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Key Clinical Message Systemic Lupus Erythematosus (SLE) can have an insidious onset and a fatal prognosis in children. Patients presenting without typical signs of SLE should undergo further evaluation if they are not responding to the initial diagnosis and treatment. This is especially true for patients with rapidly progressing symptoms and deterioration in spite of treatment. Abstract Pediatric Systemic Lupus Erythematosus is a chronic autoimmune disorder with various organ involvement pulmonary involvement in the course of this disorder is a rare yet potentially life‐threatening complication. In this case report we highlight the findings of a 16‐year‐old girl acutely and initially presenting with cough and fever, eventually complicating to diffuse alveolar hemorrhage and gradual loss of consciousness. Although the patient was started on immunosuppressive treatment after the diagnosis of lupus, based on renal and hematological impairment, was made and initially responded, she eventually deteriorated.

Purpose Idiopathic intracranial hypertension (IIH) is a clinical syndrome that mimics brain tumors with increased intracranial pressure. The present study is designed to investigate the diagnostic criteria of magnetic resonance imaging (MRI) and the severity of cerebrospinal fluid (CSF) pressure to understand the relationship and frequency of these criteria with the level of CSF pressure. Methods The present cross-sectional study was conducted on children diagnosed with IIH between the years 2011 and 2020, who were admitted to the pediatric neurology department of Ghaem Hospital, Mashhad, Iran. Clinical manifestations and imaging findings of the patients were recorded through a checklist. Results Forty-nine patients were included in the study; 27 (55.1%) were male, and 22 (44.9%) were female. The average CSF pressure was 40.64±20.63 cmH2O. The mean diameter distension of the perioptic subarachnoid space was 6.02±1.21 mm. Six (10.8%) patients had unilateral transverse sinus stenosis with an average CSF pressure of 20.47±36.80 cmH2O and 11 (21.4%) patients had bilateral transverse sinus stenosis with an average pressure of 48.22±21.04 cmH2O. In 22 (44.89%) patients, flattening of the posterior globe with the CSF pressure of 48.80±17.94 cmH2O was reported. Twenty-four (49%) patients had optic nerve tortuosity, with an average CSF pressure of 46.52±20.33 cmH2O. Among the diagnostic criteria, the pressure had a significant relationship with the flattening of the posterior globe (P

Casehardening (σi) is an internal stress-related phenomenon that develops in kiln-dried wood materials, causing shape distortion. This study focuses on the impact of drying schedule and wood parameters (e.g., density, moisture) on σi. Results indicated that the wood's final moisture content level has the highest impact when it is above 15%. However, the wood moisture gradient is the most influential factor when wood's moisture content is below 15%. Drying schedule aggressiveness and post-drying treatments also affect σi; an aggressive drying schedule followed by conditioning remarkably reduces σi occurrence.

Atomic spectral line filter is a narrow band pass optical filter which has many applications in quantum and laser systems. By engineering the system parameters like gas temperature and intensity of magnetic field, the filter with desired characteristics could be obtained. In this work, an atomic spectral line filter for Cesium D1 line (894.6nm) is implemented and characterized. The effect of system parameters on the filter transmission and its bandwidth is investigated. It is observed that by applying a magnetic field of 390 Gauss and adjusting the gas cell temperature on 40°C, a single peak filter with maximum filter transmission and FWHM of 0.24 GHz could be obtained.

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Abstract The current study evaluates a rare case of parietal bone osteoid osteoma in pediatrics and review the differential diagnosis of button sequestrum sign in the literature. A 12‐year‐old girl expressed localized pain in the right parietal bone. MRI represented enhancing nodule with button sequestrum sign appearance.

Background: Knowing the conversion risk factors of laparoscopic cholecystectomy to open surgery, helps the surgeon to plan for surgery accordingly. This study aimed to determine the risk factors for converting laparoscopic cholecystectomy to open surgery. Methods: In this analytical study, the case information of 1104 patients who underwent laparoscopic cholecystectomy in Shahid Beheshti Hospital in Qom from April 2013 to April 2017 was evaluated. Inclusion criteria were all cases of acute cholecystitis, chronic cholecystitis, symptomatic gallstones, and biliary pancreatitis who underwent laparoscopic cholecystectomy. The exclusion criteria were patients who underwent laparoscopic cholecystectomy at the same time with other procedures. Data of all patients including age, sex, history of abdominal surgery, emergency or elective surgery, blood transaminase level, blood bilirubin level, white blood cell count, amylase level, and serum alkaline phosphatase were recorded. Finally, potential risk factors were compared between the two groups. Average, standard deviation, frequency and percentage indices were used to describe the data. Independent samples t‐test and Mann-Whitney U test were used for quantitative data analysis and Chi-square test was used for qualitative data analysis. P

