Search

Guidelines are lacking for management of acute ischemic stroke and stroke prevention in patients with immune thrombocytopenia (ITP). Our aim is to highlight the dilemma inherent in managing patients with both significant bleeding and thrombotic risk factors. In this review, we present two patients with history of ITP who presented with acute ischemic stroke and received tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT), a rare management strategy in this patient population. In addition, we identified 27 case reports of ischemic stroke in patients with ITP; none of them received tPA or EVT. Furthermore, there are 92 patients with significant thrombocytopenia with no available data regarding the cause of thrombocytopenia, who were acutely treated with tPA or EVT. Conclusive evidence cannot be determined based on these limited number of cases. Future multicenter prospective cohort studies in patients with ITP are needed to provide better evidence-based treatment plans. At present, treatment of acute ischemic stroke in patients with ITP requires close collaboration between hematology and vascular neurology experts to find a balance between the benefit and risk of hemorrhagic complications.

Objective There is a need to determine whether total antioxidant capacity (TAC) in severe early childhood caries (S-ECC) is an indicator of inflammatory response to the lesion or a marker of the disease. This study compared TAC levels in children with ECC before and after dental treatment and compared the results with those of caries-free children. Design Prospective study. Setting A teaching hospital. Patient selection Salivary samples were obtained from 20 children aged 5 years and diagnosed with S-ECC, and 20 age- and sex-matched controls. Intervention details Complete dental rehabilitation under general anesthesia was performed on the children with S-ECC, and follow-up salivary samples were obtained one week and three months postoperatively. TAC was measured using a commercially available Oxygen Radical Absorbance Antioxidant Assay measurement kit (Zen-Bio ORAC™, AMS Biotechnology, Abington, UK). Outcome measures Differences between children with and without dental caries were tested using the Mann-Whitney U test; differences before and after dental treatment were analyzed using Friedman test followed by Wilcoxon sign-rank test with Bonferroni correction to compensate for multiple comparisons. Results Median TAC (1.54 mcg/L, CI 1.15–1.92) of the control group was significantly lower than that of the treated group prior to treatment (p = 0.003). Treatment of the dental lesions significantly reduced TAC of the treated group, and no significant differences were observed between the test and control groups at either one week (p = 0.076) recall or three-month recall (p = 0.096). TAC in children posttreatment was significantly reduced compared to their pretreatment values (p Conclusion Total antioxidant capacity in the saliva of children with severe early childhood caries undergoes significant reduction following treatment of the carious lesions.

Background There is a paucity of data available on hospitalization and length of stay (LOS) for different anticoagulant therapies. We sought to compare and summarize admission rates and LOS, and describe the frequency of reporting these two outcomes in randomized control trials (RCTs) comparing different anticoagulant therapies for venous thromboembolism (VTE). Methods A literature search was conducted from inception to August 15, 2016 on RCTs of anticoagulant therapy for patients with VTE. Study selection, data extraction and risk of bias analysis were done by two reviewers independently. Meta-analyses were conducted for admission rates and LOS. Results A total of 4064 articles were identified. There were 74 articles of 70 studies included in the analysis. Hospitalization rates and LOS were reported in 13 (18.6%) and 12 (17.1%) of the 70 included studies, respectively. Low-molecular-weight heparin (LMWH)-treated patients were 33.0% less likely to be admitted to hospitals compared to unfractionated heparin (UFH) (RR = 0.67, 95% CI [0.58, 0.78]). The mean difference in LOS between LMWH and UFH was 2.54 days in favor of LMWH (95% CI [−4.94, −0.14]). Compared to parenteral therapy, using rivaroxaban was associated with a lower admission rate for a difference of 1.4–5.1% in VTE, 2.5% in DVT and 0.2% in PE. The LOS of patients receiving rivaroxaban was significant shorter than the LOS in parenteral therapy group for a difference of 1–5 days in VTE, 3 days in DVT and 1 day in PE. Conclusion Admission rates were lower and LOS was shorter using LMWH compared to UFH and oral therapy compared to parenteral therapy for acute VTE treatment in RCTs, based on limited eligible RCTs. These crucial clinically relevant outcomes are underreported in the existing VTE clinical trials.

Pulmonary embolism (PE) is a major cause of mortality and morbidity. It is known that the risk of death varies by provoking factors; however, it is unknown if the risk of death persists beyond the initial diagnosis among patients with cancer-associated and non-cancer provoked patients. In this study, we aimed to investigate the effect of cancer on overall, short- and long-term mortality in a cohort of consecutive incident PE patients. Using administrative databases, we identified all incident cases of PE between 2004 and 2012 in Alberta, Canada. Cases were stratified by provoking factors (i.e. unprovoked, provoked, and cancer-associated). A multivariate Cox survival model was used to estimate the hazard ratios of short- and long-term death. We identified 8641 patients with PE, among which 42.2% were unprovoked, 37.9% were provoked and 19.9% were cancer-associated. The 1-year and 5-year survival probabilities were 60% (95% CI: 57–64%) and 39% (95% CI: 36–43%) in patients with cancer-associated PE, 93% (95% CI: 92–94%) and 80% (95% CI: 78–81%) in provoked PE, and 94% (95% CI: 93–95%) and 85% (95% CI: 83–87%) in unprovoked PE, respectively. Compared to patients with unprovoked events, both short-term and long-term survival in patients with cancer-associated PE have a higher observed risk of all-cause mortality in all age groups ( p

