of electron densities, facilitated by quantum computation, is presented here as a proof of concept. Additionally, we examine the effects of constraining and symmetrizing measured one-particle reduced density matrices on noise-driven errors in the electron density distribution. We emphasize the potential benefits and future need for high-quality electron densities derived from diffraction experiments for validating classically intractable quantum computations of materials.

Vascular Interventions in Oncology

Vascular interventions are an important and established tool in the management of the oncology patient. The goal of these procedures may be curative, palliative or adjunctive in nature. Some of the common vascular interventions used in oncology include transarterial embolisation or chemoembolisation, selective internal radiation therapy, chemosaturation, venous access lines, superior vena cava stenting and portal vein embolisation. We provide an overview of the principles, technology and approach of vascular techniques for tumour therapy in both the arterial and venous systems. Arterial interventions are currently mainly used in the management of hepatocellular carcinoma. Transarterial embolisation, chemoembolisation and selective internal radiation therapy deliver targeted catheter-delivered treatments with the aim of reducing tumour burden, controlling tumour growth or increasing survival in patients not eligible for transplantation. Chemosaturation is a regional chemotherapy technique that delivers high doses of chemotherapy directly to the liver via the hepatic artery, while reducing the risks of systemic effects. Venous interventions are more adjunctive in nature. Venous access lines are used to provide a means of delivering chemotherapy and other medications directly into the bloodstream. Superior vena cava stenting is a palliative procedure that is used to relieve symptoms of superior vena cava obstruction. Portal vein embolisation is a procedure that allows hypertrophy of a healthy portion of the liver in preparation for liver resection. Interventional radiology-led vascular interventions play an essential part of cancer management. These procedures are minimally invasive and provide a safe and effective adjunct to traditional cancer treatment methods. Appropriate work-up and discussion of each patient-specific problem in a multidisciplinary setting with interventional radiology is essential to provide optimum patient-centred care.

Radiation Synthesis of Carbon/Aluminum/Silica Aerogel Nanoporous Structure Derived from Polyacrylamide Hydrogel for High Temperature and Oil Removal Applications

Aerogel is a high-performance thermal resistance material desired for high-temperature applications like dye-sensitized solar cells, batteries, and fuel cells. To increase the energy efficiency of batteries, an aerogel is required to reduce the energy loss arising from the exothermal reaction. This paper synthesized a different composition of inorganic-organic hybrid material by growing the silica aerogel inside a polyacrylamide (PAAm) hydrogel. The hybrid PaaS/silica aerogel was synthesized using different irradiation doses of gamma rays (10-60 kGy) and different solid contents of PAAm (6.25, 9.37, 12.5, and 30 wt %). Here, PAAm is used as an aerogel formation template and carbon precursor after the carbonization process at a temperature of (150, 350, and 1100 °C). The hybrid PAAm/silica aerogel was converted into aluminum/silicate aerogels after soaking in a solution of AlCl₃. Then, the carbonization process takes place at a temperature of (150, 350, and 1100 °C) for 2 h to provide C/Al/Si aerogels with a density of around 0.18-0.040 gm/cm³ and porosity of 84-95%. The hybrid C/Al/Si aerogels presented interconnected networks of porous structures with different pore sizes depending on the carbon and PAAm contents. The sample with a solid content of 30% PAAm in the C/Al/Si aerogel was composed of interconnected fibrils whose diameter was about 50 μm. The structure after carbonization at 350 and 1100 °C was a condensed opening porous 3D network structure. This sample gives the optimum thermal resistance and a very low thermal conductivity of 0.073 (w/m·k) at low carbon content (2.71% at temperature 1100 °C) and high v_pore (95%) compared with carbon content 42.38% and v_pore (93%) which give 0.102 (w/m·k). This is because at 1100 °C, the carbon atoms evolve to leave an area between Al/Si aerogel particles, increasing the pore size. Furthermore, the Al/Si aerogel had excellent removal ability for various oil samples.

