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BackgroundTotal hip arthroplasty (THA) is a common procedure following which postoperative visits are important to optimize outcomes. The associated global billing period includes the 90 postoperative days (or approximately 13 weeks), during which professional billing is included with the surgery itself. The current study assessed clinical practice patterns relative to the global billing period.MethodsUsing the PearlDiver M91Ortho dataset, the incidence and timing of Evaluation and Management (E&M) codes in the 26 weeks following THA were assessed. The follow-up visits within and beyond the global billing period, and those conducted by surgeons versus non-surgeon advanced practice providers (APPs) were determined.Results77,843 THAs were identified. Follow-up visits peaked at postoperative weeks 3, 7, and 14. The greatest week-to-week variation in the number of follow-ups was from weeks 13 to 14 immediately following the global billing period (representing a greater than 4-fold increase in visits.) During the first 13 postop weeks, 73.8% of patients were seen by orthopedic surgeons (as opposed to APPs). In the following 13 weeks, a significantly greater percentage of visits were with surgeons (86.8%, pConclusionsFollowing the THA global billing period, there was marked increase in the number of follow-ups and transition to a greater percentage being performed by the surgeons. These results provide interesting insight into the potential impact of the billing structure on how practice is pursued.

Background: End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States’ utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis. Methods: TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA. Results: In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA. With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals (“not-for-profit” and “investor-owned”) were significantly more likely to offer TAA over AA. Conclusion: Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis. Level of Evidence: Level III, retrospective cohort study.

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) surgery has steadily increased in recent decades. The aim of the current study was to investigate the evolving burden of revision surgery and risk factors and timing of revision or implant removal. We hypothesized that there has been an increase in revision TAR and explant surgeries in the past decade and that younger age and higher comorbidity burden are risk factors for revision and explant. Methods: Using the 2010-2020 PearlDiver M151Ortho dataset, this retrospective cohort study identified primary TAR, TAR revision, and TAR explant patients. This is a large national database containing billing claims information on over 151 million patients in the United States across all payer types and sites of care. Patient factors investigated included age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated using ICD-9 and ICD-10 diagnosis codes). Annual incidence for primary and revision TAR, and explant were recorded. Multivariate logistic regression analyses were performed to determine independent risk factors for revision TAR or explant relative to primary TAR. For explants, the eventual intervention by two years was analyzed. Ten-year timing and survival to revision or explant surgery following patient-matched unilateral TAR were characterized. Results: Over the study period, there were 10,531 primary, 1,218 revision, and 1,735 explant TARs (increasing by 310%, 398%, and 9.6%, respectively). Independent predictors of revision TAR included: younger age (odds ratio [OR] 1.29 per decade decrease) and higher ECI (OR 1.23 per 2-point increase) (p < 0.0001 for both). Independent predictors of explant surgery included: younger age (OR 1.80 per decade decrease, p< 0.0001), female sex (OR 1.17, p=0.0011), and higher ECI (OR 1.35 per 2-point increase, p< 0.0001). Explanted patients went on to arthrodesis (37.7%), amputation (26.1%), revision TAR (14.7%), or no identified procedure/other procedures (21.5%) within the subsequent two years. The 10-year implant survival rate following primary TAR was 91.8%. 73% and 83% of revisions and explants occurred in the first three years following index TAR, respectively. Conclusion: The burden of TAR revision has grown substantially over the past decade. Younger age, female sex, and higher patient comorbidity burden were associated with increased risk of revision or explant surgery. If explant is pursued, most went on to arthrodesis or amputation. These results suggest that care should be taken in patient selection for TAR to minimize the occurrence of revision and explant surgery. Treatment algorithms should be modified to optimize outcomes among patients who undergo explant or revision surgery.