Background: Identifying risk factors for conversion to open surgery laparoscopic cholecystectomy and factors are difficult to predict cholecystectomy surgery is required. The aim of this study was to evaluate the findings of preoperative ultrasound in predicting the length of laparoscopic cholecystectomy surgery. Methods: The present study was performed cross-sectional on 122 patients who underwent laparoscopic cholecystectomy in Shahid Beheshti, Forghani and Nekoei’s Hospital in Qom from September 2016 to September 2017. Inclusion criteria: All cases of acute cholecystitis, chronic cholecystitis, symptomatic gallstones and biliary pancreatitis underwent laparoscopic cholecystectomy. The exclusion criteria included patients undergoing laparoscopic cholecystectomy at the same time were other procedures. Before surgery patientschr('39') information such as age, sex, ultrasound findings including gallbladder wall thickness, compressed stone and the presence of fluid around the gallbladder were recorded in the checklist. Finally, the duration of cholecystectomy was divided into two degrees of easy operation (less than 60 minutes and without complications) and difficult operation (above 60 minutes with complications) according to the mentioned variables. Data were analyzed by SPSS software, version 22 (IBM SPSS, Armonk, NY, USA). In this study, a significance level of less than 0.05 was considered. Results: 28 (22.4 percent) males and 97 (77.6 percent) females with a mean age of 44.66 13 13.85 years were studied. There were 35 difficult cases (28 percent) and 90 easy cases (72 percent). Conversion to open surgery occurred in three cases. Among the sonographic findings, there was a significant relationship between the increase in gallbladder wall thickness and Impacted stone with the duration of operation (P≤0.05). But no significant relationship was found between the findings of Presence of pericholecystic fluid and the duration of operation (P>0.05). Conclusion: Overall, the findings of this study showed that preoperative ultrasound is able to provide valuable data in predicting the duration of laparoscopic cholecystectomy.

Neurological involvement in the coronavirus disease 2019 (COVID-19) infection is increasing all over the world. Neurological manifestations include headache, dizziness, stroke, seizure, encephalopathy, neuropathy, and skeletal muscle injury. While many patients with central nervous system involvement have normal neuroimaging, some show significant abnormalities. In this article, we report five patients with neurological manifestations of COVID-19 infection and its relevant abnormalities in brain magnetic resonance imaging.

Background and Objectives: Nasal bone hypoplasia is a rare hereditary disorder, which seems to be related to other anomalies. This disorder may clearly appear in the appearance of a person by increasing age, and in terms of nasal and psychological functions, which its manifestations are different depending on the severity of the disorder. Case Report: The case was a 36-year-old woman who was referred to Beheshti Hospital of Qom city in 2016 with a chief complaint of dissatisfaction of the shape her nose. The patient had no previous surgery internal diseases, and trauma of head and face. She had no respiratory complaints, sleep apnea, nasal congestion, or rhinorrhea, but she complaint of recurrent sinusitis in the past. In the examination, her nose was cartilaginous and nasal bone impalpable on both sides. This article discusses a case of nasal bone hypoplasia, which was repaired by temporalis muscle fascia in the operating room.

Background: Increased subcutaneous fat thickness and depth of target organs in over-obese patients, results in weak signals and inadequate images. Tissue harmonic imaging has been used widely in obese patients and is believed to result in higher quality images. This superiority is not proved in modern machines with improved image quality in conventional mode. Objective: To compare the image quality between conventional and tissue harmonic ultrasound images. Methods: This cross-sectional study was carried out from March 2015 to June 2016. Seventy-six over-obese patients referred to Ghaem Hospital (Mashhad, Iran) for weight-correction surgeries, were enrolled into the study. Conventional and tissue harmonic images of their kidneys were blinded and compared back-to-back by four expert radiologists. Data were analyzed by SPSS version 16, using Cochrane’s Q test. Results: All raters reported image quality to be better in tissue harmonic compared to fundamental frequency ultrasound (p=0.000, Cochrane’s Q test). Although better image quality in tissue harmonic mode was reported by the four raters, there was weak inter-observer agreement (p=0.081 for right kidney and p=0.21 for left kidney). Conclusion: Advances in ultrasound equipment and the introduction of tissue harmonic imaging can improve the diagnostic performance in over-obese patients and this mode of imaging should be used whenever evaluating over-obese subjects.

Extraosseous accumulation of technetium-99m-methyl diphosphonate (99mTc-MDP) on bone scan is not common. This phenomenon is often attributed to abnormality of calcium metabolism and has been reported in a variety of conditions including metabolic diseases and malignancies. A five years old boy is presented here, who was admitted to the pediatric emergency suffering from fatigue, respiratory symptoms, weight loss, intermittent fevers, anorexia, nausea and vomiting, edema of legs and abdominal distension for one month. The initial laboratory analysis revealed hypercalcemia. The patient was referred for whole body bone scan with suspicion of malignancy and bone metastasis. The bone scan revealed highly increased radiotracer uptake in both lungs in the perfusion and blood pool phases. Delayed images also showed increased activity in lungs and gastric wall. The skeleton was not seen clearly. Bone marrow aspiration was done and established the diagnosis of ALL. The patient deceased due to respiratory failure 20 days later. Diffuse lung uptake in this patient was consistent with respiratory failure and poor prognosis. It is reported that bone scan may be useful for assessment of the extent of metastatic calcification and may establish suitable management to prevent organ failure.

Contracts for oil and gas development projects are naturally complex, they are explained with some of maps and technical specifications. To supply the goals of contracts, it is necessary to construct by a team having owner, consulting engineer and contractor. The unique aspects of each project and team working are resulting to disagreements. It should be noted that the majority of team workers have not previously worked together. It may not be expected to forecast all project aspects in design and preparation of tender documents process. However, in some cases it will occur inconsistencies in contract documents and possibly may be disagreements on commentary of the cases which there are in the provisions of the contract. Every root of disagreement resulted in to claim and finally dispute. Lack of foresight and/or existing ambiguous texts in some provisions of contract, not being aware of components of the project to conditions and obligations and rules of contract will complex and sometimes impossible the agreement on implementation problems. Therefore, the claims will be resulted in disputes and inflict financial losses to contractors and/or owners and then the projects will not be completed. In Iran many activities have not been carried out about claims and disputes in different orientations especially in areas futures and hence, it was studied in this research. Firstly, research history was considered and the causes of claims and disputes were identified in process of different levels of oil projects construction from primary to exploitation and then a questionnaire was prepared using the comments of experts. Finally, the questionnaire was analysed by SPSS and the approved factors in creation of claims and disputes and in their roots were ranked.