Background Acute venous thromboembolism leads to significant morbidity and mortality. Advances in pharmacotherapy facilitate outpatient care in low-risk acute venous thromboembolism. The proportion of hospitalized acute venous thromboembolism cases and the average length of stay are not known. We sought to identify predictors of hospitalization, changes in hospitalization rates and length of stay of acute venous thromboembolism over a decade in Alberta, Canada. Methods Using linked administrative health databases, we identified adult patients diagnosed primarily with acute venous thromboembolism between April 2002 and March 2012. We measured trends using Poisson regression, adjusted length of stay using analysis of covariance. We identified predictors of hospitalization using multivariate logistic regression. Results 8198 out of 31,656 acute venous thromboembolism cases were hospitalized. The overall venous thromboembolism admission rates ranged between 23.7% and 27.8% with no evident temporal trend (P = 0.10). The average admission rate was 51.9% for pulmonary embolism and 16.1% for deep vein thrombosis. The mean length of stay for deep vein thrombosis and pulmonary embolism remained unchanged with an adjusted mean for venous thromboembolism of 6.9 ± 1.0 days. Higher Charlson index, older age, male gender, pulmonary embolism at presentation and multiple comorbidities were associated with hospitalization. Hospitalization was associated with 30-day mortality (odds ratio:2.8, 95% CI: 2.2–3.5) whereas the length of stay was not (odds ratio:1.0, 95% CI: 0.99–1.0). Conclusion Hospitalization rates and mean length of stay for acute venous thromboembolism did not change significantly between 2002 and 2012. Advances in pharmacotherapy have not yet reduced hospitalization rates or length of stay for venous thromboembolism.

Venous thromboembolism (VTE) is a major health problem for both men and women. Whether sex disparities exist for outcomes after acute VTE is unknown. We sought to measure sex-specific rates of hospitalization for and mortality from acute VTE. We used a population-based administrative dataset from Alberta, Canada, covering the years 2002 to 2012. We used Poisson regression to measure the incidence rate ratio for hospitalization and Cox regression to test for sex disparities in short-term all-cause mortality after adjusting for potential confounders. Of those diagnosed with VTE, 55.9% were women. The proportion of hospitalized women for VTE was 24.4 versus 27.8% in men (p

Asymmetric planing hulls are often used on high-speed catamarans. In this study, a linearized potential-flow method is applied for modeling steady hydrodynamics of single asymmetric hulls and their catamaran setups. Numerical results are validated with available experimental data and empirical correlations. Parametric calculation results are presented for the lift coefficient and the center of pressure for variable hull geometry, spacings, and speed regimes. The lift coefficient is found to increase at smaller hull spacings and decrease at higher Froude numbers and higher deadrise angles.

Background: To review the indications, patients' demographics, and anaesthetic protocol and to analyze perioperative complications of liver transplantation surgery.Methods: Retrospective analysis of 70 cases of LT in the period between June 2004 and October 2020 at King Hussein medical centre. Preoperative factors such as patients' demographics, age, gender, etiology of hepatic pathology, laboratory investigations, model for end-stage liver disease scores, duration of surgery and type of liver donation were recorded. Intraoperative factors such as anaesthetic and surgical protocols, need of blood product transfusions and haemodynamic monitoring were analyzed. Postoperative tracking of patients' complications and outcomes was done.Results: 68 living donor and two cadaveric LT procedures. Male to female ratio was 2.9:1.The age of LT recipients ranged from 3 to 62 years with an average age of 38.45 years. Their body weights ranged from 13 to 100 kg with mean body weight of 67.03 kg. Most common indication was cryptogenic liver cirrhosis (21.4%), followed by cirrhosis due to viral hepatitis B (15.7%). Autoimmune hepatitis was an indication in 11.4% and hepatitis C liver cirrhosis in 10%. All living donors were closely related. Right hepatic lobe graft was used in 85.7% of transplantations. Average red cells concentrate (RCC) transfused (units) was 3.1±3.97 (mean±SD). Duration of surgery (hours) was 12.5±2.4 (mean±SD). Fast track LT with extubation in theatre was done in 37 LT recipients (52.9%). Readmission to operative theatre was needed in 5 recipients (7.14%). Most common long term complications were biliary leak (20%), biliary stenosis (14.2%) and recurrence of primary disease (12.9%).Conclusions: Transplantation from living donors was by far more common in our study population. Majority of recipients were male and cryptogenic liver cirrhosis was the most common indication. Right hepatic lobe graft was used mostly. Biliary leak was the most common postoperative complication. Surgical time duration and blood products transfusion decreased significantly over years since the start of LT program.

Stepped planning hulls are commonly used on fast planning boats and water-based aircraft, but numerical means for simulating their hydrodynamics are rather limited. In this study, a panel method involving hydrodynamic sources has been applied for modeling a stepped planning hull and accounting for water surface deformations in the air-ventilated cavity and surrounding water domain. Parametric calculations have been carried out for a selected hull with variable deadrise angles and at two speed regimes. Results are shown for the boat attitude, lift–drag ratio, and drag components. The variations of the wetted surfaces on two bodies of a stepped hull are also presented and related to variations in hydrodynamic characteristics of the hull.

