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Subcutaneous emphysema (SCE) of the head, neck and mediastinum most commonly arises due to penetrating trauma and iatrogenic events facilitating air entry into these spaces [1]. Spontaneous SCE can emerge due to a pressure gradient between the intra-alveolar air and surrounding structures, causing alveolar rupture and dissection of the peribronchovascular sheath. This is known as the Macklin effect. Potential consequences include pneumomediastinum, pneumothorax, facial emphysema and pneumoracchis [1]. We aim to describe a case of SCE in a 21-year-old female presenting to the emergency department (ED) after weight training. A 21-year-old female presented to the ED with a sore throat and dysphagia after weight lifting in the gym 6 h earlier. Training involved repeat Valsalva manoeuvres. She experienced sharp pain with onset over an hour, worse with swallowing. She had a history of gastro-oesophageal reflux disease. Vital signs, local examination and systemic examination were unremarkable. The diagnosis was made with soft tissue neck X-ray, demonstrating emphysema within the prevertebral space extending from the skull base to the first thoracic vertebra (Fig. 1). Her chest X-ray showed no pneumothorax or pneumomediastinum. No intervention was required beyond analgesia, and she was discharged from the ED. She was advised to avoid heavy lifting and diving. A follow-up radiograph showed resolution of the SCE. This case is an important rare entity and highlights for clinicians that pain after physical exercise may involve injuries extending beyond the area directly trained.

Background Depressive symptoms are common in patients with Parkinson’s disease and depression is a significant predictor of functional impairment, reduced quality of life and general well-being in Parkinson's disease. Despite the high prevalence of depression, evidence on the effectiveness and tolerability of antidepressants in this population is limited. The primary aim of this trial is to establish the clinical and cost effectiveness of escitalopram and nortriptyline for the treatment of depression in Parkinson’s disease. Methods This is a multi-centre, double-blind, randomised placebo-controlled trial in 408 people with Parkinson’s disease with subsyndromal depression, major depressive disorder or persistent depressive disorder and a Beck Depression Inventory-II (BDI-II) score of 14 or above. Participants will be randomised into one of three groups, receiving either escitalopram, nortriptyline or placebo for 12 months. Trial participation is face-to-face, hybrid or remote. The primary outcome measure is the BDI-II score following 8 weeks of treatment. Secondary outcomes will be collected at baseline, 8, 26 and 52 weeks and following withdrawal, including severity of anxiety and depression scores as well as Parkinson’s disease motor severity, and ratings of non-motor symptoms, cognitive function, health-related quality of life, levodopa-equivalence dose, changes in medication, overall clinical effectiveness, capability, health and social care resource use, carer health-related quality of life, adverse effects and number of dropouts. Discussion This trial aims to determine the effectiveness of escitalopram and nortriptyline for reducing depressive symptoms in Parkinson’s disease over 8 weeks, to provide information on the effect of these medications on anxiety and other non-motor symptoms in PD and on impact on patients and caregivers, and to examine their effect on change in motor severity. Trial registration ClinicalTrials.gov Identifier: NCT03652870 Date of registration – 29th August 2018

FM is a multi-sector environment where organisations vary in terms of scope, structure and services. The publication of management system standards in the FM environment has created significant challenges in implementation. Few of the World’s top 10 listed FM companies have achieved ISO 41001 certification. This opinion paper discussed the applicability and challenges of the implementation of ISO41001 standard in the South African context. An opinion piece was conducted on applicability and challenges of implementing management system standards in South Africa. The paper found that the challenges of implementing these systems include a lack of awareness, resistance to change, and lack of applicability to some organisations. Also, many organisations spend many human resources, capital, and time but still have inadequate and poorly deployed management systems. The paper recommends that ISO41001 implementation frameworks are developed that consider the varying scope, structure, and services within the FM environment to improve its success in the South African organisations.

