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Background Given the acuity of patients who receive MTPs and the resources they require, MTPs are a compelling target for performance improvement. This study evaluated adherence with our MTP’s plasma:red blood cell ratio (FFPR) of 1:2 and platelet:red blood cell ratio (PLTR) of 1:12, to test the hypothesis that ratio adherence is associated with lower inpatient mortality.Materials and Methods The registry of an urban level I trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 hours of presentation. Patients were excluded for interfacility transfer, cardiac arrest during the prehospital phase or within one hour of arrival, or for head AIS ≥5. Univariate analysis and multiple logistic regressions were performed to identify variables associated with early transfusion protocol noncompliance and the effect on inpatient mortality.Results Three hundred and eighty-three patients were included, with mean ISS of 25.9 ± 13.3 and inpatient mortality of 28.5%. Increasing age, ISS, INR, and total units of blood product transfused were associated with increased odds of mortality, while an increase in revised trauma score was associated with a decreased odds ratio of mortality. Achieving our goal ratios were protective against mortality, with OR of .451 (P= .013) and .402 (P=.003), respectively.Discussion Large proportions of critically injured patients were transfused fewer units of plasma and platelets than our MTP dictated; failure to achieve intended ratios at 4 hours was strongly associated with inpatient mortality. MTP processes and outcomes should be critically assessed on a regular basis as part of a mature performance improvement program to ensure protocol adherence and optimal patient outcome.

Abstract: Background: Atrial fibrillation, which occurs in 12% of all major foregut surgeries, can prolong hospital stay and increase morbidity. Minimally invasive techniques in foregut surgery have been suggested to cause less tissue trauma. We examined the factors associated with new-onset atrial fibrillation after foregut surgery at our institution. Methods: We retrospectively examined the records of 154 adult patients who underwent major foregut surgery which included esophagectomy, partial or total gastrectomy, redo Heller myotomy, redo or transthoracic fundoplications. Univariate and multivariate logistic regression analysis with standard modeling techniques were performed to determine risk factors for new-onset atrial fibrillation. Results: Of the 154 patients, 14 patients developed new-onset atrial fibrillation with a higher mean age of 67.1 years (±8.8 years) versus 56.4 years (±14.1 years) (p = 0.006). Laparoscopic (p = 0.004) and nonthoracic surgeries (p = 0.01) were associated with lower risk of atrial fibrillation. Patients with atrial fibrillation had received more fluid (6.5 ± 2.8 liters versus 5.3 ± 2.0 liters) and had longer operations (370 ± 103 min versus 362 ± 142 min), none of which were statistically significant. The average intensive care length of stay of patients was longer: 7.5 ± 6.8 days versus 4.0 ± 7.1 days (p = 0.004). Multivariate analysis revealed an association of atrial fibrillation with age (OR 1.08, 95% CI 1.02–1.14, p = 0.01), and laparoscopic surgery (OR 0.09, 95% CI 0.01–0.95, p = 0.04) after adjusting for surgery type. Conclusions: Laparoscopic surgery is associated with lower risk of atrial fibrillation in foregut surgery. Development of atrial fibrillation is associated with increased length of intensive care stay. We recommend a prospective trial to confirm our findings.

The recent COVID-19 pandemic has increased the use of disposable face masks (DFMs). Due to a lack of manufacturing and disposal guidelines, DFMs are among the most common solid wastes worldwide. Common masks are made of polypropylene, which releases (nano)microplastics into the environment as it ages, causing environmental problems. In this work, the mechanism of aging of DFMs under UV radiation is studied and also the interaction mechanism of three antibiotics (ciprofloxacin (CIP), sulfamethoxazole (SMX) and tetracycline (TC)) with the original and UV-aged (nano)microplastics of the mask is investigated. The results showed that aging caused more antibiotics to be adsorbed onto the mask (nano)microplastics, mainly due to the oxygen-containing groups on the surface of the aged-mask. The adsorption capacity of the different layers of the (nano)microplastic mask for antibiotics was in descending order: inner-layer > outer-layer > middle-layer. The adsorption affinity of new and aged mask (nano)microplastics for antibiotics followed SMX > CIP > TC, which positively correlated with the octanol–water partition coefficient (log Kow) of antibiotics. In general, the adsorption process of antibiotics on (nano)microplastics is mainly governed by membrane-diffusion and distribution mechanisms, and hydrophobic interactions regulate the adsorption process.