The current study compares intranasal and oral midazolam for effect on sedation for patients requiring dental procedure. Eighty subjects between the ages of 5 and 12 years were received randomly either intranasal (0.2 mg/kg) or oral (0.5 mg/kg) midazolam. The observer assessed the children for sedation level at the following time points: Immediately before the drug was administered, and 20 and 30 min after drug administration. There were significant differences in sedation level among the both groups at the time of parental separation and at the time of induction. 39 (97.5%) and 40 (100%) of the forty patients who received oral midazolam were calm, drowsy or asleep at 20 and 30 min after drug administration, respectively. For patients who received intranasal midazolam, 32 (80%) and 33 (82.5%) of the forty patients were either calm or drowsy at 20 and 30 min after drug administration, respectively. None of the patients from the intranasal group was rated as ‘asleep’. Oral midazolam was found to be statistically more effective in providing a better sedation level at the time of parental separation and at the time of induction than intranasal administration. Our findings indicate a tendency for oral midazolam to be more effective as a premedication in children before general anesthesia. Key words: Preoperative, midazolam, sedation, anesthesia, pediatrics.

Introduction The frequency and case fatality of venous thromboembolism (VTE) and major bleeding during the initial 3 months of therapy in those treated for symptomatic VTE with either direct oral anticoagulants (DOACs) or vitamin K antagonists (VKA) are important clinically relevant outcomes. We sought to measure it during the initial months of anticoagulation for symptomatic VTE. Material and Methods We searched MEDLINE, EMBASE, and CENTRAL to identify studies that enrolled patients with acute symptomatic VTE treated with DOACs or VKA and reported data on bleeding, VTE recurrence and death. Studies were evaluated according to a priori inclusion criteria and critically appraised using established internal validity criteria. Single-proportion random-effects models were used to pool estimates. Results Of the 2453 citations retrieved, 5 RCTs that enrolled 24,507 patients were included. The rate of major bleeding was 1.8 (95% CI: 1.3-2.5) and 3.1 (95% CI: 2.4-3.9) per 100 patient-years in DOAC and VKA arms, respectively. The rate of VTE recurrence was 3.7 (95% CI: 2.7-4.7) and 4.1 (95% CI: 3.0-5.4) per 100 patient-years of DOAC and VKA, respectively. The case fatality rate of bleeding was significantly higher in the VKA arms 10.4% (95% CI: 6.6-15.4) compared to DOACs 6.1% (95% CI: 2.7-11.7; p value for difference = 0.029) with no statistical difference between the case fatalities for recurrent VTE. The rate of death from either definite major bleeding or definite recurrent VTE was 0.27 (95% CI: 0.16-0.40) and 0.46 (95% CI: 0.32-0.63) per 100 patient-years for DOACs and VKAs respectively, resulting in a number needed to treat of 875 for DOACs to prevent one death. Conclusion DOACs are attractive alternatives to VKAs for initial treatment of symptomatic VTE, with lower frequency and case fatality for major bleeding. However, the incremental safety benefit of DOACs over VKAs is small, with large numbers needed to treat.

Patients with Sickle Cell Disease (SCD) frequently present for emergency care with pain or fever. The rate of emergency visits/year is between 2-4 per patient every year with 12% of patients visiting the emergency 4 or more times/year1. National medical organizations in Canada and the United States recommend pain therapy within 30 minutes of arriving to the emergency department2,3. Feedback from patients in Canada reflected a lack of awareness of the medical community regarding the disease and optimal management. As a response Canadian Haemoglobinopathy Association2 (CanHaem), created the "Sickle Cell Disease Emergency Wallet Cards" which were inspired from the successful Hemophilia "Factor First Card4". The goal of the cards was to provide simple care instructions to an emergency responder and facilitate timely care for patients in crisis. These wallet cards have recommendations for treatment of pain and fever within 30 minutes, patient's diagnosis, program contact details, and patient's individual pain plan. The cards have been in circulation for 4 years. The purpose of this study was to determine if the cards are used by parents and patients as intended. Research Questions: 1.Are the CanHaem Cards used by patients and families? 2. Do patients find the card helpful in facilitating their care delivery? Methods: The surveys were administered to patients and/or proxies. Prior to survey distribution three parents/patients have verified the utility of the questions, the content and the readability of the survey. The survey was translated into French/Arabic by two independent translators per language. It was distributed in Alberta and British Columbia, Canada in specialty clinics known to use the cards. The University of Alberta Ethics Board deemed the project a quality improvement initiative and the ARECCI tool: A pRoject Ethics Community Consensus Initiative was completed prior to quality improvement project start. Results: 140/184 participants completed the survey. The response rate: 76%. Demographics: 91% province of Alberta. Proxy: 49%; Patients: 51%. The majority of respondents were female: 54%, median age: 37 years (range 16-84 years). See graphs 1-4 below: 72.3% felt the card was helpful in their care. 78.6% carry the physical card (purse, wallet, and diaper bag), while 10.7% have a picture on their phone, 9.3% don't carry the card, 7.1% state they never received a card. The majority (63.6%) show the card at first contact in emergency, 48.9% felt staff read the card. Total of 68 comments. 67.6% of comments were positive: "Sense of security"; "Get us in to see the doctor faster..." Neutral comments (22%) ranged from requests for lamination to provider response to the card being variable "sometimes it is faster and sometime(s) doesn't really change anything". Finally, 10% were negative reflecting long wait times "Good concept, the idea itself is great. Execution... could be improved greatly", and requests for more information on the card. Conclusion: In Canada, SCD is an uncommon disease and many healthcare providers may not be aware of national and international guidelines regarding acute presentations. To help facilitate knowledge transfer and to aid communication with emergency services, CanHaem created wallet cards as a Canada-wide initiative. This survey demonstrates the patient/parent perspective of the emergency cards. Eighty-nine percent of patients/proxies carried the card (either digitally or physically) and 63% showed the card in the acute care setting. The discrepancy between those who carry the card and those who show it may reflect that numerous respondents stated they had not required emergency care since receiving the card as well some respondents were "carried away by the pain and forget to use the card". Comments revealed a sense of security and patient's appreciation for having the card available to them indicating the value of card to patients. The card demonstrates a simple and low cost intervention to facilitate emergency care for hemoglobinopathy patients. References: 1. Paulukonis ST et al. Emergency department utilization by Californians with sickle cell disease. Ped Blood and Ca 2017. doi: 1002/pbc.26390 2. CanHaem https://www.canhaem.org/healthcare-professionals/ 3. Evidence-Based Management of Sickle Cell Disease: Expert Panel, 2014. 4. Canadian Hemophilia Society. Stop the Bleeding. https://www.hemophilia.ca/files/ER%20CARD%20E_%20Jan%2009.pdf Figure Disclosures Ezzat: Novartis: Honoraria, Speakers Bureau; ApoPharma: Research Funding.