Assessment of Safety, Efficacy and Predictability of a Trifocal Intraocular Lens

Purpose:  To evaluate the performance and the visual outcomes of Acrysof PanOptix trifocal IOL in terms of safety, efficacy, predictability and assessment of the quality of vision after implantation as regards; contrast sensitivity and ocular aberrations. Study Design:  Quasi experimental study. Place and Duration of Study:  Dar el Ouyon hospital and Rowad Correction Center, Egypt, from September 2019 and January 2020. Methods:  Forty eyes of twenty-one patients with senile cataract were included by convenient sampling. All eyes underwent phacoemulsification with IOL implantation. They were divided into two groups; group A included twenty eyes of eleven patients who were implanted AcrySof IQ PanOptix trifocal IOL Model TFNT00. Group B included twenty eyes of ten patients who were implanted monofocal AcrySof IOLs as a control group. A questionnaire was given to every patient after explaining to him\her the questions in Arabic, and clarifying the aim of evaluation. Results:  Mean age was 56.6 ± 6.9 years in group A and 62.8 ± 7.1 years in group B, range 50 – 70 (P = 0.861). We found statistical significant difference between both groups with group A showing better post operative uncorrected distance, intermediate, near, and best corrected near visual acuity (P values were 0.001, 0.556, 0.001, 0.177, 0.001, 0.001 respectively). Group B showed statistically significant better post operative contrast sensitivity compared to group A. Conclusion:  In this study, Acrysof PanOptix trifocal IOL showed excellent safety, efficacy, predictability and spectacle independence at all distances, However, contrast sensitivity was compromised in comparison to the monofocal group.

Effects of graphene, alumina, and their hybrid on dynamic mechanical behavior of epoxy-based nanocomposites

Graphene has excellent mechanical and thermal properties, while alumina has inexpensive and strong thermal stability, making it ideal for electronic packaging applications. The current work examines the effects of modest loadings of reduced graphene oxide (rGO), alumina (Ala), and their hybrids on the dynamic mechanical characteristics and thermal transitions of epoxy-based nanocomposites. The rGO was made using a modified Hummers’ method. Alumina nanoparticles were used as received. Various epoxy nanocomposite samples with 1 wt% of rGO, 1 wt% of Ala, and 0.5 wt% each of rGO and Ala were created. Then, Raman spectroscopy, XRD, FTIR, XPS, TEM, AFM, and SEM were used to analyze the fillers and their hybrid and epoxy-based nanocomposites. Dynamic mechanical analysis was used to examine the hybrid epoxy-based nanocomposites’ dynamic mechanical behavior. It has been demonstrated that different epoxy nanocomposites with 1 wt% Ala and 1 wt% rGO have higher elastic moduli than those with 0.5 wt% rGO and 0.5 wt% Ala. The rGO-Ala hybrid nanocomposites, on the other hand, exhibit moderate damping and glass transition temperatures. The reason for that may be because Ala filler increases the contact area between the rGO sheets and serves as a bridge between the two fillers, decreasing the resistance to deformation. This may enhance the possibility that these stress concentrations will weaken the composites.

Reference-State Error Mitigation: A Strategy for High Accuracy Quantum Computation of Chemistry

Decoherence and gate errors severely limit the capabilities of state-of-the-art quantum computers. This work introduces a strategy for reference-state error mitigation (REM) of quantum chemistry that can be straightforwardly implemented on current and near-term devices. REM can be applied alongside existing mitigation procedures, while requiring minimal postprocessing and only one or no additional measurements. The approach is agnostic to the underlying quantum mechanical ansatz and is designed for the variational quantum eigensolver. Up to two orders-of-magnitude improvement in the computational accuracy of ground state energies of small molecules (H₂, HeH⁺, and LiH) is demonstrated on superconducting quantum hardware. Simulations of noisy circuits with a depth exceeding 1000 two-qubit gates are used to demonstrate the scalability of the method.

Training generative adversarial networks for optical property mapping using synthetic image data

We demonstrate the training of a generative adversarial network (GAN) for the prediction of optical property maps (scattering and absorption) using spatial frequency domain imaging (SFDI) image data sets that are generated synthetically with a free open-source 3D modelling and rendering software, Blender. The flexibility of Blender is exploited to simulate 5 models with real-life relevance to clinical SFDI of diseased tissue: flat samples containing a single material, flat samples containing 2 materials, flat samples containing 3 materials, flat samples with spheroidal tumours and cylindrical samples with spheroidal tumours. The last case is particularly relevant as it represents wide-field imaging inside a tubular organ e.g. the gastro-intestinal tract. In all 5 scenarios we show the GAN provides an accurate reconstruction of the optical properties from single SFDI images with a mean normalised error ranging from 1.0-1.2% for absorption and 1.1%-1.2% for scattering, resulting in visually improved contrast for tumour spheroid structures. This compares favourably with the ∼10% absorption error and ∼10% scattering error achieved using GANs on experimental SFDI data. Next, we perform a bi-directional cross-validation of our synthetically-trained GAN, retrained with 90% synthetic and 10% experimental data to encourage domain transfer, with a GAN trained fully on experimental data and observe visually accurate results with an error of 6.3%-10.3% for absorption and 6.6%-11.9% for scattering. Our synthetically trained GAN is therefore highly relevant to real experimental samples but provides the significant added benefits of large training datasets, perfect ground-truths and the ability to test realistic imaging geometries, e.g. inside cylinders, for which no conventional single-shot demodulation algorithms exist. In the future, we expect that the application of techniques such as domain adaptation or training on hybrid real-synthetic datasets will create a powerful tool for fast, accurate production of optical property maps for real clinical imaging systems.