Introduction: Reduced postsynaptic D3 dopaminergic receptor availability has been reported in the ventral striatum of pathological gamblers without Parkinson's disease (PD) and in patients with PD and impulse control disorders (ICD). However, a direct relationship between ventral striatum D3 dopaminergic receptors and the severity of ICD in PD patients has not yet been proven using a validated tool for ICD in PD, such as the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease-Rating Scale (QUIP-RS). In this pilot study, we investigated the relationship between ventral striatum D3 dopamine receptor availability and severity of impulse control disorder (ICD) in Parkinson's disease (PD). Methods: Twelve patients were assessed with PET and the high affinity dopamine D3 receptor radioligand [11C]-PHNO. Severity of ICD was assessed with the QUIP-RS. Results: We found that lower ventral striatum D3 receptor availability measured with [11C]-PHNO PET was associated with greater severity of ICD, as measured by the QUIP-RS score (rho = −0.625, p = 0.03). Conclusion: These findings suggest that the occurrence and severity of ICD in Parkinson's disease may be linked to reductions in ventral striatum dopamine D3 receptor availability. Further studies in larger cohort of patients need to be performed in order to confirm our findings and clarify whether lower ventral striatum D3 receptor may reflect a pharmacological downregulation to higher dopamine release in ventral striatum of patients with ICD or a patients' predisposition to ICD.

BackgroundEarly childhood interventions are critical for reducing child health and development inequities. While most research focuses on the efficacy of single interventions, combining multiple evidence-based strategies over the early years of a child’s life may yield greater impact. This study examined the association between exposure to a combination of five evidence-based services from 0 to 5 years on children’s reading at 8–9 years.MethodsData from the nationally representative birth cohort (n=5107) of the Longitudinal Study of Australian Children were utilised. Risk and exposure measures across five services from 0 to 5 years were assessed: antenatal care, nurse home-visiting, early childhood education and care, parenting programme and the early years of school. Children’s reading at 8–9 years was measured using a standardised direct assessment. Linear regression analyses examined the cumulative effect of five services on reading. Interaction terms were examined to determine if the relationship differed as a function of level of disadvantage.ResultsA cumulative benefit effect of participation in more services and a cumulative risk effect when exposed to more risks was found. Each additional service that the child attended was associated with an increase in reading scores (b=9.16, 95% CI=5.58 to 12.75). Conversely, each additional risk that the child was exposed to was associated with a decrease in reading skills (b=−14.03, 95% CI=−16.61 to −11.44). Effects were similar for disadvantaged and non-disadvantaged children.ConclusionThis study supports the potential value of ‘stacking’ early interventions across the early years of a child’s life to maximise impacts on child outcomes.

We construct a new measure of mortgage credit availability that describes the maximum amount obtainable by a borrower of given characteristics. We estimate this "loan frontier" using mortgage originations data from 2001 to 2014 and show that it reflects a binding borrowing constraint. Our estimates reveal that the expansion of mortgage credit during the housing boom was substantial for all borrowers, not only for low-score or low-income borrowers. The contraction was most pronounced for low-score borrowers. Using variation in the frontier across metropolitan areas over time, we show that borrowing constraints played an important role in the recent housing cycle.

Background:Human stampedes (HS) may result in mass casualty incidents (MCI) that arise due to complex interactions between individuals, collective crowd, and space, which have yet to be described from a physics perspective. HS events were analyzed using basic physics principles to better understand the dynamic kinetic variables that give rise to HS.Methods:A literature review was performed of medical and nonmedical sourced databases, Library of Congress databases, and online sources for the term human stampedes resulting in 25,123 references. Filters were applied to exclude nonhuman events. Retrieved references were reviewed for a predefined list of physics terms. Data collection involved recording frequency of each phrase and physics principle to give the final proportions of each predefined principle used a single-entry method for each of the 105 event reports analyzed. Data analysis was performed using the R statistics packages “tidyverse”, “psych”, “lubridate”, and “Hmisc” with descriptive statistics used to describe the frequency of each observed variable.Results:Of the 105 reports of HS resulting in injury or death reviewed, the following frequency of terms were found: density change in a limited capacity, 45%; XY-axis motion failure, 100%; loss of proxemics, 100%; deceleration with average velocity of zero, 90%; Z-axis displacement pathology (falls), 92%; associated structure with nozzle effect, 93%; and matched fluid dynamic of high pressure stagnation of mass gathering, 100%.Conclusions:Description or reference to principles of physics was seen in differing frequency in 105 reports. These include XY-axis motion failure of deceleration that leads to loss of human to human proxemics, and high stagnation pressure resulting in the Z-axis displacement effect (falls) causing injury and death. Real-time video-analysis monitoring of high capacity events or those with known nozzle effects for loss of proxemics and Z-axis displacement pathology offers the opportunity to prevent mortality from human stampedes.