Industrial production is the main reason for excessive fluoride content in wastewater, and it is necessary to adopt economical and effective fluoride removal methods. Therefore, be aware of the existing form of fluorine and the formation mechanism of fluoride pollution, and based on the water purification agents, environmental functions, and material innovation, this overview focuses on the defluoridation mechanism, the advantages and disadvantages of precipitation and coagulation, adsorption, electrochemical technology, and membrane separation technology. In the actual process of treating fluoride-containing wastewater, appropriate methods should be adopted according to the different characteristics of the wastewater. This review describes the research progress of fluo-ride removal methods for fluoride-containing wastewater at home and abroad in recent years, further analyzes the advantages and technical bottlenecks of these methods, and looks ahead at the major development trends in the future to provide a reference for further research on treatment technology of wastewater with a high fluoride content.

Ever since the Gravity Driven Membrane (GDM) system was proposed in 2010 as an environmentally friendly and low-carbon water treatment technology, the search for an appropriate pre-treatment measure to combat the low stable flux and membrane fouling has been of great importance for the promotion and development of GDM systems. This review summarized the effects of pre-treatment measures (particulate adsorption, coagulation, oxidation) in existing reports on stable flux, membrane fouling and water quality of GDM systems. Based on the literature reports, the internal mechanism was classified. The effects of different pretreatment conditions on stable flux were evaluated by meta-analysis, and the optimal process conditions to maintain higher stable flux with different pretreatments were predicted. The analysis revealed that appropriate pretreatment selection could improve the performance of the GDM system by removing fouling by the pretreatment itself, reducing bacterial EPS emissions, producing smaller/more hydrophilic pollutant molecules, enhancing bioactivity and generating a looser membrane structure. Moreover, the investment and operating costs of GDM systems can be reduced through suitable pre-treatment measures, thereby expanding their application in decentralized water supply and wastewater treatment. Given the variability and uniqueness of water source conditions, this review aimed to guide the design of pretreatment measures in GDM systems to improve the efficiency of targeted treatment and promote its applicability.

ABSTRACTAccurate pin placement to guide renaming of the glenoid surface in total shoulder arthroplasty (TSA) is a critical step to restore range of motion in the glenohumeral joint. Achieving proper pin position with free-hand is complicated due to inadequate intra-operative availability of pre-operative planning data. Mixed reality provides a new modality of surgical navigation for arthroplasty without distracting surgeon from the patient anatomy. However, achieving accurate alignment between the pre-operative plan and the intra-operative anatomy is challenging, especially if workflow-compliant solutions are desired. In this paper, we present a calibration-free mixed reality navigation workflow for glenoid pin placement in TSA that contributes to solving some open challenges. We use a visible light stereo camera on a surgical support arm combined with a transformer-based disparity estimation algorithm to accurately reconstruct the 3D anatomy despite surgical lighting. Besides, we introduce a slide-on marker calibrated by design to overcome perceptual difficulties that arise when trying to align real to virtual objects. In a user study on a semi-anthropomorphic phantom, we assess the end-to-end pin placement accuracy using both our system and a clinical reference standard solution that relies on patient-specific drill guides. Averaging over 15 drilled trajectories, our mixed reality system achieved a pin placement accuracy of (mm, ).

Background: The Environmental Management System (EMS) is a unique way to developan environmental policy with adequate planning, including implementation, operation,checking, and management review. Objective: The main stages of the EMS encompass environmental policy, planning, implementation,evaluation, and review. Methods: A number of environmental standards (ISO 14000), which were drawn up by the internationalstandardization organization, form an essential part of an EMS. This management systemintroduces environmental management into the day-to-day functions, long-term operations, andresource management frameworks of the organization. Results: This overview provides important information about the role of the EMS in water resourcemanagement and the scope of the EMS in the water system. This management system isused as an instrument to promote sustainable development in society. Conclusion: This paper sheds light on the topic of a sustainable water environment. In addition,some recognized successful EMS systems were reviewed and illustrated. We believe this reviewprovides a guide to a fruitful water environment for successful urbanization planning.