Background: Total ankle replacement (TAR) surgery has increased in recent decades. The aim of this study was to investigate the evolving burden of revision surgery and risk factors and timing of revision or explant. Methods: Using the 2010 to 2020 PearlDiver M151Ortho data set, this retrospective cohort study identified primary TAR, TAR revision, and TAR explant patients via Current Procedural Terminology ( CPT ) and International Classification of Disease Procedural ( ICD-P ) codes. This database contains billing claims information across all payers and sites of care in the United States. Patient factors investigated included age, sex, and Elixhauser Comorbidity Index (ECI). Annual incidence for primary TAR was normalized per 100 000 covered lives in the data set for each year of study and recorded. Annual incidence of revision TAR and explant were normalized per 100 TARs performed for each year of study. Multivariate logistic regression analyses were performed to determine independent risk factors for revision TAR or explant. For explants, the eventual intervention by 2 years was analyzed. Ten-year timing and survival to revision or explant surgery following unilateral TAR were characterized. Results: A total of 10 531 primary, 1218 revision, and 1735 explant TARs were identified. After normalization, TAR utilization increased by 284% from 2010 to 2020, annual TAR revisions rose 28%, and annual TAR explants decreased 65%. Independent predictors of revision TAR were younger age (odds ratio [OR] 1.29 per decade decrease) and higher ECI (OR 1.23 per 2-point increase). Independent predictors of explant included younger age (OR 1.80 per decade decrease), female sex (OR 1.17), and higher ECI (OR 1.35 per 2-point increase). The 10-year implant survival rate was 91.8%, of which 73% of revisions and 83% of explants occurred in the first 3 years following index TAR. Conclusion: TAR utilization has grown substantially over the past decade, with minimal increases in the annual rate of revision surgery with respect to index procedures performed. Level of Evidence: Level III, retrospective cohort study.

This study summarised the recent achievement in developing fiber reinforced geopolymer concrete. The factor of replacing Ordinary Portland Cement (OPC) which is due to the emission of carbon dioxide that pollutes the environment globally is well discussed. The introduction towards metakaolin is presented. Besides, the current research trend involved in geopolymer also has been reviewed for the current 20 years to study the interest of researchers over the world by year. Factors that contribute to the frequency of geopolymer research are carried out which are cost, design, and the practicality of the application for geopolymer concrete. Besides, the importance of steel fibers addition to the geopolymer concrete is also well discussed. The fundamental towards metakaolin has been introduced including the source of raw material, which is calcined kaolin, calcined temperature, chemical composition, geopolymerisation process, and other properties. Alkali activators which are mixing solution between sodium hydroxide (NaOH) and sodium silicate (Na2SiO3) have been reviewed. The mechanical properties of fibers reinforced metakaolin-based geopolymer concrete which is compressive and flexural are thoroughly reviewed. The compressive and flexural strength of fiber-reinforced metakaolin geopolymer concrete shows some improvement to the addition of steel fibers. The reviews in this field demonstrate that reinforcement of metakaolin geopolymer concrete by steel fibers shows improvement in mechanical performance.

Background: Physical therapy (PT) following total ankle replacement (TAR) is often considered, but guidelines for its use are not standardized. Although patient factors may dictate recommendations, this retrospective cohort study aims to characterize baseline utilization practices to set the stage for establishing generalizable recommendations. Methods: TAR patients were identified from the 2010-2019 M91 Ortho PearlDiver data set based on administrative coding. Patient factors were extracted, including age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients’ surgery was performed (Midwest, Northeast, South, West), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of home or outpatient PT utilization in the 90 days following TAR were identified. Inpatient PT was not captured. Univariate and multivariate logistic regression analyses allowed identification of predictive factors for PT utilization. Results: Of 5412 TAR patients identified, postoperative PT services were used by 2453 (45.3%). Most PT was outpatient (38.3% of the study population) compared to home (4.1% of the study population). Weekly utilization of PT was greatest in the first week following surgery (17.7% of PT visits) and thereafter followed a roughly bell-shaped curve, with utilization greatest at 7 weeks following surgery (14.9% of PT visits). Independent predictors of PT utilization following TAR included having surgery performed in the Midwest (relative to the South, OR 1.37, P < .0001), Northeast (OR 1.20, P = .0217), or West (OR 1.26, P < .0021) and having commercial (relative to Medicare, OR 1.87, P < .0001) or Medicaid insurance (OR 1.46, P = .0239). Conclusion: Of 5412 TAR patients, 42.5% used PT within 90 days of surgery. PT utilization was highest in the first and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAR, PT care pathways may be better defined. Level of Evidence: Level III, retrospective cohort study.