Erythropoiesis-stimulating agents (ESAs) have been used in orthopedic patients to reduce allogeneic blood transfusion (ABT). The purpose of this systematic review of randomized clinical trials is to evaluate the efficacy of preoperative administration of ESAs on hemoglobin level at discharge and frequency of ABT in patients undergoing hip or knee surgery. Pooled results of 26 trials with 3560 participants showed that the use of preoperative ESAs reduced ABT in patients undergoing hip or knee surgery [RR: 0.48, 95% CI: 0.38 to 0.60, P

Imatinib is the standard of care in chronic meloid leukemia (CML) therapy. However, imatinib is not curative since most patients who discontinue therapy relapse indicating that leukemia initiating cells (LIC) are resistant. Interferon alpha (IFN) induces hematologic and cytogenetic remissions and interestingly, improved outcome was reported with the combination of interferon and imatinib. Arsenic trioxide was suggested to decrease CML LIC. We investigated the effects of arsenic and IFN on human CML cell lines or primary cells and the bone marrow retroviral transduction/transplantation murine CML model. In vitro, the combination of arsenic and IFN inhibited proliferation and activated apoptosis. Importantly, arsenic and IFN synergistically reduced the clonogenic activity of primary bone marrow cells derived from CML patients. Finally, in vivo, combined interferon and arsenic treatment, but not single agents, prolonged the survival of primary CML mice. Importantly, the combination severely impaired engraftment into untreated secondary recipients, with some recipients never developing the disease, demonstrating a dramatic decrease in CML LIC activity. Arsenic/IFN effect on CML LIC activity was significantly superior to that of imatinib. These results support further exploration of this combination, alone or with imatinib aiming at achieving CML eradication rather than long-term disease control.