Engineering Symmetry-Selective Couplings of a Superconducting Artificial Molecule to Microwave Waveguides

Tailoring the decay rate of structured quantum emitters into their environment opens new avenues for nonlinear quantum optics, collective phenomena, and quantum communications. Here, we demonstrate a novel coupling scheme between an artificial molecule comprising two identical, strongly coupled transmon qubits and two microwave waveguides. In our scheme, the coupling is engineered so that transitions between states of the same (opposite) symmetry, with respect to the permutation operator, are predominantly coupled to one (the other) waveguide. The symmetry-based coupling selectivity, as quantified by the ratio of the coupling strengths, exceeds a factor of 30 for both waveguides in our device. In addition, we implement a Raman process activated by simultaneously driving both waveguides, and show that it can be used to coherently couple states of different symmetry in the single-excitation manifold of the molecule. Using that process, we implement frequency conversion across the waveguides, mediated by the molecule, with efficiency of about 95%. Finally, we show that this coupling arrangement makes it possible to straightforwardly generate spatially separated Bell states propagating across the waveguides. We envisage further applications to quantum thermodynamics, microwave photodetection, and photon-photon gates.

Native pulmonary valve endocarditis requiring pulmonary valve replacement in adulthood: a case series

Native pulmonary valve endocarditis is a rare phenomenon as native valve endocarditis tends to typically affect the left sided heart valves. However, the right-sided heart valves can be affected in patients with a history of intravenous drug use, whereby the tricuspid valve is most commonly affected. We present two cases who were diagnosed with native pulmonary valve endocarditis in the absence of congenital heart disease. In the first case, the native pulmonary valve endocarditis was probably a derivative of compounding factors of an enlarged underlying pulmonary artery and staphylococcal bacteraemia. In the second case, a common causal organism of native valve endocarditis following dental treatment and the resultant echocardiography findings was of significant interest. In summary, native pulmonary valve endocarditis is relatively rare complication in the adult population, especially in the absence of congenital heart disease.

Posterior stabilized total knee arthroplasty increases the risk of postoperative periprosthetic fractures

Background

The Insall-Burstein posterior-stabilized knee design was first developed in 1978 by adding a central cam mechanism to the articular surface geometry of the total condylar prosthesis to correct its problems being not “rolling back”. Since then, the use of posterior-stabilized (PS) implants in total knee arthroplasty (TKA) is becoming increasingly popular. However, one of the main disadvantages of PS designs is related to the amount of bone removed during femoral box osteotomy to create the housing of the PS mechanism, the clinical value of removing more or less bone during primary TKA remains to be fully established. The objective of this study was to compare the incidence of early postoperative periprosthetic fractures in the cruciate retaining (CR) and posterior stabilized (PS) knee prosthesis.

Methods

An institutional high volume arthroplasty unit database was reviewed to identify all patients who sustained a postoperative periprosthetic fracture following primary TKA between January 2014 and May 2018. A retrospective chart review was performed to collect clinical, radiographic, and operative report data. A total of 352 patients with 600 primary TKAs were identified. (300 cases of cruciate retaining TKAs from 178 patients and 300 cases of posterior stabilized TKAs from 174 patients) were retrospectively reviewed.

Results

Eleven patients (1.83%) sustained periprosthetic fractures in the postoperative setting following primary TKA. All of the fractures were located on the femur and were treated surgically. Only one knee (one patient) from the CR group sustained a periprosthetic fracture, while 10 knees (from 10 patients) from the PS group sustained a fracture. The relative risk of sustaining a fracture in the CR group was 0.10 times relative to the PS group (RR   =   0.10, 95% CI 0.0129 – 0.776).

Conclusion

Posterior stabilized total knee arthroplasties (TKAs) significantly increase the risk of periprosthetic fractures in obese Asian patients compared to cruciate retaining TKAs.

[Possibilities and prospects for experimental and clinical instrumentation techniques for determining the primary stability of dental implants in comparative analysis]

The high primary stability of dental implants provides a favorable prognosis for orthopedic treatment with implant-supported structures. The importance of assessing the stability and the bone tissue surrounding the implant as a whole is due to the fact that the process of osseointegration is a structural and functional connection between the bone and the loaded surface of the implant. Determination of the dynamics of the stability of dental implants allows timely monitoring of unpredictable changes at the stages of osseointegration and remodeling of bone tissue around the implant. Currently, in addition to clinical and radiation diagnostic methods, there are generally recognized by clinicians frequency resonance analysis and periotestometry. However, there are some scientific discrepancies indicating the lack of objectivity of these methods and the impossibility of their full-fledged application without the support of radiation and clinical diagnostic methods. In addition to these methods, there are many experimental and less common methods in clinical practice for assessing the primary stability of implants, but with reasonable objectivity. Thus, the reasons are given that for a full assessment of the relationship between the efforts exerted on implants and their movements in the space of bone tissue, devices are needed that reflect the stability and density of the contact of the implant with bone tissue in physical quantities. In particular, methods based on lasers, sound, quantitative ultrasound, and others have found experimental practical application. The ultrasound method of assessing the primary stability of the implant is estimated as the most promising, since it allows you to demonstrate the results of studies in certain physical quantities, as well as to compare these results with histomorphological indicators of osseointegration of dental implants.