Objectives:Road traffic collisions (RTC) result in a significant number of preventable deaths worldwide. In 2010, the United Nations General Assembly launched, “The Decade of Action for Road Safety (2011–2020)” with the stated goal to “reduce road traffic deaths and injuries by 50% by 2020.” This study aims to analyze trends in RTC numbers and subsequent deaths with respect to road safety laws in Nigeria and to suggest suitable interventions.Methods:Annual reports for the period 2007–2017 were obtained from the Federal Road Safety Corps of Nigeria. These reports were analyzed for trends in RTC, including reported causes, fatalities, injuries, and casualties.Results:Overall total injuries, casualties, and fatalities increased by 74.7%, 61.2%, and 9.6%, respectively. Analysis showed that the 3 main causes of RTC were speed violation, loss of control, and dangerous driving.Conclusions:Although current trends do not suggest that Nigeria will accomplish its initial goal of decreasing fatalities by 50% by 2020, there has been a reduction in the number of crashes resulting from dangerous driving. Further interventions such as implementing automated speed monitoring, collaboration, and data sharing between federal and regional agencies, and improving the state of road networks should be implemented to decrease fatalities further.

Introduction Reduction of waiting times is key to delivering high quality, efficient health care. Delays experienced by patients requiring radiographs in orthopaedic outpatient clinics are well recognised. Method To establish current patient and staff satisfaction, questionnaires were circulated over a two-week period. Waiting time data was retrospectively collected including appointment time, arrival time and the time at which radiographs were taken. Results 84% (n = 16) of radiographers believed patients would be dissatisfied. However, of the 296 patients questioned, 56% (n = 165) were satisfied. Most patients (89%) felt the waiting time should be under 30 minutes. Only 36% were seen in this time frame. There was moderate negative correlation (R=-0.5); higher waiting times led to increased dissatisfaction. Mean waiting time was 00:37 and the maximum 02:48. Key contributing factors included volume of patients, staff shortages (73.7%), equipment shortages (57.9%) and incorrectly filled request forms. Eight (42.1%) had felt unwell from work related stress. Conclusions A concerted effort is needed to improve staff and patient opinion. There is scope for change post COVID. Additional training and exploring ways to avoid overburdening the department would benefit. Numerous patients were open to different days or alternative sites. Funding requirements make updating equipment, expanding the department and recruiting more staff challenging.

The Hajj is a recurring annual mass gathering event with over three million attendants taking place at the same site for six days. During such events, major incidents and disasters can occur. It is crucial that Emergency Medical Services providers are sufficiently trained regarding disaster preparedness to respond appropriately. EMS-providers of the Saudi Red Crescent Authority who worked during the Hajj in 2016 were asked to complete a web-based survey, utilizing predetermined responses with 5-point Likert scale responses. Seven hundred respondents identified real disasters as the most common source of information about disaster preparedness and also indicated that a disaster management course was the most desired course for improving knowledge. The study has also highlighted a list of Life Support Courses providers feel should be offered as part of a disaster response training package. These findings highlight the importance of continuing education, which may be obtained through short, focused courses, or for small numbers of specialists through higher educational degrees, such as masters or doctorates. This study also examines the importance of media and its impact on increasing knowledge and awareness for EMS-providers. Consideration should be given to pairing novice providers with experienced personnel to disseminate knowledge and practical experience during Hajj missions. Simulated disaster drilling should be considered to introduce novices to the stress of mass casualty disaster response.