Category: Arthroscopy; Ankle Introduction/Purpose: Emergency department (ED) visits following total ankle arthroplasty (TAA) may impact patient satisfaction and healthcare cost. Elucidating the timing of and risk factors for ED visits in this patient population might help facilitate targeted risk reduction strategies. Methods: This retrospective cohort study utilized data from the 2010 to 2019 M91Ortho PearlDiver administrative dataset to identify patients who underwent TAA with at least 90 days of follow-up. Patient factors were extracted including: age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which their procedure was performed (midwest, northeast, south, west), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, frequency, and primary diagnoses for 90-day postoperative ED visits were identified and interpreted in the context of one-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for such ED visits. Results: Of 7,600 TAA patients identified, 743 (9.8%) visited the ED within 90 days of their procedure. Of those who visited the ED, one ED visit was reported for 571 patients, two for 117 patients, three for 26 patients, and four or more visits for 29 patients. 37.2% of all ED visits occurred within two weeks following surgery; weekly visits returned to within 0.5% of the population baseline by three weeks after surgery. 90-day readmissions were identified for 289 patients (3.80%) of the cohort. Multivariate analysis revealed several predictors of ED utilization following TAA: younger age (odds ratio (OR) 1.40 per decade decrease), female sex (OR 1.18), higher ECI (OR 1.36 per 2-point increase), and Medicaid coverage (OR 2.74; 1.92-3.90 relative to Medicare) (p < 0.05 each). Regarding reasons for ED visits, surgical site issues were identified for 74.4%, with the most common reason being surgical site pain (60.4%). Conclusion: Of 7,600 TAA patients, 9.8% returned to the ED within 90 days of surgery, with predisposing demographic actors identified. The highest incidence for these ED visits was in the first two postoperative weeks, with surgical site pain being the most common reason. By identifying the timing, predisposing factors, and reasons for ED visits following TAA, targeted care pathways should be able to be adjusted to minimize their occurrence, improve patient experience, and minimize health care utilization/costs.

Category: Ankle; Arthroscopy; Other Introduction/Purpose: Physical therapy (PT) following total ankle arthroplasty (TAA) is often considered, but guidelines for its use are not standardized. While there may be patient factors that dictate recommendations, establishing a baseline of utilization practices may set the stage for establishing generalizable recommendations. Methods: This retrospective cohort study employed data from the 2010 to 2019 M91Ortho PearlDiver administrative dataset. Those undergoing TAA were identified based on coding, and patient factors were extracted, including: age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients' surgery was performed (midwest, northeast, south, west), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of PT utilization in the 90-days following TAA were identified as occurring at home or in an outpatient setting. Univariate and multivariate logistic regression analyses allowed the identification of predictive factors for PT utilization. Results: Of 6,563 TAA patients identified, 2788 (42.5%) utilized postoperative PT services. Most services were done as an outpatient (63.4%), compared to at home (6.1%). Weekly utilization of PT was greatest in the first week following surgery (17.7% of those who utilized PT) and thereafter followed a roughly bell-shaped curve of utilization with the greatest incidence at seven weeks following surgery (14.9% of those who utilized PT). Multivariate analysis identified multiple predictors of PT utilization following TAA, including: older age (odds ratio [OR] 1.23 per decade increase, p < 0.0001), higher ECI (OR 1.03 per 2-point increase, p = 0.0383), having surgery performed in the midwest, northeast, or western US (relative to the South OR 1.43, p < 0.0001; 1.20, p = 0.0109; and 1.32, p < 0.0001, respectively), and having commercial or Medicaid insurance coverage (relative to Medicare OR 1.96, p < 0.0001 and 1.62, p = 0.0006, respectively). Conclusion: Of 6,563 TAA patients, 42.5% utilized PT within 90 days of surgery. PT utilization was highest in the first- and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAA, algorithms for PT usage may be better defined and consistently employed.