1585 The “6Pm Series” Addressing Medical Education for Final Year Medical Students During the Pandemic

Aim

Free clinical teaching online delivered by NHS junior doctors to address a drop in face-to-face teaching.

Method

We created a block-based syllabus of topics that are commonly examined and created an SBA format series of online lectures. The lectures were delivered online and the lectures were carried out by NHS doctors. We delivered 30 continuous lectures in a 30-day period that covered a variety of topics. Each lecture lasted between 45 to 60 minutes and featured real time interactive mcqs which the students had a limited time to answer to simulate exam conditions. We also maintained a unique conference like format where the lecture provider would also be assisted by a ‘host' who would provide an environment that simulated a real-life lecture with a back-and-forth conversation. Lastly each session was reinforced with a feedback survey at the end which helped us improve our service but also provided key indicators on the needs of the audience.

Results

We were able to provide a series of lectures that on average had a viewership of 120-150 attendees per lecture and grew a social media following of 3500 people. Although the following on social media is not a full reflection of our reach. A good indication is our prescribing safety assessment series which attracted over 2000 people interested and 260 confirmed for one event.

Conclusions

We feel that the format we followed in delivering medical teaching provided a very effective format and we hope to continue this into the future.

Supplementing rabbit diets with butylated hydroxyanisole affects oxidative stress, growth performance, and meat quality

Butylated hydroxyanisole (BHA) is a synthetic antioxidant analogous of vitamin E. It is used as a preservative to prevent free radical-mediated oxidation in high-fat foods, and this study's objective was to investigate the effects of BHA on oxidative stress and apoptosis in addition to delineating its efficacy as a growth-promoting feed additive. 60 weaned male rabbits (V-line) were randomly divided into four equal groups: BHA0.0 (control), BHA50, BHA100, and BHA150, administered basal diets with 0.0, 50, 100, and 150 mg BHA/kg of feed for 60 days. Animals were examined for growth performance, markers of oxidative stress and apoptosis, and meat characteristics. Compared to the control group, rabbits receiving BHA-supplemented diets exhibited increases in BW and average daily gain (P < 0.01), where BHA50 and BHA100 groups showed increased muscle content of methionine aspartic acid, serine, and glutamine (P < 0.05). These two groups also exhibited elevated catalase and superoxide dismutase activities and diminished malondialdehyde levels in the liver. Butylated hydroxyanisole upregulated fatty acid synthase gene (FASN), especially in BHA100 animals. Bcl-2-associated X/B-celllymphoma-2 (Bax/Bcl-2) ratio significantly increased in animals receiving higher doses of BHA, and the weight of the liver significantly increased following BHA treatment. Supplementing growing rabbits with lower doses of dietary BHA may promote growth performance and meat quality via maintaining the redox balance. Hence, the 50-100 mg/kg may be recommended as a safe and still effective feed additive as well as an oxidative stress attenuator.

OP0096 EXPOSURE TO DENGUE INFECTION DO NOT RAISE RISK OF RHEUMATOID ARTHRITIS: FINDINGS FROM THE MALAYSIAN EPIDEMIOLOGICAL INVESTIGATION OF RHEUMATOID ARTHRITIS (MYEIRA) CASE-CONTROL STUDY

Background:

Dengue infection is associated with joints pain mimicking disease onset symptom of rheumatoid arthritis (RA). However, there is lack of epidemiological studies on exposure to dengue infection and risk of future RA.

Objectives:

We investigated the relationship between exposure to dengue infection and risk of developing different subsets of RA, defined by the presence of anti-citrullinated peptide antibody (ACPA) in the multi-ethnic Malaysian population.

Methods:

Serum samples from 1,235 RA cases (i.e. 516 Malay, 254 Chinese, 405 Indians and 60 others/mixed-ethnicity) and 1,624 epidemiological matched population-based controls (i.e. 1,023 Malay, 208 Chinese, 297 Indians and 96 others/mixed-ethnicity) were assayed for presence of dengue IgG antibody using World Health Organization recommended ELISA kits. Positive results of dengue IgG antibodies indicates previous exposure to dengue infection(s). We performed chi-square and Mann-Whitney U analysis to determine the association of ever-exposed dengue infection with ACPA-positive/ACPA-negative RA and to investigate the antibody frequency and levels among the studied populations.