Reduced postsynaptic D3 dopaminergic receptor availability has been reported in the ventral striatum of pathological gamblers without Parkinson's disease (PD) and in patients with PD and impulse control disorders (ICD). However, a direct relationship between ventral striatum D3 dopaminergic receptors and the severity of ICD in PD patients has not yet been proven using a validated tool for ICD in PD, such as the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease-Rating Scale (QUIP-RS). In this pilot study, we investigated the relationship between ventral striatum D3 dopamine receptor availability and severity of impulse control disorder (ICD) in Parkinson's disease (PD).Twelve patients were assessed with PET and the high affinity dopamine D3 receptor radioligand [We found that lower ventral striatum D3 receptor availability measured with [These findings suggest that the occurrence and severity of ICD in Parkinson's disease may be linked to reductions in ventral striatum dopamine D3 receptor availability. Further studies in larger cohort of patients need to be performed in order to confirm our findings and clarify whether lower ventral striatum D3 receptor may reflect a pharmacological downregulation to higher dopamine release in ventral striatum of patients with ICD or a patients' predisposition to ICD.

Background Effective preparedness to respond to mass casualty incidents and disasters requires a well-planned and integrated effort by all involved professionals, particularly those who are working in healthcare, who are equipped with unique knowledge and skills for emergencies. This study aims to investigate and evaluate the level of knowledge and skills related to mass casualty and disaster management in a cohort of healthcare professionals. Methods A cross-sectional brief study was conducted using a validated and anonymous questionnaire, with a sample of 134 employees at a clinical hospital in Lublin, Poland. Results The findings of this study may indicate a need for standardization of training for hospitals employees. It also suggests a knowledge gap between different professional groups, which calls for adjusting such general training, to at least, the weakest group, while special tasks and mission can be given to other groups within the training occasion. Conclusion Pre-Training gap analyses and identification of participants’ competencies and skills should be conducted prior to training in mass casualty incidents and disasters. Such analyses provides an opportunity to develop training curriculum at various skill and knowledge levels from basic to advance. All training in mass casualty incidents and disasters should be subject to ongoing, not just periodic, evaluation, in order to assess continued competency.

The global community needs to be aware of the potential psychosocial consequences that may be experienced by health care workers who are actively managing patients with coronavirus disease (COVID-19). These health care workers are at increased risk for experiencing mood and trauma-related disorders, including posttraumatic stress disorder (PTSD). In this concept article, strategies are recommended for individual health care workers and hospital leadership to aid in mitigating the risk of PTSD, as well as to build resilience in light of a potential second surge of COVID-19. Update citation details during checkdate report - ROR

Introduction:In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed.Problem:Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed.Methods:An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning.Results:Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17).Conclusion:Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.

We read with interest the article by Matza et al on ustekinumab in giant cell arteritis (GCA) recently published in Arthritis Care and Research (1). The rationale for using ustekinumab in GCA is that it targets the Th1 and Th17 pathways felt to be centrally involved in GCA pathogenesis, potentially impacting at a more proximal stage than other agents such as tocilizumab (4). It is encouraging to see efforts to explore alternative treatment options for GCA, however we believe a number of aspects of this study require further consideration in order to inform the potential role of ustekinumab in GCA.