Graphical abstract:

Objective, Participants, and Methods: To determine whether peer educators are considered peers by their audiences, the authors compared 28 peer educators and 28 college students on their personal qualities using self-report surveys. Results: Students who wanted to become peer educators reported higher self-esteem, greater leadership skills, and fewer risky health behaviors than did demographically similar college students. However, peer educators appeared similar to their colleagues in terms of personal values and personality temperament. Conclusions: Although peer educators are natural leaders with strong self-esteem and more healthy behaviors, they appear to be quite similar to their audiences in regard to values and temperaments, making them successful role models and arguably true peers. Keywords: characteristics, college, peer education, Peer-education programs on college campuses train students to provide educational programming to fellow students. Peer educators counsel, provide information, and conduct outreach programs. Most (78%) colleges and universities use peer-education [...]

ABSTRACTTotal Shoulder Arthroplasty (TSA) is a shoulder replacement procedure to treat severe rotator cuff deficiency, primarily caused by osteoarthritis in elderly patients. One of the critical factors in reducing postoperative complications is accurate drilling of a centring hole on the glenoid surface at a precise position and orientation. While the drilling path is planned pre-operatively on 3D diagnostic images, the absence of visual guidance during surgery can lead to low reproducibility. In this paper, we present the design and feasibility analysis of a marker-less image-based registration pipeline using the Microsoft HoloLens 1 and its built-in sensors to guide glenoid drilling during TSA. Our solution intra-operatively registers the pre-operative 3D scan to the exposed glenoid surface both with and without occlusion. Our results provide a breakdown of the sources contributing to registration error. In addition to the commonly discussed errors (SLAM-based head tracking, partial overlap etc.), we find that the poor performance of the depth sensing camera becomes a major source of error. We further find that partial overlap between the source and target remains a large concern for registration in high occlusion scenarios. This work begins to characterise the depth sensor error and suggests future work towards image-based augmented reality guidance.

Background:Cytokine release storm (CRS) in severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) is thought to be the cause for organ damage and death which is independent of the actual viral burden. Tocilizumab (TCZ), an interleukin-6 receptor antagonist, is approved for the treatment of CRS. We describe the efficacy and safety of TCZ in SARS CoV-2 pneumonia. Methods:This retrospective study was conducted at a tertiary care hospital from April 20 2020 to May 21 2020. The primary endpoint was the cumulative incidence of a composite of either need for admission to the intensive care unit (ICU) with invasive mechanical ventilation or death. Safety outcomes included an increase in liver transaminases and/or evidence of infection. Results:A total of 20 patients received TCZ during the study period. The median age was 54 years (95% confidence interval [CI] 47–63). About 85% of the patients were male. Nearly 70% of the patients had at least one comorbidity. About 55% required ICU admission. The median duration of ICU stay was 11 days (95% CI: 3–13 days). The cumulative incidence of the requirement for mechanical ventilation, clinical improvement and mortality was 11% (95% CI: 0.03%–1%), 74% (95% CI 37%–89%) and 25% (95% CI: 11%–63%), respectively. There was no difference in outcomes according to age, gender or computed tomography severity score. Asymptomatic transaminitis was the most common drug reaction (55%), and one patient developed bacteraemia. Conclusions:TCZ is likely a safe and effective modality of treatment for improving clinical and laboratory parameters of SARS CoV-2 patients with a reduction in ICU stay and ventilatory care need.

The water solubility and polymerizability of maleoyl chitosan (MCS) was significantly improved by introducing a maleoyl group into the chitosan chain and MCS is a promising monomer for preparing chitosan-based flocculants with good water solubility. In this study, MCS was grafted with acrylamide and diallyldimethylammonium chloride to prepared a cationic chitosan modified flocculant chitosan-graft-poly (acrylamide diallyldimethylammonium chloride) (PMAD) with excellent solubility by ultraviolet (UV)-induced copolymerization techniques. The effects of monomer concentration, the percentage of maleated chitosan, photoinitiator concentration and illumination time on the intrinsic viscosity, grafting efficiency and dissolution time of PMAD were investigated by single factor experiments. The optimal synthesis conditions were determined with monomer concentration 12.5%, MCS percentage 10%, cationicity 11.25%, photoinitiator concentration 0.3% and illumination time 120 min, proving that UV initiated method was benefited to improve water solubility of PMAD. PMAD prepared at the optimized condition has the optimal viscosity of 4,823.2 mg L–1, the grafting efficiency of 70.7% and the dissolution time of 75 min. At the same time, the synthesized products PMAD were characterized by infrared spectroscopy, scanning electron microscopy, H-nuclear magnetic resonance, thermogravimetric and X-ray diffraction techniques. The flocculation experiments of PMAD on algae-containing water showed that the flocculation performance of PMAD was remarkably higher than that of commercially available polyacrylamide and polyaluminum ferric chloride. The optimal removal rate of Chl a (81.2%), turbidity (94.9%), and algae cell concentration (99.7%) by PMAD was obtained at dosage of 40 mg L–1, pH value 8 and G value 500 s–1. The obtained zeta potential results proved that the main flocculation mechanism of PMAD was the function of adsorption bridging.