Results:

We observed high occurrence of dengue IgG antibody in the overall RA cases (79.7%) and matched controls (77.3%), with no significant differences detected between the ACPA subsets of RA. Ethnicity stratification analysis revealed a decrease risk of developing ACPA-positive RA in the Indian patients with positive dengue IgG antibody (OR=0.59, 95% CI=0.37-0.94, p=0.03), and in particular patients with elevated level of dengue IgG antibody (OR=0.44, 95% CI=0.25-0.78, p<0.05). On the other hand, the significant decrease mean levels of dengue IgG antibody were observed in the ACPA-positive RA subset for all three major ethnic groups (i.e. Malay, p<0.0001, Chinese, p<0.01 and Indian<0.05) (Figure 1). No association was observed between presence of dengue IgG antibody and ACPA-negative RA subset.

Figure 1.

Comparison of mean dengue IgG antibody level between ever-exposed dengue infection RA cases, stratified by ACPA status. Comparison of median dengue IgG antibody level between the ever-exposed dengue infection ACPA-positive RA and normal controls in the four ethnic groups. The red line indicates the mean level of dengue IgG antibody level

Conclusion:

Our findings demonstrated that exposure to dengue infection do not increase the risk of developing future RA in the multi-ethnic Malaysian population. The inverse associations observed in the Indian ethnic group are in line with the other studies investigating exposure to viral infection and risk of RA.

References:

[1]Sherina et al (2017) Low levels of antibodies against common viruses associate with anti-citrullinated protein antibody-positive rheumatoid arthritis; implications for disease aetiology. Arthritis Research & Therapy 2017, 19:2169

[2]Gissel García et. al. (2011) Long-term persistence of clinical symptoms in dengue-infected persons and its association with immunological disorders. International Journal of Infectious Diseases 15 (2011) e38–e43

Acknowledgements:

The authors would like to thank the Director General of Health, Ministry of Health Malaysia for supporting this study. The authors are also indebted to participants for their kind participation. This study was financially supported by the Ministry of Health, Malaysia (JPP-IMR 17-025) and the short-term research grant by UniKL RCMP (str16037).

Disclosure of Interests:

None declared

Subclinical hepatitis C virus infection in Egyptian patients with rheumatic diseases: a multi-center study

Background

Hepatitis C virus (HCV) infection is highly prevalent in Egypt. It was found to be 7.0% in a study done in 2015. There are some studies on the prevalence of HCV in rheumatoid arthritis, but to our knowledge, no previous study was done to detect it in other rheumatologic diseases. This study aims at detecting the prevalence of subclinical HCV infection in Egyptian patients with different rheumatic diseases. In the current study, eight hundred and three patients with different rheumatic diseases collected from five—geographically different—Egyptian rheumatology departments were studied. Patients with known current or previous HCV infection were excluded from the study. Screening for the positive anti-HCV antibodies was done for all patients. Screening for the presence of HCV ribonucleic acid (RNA) was done in patients with positive serology by reverse transcriptase-polymerase chain reaction.

Results

In the studied population, 675 (84.1%) patients were women. The mean age [± SD] was 44.2 [± 12.9] years. Hepatitis C antibody positivity was found in 73 (9.1%) of the patients, while 67 (8.3%) were having positive HCV-RNA quantitative PCR tests. The highest prevalence of seropositive HCV was found in drug-induced vasculitis (DIV) and cryo-vasculitis (100%), while in RA, HCV antibodies and PCR were found to be positive in 9.1% and 8.3% of patients, respectively.

Conclusions

Detection of the presence of HCV infection in 9.1 % of the studied middle-aged Egyptian patients with rheumatologic conditions points to the importance of screening for HCV in such population for early detection and intervention especially for those patients that are planned to start biologic therapy.

Delayed cardiac tamponade following blunt chest trauma due to disruption of fourth costal cartilage with posterior dislocation

Cardiac tamponade is a recognised sequelae of non-penetrating and penetrating chest trauma. Delayed cardiac tamponade has been described following blunt chest trauma. We present a 29 year-old gentleman who had initially presented to peripheral district general hospital following direct blunt chest wall trauma. His initial trauma CT demonstrated a small mediastinal haematoma and large left haemopneumothorax and disruption/dislocation of the costal cartilage. He initially underwent a thoracoscopic procedure uneventfully. He then had worsening chest radiograph appearances with enlarging cardiac contours. Transthoracic echocardiography confirmed cardiac tamponade. He underwent creation of a pericardial window and excision of the protruding fourth costal cartilage.