Here, the population transfer between two specific levels of Cesium atomunder the influence of chirped laser source has been numerically investigated. The maingoal of this study is the engineering of the population transfer between the 62S1/2 and 62P1/2levels of Cesium which is corresponding to its D1 transition line using a chirped lasersource. Constructing the system Hamiltonian, as well as the initial and boundaryconditions, the time-dependent Schrödinger equations are numerically solved and thepopulation versus time for different physical parameters has been investigated. The finalpopulation of each state is calculated and discussed for changing the parameters such aslaser intensity, laser frequency and chirping parameter. The results show that using thechirped laser source with tuned parameters, we can arbitrarily control the population oflevels.

Canthariasis is a human disease caused by infestation of beetle larvae. We report here an unusual cause of urogenital in­fection due to Tenebrio molitor in a 10-year-old boy suffering from severe and intermittent suprapubic pain from Nehban­dan City, Northeastern Iran in 2018. After 9 months, three larvae were excreted. Keratinization of bladder wall was ob­served in histopathology. All laboratory evaluations were normal except for presence of microscopic hematuria. This re­port implicated that T. molitor could infest bladder accidentally and cause canthariasis and clinical symptoms that may lead to severe pain and bladder inflammation and hyperemia.

Introduction: This systematic review studies the prognostic value of two conventional imaging tools, sestamibi and gallium scans, for predicting how patients with Hodgkin lymphoma will respond to treatment.Methods: The PubMed database was searched for English-language articles that contained the following search terms: (Hodgkin AND [mibi OR sestamibi OR gallium OR spect] AND response). All articles that were identified during this search were included in the study, regardless of date published. The inclusion criteria were as follows: articles that described studies that were limited to Hodgkin patients and that reported the predictive value of conventional imaging tools. Articles about other types of lymphoma and/or those that focused on the diagnostic and staging accuracy of mibi and gallium scans were excluded.Result: In total, 14 articles were retrieved. Of these, the majority met the inclusion criteria of the systematic review with the exception of two, which were limited to an examination of the reliability of performing sestamibi scans to predict the response to treatment. All remaining 12 articles considered both the sestamibi scans and the gallium scintigraphy.The results of the systematic review indicate that positive gallium scan results can be proposed as a poor prognostic factor that is associated with partial or full recurrence of Hodgkin disease, a reduction in overall survival rate, and progression-free survival compared with patients with a negative scan.Discussion: Both sestamibi and gallium scans revealed high sensitivity and specificity in predicting the response to treatment including complete remission, partial remission, and recurrence of the disease.Conclusion:These imaging tools can appropriately assess how Hodgkin patients will respond to chemotherapy. As such, clinicians can use these tools to devise appropriate treatment strategies.

Purpose: Rib fractures are the most common skeletal thoracic injuries resulting from blunt chest trauma. Half of the rib fractures are not detected upon a precise physical evaluation and radiographs. Recently ultrasonography (USG) has been investigated to detect rib fractures. But based on literature the usefulness of USG varies widely. This study was conducted to investigate the role of USG in the detection of possible rib fractures in comparison with radiography. Methods: In this cross-sectional study, consecutive patients with minor blunt chest trauma and suspected rib fractures presenting in Imam Reza Hospital located in Mashhad-Iran, between April 2013 and October 2013 were assessed by USG and radiography. The radiography was performed in a posteroanterior (PA) chest projection and oblique rib view centered over the area of trauma. The time duration spent in taking USG and radiography were recorded. The prevalence and location of fractures revealed by USG and radiography were compared. Results: Sixty-one suspected patients were assessed. The male to female ratio was 2.4:1 (43 men and 18 women) with a mean ± SD age of (44.3 ± 19.7) years. There were totally 59 rib fractures in 38 (62.3%) patients based on radiography and USG, while 23 (37.7%) patients had no diagnostic evidence of rib lesions. USG revealed 58 rib fractures in 33 (54.1%) of 61 suspected patients and radiographs revealed 32 rib fractures in 20 (32.8%) of 61 patients. A total of 58 (98.3%) rib fractures were detected by USG, whereas oblique rib view and PA chest radiography showed 27 (45.8%) and 24 (40.7%) rib fractures, respectively. The average duration of USG was (12 ± 3) min (range 7–17 min), whereas the duration of radiography was (27 ± 6) min (range 15–37 min). The kappa coefficient showed a low level of agreement between both USG and PA chest radiography (kappa coefficient = 0.28), and between USG and oblique rib view (kappa coefficient = 0.32). Conclusion: USG discloses more fractures than radiography in most patients presenting with suspected rib fractures. Moreover USG requires significantly less time than radiography.