In this paper, highly efficient Ti-Ag/γ-Al2O3particle electrodes were prepared for efficient degradation of chloramphenicol (CAP) by using three-dimensional electrocatalytic technology. The effects of preparation factors, such as mass ratio of Ti/Ag, loading times, and calcination temperature, on the electrocatalytic performance of Ti-Ag/γ-Al2O3particle electrode were investigated. In addition, Ti-Ag/γ-Al2O3particle electrodes under different conditions were characterized by SEM, EDS, XRF, and XRD. The optimal removal rate of chloramphenicol was 84.2% with initial concentration of chloramphenicol 100 mg/L, conductivity 6,000 μs cm–1, initial pH 4.0, current intensity I = 0.2 A, and flow rate 1.0 L/min. The elimination of •OH by addition of t-butanol reduced the chloramphenicol removal rate by 56.0% under the same working conditions, indicating that the degradation of chloramphenicol was caused by the combination of •OH indirect oxidation and anodic indirect oxidation. Meanwhile, the degradation process of chloramphenicol was approximately in accordance with the first-order kinetic equation.

In this work, carboxylated chitosan and acrylamide are used to synthesize a graft-modified natural polymer flocculant carboxylated chitosan-graft-acrylamide (CCSPAM) by UV-induced polymerization for copper and chromium removal. The effects of total monomer concentration, monomer mass ratio, pH value, photoinitiator concentration, and illumination time on the synthesis performance of CCSPAM were investigated regarding intrinsic viscosity (IV), grafting rate (GR), and grafting efficiency (GE). Various analytical techniques characterize the physicochemical characteristics of CCSPAM. Single factor experiments are used to investigate the effect of dosage, pH value, and reaction time on the chelation and capture of heavy metal ions by CCSPAM. The results show that the optimal IV, GR, and GE of CCSPAM achieved at total monomer concentration 30%, monomer mass ratio 1:4, pH 7.0, photoinitiator concentration 0.03%, and irradiation time 2 h are 1412.2 mL/g, 394.1%, and 84.1%, respectively. The experimental data of flocculation show that CCSPAM has a good total Cu and total Cr removal efficiency of 74.8% and 70.6% at dosage 2.0 mg/L, pH 6.0, and reaction time 2h, respectively. Fom the investigation, it is concluded that the grafted chitosan (CCSPAM) could be a be an effective and eco-friendly flocculant for removal of total Cu and total Cr ions from aqueous system.

Melioidosis is endemic in India and well described from western and eastern coastal states. Sporadic cases of melioidosis have been diagnosed from Gujarat prior to current case series in patient with travel history to endemic areas. We noticed a rise in melioidosis cases from Gujarat and Rajasthan in the last two years. With this case series, we are reporting eleven melioidosis cases who have no travel history to endemic areas and acquired melioidosis locally. This case series alerts practicing clinicians in Gujarat and Rajasthan to look for and keep melioidosis as one of the differential diagnosis in appropriate clinical syndrome.

SARS-CoV-2 predominantly involves the lungs producing acute lung injury, but it can also give rise to a variety of complications involving the central nervous system, gastrointestinal system, kidney and also viral sepsis. With this case report, we are discussing unusual series of complication from acute lung injury, followed by viral sepsis then encephalitis, followed by progressive macrophage activation syndrome.

The article offers information on the National Weekend of Honor, three-day memorial service in Arlington, Virginia, held by the National EMS Memorial Service, paying tribute to fallen Emergency medical services (EMS) providers through events.

Evaluation of febrile illness in a returning traveler is challenging as it requires careful history taking and knowledge of local epidemiology of endemic and epidemic diseases. Incorporating information of host characteristics for susceptibility of infections is also important for endemic mycosis apart from history of tick bites and animal exposures. Laboratory tests directed by clinical and laboratory parameters will help to reach final diagnosis.