Glauconite clay-functionalized chitosan nanocomposites for efficient adsorptive removal of fluoride ions from polluted aqueous solutions

We herein have developed a mild approach for the fabrication of glauconite clay (G)-modified chitosan (CS) nanocomposites by the combination of a simple blending and crosslinking method. The chitosan was modified with ethylenediaminetetraacetic acid (EDTA), glutaraldehyde (GL), sodium dodecyl sulfate (SDS), and cetyltrimethyl ammonium bromide (CTAB). The as-prepared composites were identified using Fourier-transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), field emission scanning electron microscopy (FE-SEM), nitrogen physical adsorption (BET), atomic absorption spectrophotometry (AA), and thermal gravimetric analysis (TGA). The adsorption activities of the as-prepared materials were assessed for the removal of fluoride ions from aqueous media using a batch technique. Raw glauconite (G), GL-CS/G, SDS-CS/G, EDTA-GL-CS/G, and CTAB-CS/G adsorbents displayed maximum adsorption capacity values of 1.15, 4.31, 4.55, 6.90, and 9.03 mg g⁻¹, respectively. The adsorption results were well described by employing the pseudo-second-order kinetic and Langmuir isotherm models. The estimated thermodynamic constants indicated that the F⁻ ion adsorption was a spontaneous, physisorption process. Furthermore, the modified chitosan adsorbents are good candidates for the adsorptive elimination of F⁻ ions from aqueous solutions, according to their reusability, high stability, good adsorption capacity, and applicability for actual field water samples.

We herein have developed a mild approach for the fabrication of glauconite clay (G)-modified chitosan (CS) nanocomposites by the combination of a simple blending and crosslinking method.

Hepatoprotective action of papain-hydrolyzed buffalo milk protein on carbon tetrachloride oxidative stressed albino rats

Buffalo skim milk retentate was hydrolyzed with papain for 4 h (enzyme:substrate, 1:200), resulting in a retentate hydrolysate (RH) with a degree of hydrolysis of 23%. We then investigated the potential hepatoprotective activity of RH at 250 and 500 mg/kg of body weight per day on carbon tetrachloride (CCl₄)-induced oxidative stress in albino rats. Liver biomarkers (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and lactate dehydrogenase), kidney biomarkers (urea, creatinine), and serum lipid profile (total lipids and triglycerides) were measured, in addition to histopathological status. Injection of CCl₄ significantly increased all liver and kidney biomarkers compared with the negative control. In contrast, CCl₄ injection significantly reduced hepatic antioxidant enzyme activities; that is, glutathione peroxidase and superoxide dismutase. Oral administration of RH for 28 d effectively maintained a physiologically normal range of liver and kidney biomarkers compared with the positive control. Furthermore, RH administration significantly increased activities of glutathione peroxidase and superoxide dismutase. Histopathological sections of CCl₄-stressed rats treated with RH were different from that of the positive control and were similar to those of the negative control, in a concentration-dependent manner. Our results demonstrated the antihepatotoxic activities of buffalo milk RH and demonstrated that the higher RH concentration (500 mg/kg of body weight per day) could maintain the healthy biological status of the CCl₄-injected rats.

P2533Prospective randomized study on implanted cardiac rhythm recorders in pregnant women with symptomatic arrhythmia and/or structural heart disease

Background

Cardiac arrhythmia is an important cause of maternal morbidity and mortality in pregnancy, but is difficult to diagnose.

Purpose

The aim of this single-centre, prospective, randomized pilot study was to compare the implantable loop recorder (ILR) with standard assessment of arrhythmia (12-lead ECG; 24-hour Holter ECG) in terms of acceptability, detection of arrhythmias and impact on outcome in pregnant women with symptomatic arrhythmias and/or structural heart disease (SHD).

Methods

The study recruited 40 consecutive patients from a weekly, dedicated cardiac obstetric clinic. Inclusion criteria: symptoms of arrhythmia and/or having SHD at risk of arrhythmia. Patients were randomized to either standard care (SC) or standard care plus ILR (SC-ILR). ILR recordings were read at the monthly visits and/or when presenting with symptoms.

Results

There were no demographic differences between the study groups. Seventeen patients consented to ILR insertion, all of whom found the procedure acceptable. No arrhythmias were recorded by the 12-lead ECGs. Holter monitoring detected arrhythmias in 10 of 23 patients (43%) from the SC group. In the SC-ILR group, 8 of 17 patients (47%) had arrhythmias detected by Holter, whereas 13 of 17 patients (76%) patients had arrhythmias detected by ILR (p=0.157). One of 4 patients with supraventricular tachycardia, 2 of 3 patients with premature ventricular complexes and 2 patients with paroxysmal atrial fibrillation (AF) recorded by ILR did not have the arrhythmias detected by Holter monitoring (Figure 1A shows a scatter plot of the variable R-R intervals seen in AF and 1B a rhythm strip of AF with irregular RR intervals and the absence of P waves, both downloaded from the ILR). Four of these 5 patients (80%) had a change in management as a direct result of their ILR recordings. There were no maternal deaths up to 42 days postpartum in either of the study groups. Nine babies were born with a low birthweight (<2500g), 5 stillbirth/neonatal deaths and 1 pregnancy termination occurred (5 in the Holter group and 1 in ILR group, p=0.37).