The effect of low-dose epsilon-aminocaproic acid (EACA) on the postoperative course of 46 patients was studied. Patients undergoing coronary artery bypass grafting were randomly selected in two groups. Group 1 (20 patients) received 5 g EACA upon initiation of cardiopulmonary bypass (CPB). Group 2 (26 patients) received no antifibrinolytic drugs prior to CPB. Neither group received antifibrinolytic drugs after CPB. There was no significant difference between the two groups' blood usage on CPB: 0.65 units in Group 1 and 0.60 units in Group 2. After CPB, blood usage significantly differed: 2.2 ± 1.7 (SD) units in Group 1 and 3.9 ± 3.0 units in Group 2 (p = 0.033). Significant difference was also demonstrated in postoperative blood loss in the first 24 hours: 1610 ± 531 ml in Group 1 versus 2025 ± 804 ml in Group 2 (p = 0.043). Pre-CPB administration of low-dose EACA significantly decreases blood loss and blood usage in the postoperative period. [ABSTRACT FROM PUBLISHER]

Patients with coagulation disorders present the entire open-heart surgical team with an increased challenge. A patient with a known history of moderately severe Factor IX deficiency (2.4% activity) was evaluated for coronary artery disease. Cardiac catheterization revealed a 99% right coronary artery lesion, a long 99% circumflex lesion and normal left ventricular function. Sextuple coronary artery bypass grafting was performed with the aid of aprotinin and Factor IX transfusions. The patient's platelet count after cardiopulmonary bypass was 65 000/mm3, down from a preoperative level of 172 000/mm3, requiring the transfusion of six units of pooled platelets immediately postoperation. The patient was extubated five and a half hours after arriving in the Intensive Care Unit, and his chest-tube drainage after the first 24 hours was 373 ml. Other than a transient episode of atrial fibrillation on the third postoperative day, the patient had an uneventful postoperative course and was discharged on the sixth postoperative day. With the use of aproptinin and the newer monoclonal antibody-purified Factor IX concentrates that have been developed, many of the added risks of performing open-heart surgery on patients with haemophilia B are greatly reduced if not eliminated. [ABSTRACT FROM PUBLISHER]

Bone involvement in hydatid disease is rare, and when it does occur, the most common sites of involvement are the spine and pelvis. A case of bone hydatid disease involving the sacrum is reported here.

A true estimation of gestational age (GA) plays an important role in quality maternity care and scheduling the labor date. This study aimed to evaluate the normal fetal kidney length (KL) and its correlation with GA. A cross-sectional study on 92 pregnant women between 8th and 10th week of gestation with normal singleton pregnancy underwent standard ultrasound fetal biometry and kidney length measurement. univariate and multivariate linear regression analysis was used to create a predictive equation to estimate GA on the KL and fetobiometry parameters. A significant correlation was found between GA and KL (r=0.83, P

Intraosseous pneumatocysts are benign gas-filled cavities within bones which are most commonly found in ilium, sacrum and vertebrae. The lesions are asymptomatic and found incidentally while evaluating for other injuries. Here, we present an intraosseous pneumatocyst of ilium in a 23-year-old male patient. Although once thought to be rare, intraossseous pneumatocyst are now believed to be more common. Thus, familiarity with their appearance is essential to avoid unnecessary workup. Intraosseous pneumatocysts are differentiated from more clinically significant differential diagnoses like osteonecrosis and osteomyelitis by their characteristic appearance of intraosseous air collections with sclerotic rim.

Objectives. The aim of this article is to represent the first reported case with cooccurrence of two rare alcohol related complications. Case Report. We report a 38-year-old man with chronic alcoholism who presented with both cranial and peripheral nerve palsy. On MRI examination characteristic findings of Marchiafava-Bignami disease were recognized. Discussion. Marchiafava-Bignami disease (MBD) is a rare complication of long-term, heavy alcohol abuse that has characteristic MRI findings. Acute alcohol related polyneuropathy (AARP) is another rare and not-well-understood complication of chronic alcohol abuse. We could not find any previous report of the cooccurrence of these two complications in the literature.

Objcctive(s): To determine age-specific rubella seroprevalence in the O to 45 years-old unvaccinated population in Uremia, Iran and also to propose a vaccination strategy against rubella this study designed. Material & Methods: A total of 770 unvaccinated persons O to 45 years old were selected for the study with cluster sampling. Sera from 392 females and 378 males were tested for rubella IgG antibody using enzyme linked immonosurbent assay (ELIZA) technique. Rubella seropositivity was defined as serum rubella IgG antibody level> or= I 3IU/ml. Results: Of the 770 cases, 58.1 % were seropositive. Due to maternal derived antibodies, 100% of the newborns was seropositive. This figure decreased with time until it became zero in children aged 9 months. Then from years 4 increased with age gradually until it peaked at 93.4% in the age group of 15- 19 years. The seropositivity decreased to 85.7% in the age group of >35 years. Of women in the reproductive age groups (15-45years old), 89.6% were seropositive. Conclusion:-. Because a substantial proportion of women in their childbearing years are susceptible to rubella, immunization efforts should be directed at infants and/or prepubertal children.

The simulation results for electromagnetic energy harvesters (EMEHs) under broad band stationary Gaussian random excitations indicate the importance of both a high transformation factor and a high mechanical quality factor to achieve favourable mean power, mean square load voltage, and output spectral density. The optimum load is different for random vibrations and for sinusoidal vibration. Reducing the total damping ratio under band-limited random excitation yields a higher mean square load voltage. Reduced bandwidth resulting from decreased mechanical damping can be compensated by increasing the electrical damping (transformation factor) leading to a higher mean square load voltage and power. Nonlinear EMEHs with a Duffing spring and with linear plus cubic damping are modeled using the method of statistical linearization. These nonlinear EMEHs exhibit approximately linear behaviour under low levels of broadband stationary Gaussian random vibration; however, at higher levels of such excitation the central (resonant) frequency of the spectral density of the output voltage shifts due to the increased nonlinear stiffness and the bandwidth broadens slightly. Nonlinear EMEHs exhibit lower maximum output voltage and central frequency of the spectral density with nonlinear damping compared to linear damping. Stronger nonlinear damping yields broader bandwidths at stable resonant frequency.