Introduction:Colombia is the fourth largest country in South America. It is an upper middle-income country with an estimated population of 49.2 million people, and road traffic collisions (RTCs) are the second most common cause of traumatic death. The United Nations (UN) proclaimed 2011 to 2020 as the “Decade of Action for Road Safety.” In this context, the government of Colombia established the National Road Safety Plan (PNSV) for the period 2011-2021, aiming to reduce RTC-related deaths by 26%. Some road safety laws (RSLs) were implemented before the PNSV, but their impact on deaths and injuries is still not known.Study Objective:The aim of this study was to evaluate whether these RSLs have had a long-term effect on road safety in the country.Methods:Data on RTC casualties, deaths, and injuries from January 1, 2001 through December 31, 2017 were collated from official Colombian governmental publications. Three different periods were considered for analysis: 2001-2010 to evaluate the Transit Code; 2011-2017 to evaluate the PNSV; and 2001-2017 to evaluate a composite of the full study period. Analyses of trends in deaths and injuries were related to dates of new RSLs.Results:A total of 102,723 deaths (12.7%) and 707,778 injuries (87.3%) were reported from 2001 through 2017. The Transit Code period (2001-2010) showed a 10.1% decline in deaths, 16.6% decline in injuries, and rates per 100,000 inhabitants and per 10,000 registered vehicles also declined. During the period of the PNSV (2011-2017), there was an increase in the number of deaths by 16.6%, injuries decreased by 1.7%, and death rates per 100,000 inhabitants also increased. During the total study period, a 12.4% reduction in the total number of casualties was achieved, and death and injury rates per 100,000 inhabitants decreased by 12.4% and 27.5%, respectively.Discussion:Despite the introduction of the PNSV, RTCs remain the second most common cause of preventable death in Colombia. Overall, while the absolute number of RTCs and deaths has been increasing, the rate of RTCs per 10,000 registered vehicles has been decreasing. This suggests that although the goals of the PNSV may not be realized, some of the laws emanating from it may be having a beneficial effect. Further study is required over a protracted period to determine the longer-term impact of these initiatives.

Objective To develop a patient/care-giver reported scale capable of easily and reliably assessing functional disability in 4 repeat tauopathies (4RTs). Background 4R tauopathies including progressive supranuclear palsy, corticobasal degeneration and a subset of frontotemporal dementias manifest a range of overlapping clinical phenotypes. No available rating scale is capable of evaluating the functional impact of these complex disorders. Methods A multi-staged modified Delphi process was used to propose, evaluate and rank potential scale items providing content validity ratios. Staged cognitive pretesting involving input from examiners, patients and caregivers was followed by validation testing in patients participating in the 4R Tauopathy Neuroimaging Initiative or the PROgressive Supranuclear Palsy CorTico-Basal Syndrome MSA Longitudinal Study. Clinimetric properties were examined using classical test theory and item response methods, assessing data quality, reliability, construct validity, convergent validity and known-group validity. Results The resultant Cortical Basal ganglia Functional Scale (CBFS) included questions on Motor Experiences in Daily Living (14 items) and Non-Motor Experiences of Daily Living (17 items). Reliability was acceptable for internal consistency, test-retest stability, item discrimination, item-scaling thresholds and item-fit. Examination of construct validity revealed a parsimonious two-factor solution, and concurrent validity demonstrated significant correlations between the CBFS and other measures of disease severity and functional impairment. The CBFS significantly discriminated between all diagnostic groups and controls (all AUCs>90). The CBFS scores demonstrated sensitivity to change over a 12 month follow-up in patients with probable 4RTs. Conclusions The CBFS is a patient/care-giver reported outcome measure with excellent clinimetric properties that captures disability correlated with motor, cognitive and psychiatric impairments.