Figure 1

Conclusion(s)

This study suggests that an ILR is an acceptable diagnostic modality in pregnant women with a suspected or at risk of arrhythmia. The ILR increased the diagnostic yield to detect arrhythmias that were not detected by routine ECG and Holter monitoring which led to a change in management in the SC-ILR group and was associated with better maternal and neonatal outcomes. The impact of ILR monitoring should be further assessed in larger studies with longer follow up.

Successful Treatment of Recurrent Focal Segmental Glomerulosclerosis After Transplantation in Children: A Single-Center Experience

OBJECTIVE

We aim to report our experience managing cases of recurrent focal segmental glomerulosclerosis (FSGS) in a group of pediatric renal transplant recipients.

METHODS

This study was a retrospective chart review of pediatric patients who had their first kidney transplant at King Faisal Specialist Hospital & Research Center between 2014 and 2016.

RESULTS

We reviewed the files of 6 patients, 3 of whom were male. The median age of the children was 2.75 years (range, 2-4 years) at disease onset, with an average time of progression to end-stage renal disease of 19 months (range, 8-30 months). Five of the patients received a living related donor transplant, and 1 received a living nonrelated donor transplant. Patients had FSGS recurrence at varying intervals (1 to 3 days) post transplant. All cases had plasmapheresis prior to receiving abatacept or rituximab. The therapeutic strategy in 4 patients involved switching tacrolimus to cyclosporine. A complete response was observed in 5 of the 6 patients (83.3%), and treatment was well tolerated in 5 patients. Patient 1 had severe oliguria and required intermittent hemodialysis during the first 3 weeks post transplant. He showed minimal response to the therapeutic plasma exchange and rituximab and was subsequently treated with abatacept. However, he died 8 months post transplant of pneumonia and sepsis.

CONCLUSION

Rituximab and switching tacrolimus to cyclosporine, in conjunction with plasmapheresis, appeared to be effective and safe in children with recurrent FSGS. Conversely, abatacept did not appear to provide clinical benefit.

Suspended low-loss germanium waveguides for the longwave infrared

Germanium is a material of high interest for mid-infrared (MIR) integrated photonics due to its complementary metal-oxide-semiconductor (CMOS) compatibility and its wide transparency window covering the 2-15 μm spectral region exceeding the 4 and 8 μm limit of the silicon-on-insulator platform and Si material, respectively. In this Letter, we report suspended germanium waveguides operating at a wavelength of 7.67 μm with a propagation loss of 2.6±0.3  dB/cm. To the best of our knowledge, this is the first demonstration of low-loss suspended germanium waveguides at such a long wavelength. Suspension of the waveguide is achieved by defining holes alongside the core providing access to the buried oxide layer and the underlying Si layer so that they can be wet etched using hydrofluoric acid and tetramethylammonium hydroxide, respectively. Our MIR waveguides create a new path toward long wavelength sensing in the fingerprint region.

Haemorrhage and other complications in pregnant women on anticoagulation for mechanical heart valves: a prospective observational cohort study

OBJECTIVE

To document maternal and foetal morbidity and mortality in anticoagulated, pregnant patients with mechanical heart valves until 42 days postpartum.

METHODS

In a tertiary single-centre, prospective cohort, 178 consecutive patients at the cardiac-obstetric clinic were screened for warfarin use between 1 July 2010 and 31 December 2015. Of 33 pregnancies identified, 29 were included. Patients received intravenous unfractionated heparin from six to 12 weeks' gestation and peripartum, and warfarin from 12 to 36 weeks. Maternal outcomes including death, major haemorrhage and thrombosis, and foetal outcomes were documented.

RESULTS

There were two maternal deaths, five returns to theatre post-delivery, eight patients transfused, six major haemorrhages, one case of infective endocarditis and three ischaemic strokes. Ten pregnancies had poor foetal outcomes (six miscarriages, three terminations, one early neonatal death). Twenty patients required more than 30 days' hospitalisation, and 15 required three or more admissions. HIV positivity was associated with surgical delivery (p = 0.0017).

CONCLUSION

Complication rates were high despite centralised care.

Effects of a pH 7.4, lactate-based and a pH 7.4, bicarbonate-based peritoneal dialysis solutions on neutrophil superoxide generation

Neutrophil superoxide formation was similar when cells were incubated in self-made, non-autoclaved, pH 7.4, lactate-based peritoneal dialysis solutions or in their self-made, non-autoclaved, pH 7.4, bicarbonate-based counterparts. On the other hand, commercially available, autoclaved, pH 7.4, lactate-based peritoneal dialysis solutions resulted in inhibition of superoxide production when compared to their self-made, non-autoclaved, pH 7.4, lactate-based or bicarbonate-based counterparts. The cause for this inhibition of superoxide generation is at present unknown.