Golestan Province in northeastern Iran has one of the highest incidences of esophageal squamous cell carcinoma (ESCC) in the world with rates over 50 per 100,000 person-years in both sexes. We have analyzed TP53 mutation patterns in tumors from this high-risk geographic area in search of clues to the mutagenic processes involved in causing ESCC.Biopsies of 119 confirmed ESCC tumor tissue from subjects enrolled in a case-control study conducted in Golestan Province were analyzed by direct sequencing of TP53 exons 2 through 11. Immunohistochemical staining for p53 was carried out using two monoclonal antibodies, DO7 and 1801. A total of 120 TP53 mutations were detected in 107/119 cases (89.9%), including 11 patients with double or triple mutations. The mutation pattern was heterogeneous with infrequent mutations at common TP53 "hotspots" but frequent transversions potentially attributable to environmental carcinogens forming bulky DNA adducts, including 40% at bases known as site of mutagenesis by polycyclic aromatic hydrocarbons (PAHs). Mutations showed different patterns according to the reported temperature of tea consumption, but no variation was observed in relation to ethnicity, tobacco or opium use, and alcoholic beverage consumption or urban versus rural residence.ESCC tumors in people from Golestan Province show the highest rate of TP53 mutations ever reported in any cancer anywhere. The heterogeneous mutation pattern is highly suggestive of a causative role for multiple environmental carcinogens, including PAHs. The temperature and composition of tea may also influence mutagenesis.

This descriptive study was aimed to identify how provided nursing care related to physical problems caused by traction and cast in patients with fracture and dislocation in cervical spinal cord in educational hospitals of Tehran University of Medical Sciences. Samples, including 46 patients were recruited from neurosurgery and orthopedic wards, and also from Neurosurgical Intensive Care Units during 8 months period. Results showed that nursing care provided by nurses were in a proper level. There was no significant relationship between variables such as age, gender, level of education, kind of neurological lesions and provided nursing care. A significant relationship between cervical lesion and provided nursing care was found

For positive integers b and c, with c even, satisfying the inequalities b+1≤c≤2b, the minimum order of a connected cubic graph with b bridges and c cutpoints is computed. Furthermore, the structure of all such smallest cubic graphs is determined. For each positive integer c, the minimum order of a quartic graph with c cutpoints is calculated. Moreover, the structure and number of all such smallest quartic graphs are determined.

The bridge degree bdeg v and cycle degree cdeg v of a vertex v in a graph G are, respectively, the number of bridges and number of cycle edges incident with v in G. A characterization of finite nonempty sets S of nonnegative integers is given for which S is the set of bridge degrees (cycle degrees) of the vertices of some graph. The bridge-cycle degree of a vertex v in a graph G is the ordered pair (b,c), where bdeg v=b and cdeg v=c. Those finite sets S of ordered pairs of nonnegative integers for which S is the set of bridge-cycle degrees of the vertices of some graph are also characterized.

Effect of perfusion with low temperature Locke solution on the isolated hearts of adult rabbits and mongrel puppies was studied. The study showed no arrhythmias or myocardial fibrillation at low temperatures in the isolated mammalian heart.

Importance: Acute kidney injury (AKI) is a common complication during hospitalization and is associated with adverse outcomes., Objective: To evaluate whether diagnostic and therapeutic recommendations sent by a kidney action team through the electronic health record improve outcomes among patients hospitalized with AKI compared with usual care., Design, Setting, and Participants: Randomized clinical trial conducted at 7 hospitals in 2 health systems: in New Haven, Bridgeport, New London, and Waterbury, Connecticut, and Westerly, Rhode Island; and in Baltimore, Maryland. Hospitalized patients with AKI were randomized between October 29, 2021, and February 8, 2024. Final follow-up occurred February 22, 2024., Intervention: An alert about AKI was sent to the kidney action team, consisting of a study physician and study pharmacist, which sent personalized recommendations through the electronic health record in 5 major categories (diagnostic testing, volume, potassium, acid base, and medications) within 1 hour of AKI detection. The note was immediately visible to anyone with access to the electronic health record. Randomization to the intervention or usual care occurred after the recommendations were generated, but the note was only delivered to clinicians of patients randomized to the intervention group., Main Outcomes and Measures: The primary outcome was a composite outcome consisting of AKI progression to a higher stage of AKI, dialysis, or mortality occurring while the patient remained hospitalized and within 14 days from randomization., Results: Of the 4003 patients randomized (median age, 72 years [IQR, 61-81 years), 1874 (47%) were female and 931 (23%) were Black patients. The kidney action team made 14 539 recommendations, with a median of 3 (IQR, 2-5) per patient. The primary outcome occurred in 19.8% of the intervention group and in 18.4% in the usual care group (difference, 1.4%, 95% CI, -1.1% to 3.8,% P = .28). Of 6 secondary outcomes, only 1 secondary outcome, rates of recommendation implementation, significantly differed between the 2 groups: 2459 of 7270 recommendations (33.8%) were implemented in the intervention group and 1766 of 7269 undelivered recommendations (24.3%) were implemented in the usual care group within 24 hours (difference, 9.5%; 95% CI, 8.1% to 11.0%)., Conclusions and Relevance: Among patients hospitalized with AKI, recommendations from a kidney action team did not significantly reduce the composite outcome of worsening AKI stage, dialysis, or mortality, despite a higher rate of recommendation implementation in the intervention group than in the usual care group., Trial Registration: ClinicalTrials.gov Identifier: NCT04040296.