Background: Total ankle replacement (TAR) utilization in the United States has steeply increased in recent decades. Emergency department (ED) visits following TAR impacts patient satisfaction and health care costs and warrant exploration. Methods: This retrospective cohort study utilized the 2010 to 2019 M91Ortho PearlDiver data set to identify TAR patients with at least 90 days of follow-up. PearlDiver contains billing claims data across all sites of care throughout the United States for all indications for care. Patient factors extracted included age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which surgery was performed, insurance plan, and postoperative hospital length of stay. Ninety-day postoperative ED visit incidence, timing, frequency, and primary diagnoses were identified and compared to 1-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for ED visits. Results: Of 5930 TAR patients identified, ED visits within 90 days were noted for 497 (8.4%) patients. Of all ED visits, 32.0% occurred within 2 weeks following surgery. Multivariate analysis revealed several predictors of ED utilization: younger age (odds ratio [OR] 1.35 per decade decrease), female sex (OR 1.20), higher ECI (OR 1.32 per 2-point increase), TAR performed in the western US (OR 1.34), and Medicaid coverage (OR 2.70; 1.71-4.22 relative to Medicare) ( P < .05 each). Surgical site issues comprised 78.0% of ED visits, with surgical site pain (57.0%) as the most common problem. Conclusion: Of 5930 TAR patients, 8.4% returned to the ED within 90 days of surgery, with predisposing demographic factors identified. The highest incidence of ED visits was in the first 2 postoperative weeks, and surgical site pain was the most common reason. Pain management pathways following TAR should be able to be adjusted to minimize the occurrence of postoperative ED visits, thereby improving patient experiences and decreasing health care utilization/costs. Level of Evidence: Level III, retrospective cohort study.

Abstract Background Cushing’s syndrome occurs due to overproduction of cortisol from adrenal glands. Endogenous hypercortisolemia can occur secondary to adrenocorticotropic hormone (ACTH) dependent as well as independent causes. The presence of non-specific symptoms and signs contributes to a delay in diagnosis. Early identification and prompt definitive management is crucial. It is important to be alert about the post-operative complications including multiple thrombotic phenomena, which can add to the mortality. We report a case of Cushing’s disease in a young female managed with trans-sphenoidal surgery, followed by a challenging post-operative period complicated with multiple thrombotic phenomena, ultimately succumbed. Case presentation A 32-year-old Sri Lankan female presented with overt features of Cushing’s syndrome and diagnosed to have ACTH dependent Cushing’s disease with pituitary microadenoma. She underwent trans-sphenoidal surgery, following which she developed fatal multiple complications including diverticular rupture and ischemic colitis, needing hemicolectomy, followed by a parieto-occipital infarction. Conclusion This case highlights important and aggressive complications associated with Cushing’s syndrome giving rise to a challenging post-operative course. Diverticular rupture had been described in association with hypercortisolemia and this case adds to the existing literature. Post-operative ischemic colitis and stroke which contributed to the death of this patient could have been due to the procoagulant state associated with Cushing’s syndrome, with a high risk during the immediate post-operative period. This emphasizes the need to consider post-operative thromboprophylaxis in patients undergoing surgery for Cushing’s syndrome.

Over four decades, researchers have extensively focused on bonding flexible pavement layers. Scholars have concentrated on the partial or complete lack of interlayer bonding between asphalt layers, which is the primary cause of premature pavement failures, such as cracking, rutting, slippage of wearing courses, and decline in pavement life. These defects are observed within the high horizontal force areas owing to increased speed, braking, and sharp angles when entering or exiting highways and the variations in paving materials, traffic load, and climatic factors. Various studies have investigated the debonding of flexible pavements, and test methods have been developed to find effective solutions. This review is aimed at summarising and discussing certain factors influencing shear strength performance, such as tack coat material, surface characteristics of multi-layer construction of flexible pavements, and different mechanical shear tests. First, bonding in the interface zone area and its Effect on the shear strength performance is reviewed. Subsequently, the types of materials and construction methods and their effects on the bonding quality of the interface zone area are clarified. Finally, the linear relationships between certain effects and the Ability of nanofibers to improve the emulsion properties are discussed. However, no agreement on the optimum tack coat could be obtained owing to the variety of surfaces. Hence, a milling surface is recommended for higher shear strength. The shear test is the most used method for verifying the interlayer bonding strengths, and continuous research endeavours are recommended to analyse debonding in multi-layer asphalt pavements.

Rubberized asphalt is known for its elastic deformation recovery and good resilience in response to loads owing to the elastic characteristics of tire rubber powder. There are several methods for the prediction of the stiffness modulus of asphalt mixtures. However, there are limited studies on predicting the stiffness modulus incorporating both wet and dry rubberization methods based on the available methods of Asphalt Institute (AI) and IDOT (Illinois department of transportation). In this research, Stone Mastic Asphalt (SMA) mixtures were modified with truck tire rubber powder (TRP) with two different processes: SMA-WP (SMA mixtures modified in the wet process) and SMA-DP (SMA mixtures modified in the dry process). In both methods, 3%, 6%, and 9% of TRP were used for modification, and the performance of the control and modified mixtures was evaluated under indirect tensile strength (ITS) and indirect tensile stiffness modulus (ITSM) tests. Finally, the results of ITSM were compared to predicted resilient modulus based on the Asphalt Institute (AI) and Illinois Department of Transportation (IDOT). The experiments revealed that SMA-DP mixes have higher ITS than SMA-WP. At the same time, both methods showed a decrease in ITS as TRP content increases. Furthermore, the SMA-WP samples showed a lower phase angle than SMA-DP samples, indicating higher elasticity for the mixtures. In addition, SMA-WP showed lower horizontal deformation than SMA-DP, which helps reduce rutting on the surface layer. Finally, the prediction results showed that the IDOT method could not predict the Stiffness Modulus, while the AI method was more accurate and can be used for prediction.

Abstract Background Although patients with acute myeloid leukemia (AML) were shown to have an increased risk of thrombosis, no thrombosis risk assessment scoring system has been developed for AML patients. The Khorana Risk Score (KRS), which has been widely used for thrombosis risk assessment in the clinical setting, was developed on the basis of solid tumor data and has not been validated among AML patients. This study aims to validate the use of the KRS as a thrombosis risk-scoring system among patients with AML. Methods Using data from H. Lee Moffitt Cancer Center and Research Institution’s Total Cancer Care Research Study, we retrospectively identified patients who were histologically confirmed with AML from 2000 to 2018. Clinical and laboratory variables at the time of AML diagnosis were characterized and analyzed. The thrombotic event rate was estimated with the Kaplan-Meier method and compared using the log-rank test. Results A total of 867 AML patients were included in the analysis. The median age at AML diagnosis was 75 years (range, 51–96), and the majority were male (65%, n = 565). A total of 22% (n = 191), 51% (n = 445), 24% (n = 207), and 3% (n = 24) of patients had a KRS of 0, 1, 2, and 3, respectively. A total of 42 thrombotic events (3% [n = 6/191] with a KRS of 1; 5% [n = 23/445] with a KRS of 2; 6.3% [n = 13/207] with a KRS of 3) were observed, with a median follow-up of 3 months (range, 0.1–307). There was no statistical difference in the risk of thrombosis between these groups (P = .1949). Conclusions Although there was an increased risk of thrombosis associated with a higher KRS among AML patients with a KRS of 1 to 3, the difference was not statistically significant. Furthermore, only a few patients were found to have a KRS > 3, and this was largely due to pancytopenia, which is commonly associated with AML. These results indicate the need for a better thrombotic risk-scoring system for AML patients.

No abstract available

End TB strategy by the WHO suggest active screening of high-risk populations for tuberculosis (TB) to improve case detection. Present study generates evidence for the effectiveness of screening patients with diabetes mellitus (DM) for Pulmonary TB (PTB). A study was conducted among 4548 systematically recruited patients over 45 years attending DM clinic at the National Hospital of Sri Lanka. The study units followed an algorithm specifying TB symptom and risk factor screening for all, followed by investigations and clinical assessments for those indicated. Bacteriologically confirmed or clinically diagnosed PTB were presented as proportions with 95% CI. Mean (SD) age was 62·5 (29·1) years. Among patients who completed all indicated steps of algorithm, 3500 (76·9%) were investigated and 127 (2·8%) underwent clinical assessment. Proportion of bacteriologically confirmed PTB patients was 0·1% (n = 6,95%CI = 0·0-0·3%). None were detected clinically. Analysis revealed PTB detection rates among males aged ≥60 years with HbA1c ≥ 8 to be 0·4% (n = 2, 95%CI = 0·0-1·4%). The study concludes that active screening for PTB among all DM patients at clinic settings in Sri Lanka, to be non-effective measure to enhance TB case finding. However, the sub-category of diabetic males with uncontrolled diabetics who are over 60 years of age is recommended as an option to consider for active screening for PTB.

Abstract Background Dyskeratosis congenita (DC) is a rare genetic disorder of bone marrow failure inherited in an X-linked, autosomal dominant or autosomal recessive pattern. It has a wide array of clinical features and patients may be cared for by many medical sub specialties. The typical clinical features consist of lacy reticular skin pigmentation, nail dystrophy and oral leukoplakia. As the disease advances, patients may develop progressive bone marrow failure, pulmonary fibrosis, oesophageal stenosis, urethral stenosis, liver cirrhosis as well as haematological and solid malignancies. Several genes have been implicated in the pathogenesis of dyskeratosis congenita, with the dyskerin pseudouridine synthase 1 (DKC1) gene mutations being the X-linked recessive gene. Case presentation Herein, we report a 31-year-old male with history of recurrent febrile episodes who was found to have reticulate skin pigmentation interspersed with hypopigmented macules involving the face, neck and extremities, hyperkeratosis of palms and soles, nail dystrophy, leukoplakia of the tongue, premature graying of hair, watery eyes and dental caries. Several of his male relatives, including two maternal uncles and three maternal cousins were affected with a similar type of disease condition. Pedigree analysis suggested a possible X-linked pattern of inheritance. Genetic testing in the proband showed a novel hemizygous, non-synonymous likely pathogenic variant [NM_001363.4: c.1054A > G: p.Thr352Ala] in the PUA domain of the DKC1 gene. Quantitative polymerase chain reaction for relative telomere length measurements performed in the proband showed that he had very short telomeres [0.38, compared to a control median of 0.71 (range 0.44–1.19)], which is consistent with the DC diagnosis. Co-segregation analysis of the novel mutation and telomere length measurements in the extended family members could not be performed as they were unwilling to provide consent for testing. Conclusions The novel variant detected in the DKC1 gene adds further to the existing scientific literature on the genotype-phenotype correlation of DC, and has important implications for the clinical and molecular characterization of the disease.

Abstract Background Chest pain is one of the common presenting symptoms encountered in an emergency department. Prompt history taking and careful clinical examination do help to differentiate cardiac chest pain from other causes. Mondor’s disease is a rare cause of chest pain which is often underdiagnosed due to lack of awareness. Mondor’s disease is a condition characterized by thrombophlebitis of the superficial veins of breast and anterior chest wall. The diagnosis is often made clinically. Case presentation Here we report a case of a 37-year-old Sri Lankan Tamil woman who presented with chest pain and was clinically diagnosed as having Mondor’s disease after a physical examination, which was confirmed with demonstration of thrombophlebitis by ultrasound scan imaging. Although it is a self-limiting condition, non-steroidal anti-inflammatory drugs are used in the treatment to hasten recovery in addition to giving reassurance. Conclusions Mondor’s disease is not considered a differential diagnosis for chest pain due to lack of awareness of this medical condition. Creating awareness of this condition via this case would help to cut down unnecessary investigations and valuable time spent in emergency departments, and it helps to identify a serious underlying cause especially carcinoma of the breast at its early stage.

Geopolymer concrete has the potential to replace ordinary Portland cement which can reduce carbon dioxide emission to the environment. The addition of different amounts of steel fibers, as well as different types of end-shape fibers, could alter the performance of geopolymer concrete. The source of aluminosilicate (fly ash) used in the production of geopolymer concrete may lead to a different result. This study focuses on the comparison between Malaysian fly ash geopolymer concrete with the addition of hooked steel fibers and geopolymer concrete with the addition of straight-end steel fibers to the physical and mechanical properties. Malaysian fly ash was first characterized by X-ray fluorescence (XRF) to identify the chemical composition. The sample of steel fiber reinforced geopolymer concrete was produced by mixing fly ash, alkali activators, aggregates, and specific amounts of hook or straight steel fibers. The steel fibers addition for both types of fibers are 0%, 0.5%, 1.0%, 1.5%, and 2.0% by volume percentage. The samples were cured at room temperature. The physical properties (slump, density, and water absorption) of reinforced geopolymer concrete were studied. Meanwhile, a mechanical performance which is compressive, as well as the flexural strength was studied. The results show that the pattern in physical properties of geopolymer concrete for both types of fibers addition is almost similar where the slump is decreased with density and water absorption is increased with the increasing amount of fibers addition. However, the addition of hook steel fiber to the geopolymer concrete produced a lower slump than the addition of straight steel fibers. Meanwhile, the addition of hook steel fiber to the geopolymer concrete shows a higher density and water absorption compared to the sample with the addition of straight steel fibers. However, the difference is not significant. Besides, samples with the addition of hook steel fibers give better performance for compressive and flexural strength compared to the samples with the addition of straight steel fibers where the highest is at 1.0% of fibers addition.