INTRODUCTION: The pathogenesis of infective endocarditis (IE) , a typical biofilm-associated infectious disease frequently caused by commensal or pathogenic bacteria, is mainly attributed to the formation of septic vegetations, which are fibrin-platelet complexes embedded with bacteria on heart valves detected by echocardiography. Patients with acute myeloid leukemia (AML) are prone to neutropenia, immunosuppression and central venous catheters leading to high rates of bacteremia. It has been postulated that despite high rates of bacteremia, patients with AML undergoing intensive chemotherapy are only rarely able to form vegetations due the frequent thrombocytopenia associated with such treatment (McCormick 2002). Here, we sought to determine the rate of echocardiographic detection of IE in patients with AML and chemotherapy induced thrombocytopenia . METHODS: To assess the yield of echocardiography, we conducted a retrospective, single center, analysis of patients with AML who underwent treatment using anthracycline or fludarabine induction and intermediate/high dose cytarabine based consolidation. At all time points, patients with febrile neutropenia were empirically treated with piperacillin/tazobactam ± aminoglycosides and underwent appropriate investigations including blood cultures. Cultures were drawn every 24 to 48 hours with fevers and daily, if positive, till culture clearance. Patients with positive blood cultures for organisms associated with IE underwent an echocardiogram as standard of care. RESULTS: From January 2010 to January 2018, 296 patients underwent curative intent chemotherapy for treatment of acute myeloid leukemia (AML) at the University of Alberta Hospital, Edmonton, Canada. The median age of all patients was 56.7 years (IQR: 44-64) and 40.2% were females. During the induction or consolidation chemotherapy , 53 echocardiogram were done to investigate 53 episodes of bacteremia in 50 patients (16.9%) who had organisms associated with IE (Table 1). Two echocardiograms were done to investigate possible culture negative IE based upon clinical suspicion. Transesophageal echocardiogram were utilized in 19 patients (36%) while transthoracic echocardiogram were done in 34 patients (64%). The median platelets count on the day of the echocardiogram was 23 x109/L (IQR: 14-38). Viridans Group Streptococci and Staphylococcus aureus were the most frequent isolates cultured in the blood in 36% and 16% of cases, respectively. The median duration of bacteremia was 1 day (IQR 1-2). Three (5.6%) patients had echocardiographic findings suggestive of IE based on a positive transesophageal study (n=2) or transthoracic study (n=1). Among these, two were secondary to Enterococcus bacteria and involved the mitral valve and the third was secondary to a non-HACEK gram-negative bacteria leading to tricuspid valve involvement . CONCLUSION: This study is the first to suggest that despite the high prevalence of Viridans Group Streptococci and Staphylococcusaureus in patients with AML undergoing chemotherapy, echocardiographic findings of IE in these patients are rare, with the notable exception of Enterococcal and Non-HACEK gram negative organisms. In contrast, in the general population, Viridans Group Streptococci and Staphylococcus aureus and bacteremia are associated with IE in 20% and 63% %, respectively (Westling 2009, Rasmussen 2011). The low incidence in our cohort may be attributed to impaired fibrin-platelet deposition in these patients with inability to mount a vegetation response, or the early initiation of broad spectrum antibiotics. Given these findings, the value of routine echocardiography should be questioned in patients with AML without other clinical features of IE. Disclosures Sandhu: Bioverativ: Honoraria; Celgene: Honoraria; Novartis: Honoraria; Janssen: Honoraria; Amgen: Honoraria. Brandwein:Pfizer: Consultancy; Celgene: Consultancy; Boehringer Ingelheim: Consultancy, Research Funding; Novartis: Consultancy; Lundbeck: Consultancy.

Background Venous thromboembolism is a major cause of morbidity and mortality, and comprehensive studies profiling the epidemiology and pattern of health services use are needed. In this study we provide contemporary estimates of venous thromboembolism incidence and case fatality over the past decade. Methods We developed a population-based venous thromboembolism dataset by linking 6 administrative health databases in Alberta, Canada from April 1, 2002 to March 31, 2012. We defined acute symptomatic cases using a validated algorithm and used Poisson regression to model annual venous thromboembolism counts. Results We identified 31,656 cases of acute symptomatic venous thromboembolism between April 1, 2002 and March 31, 2012. The age- and sex-adjusted incidence rate of venous thromboembolism was 1.38 (95% confidence interval [CI], 1.37-1.40) per 1000 person-years. For pulmonary embolism it was 0.38 (95% CI, 0.36-0.40) per 1000 person-years, and for deep vein thrombosis it was 1.0 (95% CI, 0.99-1.1) per 1000 person-years. The adjusted model showed no significant change in the incidence of venous thromboembolism during the study period. The 30-day case fatality rate of venous thromboembolism was 2.0% (95% CI, 1.89-2.21) and was almost doubled in patients with pulmonary embolism: 3.9% (95% CI, 3.50-4.33). The 1-year case fatality rate was 9.2% (95% CI, 8.88-9.52) for venous thromboembolism and 12.9% (95% CI, 12.2-13.6) for patients with pulmonary embolism. The case fatality rate increased with increasing subject age. The 1-year and 5-year survivals after first acute venous thromboembolism were similar in patients with unprovoked and provoked events. However, in patients with cancer-associated thrombosis, the 1-year and 5-year survival rate was 66% (95% CI, 64.71%-67.29%) and 46% (95% CI, 43.28%-48.72%), respectively. Conclusion The incidence of acute venous thromboembolism remained unchanged over a 10-year period. However, the case fatality of venous thromboembolism is substantial.

This study covers the feasibility of production lightweight ceramics teils (light weight clay bricks) by adding local various types of combustible materials to the clay. It was found those substantial quantities of bagasse, sawdust, rice husks and straw are suitable for the production of lightweight bricks and distributed combustible materials finely was mixed with clay and molded into bricks. During firing in the kiln the combustible materials burnt out and leave air spaces, which contribute, to the high thermal insulation value of the bricks. It was possible to produce bricks with densities between 800 and 900 Kg m3 and thermal conductivity between 0.19 and 0.22 Kcal mh1