Introduction: we sought to explore the efficacy of ketamine in a patient on extracorporeal membrane oxygenation (ECMO) receiving ketamine for sedation by investigating the utility of plasma ketamine concentrations. Case report: retrospective chart review of one critically ill patient on ECMO Discussion: This was a descriptive review of serial plasma ketamine concentrations in an ECMO patient. Although no reference plasma concentrations exist in ECMO patients, ketamine levels appeared to be lower than those seen in surgical patients not on ECMO. Conclusion: At this point, no reference plasma concentrations exist for ketamine in ECMO patients, further research may help understand the effects of ECMO on ketamine disposition and that lower ketamine concentrations may be used for effective analgesia or sedation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The convergence of an interdisciplinary team of neurocritical care specialists to organize the Curing Coma Campaign is the first effort of its kind to coordinate national and international research efforts aimed at a deeper understanding of disorders of consciousness (DoC). This process of understanding includes translational research from bench to bedside, descriptions of systems of care delivery, diagnosis, treatment, rehabilitation, and ethical frameworks. The description and measurement of varying confounding factors related to hospital care was thought to be critical in furthering meaningful research in patients with DoC. Interdisciplinary hospital care is inherently varied across geographical areas as well as community and academic medical centers. Access to monitoring technologies, specialist consultation (medical, nursing, pharmacy, respiratory, and rehabilitation), staffing resources, specialty intensive and acute care units, specialty medications and specific surgical, diagnostic and interventional procedures, and imaging is variable, and the impact on patient outcome in terms of DoC is largely unknown. The heterogeneity of causes in DoC is the source of some expected variability in care and treatment of patients, which necessitated the development of a common nomenclature and set of data elements for meaningful measurement across studies. Guideline adherence in hemorrhagic stroke and severe traumatic brain injury may also be variable due to moderate or low levels of evidence for many recommendations. This article outlines the process of the development of common data elements for hospital course, confounders, and medications to streamline definitions and variables to collect for clinical studies of DoC., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Cerebral venous sinus thrombosis (CVST) is an uncommon condition accounting for 0.5-1% of all strokes. It occurs more commonly in women, particularly in the age group of 20-40 years of age due to pregnancy and oral contraceptive use. Systemic anticoagulation is recommended as first line treatment but 10-20% of patients deteriorate despite medical treatment and require surgical or endovascular interventions. We summarize a 41-year-old female with a past medical history of acute disseminated encephalomyelitis who presented with headaches and worsening mental status. Further workup confirmed inferior sagittal sinus thrombus with intraventricular hemorrhage for which she was initiated on heparin continuous infusion. Due to worsening of clot burden and cerebral edema, a right frontal external ventricular drain was placed in addition to medical management of elevated ICP. Intravenous heparin infusion was stopped intermittently for such procedures. However, even when heparin was continued, sub-therapeutic and supra-therapeutic ranges were commonly observed, making anticoagulation management challenging. A new left-sided EVD had to be placed after increased IVH and worsening of hydrocephalus due to clotting. Due to patient's clinical worsening, a microcatheter was placed in the straight sinus and continuous alteplase via intra-sinus catheter was initiated at a rate of 1 mg/hour. This was continued for 72 hours in addition to the continuous heparin infusion. Additionally, she received intraventricular alteplase 1 mg x 3 doses for IVH. Unfortunately, she continued to deteriorate despite maximal medical therapy. She was made comfort care and expired.

Introduction: Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for those in cardiopulmonary failure, including post-cardiac arrest. Despite a high volume of ECMO patients using anti-seizure medication, there is a paucity of data concerning the dosing, levels, and clinical scenarios for their use., Case Report: We present three cases of ECMO patients post-PEA arrest who were on valproic acid (VPA) for treatment of seizure and/or myoclonus. The total and free levels of VPA are reported., Discussion: The trough levels are consistent throughout therapy, suggesting VPA is not significantly removed by the ECMO circuitry. Although the total serum levels remained below the toxic range, the free level was elevated in two patients. These patients did not develop signs of toxicity., Conclusion: VPA may be an effective anti-seizure medication in ECMO patients. Free VPA levels should be more readily available to better quantify efficacy or toxicity, especially in ECMO patients.

Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation., Competing Interests: J.C.G. reports grants from CSL Behring, outside the submitted work., (Thieme. All rights reserved.)

