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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.

In this paper, we are motivated to establish a generalization of $_pR_q(\alpha,\beta;z)$ function in terms of incomplete exponential functions and obtain some properties of the incomplete exponential $_pR_q(\alpha,\beta;z)$ function. Further we give generating relations for incomplete exponential $_pR_q(\alpha,\beta;z)$ function. Some applications related to ground water pumping (Hydrology) modelling and probability theory have also been discussed.

Due to the applicability of new advanced functionally graded materials (FGMs) in numerous tribological systems, this manuscript aims to present computational and empirical indentation models to investigate the elastoplastic response of FG substrate under an indention process with spherical rigid punch. The spatial variation of the ceramic volume fraction through the specimen thickness is portrayed using the power law and sigmoid functions. The effective properties of two-constituent FGM are evaluated by employing a modified Tamura–Tomota–Ozawa (TTO) model. Bilinear hardening behavior is considered in the analysis. The finite element procedure is developed to predict the contact pressure, horizontal displacement, vertical deformation, and permanent deformation of FG structure under the rigid cylindrical indentation. The empirical forms for permanent deformation were evaluated and assigned. Model validation with experimental works was considered. The convergence of the mesh and solution procedure was checked. Numerical studies were performed to illustrate the influence of gradation function, gradation index, and indentation parameters on the contact pressure, von Mises stresses, horizontal/vertical displacements, and permanent plastic deformation. The present model can help engineers and designers in the selection of an optimum gradation function and gradation index based on their applications.

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

During a survey on species diversity of trichodinid ciliates from freshwater fishes in the Beel Dakatia located in Khulna District of Bangladesh, a new species of trichodinid ciliate was identified from the gills of Long Whiskers Catfish, Mystus gulio. This ciliate is described here as new species based on distinctness in a combination of morphological characters. The species differs morphologically from its congeners by its relatively small body diameter, with white porcelain Chinese soup spoons-shaped denticle and the argentophobic central area of adhesive disc looks like a centrally located glistening, undivided, almost spotless white circle, surrounded by dark and narrow wrinkle free perimeter and some other measurements.

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.

Despite rising popularity of planing catamarans, numerical methods for predicting their hydrodynamics are rather scarce and incomplete. The hydrodynamic interaction between hulls planing parallel to each other is known to become significant when spacing between hulls is sufficiently small. In the present study, a potential-flow method of hydrodynamic sources is applied for modeling steady hydrodynamic characteristics of twin-hull setups. Parametric calculations are carried out for symmetric hulls in variable speed regimes at different spacings, hull aspect ratio, and deadrise angles. Results are presented for the lift coefficient and center of pressure, and some illustrations are given for the water surface elevations. The lift coefficient is found to increase with smaller spacings and higher aspect ratios at moderate and high Froude numbers.

During a survey on species diversity of trichodinid ciliates from freshwater fishes in the Baikka Beel of Moulvibazar district in Sylhet division from January to December 2015, two species of ciliates were identified, of which one is new to science. Trichodina hoffmani Wellborn, 1967 is collected from the gills of Mystus tengara, and Trichodina amblypharyngodoni sp. n. is described from Amblypharyngodon mola using the silver nitrate impregnation method. T. amblypharyngodoni sp. n. is characterized by having a large, darkly stained central area; rectangularly-rounded butterspoon-shaped blade with very narrow interblade space and blunt tangent point; indistinct anterior and posterior blade apophysis, but a rounded apex near the base of the central part of denticle; slender, sometimes slightly triangular central part with rounded tip; and filamentous, curved, anteriorly directed rays with inflated tip and indistinct central groove. Based on these characters and the unique shape and absence of variability of the denticles among the silver impregnated specimens of the present species, it may be said that to a lesser extent, it resembles Trichodina prowazeki Grupcheva and Lom, 1980.

Background: With acute myeloid leukemia (AML), there are limited data about the accuracy of day 14 bone marrow (BM) biopsies for predicting complete remission as compared to day 28 BM biopsy results. We here aimed to estimate the correlation between, and the diagnostic accuracy of, both approaches. Materials and Methods: We reviewed 84 patients with AML treated with standard induction chemotherapy to evaluate the remission rate and treatment decisions based on day 14 BM biopsy from 2000-2012. Results: Sixty five patients (77%) demonstrated remission (CR) with less than 5% blasts on their day 14 BM. Thirteen patients (16%) had residual disease (RD), and 6 (7%) were classified as indeterminate response (IR) i.e., blasts 5-20%. Two patients with RD on day 14 underwent re-induction. Out of the 17 remaining cases with RD+IR, 14 (all 6 with IR and 8 out of 11 with residual disease with no re-induction) demonstrated a morphologic complete remission (CR) on day 28 BM. The percentages for complete remissions on days 28 and 14 were significantly different [94% versus 79.3%, respectively; p=0.004, (OR= 0.143, 95% CI: 0.032-0.63)]. Day 14 BM had 82% sensitivity in predicting CR on Day 28; however, it had insufficient specificity (60%) in predicting failure of CR. Conclusions: Induction treatment response assessment based on day 14 BM does not accurately predict the response rate on day 28 and the use of day 14 BM as a sole marker of response to therapy might expose patients to unnecessary interventions.

Total and regional allometric growth rates and termination sites of the spinal cord related to the respective vertebra were studied in 36 goat fetuses, from the Ahvaz slaughterhouse. These specimens were assigned to 3 groups, group 1 (CRL 10-20 cm), group 2 (CRL 21-30 cm), and group 3 (CRL 31-40 cm), each consisting of 6 male and 6 female fetuses. Observations in all 3 groups revealed that although the growth of the vertebral column was greater than that of the spinal cord, the difference in growth was not constant throughout the spine. While in cervical and thoracic regions the growth rate of the spinal cord in relation to the vertebral column was almost isometric, in the caudal part of the spine there was marked decline in growth of the spinal cord compared to the respective regions of the vertebral column. Craniocaudally, the allometric growth rate became drastically negative. There was no significant difference (P>0.05) between males and females. Except in thoracic region, all other regions showed significant differences (P0.05). As a consequence of the negative allometric growth of the spinal cord in relation to the vertebral column in the caudal part of the spine, the conus medullaris was displaced from S4-S5 in group 1 to S2 in group 3. No significant difference (P>0.05) between male and female fetuses concerning the termination of the spinal cord was found.

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.