Introduction The duration of anticoagulation after venous thromboembolic events (VTE) is based on the balance between the risk of recurrent VTE and bleeding. The purpose of this study was to estimate the frequency and case-fatality rate of major bleeding and recurrent VTE during secondary prevention of VTE. Materials and methods MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched through September 2014. Two reviewers independently screened citations to identify trials that enrolled patients for secondary prevention of VTE with direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), aspirin or placebo. Two reviewers independently extracted data onto standardized forms. Results Twelve RCTs that enrolled 10,542 patients were included. The rate of major bleeding was 1.6 per 100 patient-years (95% CI, 1.2-2.1), and 0.58 per 100 patient-years (95% CI, 0.24-1.1) on VKAs and DOACs, respectively, with an incidence rate ratio of 0.35 (95% CI, 0.17-0.68, p = 0.0023). The case-fatality rates for DOACs and VKAs were not significantly different at 0% (95% CI, 0.0-15.4) and 6.8% (95% CI, 1.4-18.6), respectively. The rate of recurrent VTE was not different between DOACs and VKA, IRR 0.88 (95% CI, 0.15-4.8, p = 0.88). Case-fatality rates for recurrent VTE for DOAC and VKAs were 10.8% (95% CI, 4.4-20.9) and 5.6% (95% CI, 1.2-15.4), respectively. Only DOACs showed a significant reduction in the composite outcome of fatal recurrent VTE and fatal bleeding when compared to placebo, IRR 0.40 (95% CI, 0.14-1.0, p = 0.03). Conclusion Case-fatality rates for major bleeding and recurrent VTE for DOACs appear to be similar to those for VKA and the composite of fatal events is lower for DOACs than placebo. Overall, given the favorable safety profile and comparable efficacy of DOAC therapy, the threshold to continue anticoagulation with DOACs after unprovoked VTE should be low if the baseline risk of anticoagulation-related bleeding is not high.

Background: Sickle cell disease (SCD) is associated with perioperative vascular (SCD-related) and nonvascular complications. To minimize perioperative complications during elective surgery, either exchange blood transfusion or simple blood transfusion can be used. We systematically reviewed the literature and meta-analyzed randomized and observational trials comparing exchange transfusion to simple transfusion, as well as studies comparing preoperative transfusion to no transfusion to assess the relative risk (RR) and benefit of each strategy in sickle cell patients undergoing surgery. Methods: Medline, Embase, and the Cochrane-controlled trial register were searched to identify studies that evaluated exchange transfusion to simple transfusion, as well as studies comparing any form of blood transfusion with no transfusion. Studies were evaluated according to a priori inclusion criteria and critically appraised using established internal validity criteria. Pooled RR was estimated using a random effects model. Results: Three randomized trials and seven observational studies were included. We found there was no difference between exchange transfusion and simple transfusion for perioperative mortality, vascular, or non-vascular perioperative complications. However, transfusion-related complications (RR 2.41, 95% confidence interval (CI): 1.49–3.91) and the amount of blood transfused (mean difference 2.03, 95% CI: 1.23–2.83) were higher in those treated with exchange transfusion versus simple transfusion. Similarly, there was no difference in perioperative mortality, vascular, or non-vascular perioperative complications between those treated with preoperative transfusion strategy and no transfusion strategy. Conclusion: Based on the current literature, neither preoperative exchange transfusion nor simple transfusion reduces perioperative complications in patients with SCD who are undergoing surgery; however, available studies were underpowered to detect a treatment effect.

In a bubble column-based photobioreactor, sparger design and placement govern the bubble size distribution and gas hold-up. These factors in turn influence flow pattern, effective interfacial area, rates of mass and heat transfer, and mixing. Previous computational studies of the hydrodynamic and heat transfer effects within a column photobioreactor for one sparger row have found that bubble Nusselt number and heat transfer coefficient with respect to superficial velocity do not follow any particular pattern. This study evaluates the temperature distribution and heat transfer within a photobioreactor in an effort to explain the earlier study results. Experimental and computational studies will focus on the bubble flow pattern and heat transfer within a rectangular column photobioreactor (33.65 cm long × 30.48 cm wide × 33.97 cm tall) with a single row sparger located either lengthwise or widthwise at the center of the base (27.94 cm long × 1.27 cm wide). Temperature distribution and heat transfer for both sparger positions will be compared. Carbon dioxide, water, light photons, algal cells, and nutrients need to come together continuously for successful algal production, hence mixing of the nutrients, algal cells, and carbon dioxide is essential. Instead of a light source, a heat source is used in the system. Constant electric energy is supplied to the heating pad, which converts the electric energy to thermal energy. Thermocouples are placed inside the PBR to record temperature at 36 different spatial positions. The experimental results are compared with previously developed CFD simulations. The sparger not only effects the aeration inside the PBR, but also creates mixing in the PBR. Proper design and placement of the sparger ensures proper mixing in the PBR. The present study shows the effects bubble movement and flow pattern have on the temperature distribution and how well the simulation predicts the temperature distribution inside a PBR. The present research is a continuum of previous work aimed at pursuing the optimum design of a column PBR which is commercially viable and effective at producing algal biofuels and bioproducts.Copyright © 2013 by ASME

Introduction Bleeding complications occur more frequently in women than men in clinical trials of warfarin and thrombolytics. It is unknown whether these sex-related differences exist for new oral anticoagulants, including dabigatran, rivaroxaban, and apixaban. To determine whether women suffer more bleeding complications with these agents, we conducted a systematic review and meta-analysis of randomized controlled trials on new oral anticoagulants for venous thromboembolism (VTE). Materials and Methods Medline, Embase, and the Cochrane-controlled trial register on the Cochrane library were searched to identify studies that evaluated novel oral anticoagulants versus any comparator, and reported outcomes, including major bleeding and recurrent VTE, stratified by sex. No language restrictions were applied. Studies were evaluated according to a priori inclusion criteria and critically appraised using established internal validity criteria. Pooled relative risk was estimated using a random effects model. Results Eight studies were eligible, comprising 9417 patients. There was no difference in the primary efficacy outcome of recurrent VTE between men and women [Relative Risk (RR) 1.02, 95% confidence interval (CI) 0.74-1.39]. However, men had less major bleeding with novel oral anticoagulants compared to women [RR 0.79, 95% CI 0.66-0.97, p = 0.03]. All-cause mortality was not reported by sex in any of the studies. Conclusion Women suffer more bleeding complications than men when receiving novel oral anticoagulants for VTE. Future clinical trials should report outcomes stratified by sex, and further studies are needed to investigate the clinical impact of this sex-related safety difference.

An important factor in designing photobioreactors is appropriate selection of sparger geometry and placement. The sparger governs the bubble size distribution and gas hold-up. These factors in turn influence flow pattern, effective interfacial area, rates of mass transfer, heat transfer, and mixing. This project investigates the effects of sparger geometry and placement on bubble and fluid flow patterns and convective heat transfer within a column photobioreactor (PBR) using Computational Fluid Dynamics (CFD). Experimental and computational studies have been completed that focused on the hydrodynamics and heat transfer within a rectangular column photobioreactor (34.29 cm long × 15.25 cm wide × 34.29 cm tall) with a single sparger located at the center of its base (33.02 cm × 1.27 cm) running lengthwise. Similar studies have also been completed analyzing a full width sparger on the bottom of the PBR similar to a porous membrane sparger. This study extends previous work by investigating the flow patterns and heat transfer effects due to multiple rows of spargers at different spacings running perpendicular to the length of the PBR. Comparison of hydrodynamic and heat transfer parameters are made for the different types of spargers at different volumetric flow rates. The gas bubbles and the water-based media within the photobioreactor are modeled using the Lagrangian-Eulerian approach. A low Reynolds k-Epsilon turbulence model is used to predict near-wall flow patterns. The main interaction forces between the bubbles and the media, including drag forces, added mass forces, and lift forces, are considered. The overarching goal of this research is to improve PBR designs, thus enhancing microalgae production for biofuel and bioproducts production. It is hypothesized that changing the spacing of the PBR spargers will alter the bubble flow patterns. Despite its importance, optimizing the sparger geometry and placement in PBRs for microalgae production is still largely not understood. In this study, simulation results are presented for various sparger spacings, which can be helpful in designing sparger geometry and placement for maximized microalgae production.Copyright © 2012 by ASME

This project investigates the effects of sparger geometry and placement on bubble and fluid flow patterns and convective heat transfer within a column photobioreactor (PBR) using Computational Fluid Dynamics (CFD). Experimental and computational studies have been completed that focused on the hydrodynamics and heat transfer within a rectangular column photobioreactor (34.29 cm long × 15.25 cm wide × 34.29 cm tall) with a single sparger located at the center of its base (33.02 cm × 1.27 cm) running lengthwise. This study extends previous work by investigating the flow patterns and heat transfer effects due to full bottom sparger or porous sparger. The gas bubbles and the water-based media within the photobioreactor are modeled using the Lagrangian-Eulerian approach. A low Reynolds k-Epsilon turbulence model is used to predict near-wall flow patterns. A flat surface photobioreactor is used to achieve sufficient light penetration into the system. The main interaction forces between the bubbles and the media, including drag forces, added mass forces, and lift forces are considered. The overarching goal of this research is to produce biofuels and bioproducts through the improved design of column PBRs used for microalgae production. An important factor in designing photobioreactors is the appropriate selection of sparger geometry and placement. The sparger governs the bubble size distribution and gas holdup. These factors in turn influence flow pattern, effective interfacial area, rates of mass transfer, heat transfer, and mixing. It is hypothesized that increasing the sparger width will improve uniformity of bubble distribution as well as mixing. Despite its importance, optimizing the sparger geometry and placement in PBRs for microalgae production is still largely not understood. In this study, the simulation’s results are presented for various spargers, which can be helpful in designing appropriate sparger geometry and proper placement for increased microalgae production.Copyright © 2012 by ASME

Aims and Objectives: Parents play an important role in the dental behavior of a child patient. This study aimed to assess the effect of parental presence on the behavior of the child and objectively measure the behavior using pulse oximetry. Materials and Methods: The study was registered with the clinical trials registry of the National Institutes of Health (NCT02619981). The children were divided into three groups, those who had no accompanying parent, those accompanied by their fathers, and those accompanied by their mothers. The Venham anxiety and behavior scores were used for subjective measurements whereas the objective measurement of fear was done by measuring the heart rate using a portable pulse oximeter at six critical clinical situations. Statistical analysis was carried out using the Statistical Package for the Social Sciences version 21 (IBM corp. Armonk, NY, USA). Results: One hundred and twenty two children aged between 6 years and 8 years completed the study. Most of the children accompanied by fathers were males while most of the children accompanied by their mother were females. It was seen that females showed a higher mean heart rate than males at all steps. Children who had their parents outside the operatory exhibited lower anxiety and behavior scores than those whose parents were present; however, they showed a significantly higher pulse rate at all procedures. Boys had higher anxiety and behavior scores than girls, however, these differences were not statistically significant. Conclusion: The results of this study suggest that the presence of the parent in the operatory reduces the physiological manifestations of anxiety in children in their first restorative dental visit.