Background/objective: Inactivated four-factor prothrombin complex concentrate (I4F-PCC, Kcentra ® ) has become an important agent for the urgent or emergent reversal of bleeding associated with vitamin K antagonists such as warfarin. There is recognized inter-institutional variability with the use of I4F-PCC, especially as it relates to dosing practices. We sought to characterize variations in I4F-PCC dosing practices and their impact on patient outcomes and describe overall real-world clinical practice surrounding I4F-PCC utilization in the context of the management of warfarin-related intracranial hemorrhage (ICH)., Methods: This is a multicenter retrospective pragmatic registry study of adult patients admitted at a participating study site between January 1, 2014, and December 31, 2015, who received I4F-PCC for reversal of warfarin-related ICH. Practices around warfarin-related ICH reversal in context of I4F-PCC utilization are described, including repeat I4F-PCC dosing, adjunctive reversal agents, and dose rounding policies (i.e., rounding doses to nearest vial size vs preparing exact/unrounded doses). All research was approved by local human investigation committees at each institution., Results: Seventeen institutions contributed data on 528 patients to this registry. These institutions were primarily urban centers (74%), located in the southeast USA (47%), with Level 1 Trauma designation (79%), and with Comprehensive Stroke Center designation (74%). Most patients included in the study had sustained a non-traumatic ICH (68%), had a median admission GCS of 14 (IQR 7-15), and were receiving warfarin for atrial fibrillation (57.4%). There was substantial time latency between baseline INR and I4F-PCC (median 2.4 h, IQR 1.4-4.5 h). Most patients received adjunctive reversal agents, including vitamin K (89.5%) and fresh frozen plasma (FFP) (31.9%). A smaller proportion (6.0%) of patients received repeat I4F-PCC dosing. The median ICU length of stay (LOS) was 3 days (IQR 2-7 days), median hospital LOS was 6 days (IQR 3-12 days), and overall mortality rate was 28.8%. For institutions rounding doses to the nearest vial size, the first post-I4F-PCC dose INR was statistically but not clinically significantly lower than for institutions without vial size dose rounding, with comparable degrees of INR reduction from baseline. No differences were observed between dose rounding cohorts in adverse effects, ICU or hospital LOS, modified Rankin score at discharge, or mortality rates., Conclusions: Most patients received single doses of I4F-PCC, with adjunctive reversal agents and rounding doses to vial size. The time difference from baseline INR to factor product administration is a potential opportunity for process improvement in the management of warfarin-related ICH., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Background: Intra- and postprocedural thrombosis are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization. The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuro-endovascular patients is inferred from the cardiology literature without large clinical trials to support it in neuro-endovascular patients., Objective: We conducted an electronic survey to identify practice variations surrounding the use of oral antiplatelets in patients undergoing endovascular neuro-interventional procedures across neuro-endovascular centers in the United States., Methods: An electronic survey was distributed via the Web. Any practicing neuro-intensive care unit (ICU), neuro-interventional or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to this survey between June and October 2017., Results: A total of 33 responses were collected during the survey period. A response rate of 16% was calculated after taking into account all comprehensive stroke centers in the United States. Aspirin and clopidogrel was the standard-of-care antiplatelet regimen utilized in the majority of institutions (82%). Alternatively, 4 institutions used monotherapy (aspirin [n = 2], clopidogrel [n = 1], either aspirin or clopidogrel [n = 1]) and 2 institutions reported practitioner-dependent practices. Just under half of the centers reported ticagrelor as the primary alternative in clopidogrel nonresponders (48%)., Conclusion: Dual antiplatelet therapy with aspirin and clopidogrel appears to be standard of care in this setting based on our survey. About half of responding institutions use ticagrelor in cases where clopidogrel resistance is suspected. Large society-wide patient registries are needed to provide data for future safety and efficacy studies.

Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.

We previously demonstrated that the transcription factor Grainyhead-like 3 (GRHL3) has essential functions in endothelial cells by inhibiting apoptosis and promoting migration as well as activation of endothelial nitric oxide synthase (eNOS). We now show that a large portion of the protein is localized to myo-endothelial projections of murine arteries suggesting extra-nuclear functions. Therefore, we generated various deletion mutants to identify the nuclear localization signal (NLS) of GRHL3 and assessed potential extra-nuclear functions. Several large-scale deletion mutants were incapable of activating a GRHL3-dependent reporter construct, which could either be due to deficiencies in transcriptional activation or to impaired nuclear import. One of these mutants encompassed a predicted bipartite NLS whose deletion led to the retention of GRHL3 outside the nucleus. Interestingly, this mutant retained functions of the full-length protein as it could still inhibit pathways inducing endothelial cell apoptosis. As apoptosis protection by GRHL3 depends on NO-production, we examined whether GRHL3 could interact with eNOS and showed a direct interaction, which was enhanced with the extra-nuclear GRHL3 variant. The observation that endogenous GRHL3 also interacts with eNOS in intact murine arteries corroborated these findings and substantiated the notion that GRHL3 has important extra-nuclear functions in the endothelium.

Objective: Blood transfusions are given to approximately one-fifth of patients undergoing elective lumbar spine surgery, and previous studies have shown that transfusions are accompanied by increased complications and additional costs. One method for decreasing transfusions is administration of tranexamic acid (TXA). The authors sought to evaluate whether the cost of TXA is offset by the decrease in blood utilization in lumbar spine surgery patients., Methods: The authors retrospectively reviewed patients who underwent elective lumbar or thoracolumbar surgery for degenerative conditions at a tertiary care center between 2016 and 2018. Patients who received intraoperative TXA (TXA patients) were matched with patients who did not receive TXA (non-TXA patients) by age, sex, BMI, ASA (American Society of Anesthesiologists) physical status class, and surgical invasiveness score. Primary endpoints were intraoperative blood loss, number of packed red blood cell (PRBC) units transfused, and total hemostasis costs, defined as the sum of TXA costs and blood transfusion costs throughout the hospital stay. A subanalysis was then performed by substratifying both cohorts into short-length (1-4 levels) and long-length (5-8 levels) spinal constructs., Results: Of the 1353 patients who met inclusion criteria, 68 TXA patients were matched to 68 non-TXA patients. Patients in the TXA group had significantly decreased mean intraoperative blood loss (1039 vs 1437 mL, p = 0.01). There were no differences between the patient groups in the total costs of blood transfusion and TXA (p = 0.5). When the 2 patient groups were substratified by length of construct, the long-length construct group showed a significant net cost savings of $328.69 per patient in the TXA group (p = 0.027). This result was attributable to the finding that patients undergoing long-length construct surgeries who were given TXA received a lower amount of PRBC units throughout their hospital stay (2.4 vs 4.0, p = 0.007)., Conclusions: TXA use was associated with decreased intraoperative blood loss and significant reductions in total hemostasis costs for patients undergoing surgery on more than 4 levels. Furthermore, the use of TXA in patients who received short constructs led to no additional net costs. With the increasing emphasis put on value-based care interventions, use of TXA may represent one mechanism for decreasing total care costs, particularly in the cases of larger spine constructs.