Spillage of gallstones into the peritoneal cavity (dropped gallstones) is more common in laparoscopic compared with open cholecystectomy. Subsequent infectious complications are often delayed, occurring in 0.1 to 2.9 of cases. We present the first reported case of Salmonella entericasubphrenic abscess and empyema complicating dropped gallstones, treated with video-assisted thoracoscopic surgery (VATS), and surgical retrieval.

Abstract: Background: Atrial fibrillation, which occurs in 12% of all major foregut surgeries, can prolong hospital stay and increase morbidity. Minimally invasive techniques in foregut surgery have been suggested to cause less tissue trauma. We examined the factors associated with new-onset atrial fibrillation after foregut surgery at our institution. Methods: We retrospectively examined the records of 154 adult patients who underwent major foregut surgery which included esophagectomy, partial or total gastrectomy, redo Heller myotomy, redo or transthoracic fundoplications. Univariate and multivariate logistic regression analysis with standard modeling techniques were performed to determine risk factors for new-onset atrial fibrillation. Results: Of the 154 patients, 14 patients developed new-onset atrial fibrillation with a higher mean age of 67.1 years (±8.8 years) versus 56.4 years (±14.1 years) (p = 0.006). Laparoscopic (p = 0.004) and nonthoracic surgeries (p = 0.01) were associated with lower risk of atrial fibrillation. Patients with atrial fibrillation had received more fluid (6.5 ± 2.8 liters versus 5.3 ± 2.0 liters) and had longer operations (370 ± 103 min versus 362 ± 142 min), none of which were statistically significant. The average intensive care length of stay of patients was longer: 7.5 ± 6.8 days versus 4.0 ± 7.1 days (p = 0.004). Multivariate analysis revealed an association of atrial fibrillation with age (OR 1.08, 95% CI 1.02–1.14, p = 0.01), and laparoscopic surgery (OR 0.09, 95% CI 0.01–0.95, p = 0.04) after adjusting for surgery type. Conclusions: Laparoscopic surgery is associated with lower risk of atrial fibrillation in foregut surgery. Development of atrial fibrillation is associated with increased length of intensive care stay. We recommend a prospective trial to confirm our findings.

Psoriasis is a chronic disease treated using topical application of calcineurin inhibitors. However, due to physico-chemical nature of psoriatic stratum corneum, the topical drug delivery is very challenging. The present study aims to explore the potential of niosomes to improve the topical delivery of cyclosporine (penetration and deposition) for effective treatment of psoriasis. The niosomes-gel was prepared by film hydration method using cholesterol, Span 60 and Carbopol 940 (gelling agent). The factorial design (32) was applied to optimize the size (128 nm) and poly dispersibility index (PDI = 0.14) of niosomes by selecting cholesterol: Span 60 ratio at 160 mg: 313.6 mg and hydration time at 42.9 min. In ex vivopermeability studies (rat skin), the niosomes showed high permeation (50.57% in 24 h) in comparison to the cyclosporine suspension (10.13% in 24 h). The drug deposition study showed 59 fold increase in the cyclosporine deposition in the stratum corneum (SC) and the viable epidermis/dermis (VED) layers, which was further ensured by Coumarin 6 fluorescence microscopy. The histopathology and psoriasis area - severity index (PASI) scores in the imiquimod induced psoriatic plaque model showed significant drop in the scoring with niosomes. In conclusion, the optimized niosomes showed promising results to improve the cyclosporine penetration and deposition in the skin tissue for the effective treatment of psoriasis.

Background: Acute lymphoblastic leukemia (ALL) is the most frequent pediatric malignancy, of which T- cell acute lymphoblastic leukemia (T-ALL) constitutes an aggressive subset. Due to the advent of new therapies, T-ALL now has a 5-year event-free survival (EFS) rate exceeding 85%. However, some patients still relapse and display resistance to therapy. Moreover, adverse side-effects of intensive chemotherapy worsen the duration of treatment. Therefore, we still need to improve our current treatment beyond that of the chemotherapeutic approaches. It has been shown that the maturation stage of T-ALL decides its dependency on Bcl-2/Bcl-xL. The immature early T cell progenitor ALL (ETP-ALL) rely on Bcl-2 for their survival while all the other stages of T-ALL and primary patient samples depend on Bcl-xL. Bcl-2 inhibitors have thus shown to display promising antitumor activity against ETP-ALL, a subgroup with a high risk of relapse, but with a variable response across these patients. Therefore, there is a need for predictive biomarkers and further investigation towards finding a combination of drugs for the treatment of these patients.