To systematically evaluate published experimental studies of sustained nurse home visiting (SNHV) programs. This review summarizes the evidence and identifies gaps in the literature to inform practice, policy, and future research.Restricted systematic review with narrative summary.Databases searched were Medline, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials. Year of publication was originally restricted from 2008 to the date of search (13 February 2018, with supplementary searches conducted to identify more recent publications (up to 2019). Several reputable evidence clearinghouses were also searched.Studies were included if they used a randomized or cluster-randomized controlled trial to evaluate a home visiting program that: (a) targeted disadvantaged mothers; (b) commenced during pregnancy or prior to the child's first birthday; (c) had an intended duration of at least 12 months from the time of enrolment; and (d) was substantively delivered by nurses or midwives. Meta-analyses and reviews of studies meeting these criteria were also included. A quality appraisal was conducted for all studies.Of 1,393 total articles, 30 met inclusion criteria. Seven specific SNHV programs were identified. Each demonstrated evidence of a positive statistical effect on at least one child or maternal outcome.Sustained nurse home visiting programs benefit disadvantaged families, though effects vary across outcomes and subgroups. Further research is needed to discern the critical components of effective programs.As SNHV programs have gained policy appeal, the need to evaluate the evidence-base supporting such interventions has become imperative. The findings of this review will assist policy-makers and practitioners in high-income countries to make evidence-informed decisions about which programs are best suited to addressing specific maternal and child outcomes for disadvantaged families. This should in turn ameliorate some of the inequalities in child development that have significant social and economic costs.目标: 对已发表的持续护士家访(SNHV)项目实验研究进行系统性评价。这篇评价文章对相关证据进行概述,确定文献中存在的差距,供实践、政策和未来研究作参考。 设计: 有限的系统性回顾和叙述性总结。 数据来源: 进行检索的数据库包括联机医学文献分析和检索系统(MEDLINE)、护理学数据库(CINAHL)、心理学文摘(PsycINFO)和Cochrane对照试验中央寄存器。出版年份起止日期为2008年至检索当日(2018年2月13日,进行补充检索以确定较新的发表文章(截至2019年)。此外,也搜索了几个著名的证据资料库。 评价方法: 将采用随机对照试验或群随机对照试验评估家访项目的研究纳入在内:(a)目标弱势母亲;(b)在怀孕期间或孩子一岁前开始;(c)从登记之日起至少12个月的计划时间;(d)实质上由护士或助产士接生。此外,将符合这些标准的研究荟萃分析和评价纳入在内。对所有研究进行质量评估。 结果: 在共计1393篇文章中,有30篇符合入选标准。确定了7个特定的持续护士家访项目。每一个项目均有证据表明至少对一个孩子或母亲具有积极统计影响的成果。 结论: 持续护士家访项目有益于弱势家庭,尽管其有益的效果会因成果和不同子组而有所不同。需要开展进一步的研究,觉察到有效项目的关键组成部分。 影响: 随着持续护士家访项目获得政策倾向,评估支持此类干预措施的循证需求变得势在必行。这篇评价文章的结果将有助于高收入国家的政策制定者和实施人员就哪些项目最为适合解决弱势家庭中母亲和儿童具体问题做出循证决策,进而改善会造成社会和经济代价的儿童发展中的一些不平等现象。.

Giant cell arteritis (GCA) is the most common form of systemic vasculitis. Glucocorticoids are an effective treatment but have significant adverse events and relapses are common. Interleukins 12 (IL-12) and 23 (IL-23) stimulate TWe performed a prospective open label study of ustekinumab in patients with refractory GCA. Ustekinumab 90mg was administered subcutaneously every 12 weeks. The primary outcome was the comparison of the median glucocorticoid dose prior to commencement of ustekinumab and at 52 weeks. Secondary outcomes included physician assessed relapse, acute phase reactants, and imaging assessment of large vessel vasculitis (LVV).Twenty-five GCA patients received ustekinumab. All patients had failed to taper glucocorticoids despite addition of a median of 1 other immunosuppressive agent. At week 52, median (IQR) daily prednisolone dose decreased from 20 (15, 25)mg to 5 (2.5, 5)mg (p0.001). Six patients (24%) stopped prednisolone completely. No patient experienced a relapse of GCA while receiving ustekinumab. Median (IQR) CRP decreased significantly from 12.9 (5.3, 42) to 6 (2.6, 12.5)mg/L (p = 0.006). CT angiography demonstrated improvement of LVV in all patients studied. No unexpected adverse events were observed with ustekinumab.Ustekinumab may be effective for the treatment of GCA and warrants further assessment in a randomized controlled trial.