This paper presents the results of a laboratory study based, upon evaluating the fatigue characteristics of Stone Matrix Asphalt (SMA) Mixtures using different percent of bio-oil produced from pyrolysis process of house hold waste. The indirect tensile fatigue (ITFT) test was used to study fatigue behavior. The fatigue tests were performed at three temperatures (15, 20, and 25°C) using one asphalt binder, 80/100 penetration asphalt. The outcomes demonstrated that the addition of DWBO has slightly lowered the resilient modulus, and reduced the fatigue performance of the SMA Mixtures. For the effect of the temperature on fatigue life of 80/100 bio-binders, it is reasonable to use DWBO in asphalt mixture as an additive in cold to moderate temperature regions. The study shows that the DWBO can be used with petroleum binders in the pavement industry with a percent not exceeding 3% by weight of the base binder.

This research develops a spectral index to automatically extract asphalt road networks named road extraction index (REI). This index uses WorldView-2 (WV-2) imagery, which has high spatial resolution and is multispectral. To determine the best bands for WV-2, field spectral data using a field spectroradiometer were collected. These data were then analyzed statistically. The bands were selected through the methodology of stepwise discriminant analysis. The appropriate WV-2 bands were distinguished from one another as per significant wavelengths. The proposed index is based on this classification. By applying REI to WV-2 imagery, we can extract asphalt roads accurately. Results demonstrate that REI is automated, transferable, and efficient in asphalt road extraction from high-resolution satellite imagery.

It is known that a number of toxic substances produce myocardial injury by several mechanisms involving interruption of coronary blood flow due to stimulation of clotting mechanism and coronary vasospasm. Number of toxic substances may cause direct myocardial toxicity independent of coronary blood flow. Acute myocardial injury due to stings and bites is a rare entity and not well understood. Here we illustrate a case of myocardial injury due to Russell’s viper envenomation.

Aims: SGLT2 inhibitors provide cardiovascular and renal protection in people with type 2 diabetes (T2DM). Real-world data on their effect on improving glucose and cardiovascular risk factors, and adverse effects in South Asians are limited.Methods: We retrospectively analyzed clinical, demographic, anthropometric and biochemical data among adults with T2DM, commenced on empagliflozin and followed up for at least one month in a diabetes clinic in Colombo.Results: Among 1523 participants (men 49.6 %, age 54.9 (± 10.8) years, diabetes duration 11.5 (± 7.6) years, body mass index 28.2 (± 4.5 kg/m2), over a median follow up of 12 months (range: 1-24 months), reduction in HbA1c, weight, systolic blood pressure (SBP) and urine albumin-creatinine ratio were evident within the first month. Benefits sustained up to two-years (mean changes from baseline: HbA1c - 0.31 (± 1.49), weight - 1.14 (± 4.17), SBP - 3.44 (± 21.75), UACR - 19.84 (± 108.22) follow up. eGFR declined by the third month, returned to baseline by 12th and remained stable over 24 months. Higher baseline HbA1c, weight and SBP predicted greater decline in HbA1c, weight and SBP respectively. Weight reduction independently predicted the SBP reduction. Eighteen participants per 100 patient-years discontinued therapy due to adverse effects: genital mycotic infections and features of hypovolaemia were the commonest. We observed only two events of diabetic ketoacidosis.Conclusions: Empagliflozin effectively improves glucose, weight and SBP and retards progression of renal impairment in South Asians with T2D. Genital mycotic infections and hypovolaemia were the commonest reasons for discontinuation. Careful patient selection and advice can avoid other sinister complications. [ABSTRACT FROM AUTHOR]

The nanostructure of β-gallium oxide crystals influences the conversion to carbamates; specifically, for the synthesis of alkyl carbamates (like propyl N-octylcarbamate) from CO2 and n-propanol in the absence of phosgene. The nanostructures with variable aspect ratios (length (L)/width (D); from 2 to 18) were prepared by the controlled addition of neutral and cationic surfactants during gallium oxide synthesis. These catalysts displayed selectivities to the corresponding carbamates as high as ~70%, superior to non-nanostructured Ga2O3 catalysts. The conversion was found to be inversely proportional to the square of the relative crystallinity. The catalysts retained their structure and catalytic performance upon recycling.