Objectives: To review the neurocritical care aspects of patients supported by extracorporeal membrane oxygenation, including cerebral physiology, neurologic monitoring, use of sedatives and anti-seizure medications, and prevalence and management of extracorporeal membrane oxygenation associated brain injury., Data Sources: PubMed database search using relevant search terms related to neurologic complications, neurocritical care management, and brain injury management in patients with extracorporeal membrane oxygenation., Study Selection: Articles included original investigations, review articles, consensus statements and guidelines., Data Extraction: A detailed review of publications performed and relevant publications were summarized., Data Synthesis: We found no practice guidelines or management strategies for the neurocritical care of extracorporeal membrane oxygenation patients. Such patients are at high risk for hypoxic-ischemic brain injury, intracranial hemorrhage, cerebral edema, and brain death. Improving clinical outcomes will depend on better defining the neurologic complications and underlying pathophysiology that are specific to extracorporeal membrane oxygenation. Currently, insufficient understanding of the pathophysiology of neurologic complications prevents us from addressing their etiologies with specific, targeted monitoring techniques and interventions., Conclusions: A large knowledge gap exists in our understanding and treatment of extracorporeal membrane oxygenation-related neurologic complications. A systematic and multidisciplinary approach is needed to reduce the prevalence of these complications and to better manage the neurologic sequelae of extracorporeal membrane oxygenation in a way that will improve patient outcomes.

Purpose: Optimization of antifungal therapy with voriconazole can be challenging due to inter- and intrapatient variability in voriconazole pharmacokinetics (PK). In this case, we introduce challenges in voriconazole therapy due to drug-drug interactions, autoinduction, and saturable metabolism., Summary: A 32-year-old male on chronic prednisone developed central nervous system (CNS) aspergillosis. He was started on high-dose intravenous (IV) voriconazole 8.5 mg/kg every 12 hours due to concerns for lasting induction effects of recent rifampin therapy. The initial voriconazole trough was 2 μg/mL. Frequent dose adjustments were made to maintain the therapeutic trough goal. On day 24 of voriconazole therapy, his trough was undetectable on IV voriconazole 5.5 mg/kg every 12 hours. His dose was escalated to 8.5 mg/kg every 12 hours to avoid subtherapeutic levels and therapeutic failure. On day 48, his trough level was 1.1 μg/mL on the same dose. His regimen was changed to 6.5 mg/kg every 8 hours at this point. Sixteen days after this regimen on day 74 of voriconazole therapy, his trough was 27.2 μg/mL indicating saturable PK of voriconazole in the absence of interacting drugs., Conclusion: Our findings highlight the unpredictable PK of voriconazole and reinforce the importance of continuous therapeutic drug monitoring in critically ill patients.

Purpose: The purpose of this analysis is to assess the effect of antiepileptics (AEDs) on seizure prevention and short and long term functional outcomes in patients with acute intracerebral hemorrhage., Method: The meta-analysis was conducted using the PRISMA guidelines. A literature search was performed of the PubMed, the Cochrane Library, and EMBASE databases. Search terms included "Anticonvulsants", "Intracerebral Hemorrhage", and related subject headings. Articles were screened and included if they were full-text and in English. Articles that did not perform multivariate regression were not included. Overall effect size was evaluated with forest plots and publication bias was assessed with the Begg's and Egger's tests., Results: A total of 3912 articles were identified during the initial review. After screening, 54 articles remained for full review and 6 articles were included in the final analysis. No significant association between the use of AEDs after ICH and functional outcome (OR 1.53 [95%CI: 0.81-2.88] P = 0.18, I 2  = 81.7%). Only one study evaluated the effect AEDs had in preventing post-ICH seizures., Conclusions: The use of prophylactic AEDs was not associated with improved short and long outcomes after acute ICH. This analysis supports the 2015 AHA/ASA recommendation against prophylactic AEDs (class III; level of evidence b)., (Copyright © 2019 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background: Rapid administration of hypertonic saline 23.4% is crucial in treatment of herniation syndromes. Hypertonic 23.4% saline must be administered via a central line. In cases where central line access is difficult to obtain and leads to delay in therapy, placement of intraosseous access can be lifesaving., Main Body: The purpose of this case series is to describe the use of intraosseous administration of 23.4% saline in critically ill patients and to assess feasibility., Conclusion: Intraosseous administration of 23.4% saline in 6 adult patients with neurological emergencies was feasible and should be considered in cases where obtaining intravenous access is time consuming.

Purpose of Review: To discuss recent updates in fluid management and use of hyperosmolar therapy in neurocritical care., Recent Findings: Maintaining euvolemia with crystalloids seems to be the recommended fluid resuscitation for neurocritical care patients. Buffered crystalloids have been shown to reduce hyperchloremia in patients with subarachnoid hemorrhage without causing hyponatremia or hypo-osmolality. In addition, in patients with traumatic brain injury, buffered solutions reduce the incidence of hyperchloremic acidosis but are not associated with intracranial pressure (ICP) alteration. Both mannitol and hypertonic saline are established as effective hyperosmolar agents to control ICP. Both agents have been shown to control ICP, but their effects on neurologic outcomes are unclear. A recent surge in preference for using hypertonic saline as a hyperosmolar agent is based on few studies without strong evidence., Summary: Fluid resuscitation with crystalloids seems to be reasonable in this setting although no recommendations can be made regarding type of crystalloids. Based on current evidence, elevated ICP can be effectively reduced by either hypertonic saline or mannitol.