We present a model to describe carbon dioxide (CO2) capture using reactive silicate-based mineral slurries exposed to a gas flow containing CO2. The model is validated through experimentation using thermally conditioned or heat-activated serpentinite (hydrous metamorphic ultramafic rock) in a laboratory-scale bubble column reactor. The kinetic model developed advocates a holistic modeling approach, offering an expanded view of the dissolution of heat-activated serpentinite under lean CO2 conditions, in which the gas–liquid–solid system and its influence on CO2 dissolution and the coupled dissolution behavior of the material are considered in their entirety. Modeling incorporates the characteristics of the gas to liquid phase interaction, such as CO2 composition of the gas phase and interfacial area, the composition of the aqueous phase and its temperature, and compositional and morphological features of the solid. We demonstrate that such an approach is essential when considering proton-limiting condition...

This paper describes an alternative process for chloroform decomposition via nonthermal plasma polymerization at atmospheric pressure and investigates the effect of methane and hydrogen addition on the process. The effect of both additives was assessed separately, where experiments were conducted in a double dielectric barrier discharge reactor under nonoxidative conditions. The most profound impact of the additives was a significant increase in the yield of non-cross-linked polymer produced compared to that in their absence. The addition of methane resulted in a 120% increase in polymer yield, while in hydrogen the increase was 31%. Critical parameters such as effect of the methane and hydrogen concentration on the conversion of chloroform at various applied voltages, the product distribution, mass balance, and polymer characterization are elucidated in this paper. Single pass conversions of 61% and 68% (with corresponding mass balances of 98% and 95%, respectively) were achieved for CHCl3 + CH4 and CHCl3 + H2 feed scenarios, respectively. Furthermore, a polymerization mechanism which explains the formation of major chain structures as well as structural defects in the polymer is expounded upon in the paper.

Purpose: To report a unique case of orbital inflammatory disease which was ultimately diagnosed as granulomatosis with polyangitis (GPA) and thus successfully treated. Observation: A 47 year-old man presented with a rapidly progressive necrotic soft tissue mass within the medial antero-superior aspect of the right eyelid and orbit. He also had transient retinal vasculitis in the left. Serology, histology and imaging were atypical of, but consistent with, GPA. He was thus successfully treated with intravenous rituximab followed by reconstruction of the medial eyelid. Conclusion and importance: A high index of suspicion of GPA is required in orbital inflammatory disease, especially when typical diagnostic findings are absent. Keywords: Orbital inflammatory disease, Rituximab, Eyelid reconstruction, Granulomatosis with polyangiitis