The goal of this study was to determine the effect, if any, that hidradenitis suppurativa (HS) had on outcomes following total shoulder arthroplasty (TSA). Based on the proximity of the suppurative lesions to the incision site, it was hypothesized that it would lead to increased risk of infection. HS is a chronic skin disorder that is characterized by skin lesions, primarily affecting the axillary and inguinal regions. The skin lesions of HS are known to be sites of bacterial growth, and are thus a potential risk factor for infection for procedures done in those regions, such as a TSA. Adult patients undergoing TSA for degenerative conditions were identified from the Pearldiver MUExtr dataset. HS patients were matched 1:4 to non-HS based on age, sex, and Elixhauser Comorbidity Index due to differences between the nonmatched cohorts. The incidence of the 90-day any, severe, and minor adverse events, as well surgical site infection and wound dehiscence were tabulated and compared using both univariate and multivariate analyses. The 5-year revision rates of the matched cohorts were plotted using Kaplan-Meier survival curves and compared with a log rank Mantel-Cox test. Of 118,269 TSA patients identified, HS was noted for 218 patients (0.18%). After matching, HS patients were at significantly increased risk of 90-day any adverse event (odds ratio [OR]: 1.69, P =.03), severe adverse event (OR: 2.13, P =.03), minor adverse event (OR: 1.85, P =.02), surgical site infection (OR: 9.85, P =.001), and wound dehiscence (OR: 2.55, P =.002). There were no significant differences between the HS and non-HS groups in terms of 90-day readmissions (P =.34) or 5-year reoperation rates (95.7% vs. 98.1%, P =.097). HS is a rare comorbidity for TSA patients (0.18%). Not only do these patients have a significantly higher comorbidity burden, but after matching were also found to have a significantly increased risk of 90-day postoperative complications, which were most notably surgical site infections and wound dehiscence. Nonetheless, five-year implant survival was similar for those with and without HS in the present study. These findings may help with the required surgical planning in terms of postoperative management of these patients to manage these potential complications. [ABSTRACT FROM AUTHOR]

In this study, alkali activated material was produced by using Class F fly ash from Manjung power station, Lumut, Perak, Malaysia. Fly ash then was activated by alkaline activator which is consisting of sodium silicate (Na2SiO3) and sodium hydroxide (NaOH). Hooked end steel fibers were added into the alkali activated material system with percentage vary from 0 % – 5 %. Chemical compositions of fly ash were first analyzed by using x-ray fluorescence (XRF). All hardened alkali activated material samples were tested for density, workability, and compression after 28 days. Results show a slight increase of density with the addition of steel fibers. However, the workability was reduced with the addition of steel fibers content. Meanwhile, the addition of steel fibers shows the improvement of compressive strength which is about 19 % obtained at 3 % of steel fibers addition.

Background: Implantable cardioverter defibrillators (ICD) are recommended for secondary prevention after sudden cardiac arrest (SCA). The outcomes of pediatric patients receiving an ICD after SCA remain unclear. The objective of this study is to evaluate outcomes, future risk for appropriate shocks, and identify characteristics associated with appropriate ICD therapy during follow-up.Methods: Multicenter retrospective analysis of patients (age ≤21 years) without prior cardiac disease who received an ICD following SCA. Patient/device characteristics, cardiac function, and underlying diagnoses were collected, along with SCA event characteristics. Patient outcomes including complications and device therapies were analyzed.Results: In total, 106 patients were included, median age 14.7 years. Twenty (19%) received appropriate shocks and 16 (15%) received inappropriate shocks (median follow-up 3 years). First-degree relative with SCA was associated with appropriate shocks (P<0.05). In total, 40% patients were considered idiopathic. Channelopathy was the most frequent late diagnosis not made at time of presentation. Neither underlying diagnosis nor idiopathic status was associated with increased incidence of appropriate shock. Monomorphic ventricular tachycardia (hazard ratio, 4.6 [1.2-17.3]) and family history of sudden death (hazard ratio, 6.5 [1.4-29.8]) were associated with freedom from appropriate shock in a multivariable model (area under the receiver operating characteristic curve, 0.8). Time from diagnoses to evaluation demonstrated a nonlinear association with freedom from appropriate shock (P=0.015). In patients >2 years from implantation, younger age (P=0.02) and positive exercise test (P=0.04) were associated with appropriate shock.Conclusions: The risk of future device therapy is high in pediatric patients receiving an ICD after SCA, irrelevant of underlying disease. Lack of a definitive diagnosis after SCA was not associated with lower risk of subsequent events and does not obviate the need for secondary prophylaxis. [ABSTRACT FROM AUTHOR]