Introduction Abdominal or pelvic surgery for cancer increases the risk of postoperative venous thromboembolism (VTE) by 2- to 3-fold. The use of low-molecular weight heparin (LMWH) to prevent post-operative thrombotic events is recommended in high VTE-risk patients; however, the role of extended thromboprophylaxis in this setting is controversial. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective observational studies to determine the effect of extended LMWH thromboprophylaxis on all VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and all-cause mortality after abdominal or pelvic surgery for cancer. Methods We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, conference abstracts, and trial registries with no language restriction. Studies were included if they compared extended duration (i.e., administration of prophylactic doses of LMWH for more than 2 weeks, up to 6 weeks) versus conventional duration of thromboprophylaxis (i.e., administration of LMWH for two weeks or less) after cancer surgery. Two reviewers independently performed study selection, data extraction, and quality assessment. Studies were evaluated according to a priori inclusion criteria and critically appraised using the Newcastle-Ottawa Quality Assessment Scale (NOQA). Pooled relative risk was estimated using a random effects model. Results Three RCTs and 4 observational studies were included, comprising 4807 adult patients who underwent open or laparoscopic abdominal or pelvic surgery for gastrointestinal, gynecological or urological cancers. The 3 RCTs employed screening for asymptomatic DVT using bilateral lower limb compression ultrasound or venography after 4 weeks of surgery. Most of studies were of good quality (NOQA higher or equal to 6). The extended thromboprophylaxis regimen was associated with a significantly reduced incidence of all VTE (2.6% [59/2292] vs 5.6% [124/2209]; RR=0.44 [95% CI 0.28-0.70]) and proximal DVT (1.4% [14/966] vs 2.8% [24/862]; RR=0.33 [95% CI 0.15-0.73]). No data were available for symptomatic DVT. There was no statistically significant difference in the incidence of symptomatic PE between the two groups (0.8% [8/966] vs 1.3% [11/862]; RR= 0.56 [95% CI 0.23-1.40]). We found no significant difference in major bleeding at 1.8% (14/787) in the extended thromboprophylaxis group vs 1.0% (7/713) in the short thromboprophylaxis group (RR=1.19 [95% CI 0.47-2.97]). There was no significant difference in all-cause mortality at 3 months (4.2% [30/720] vs 3.6% [23/643], respectively; RR= 0.79 [95% CI 0.47-1.33]). There was minor heterogeneity between the studies in all extracted outcomes. Conclusion Extended thromboprophylaxis with LMWH after abdominal or pelvic surgery for cancer significantly decreased the incidence of all VTE and proximal DVT, but had no impact on symptomatic PE, major bleeding or 3-month mortality. Table 1. Table 1. Disclosures Lee: Pfizer: Consultancy, Honoraria; LEO Pharma: Consultancy, Honoraria; BMS: Research Funding; Bayer: Consultancy. Wu:Leo Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

Background The Saudi national asthma protocol (SNAP) for asthma management was released in 1995 in an attempt to streamline asthma management practices in Saudi Arabia and improve the quality of care for asthma. Up to our knowledge, few studies assessed the adherence of Saudi physicians to the national asthma guidelines. Objectives The objective of this present study was to assess the level of adherence of pediatricians and primary care physicians (PCPs) to the current SNAP recommendations and identify barriers to physician adherence. Methodology This is a cross-sectional study involving pediatricians and PCPs selected randomly from five major governmental hospitals in Riyadh, Saudi Arabia. Subjects were administered a self-administered questionnaire comprising 24 questions assessing their awareness of SNAP and their level of adherence to the recommendations. Results The response rate was 38% (80/206). Out of most of the physicians who responded, 70% (56) were aware of SNAP, and only 78.2% (n = 43) of them had modified their management of asthmatic patients according to the SNAP recommendations. The level of knowledge of the pharmacotherapy and diagnostic parts of the guidelines ranged between 41.5% and 90.7% in the pharmacotherapy part, and 53.7–59.6% in the diagnostic part. The most common barriers to adherence to SNAP were lack of awareness (25.2%), patient non- compliance (18.9%) and lack of resources (13.5%). There was no significant difference in awareness between pediatricians and PCPs (69.2%, 70.7% respectively). Conclusion This study reveals a substantial gap between the actual care provided by pediatricians and PCPs to asthmatic patients and the recommendations formulated in the Saudi National Asthma Protocol (SNAP). Lack of awareness remains the most common barrier for adherence to the guidelines followed by patient non-compliance. To improve SNAP guideline adherence, tailored interventions that address barriers to adherence need to be implemented.

We describe a 3½-year-old boy with the Klippel-Trenaunay and Sturge-Weber syndromes. The child had congenital superficial capillary hemangiomas, congenital glaucoma and mild hydrocephalus. During the first year of life he experienced intermittent hematuria. When he was 3 years old he presented with seizures and left hemihypertrophy first was noted. Several months later radiological examination of a large abdominal mass demonstrated its origin to be in the right kidney. Radical nephrectomy documented the presence of renal hemangioma with complicating perirenal hematoma. A double inferior vena cava was another unexpected surgical finding that complicated the course of this patient. All of these unusual features in these rare syndromes with their clinical, pathogenetic and therapeutic implications are discussed. The differential diagnosis of renal masses in these syndromes also is presented.