Suspended silicon waveguides for long-wave infrared wavelengths

In this Letter, we report suspended silicon waveguides operating at a wavelength of 7.67 μm with a propagation loss of 3.1±0.3  dB/cm. To our knowledge, this is the first demonstration of low-loss silicon waveguides at such a long wavelength, with loss comparable to other platforms that use more exotic materials. The suspended Si waveguide core is supported by a sub-wavelength grating that provides lateral optical confinement while also allowing access to the buried oxide layer so that it can be wet etched using hydrofluoric acid. We also demonstrate low-loss waveguide bends and s-bends.

Species identification and molecular typing of human Brucella isolates from Kuwait

Brucellosis is a zoonotic disease of major concern in Kuwait and the Middle East. Human brucellosis can be caused by several Brucella species with varying degree of pathogenesis, and relapses are common after apparently successful therapy. The classical biochemical methods for identification of Brucella are time-consuming, cumbersome, and provide information limited to the species level only. In contrast, molecular methods are rapid and provide differentiation at intra-species level. In this study, four molecular methods [16S rRNA gene sequencing, real-time PCR, enterobacterial repetitive intergenic consensus (ERIC)-PCR and multilocus variable-number tandem-repeat analysis (MLVA)-8, MLVA-11 and MLVA-16 were evaluated for the identification and typing of 75 strains of Brucella isolated in Kuwait. 16S rRNA gene sequencing of all isolates showed 90-99% sequence identity with B. melitensis and real-time PCR with genus- and species- specific primers identified all isolates as B. melitensis. The results of ERIC-PCR suggested the existence of 75 ERIC genotypes of B. melitensis with a discriminatory index of 0.997. Cluster classification of these genotypes divided them into two clusters, A and B, diverging at ~25%. The maximum number of genotypes (n = 51) were found in cluster B5. MLVA-8 analysis identified all isolates as B. melitensis, and MLVA-8, MLVA-11 and MLVA-16 typing divided the isolates into 10, 32 and 71 MLVA types, respectively. Furthermore, the combined minimum spanning tree analysis demonstrated that, compared to MLVA types discovered all over the world, the Kuwaiti isolates were a distinct group of MLVA-11 and MLVA-16 types in the East Mediterranean Region.

Effect of the 2008 economic crisis on the cardiovascular mortality of the Irish population: an ecological 12-year study of a heart-broken Celtic Tiger

Ireland has endured a substantial financial crisis in 2008 and we sought to explore the effect of economic recession on Irish cardiovascular mortality. We found an increase by 17.2% in CVA-deaths during the financial crisis years (95% CI 11.1% to 23.6%). In males, we found a notable rise in the annual IHD rate by 7.56% (95% CI 4.73% to 10.46%), in annual MI rate by 2.96% (95% CI 0.16% to 5.84%), and in annual CVA death rate by 20.07% (95% CI 16.13% to 24.14%). In females our findings indicated an increased rate of CVA-related deaths during the economic crisis by 15.54% (95% CI 6.67% to 25.16%). Irish CVA-related deaths increased during the economic crisis for males and females alike. Male IHD-related deaths have also risen indicating a potential differential effect for financial hardships on male gender mortality.

The effect of intrauterine HCG injection on IVF outcome: a systematic review and meta-analysis

In this systematic review and meta-analysis, the effect of intrauterine HCG infusion before embryo transfer on IVF outcomes (live birth rate, clinical pregnancy rate and spontaneous aboretion rate) was investigated. Searches were conducted on MEDLINE, EMBASE and The Cochrane Library. Randomized studies in women undergoing IVF and intracytoplasmic sperm injection comparing intrauterine HCG administration at embryo transfer compared with no intrauterine HCG were eligible for inclusion. Eight randomized controlled trials were eligible for inclusion in the meta-analysis. A total of 3087 women undergoing IVF and intracytoplasmic sperm injection cycles were enrolled (intrauterine HCG group: n = 1614; control group: n = 1473). No significant difference was found in the live birth rate (RR 1.13; 95% CI 0.84 to 1.53) and spontaneous abortion rate (RR 1.00, 95% CI 0.74 to 1.34) between women who received intrauterine HCG and those who did not receive HCG. Although this review was extensive and included randomized controlled trials, no significant heterogeneity was found, and the overall included numbers are relatively small. In conclusion the current evidence does not support the use of intrauterine HCG administration before embryo transfer. Well-designed multicentre trials are needed to provide robust evidence.