Background:No universally accepted definition of flare currently exists in giant cell arteritis (GCA). Although relapses are defined mostly on clinical grounds (recurrence of GCA-related signs/symptoms), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) help clinicians assess disease activity. In fact, >70% of patients on glucocorticoids (GCs) alone have increased CRP or ESR when the disease is active. In contrast, tocilizumab, given its IL-6-blockade effect in the liver, rapidly reduces CRP and ESR levels, rendering them unreliable for disease activity monitoring. Mavrilimumab – a GM-CSF receptor α inhibitor with demonstrated efficacy in a Phase 2 GCA trial1 – downregulates inflammation upstream of IL-6. We hypothesized that mavrilimumab would not interfere with the utility of CRP and ESR in monitoring disease activity and in identifying GCA relapse.Objectives:To analyze the relationship between CRP/ESR and clinical disease activity in GCA patients treated with mavrilimumab.Methods:New-onset and relapsing GCA patients with active disease were recruited. GC-induced remission (no GCA symptoms and CRP This post hoc analysis assessed the association of recurrent GCA-related signs/symptoms with concurrent CRP or ESR elevation post-randomization by treatment arm. We also assessed the proportion of patients with CRP or ESR elevation without GCA-related signs/symptoms up to Week 26.Results:Seventy patients were enrolled (mavrilimumab, N=42; placebo, N=28). The association of CRP or ESR elevation with unequivocal GCA-related signs/symptoms post-randomization was consistent regardless of treatment arm: 8/8 in the mavrilimumab group and 13/13 in the placebo group (Table 1). During relapse, median (range) CRP was 1.8 (1.4 – 8.4) mg/dL (mavrilimumab group) and 1.8 (1.1 – 9.0) mg/dL (placebo group). Corresponding ESR values were 39.5 (30 – 102) mm/hr (mavrilimumab group) and 49 (31 – 101) mm/hr (placebo group). Four mavrilimumab recipients had self-limited, equivocal GCA-related signs/symptoms without concurrent CRP or ESR elevation; all 4 completed the prespecified GC taper by Week 26 without need for rescue GCs, so relapse was not confirmed. At least 1 elevated CRP or ESR value in the absence of GCA-related signs/symptoms was observed in 58.8% of mavrilimumab recipients and 93.3% of placebo recipients by Week 26.Conclusion:The observed association of CRP or ESR elevation with GCA-related signs/symptoms is consistent with the upstream mechanism and supports the utility of the stringent protocol definition of relapse. The frequency and magnitude of CRP and ESR elevations at relapse were similar in both treatment groups, suggesting that CRP and ESR remain useful in assessments of disease activity in mavrilimumab-treated patients. CRP and ESR elevations without GCA-related signs/symptoms occurred more often in placebo recipients.References:[1]Cid, Unizony et al. Arthritis Rheumatol. 2020; 72 (suppl 10)Table 1.CRP and ESR levels in patients with or without GCA relapseAssessment§MavrilimumabPlaceboMavrilimumabPlaceboN=42N=28N=42N=28With RelapseWithout Relapse# of patients8 (19.1)13 (46.4)34 (81.0)15 (53.6) Elevated CRP* or ESR†8 (100.0)13 (100.0)20 (58.8)14 (93.3) Elevated CRP*7 (87.5)10 (76.9)10 (29.4)11 (73.3) Median (range) mg/dL1.8 (1.4 - 8.4)1.8 (1.1 - 9.0)2.6 (1.3 – 7.0)2.0 (1.0 – 6.6) Elevated ESR†6 (75.0)9 (69.2)16 (47.1)10 (66.7) Median (range) mm/hr39.5 (30 - 102)49.0 (31 - 101)41.5 (30 - 110)53.5 (30 - 82)§# (%), except where indicated otherwise.*CRP ≥ 1 mg/dL†ESR ≥ 30 mm/hrDisclosure of Interests:Sebastian Unizony Consultant of: Janssen and Kiniksa, Grant/research support from: Genentech, Maria C. Cid Speakers bureau: Roche and Kiniksa, Paid instructor for: GSK and Vifor, Consultant of: Janssen, GSK, and Abbvie, Grant/research support from: Kiniksa, Elisabeth Brouwer Speakers bureau: Dr. E.Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017 2018 which were paid to the UMCG., Consultant of: Dr. E.Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017 2018 which were paid to the UMCG., Lorenzo Dagna Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celltrion, Galapagos, Glaxo SmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Galapagos, Glaxo SmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI; clinical trial for Kiniksa, Grant/research support from: Abbvie, Amgen, BMS, Celltrion, Galapagos, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI, Merk Sharp &Dohme, Janssen, Kiniksa, Bhaskar Dasgupta Paid instructor for: Educational grant symposium/workshop for Roche-chugai, Sanofi, and Abbvie, Consultant of: CI UK for the Kiniksa trial, Grant/research support from: Educational grant symposium/workshop for Roche-chugai, Sanofi, and Abbvie, Bernhard Hellmich Consultant of: Honoraria paid to the institution for participation in the clinical trial, Eamonn Molloy: None declared, Carlo Salvarani: None declared, Bruce C. Trapnell Consultant of: Consultant member of DSMB for Kiniksa., Kenneth J Warrington Consultant of: Clinical trial support from Eli Lilly and Kiniksa, Ian Wicks: None declared, Manoj Samant Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Teresa Zhou Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Lara Pupim Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, John F. Paolini Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals