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The present study was conducted to evaluate the potential of aquatic vascular plant,Nasturtium officinale, for degradation of C.I. Acid Blue 92 (AB92). The effect of operational parameters such as initial dye concentration, plant biomass, pH, and temperature on the efficiency of biological decolorization process was determined. The reusability of the plant in long term repetitive operations confirmed the biological degradation process. The by-products formed during biodegradation process were identified by GC-MS technique. The effects of the dye on several plant physiological responses such as photosynthetic pigments content and antioxidant enzymes activity were investigated. The content of chlorophyll and carotenoids was significantly reduced at 20 mg/L of the dye. The activities of superoxide dismutase and peroxidase were remarkably increased in the plant root verifying their importance in plant tolerance to the dye contamination. [ABSTRACT FROM PUBLISHER]

This study was carried out to investigate the potential of duckweed ( Lemna minor L.) for bioremediation of C.I. Basic Red 46 (BR46) solution. Our results revealed the notable ability of the plant species in biological degradation of BR46. The reusability of the plant in long-term repetitive operations was also confirmed. The decolorization efficiency was extremely dependent on different operational parameters such as initial dye concentration, pH, temperature, and amount of plant. Interestingly, activities of superoxide dismutase and peroxidase as antioxidant enzymes were increased in different concentrations of the dye. In contrast, catalase activity declined in duckweed plants exposed to the dye. An artificial neural network (ANN) model was developed to predict the biological decolorization efficiency. The obtained data indicated that ANN provide realistic predictive performance ( R2 = 0.981). © 2012 American Institute of Chemical Engineers Environ Prog, 32: 1082-1089, 2013 [ABSTRACT FROM AUTHOR]

The chemical composition of the volatile organic compounds (VOCs) released from the leaves and flowers of Artemisia fragrans Willd. (Asteraceae) was investigated using headspace solid-phase microextraction (HS-SPME) coupled to gas chromatography (GC) and/or GS/mass spectrometry (GC/MS). The efficiency and reliability of different fibres such as modified pencil lead and commercial polyacrylate (PA) as well as polydimethylsiloxane (PDMS) were evaluated, and pencil lead was selected to be the most suitable fibre for the extraction and sampling of the compounds. The extraction and chromatographic conditions were also optimised. Under the optimal conditions, a range of VOCs released from the leaves and flowers of A. fragrans were identified and compared. Accordingly, some bioactive components such as camphor, 1,8-cineole, α-terpinolene, γ-terpinene and carvacrol were the main compounds in the VOCs released from either flowers or leaves. However, the nature and level of the volatiles in studied parts of the plant were notably varied. [ABSTRACT FROM AUTHOR]

Biomechanics-based patient-specific modeling is a promising approach that has proved invaluable for its clinical potential to assess the adversities caused by ischemic heart disease (IHD). In the present study, we propose a framework to find the passive material properties of the myocardium and the unloaded shape of cardiac ventricles simultaneously in patients diagnosed with ischemic cardiomyopathy (ICM). This was achieved by minimizing the difference between the simulated and the target end-diastolic pressure-volume relationships (EDPVRs) using black-box Bayesian optimization, based on the finite element analysis (FEA). End-diastolic (ED) biventricular geometry and the location of the ischemia were determined from cardiac magnetic resonance (CMR) imaging. We employed our pipeline to model the cardiac ventricles of three patients aged between 57 and 66 years, with and without the inclusion of valves. An excellent agreement between the simulated and the target EDPVRs has been reached. Our results revealed that the incorporation of valvular springs typically leads to lower hyperelastic parameters for both healthy and ischemic myocardium, as well as a higher fiber Green strain in the viable regions compared to models without valvular stiffness. Furthermore, the addition of valve-related effects did not result in significant changes in myofiber stress after optimization. We concluded that more accurate results could be obtained when cardiac valves were considered in modeling ventricles. The present novel and practical methodology paves the way for developing digital twins of ischemic cardiac ventricles, providing a non-invasive assessment for designing optimal personalized therapies in precision medicine., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The modified Brain Injury Guidelines (mBIG) were developed to stratify traumatic brain injuries (TBIs) and improve health care utilization by selectively requiring repeat imaging, intensive care unit admission, and neurosurgical (NSG) consultation. The goal of this study is to assess safety and potential resource savings associated with the application of mBIG on interhospital patient transfers for TBI., Methods: Adult patients with TBI transferred to our Level I trauma center from January 2017 to December 2022 meeting mBIG inclusion criteria were retrospectively stratified into mBIG1, mBIG2, and mBIG3 based on initial clinicoradiological factors. At the time, our institution routinely admitted patients with TBI and intracranial hemorrhage (ICH) to the intensive care unit and obtained a repeat head computed tomography with NSG consultation, independent of TBI severity or changes in neurological examination. The primary outcome was progression of ICH on repeat imaging and/or NSG intervention. Secondary outcomes included length of stay and financial charges. Subgroup analysis on isolated TBI without significant extracranial injury was performed., Results: Over the 6-year study period, 289 patients were classified into mBIG1 (61; 21.1%), mBIG2 (69; 23.9%), and mBIG3 (159; 55.0%). Of mBIG1 patients, 2 (2.9%) had radiological progression to mBIG2 without clinical decline, and none required NSG intervention. Of mBIG2, 2 patients (3.3%) progressed to mBIG3, and both required NSG intervention. More than 35% of transferred patients had minor isolated TBI. For mBIG1 and mBIG2, the median hospitalization charges per patient were $152,296 and $149,550, respectively, and the median length of stay was 4 and 5 days, respectively, with the majority downgraded from the intensive care unit within 48 hours., Conclusion: Clinically significant progression of ICH occurred infrequently in 1.5% of patients with mBIG1 and mBIG2 injuries. More than 35% of interfacility transfers for minor isolated TBI meeting mBIG1 and 2 criteria are low value and may potentially be safely deferred in an urban health care setting., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Due to the intensified industrial activities and other anthropogenic actions, contamination of polycyclic aromatic hydrocarbons (PAHs) has been growing at an alarming rate, turning in to a serious environmental concern. Bioremediation, as an eco-friendly and sustainable removal technology, can be used by organisms to reduce the resulting contaminations. In the present study, the ability of Tetradesmus obliquus to remove of fluoranthene (FLA) was evaluated. It was confirmed that FLA removal efficiency was managed by various environmental parameters and pH was found to be one of the most important influencial factors. The reusability of the algae in long-term repetitive operations confirmed the occurrence of biodegradation along with other natural attenuation and 10 intermediate compounds were identified in the FLA biodegradation pathway by GC-MS. As a result of physiological assays, induced antioxidant enzymes activities and augmentation of phenol and flavonoids contents, after the treatment of the microalgae by a high concentration of FLA, confirmed the ability of the microalgae to upregulate its antioxidant defense system in response to the toxic effects of FLA. An artificial neural network (ANN) model was then developed to predict FLA biodegradation efficiency and the appropriate predictive performance of ANN was confirmed by comparing the experimental FLA removal efficiency with its predicted amounts (R 2 = 0.99).

Layered double hydroxides (LDHs), regarding their physical and structural properties, have different and wide applications industry and their increasing use may raise ecological and human health concerns. However, the potential toxicity mechanisms of LDHs in different organisms are still unclear. In the present work, after synthesizing of ZnFe-SO 4 LDH and studying of its characterization by XRD, FT-IR, SEM, EDX-mapping, TEM and Raman, its toxicity in Tetradesmus obliquus was evaluated. According to experimental results, the growth of the algae and content of photosynthetic pigments were significantly decreased after treatment with 100 mg/L of ZnFe-SO 4 LDH. The high dose exposure to the LDH also inhibited the activity of SOD and POD enzymes, possibly due to the LDH- catalyzed reactive oxygen species production. In addition, lipid peroxidation and the content of phenolic compounds, as no-enzymatic antioxidants were increased by enhancement of the LDH concentration. The rise of phenol, flavonoids and MDA contents could be regarded as some manifestations and responses to the toxic effects of the contaminant in the algae cells. The results provided a better understanding of the undesirable effects and toxicity of LDHs in aquatic organisms., (© 2024. The Author(s).)

Purpose: The conventional aqueous outflow pathway, which includes the trabecular meshwork (TM), juxtacanalicular tissue (JCT), and the inner wall endothelium of Schlemm's canal (SC), regulates intraocular pressure (IOP) by controlling the aqueous humor outflow resistance. Despite its importance, our understanding of the biomechanics and hydrodynamics within this region remains limited. Fluid-structure interaction (FSI) offers a way to estimate the biomechanical properties of the JCT and SC under various loading and boundary conditions, providing valuable insights that are beyond the reach of current imaging techniques., Methods: In this study, a normal human eye was fixed at a pressure of 7 mm Hg, and two radial wedges of the TM tissues, which included the SC inner wall basement membrane and JCT, were dissected, processed, and imaged using 3D serial block-face scanning electron microscopy (SBF-SEM). Four different sets of images were used to create 3D finite element (FE) models of the JCT and inner wall endothelial cells of SC with their basement membrane. The outer JCT portion was carefully removed as the outflow resistance is not in that region, leaving only the SCE inner wall and a few µm of the tissue, which does contain the resistance. An inverse iterative FE algorithm was then utilized to calculate the unloaded geometry of the JCT/SC complex at an aqueous humor pressure of 0 mm Hg. Then in the model, the intertrabecular spaces, pores, and giant vacuole contents were replaced by aqueous humor, and FSI was employed to pressurize the JCT/SC complex from 0 to 15 mm Hg., Results: In the JCT/SC complex, the shear stress of the aqueous humor is not evenly distributed. Areas proximal to the inner wall of SC experience larger stresses, reaching up to 10 Pa, while those closer to the JCT undergo lower stresses, approximately 4 Pa. Within this complex, giant vacuoles with or without I-pore behave differently. Those without I-pores experience a more significant strain, around 14%, compared to those with I-pores, where the strain is roughly 9%., Conclusions: The distribution of aqueous humor wall shear stress is not uniform within the JCT/SC complex, which may contribute to our understanding of the underlying selective mechanisms in the pathway., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Background: Physical restraints are used in the emergency department (ED) for agitated patients to prevent self-harm and protect staff. Prior studies identified associations between sociodemographic factors and ED physical restraints use., Objectives: The primary objective was to compare characteristics of ED patients receiving physical restraints for violent and nonviolent indications vs. patients who were not restrained. The secondary objective was to compare rates of restraint use among ED providers., Methods: This was a single-center cross-sectional study of adult ED patients from March 2019 to February 2021. Factors compared across groups were age over 50 years, gender, race, ethnicity, insurance, housing, primary language, Emergency Severity Index, time of arrival, mode of arrival, chief complaint, and medical admission. Odds ratios were reported. Rates of emergency physician restraint orders were compared using the chi-square test., Results: Restraints were used in 1228 (0.9%) visits. Younger age, male gender, "unknown" ethnicity, self-pay or "other" nonprivate insurance, homelessness, arrival by first responders, and medical hospitalization were associated with increased odds of restraint. Black patients had lower odds of any restraint than White patients (odds ratio 0.93; 95% confidence interval 0.79-1.09) and higher odds of violent restraint than White patients, although not significant (odds ratio 1.55; 95% confidence interval 0.95-2.54). ED providers had significant differences in total and violent restraint use (p-values < 0.0001 and 0.0003, respectively)., Conclusion: At this institution, certain sociodemographic characteristics were associated with receiving both types of physical restraint. Emergency physicians also differed in restraint-ordering practice. Further investigation is needed to understand the influence of implicit bias on ED restraint use., Competing Interests: Declaration of Competing Interest Drs. Stillman, Geiderman, Torbati, and Mr. Mirocha report no potential conflicts of interest pertaining to this manuscript., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: There is a clinical need for therapeutics for COVID-19 patients with acute hypoxemic respiratory failure whose 60-day mortality remains at 30-50%. Aviptadil, a lung-protective neuropeptide, and remdesivir, a nucleotide prodrug of an adenosine analog, were compared with placebo among patients with COVID-19 acute hypoxaemic respiratory failure., Methods: TESICO was a randomised trial of aviptadil and remdesivir versus placebo at 28 sites in the USA. Hospitalised adult patients were eligible for the study if they had acute hypoxaemic respiratory failure due to confirmed SARS-CoV-2 infection and were within 4 days of the onset of respiratory failure. Participants could be randomly assigned to both study treatments in a 2 × 2 factorial design or to just one of the agents. Participants were randomly assigned with a web-based application. For each site, randomisation was stratified by disease severity (high-flow nasal oxygen or non-invasive ventilation vs invasive mechanical ventilation or extracorporeal membrane oxygenation [ECMO]), and four strata were defined by remdesivir and aviptadil eligibility, as follows: (1) eligible for randomisation to aviptadil and remdesivir in the 2 × 2 factorial design; participants were equally randomly assigned (1:1:1:1) to intravenous aviptadil plus remdesivir, aviptadil plus remdesivir matched placebo, aviptadil matched placebo plus remdesvir, or aviptadil placebo plus remdesivir placebo; (2) eligible for randomisation to aviptadil only because remdesivir was started before randomisation; (3) eligible for randomisation to aviptadil only because remdesivir was contraindicated; and (4) eligible for randomisation to remdesivir only because aviptadil was contraindicated. For participants in strata 2-4, randomisation was 1:1 to the active agent or matched placebo. Aviptadil was administered as a daily 12-h infusion for 3 days, targeting 600 pmol/kg on infusion day 1, 1200 pmol/kg on day 2, and 1800 pmol/kg on day 3. Remdesivir was administered as a 200 mg loading dose, followed by 100 mg daily maintenance doses for up to a 10-day total course. For participants assigned to placebo for either agent, matched saline placebo was administered in identical volumes. For both treatment comparisons, the primary outcome, assessed at day 90, was a six-category ordinal outcome: (1) at home (defined as the type of residence before hospitalisation) and off oxygen (recovered) for at least 77 days, (2) at home and off oxygen for 49-76 days, (3) at home and off oxygen for 1-48 days, (4) not hospitalised but either on supplemental oxygen or not at home, (5) hospitalised or in hospice care, or (6) dead. Mortality up to day 90 was a key secondary outcome. The independent data and safety monitoring board recommended stopping the aviptadil trial on May 25, 2022, for futility. On June 9, 2022, the sponsor stopped the trial of remdesivir due to slow enrolment. The trial is registered with ClinicalTrials.gov, NCT04843761., Findings: Between April 21, 2021, and May 24, 2022, we enrolled 473 participants in the study. For the aviptadil comparison, 471 participants were randomly assigned to aviptadil or matched placebo. The modified intention-to-treat population comprised 461 participants who received at least a partial infusion of aviptadil (231 participants) or aviptadil matched placebo (230 participants). For the remdesivir comparison, 87 participants were randomly assigned to remdesivir or matched placebo and all received some infusion of remdesivir (44 participants) or remdesivir matched placebo (43 participants). 85 participants were included in the modified intention-to-treat analyses for both agents (ie, those enrolled in the 2 x 2 factorial). For the aviptadil versus placebo comparison, the median age was 57 years (IQR 46-66), 178 (39%) of 461 participants were female, and 246 (53%) were Black, Hispanic, Asian or other (vs 215 [47%] White participants). 431 (94%) of 461 participants were in an intensive care unit at baseline, with 271 (59%) receiving high-flow nasal oxygen or non-invasive ventiliation, 185 (40%) receiving invasive mechanical ventilation, and five (1%) receiving ECMO. The odds ratio (OR) for being in a better category of the primary efficacy endpoint for aviptadil versus placebo at day 90, from a model stratified by baseline disease severity, was 1·11 (95% CI 0·80-1·55; p=0·54). Up to day 90, 86 participants in the aviptadil group and 83 in the placebo group died. The cumulative percentage who died up to day 90 was 38% in the aviptadil group and 36% in the placebo group (hazard ratio 1·04, 95% CI 0·77-1·41; p=0·78). The primary safety outcome of death, serious adverse events, organ failure, serious infection, or grade 3 or 4 adverse events up to day 5 occurred in 146 (63%) of 231 patients in the aviptadil group compared with 129 (56%) of 230 participants in the placebo group (OR 1·40, 95% CI 0·94-2·08; p=0·10)., Interpretation: Among patients with COVID-19-associated acute hypoxaemic respiratory failure, aviptadil did not significantly improve clinical outcomes up to day 90 when compared with placebo. The smaller than planned sample size for the remdesivir trial did not permit definitive conclusions regarding safety or efficacy., Funding: National Institutes of Health., Competing Interests: Declaration of interests SMB reports funding from the National Institutes of Health during the conduct of the study and chairing a Data and Safety Monitoring Board (DSMB) for Hamilton Ventilators, outside of the study. CEB reports funding from the National Institutes of Health (NIH) for the Aviptadil study, during the conduct of the study. BG reports grants from the NIH, during the conduct of the study. SS reports a grant from the NIH, during the conduct of the study. ANP reports grants from the Wellcome Trust, the National Institute for Health and Care Research, UK Research and Innovation (UKRI), and the Bill & Melinda Gates Foundation, and consulting fees from the Bill & Melinda Gates Foundation, outside of the submitted work. IDP reports funding from NIH and the National Institute of General Medical Sciences, during the conduct of the study, a grant from Janssen for a study of influenza patient reported outcomes, and a contract with Regeneron for a COVID-19 therapy trial, outside of the submitted work. JRB reports a grant from the NIH, during the conduct of the study, grants from the NIH, Quantum Leap Healthcare Collaborative, and Sedana Medical, consulting fees from Sedana Medical, Biomarck, and Global Blood Therapeutics, and compensation from Hamilton Medical for participation as a medical monitor, outside of the submitted work. ESHa reports study materials from NeuroRx and Gilead through a National Heart, Lung, and Blood Institute (NHLBI) subcontract, during the conduct of the study, subcontracts with Bristol Meyers Squibb (BMS), Allergan, Gilead, and Janssen for the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV-1) clinical trial, subcontracts with AstraZeneca, Brii Biosciences, Vir Biotechnology, and Eli Lilly for the Therapeutics for Inpatients with COVID-19 (TICO) clinical trial, and additional subcontracts with Rigel, APEIRON Biologics, and Trevena for the Novel Experimental COVID-19 Therapies Affecting Host Response (NECTAR) clinical trial, outside of the submitted work. EAM reports study materials from NeuroRx and Gilead through an NHLBI subcontract, during the conduct of the study, subcontracts with BMS, Allergan, Gilead, and Janssen for the ACTIV-1 clinical trial, subcontracts with AstraZeneca, Brii Biosciences, Vir Biotechnology, and Eli Lilly for the TICO clinical trial, and additional subcontracts with Rigel, APEIRON Biologics, and Trevena for the NECTAR clinical trial, outside of the submitted work. MAGB reports study materials from NeuroRx and Gilead through an NHLBI subcontract, during the conduct of the study, subcontracts with BMS, Allergan, Gilead, and Janssen for the ACTIV-1 clinical trial, subcontracts with AstraZeneca, Brii Biosciences, Vir Biotechnology, and Eli Lilly for the TICO clinical trial, and subcontracts with Rigel, APEIRON Biologics, and Trevena for the NECTAR clinical trial, outside of the submitted work. KSM reports grants and contracts from NIH, NHLBI, and the Society for Critical Care Medicine, participation as a steering committee member for Roivant-Kinevant Sciences, and employment as a clinical research physician at Chiesi USA, outside of submitted work. JM reports receiving study materials and funding from the Albert Einstein College of Medicine for the study protocol, during the conduct of the study. CH reports funding from the National Institute of Allergy and Infectious Diseases (NIAID) in the form of per-patient payments for A Multicenter, Adaptive, Randomized, Blinded Controlled Trial of the Safety and Efficacy of Investigational Therapeutics for Hospitalized Patients with Acute Respiratory Distress Syndrome Associated with COVID-19, during the conduct of the study. AK reports grants from Eli Lilly, AstraZeneca, 4D Medical, United Therapeutics, Regeneron Pharmaceuticals, and Dompe Pharmaceuticals and consulting fees from Dompe Pharmaceuticals for clinical trial design, outside of the submitted work. AD reports grants from NHLBI Prevention and Early Treatment of Acute Lung Injury network and the US Centers for Disease Control and Prevention (CDC) and data safety monitoring board (DSMB) or advisory board participation for Alung Technologies, outside of the submitted work. SD reports a grant from Chest Sonosite Ultrasound to study the incidence of deep vein thrombosis in patients with COVID-19, during the conduct of the study. AJG reports payment from Sound Pharmaceuticals for participation as a medical monitor for a COVID therapeutic trial, outside of the submitted work. USS reports consulting fees from Shionogi, Paratek, and ViiV Healthcare for participation on advisory boards and speaking fees from Shionogi and Paratek, outside of the submitted work. NJJ reports grants from the CDC, the US Department of Defense (DOD), and NIH and participation on a DSMB for the Legacy Health System, outside of the submitted work. MAM reports grants from NIH and NIAID, during the conduct of the study. NRA reports funding from NIH, during the conduct of the study. JDC reports grants from NIH and DOD, outside of the submitted work. DDM reports funding from the Danish National Research Foundation (DNRF126), during the conduct of study. AAG reports funding from NIH, during the conduct of the study, grants or contracts from NIH, DOD, CDC, Faron Pharmaceuticals, and Abbvie, and participation on a DSMB or advisory board for NIH, outside of the submitted work. WHS reports funding from NIH and NIAID, during the conduct of the study. CFO reports contracts with NIH and NHLBI, outside of the submitted work. BTT reports a grant from NHLBI, consulting fees from Bayer, Genetec, and Novartis, and participation on a DSMB or advisory board for Aperion, outside of the submitted work. During a portion of this research, BTT had a financial interest in Direct Biologics, a developer and manufacturer of regenerative biologic products, including an investigational treatment of COVID-19-associated ARDS. BTT's interests were reviewed and are managed by Massachusetts General Hospital and Mass General Brigham in accordance with their conflict of interest policies, and had no relationship to the agents studied. VK reports subcontracts with University of Minnesota, NIAID, and NIH for the TICO and Therapeutics for Severely Ill Inpatients with COVID-19 platform trials, outside of the submitted work. AGB reports a grant from University of Minnesota, during the conduct of the study, grants from the Medical Reserve Corps and UKRI, payment from NIAID for participation on a COVID-19 Vaccines DSMB, and participation on the WHO Trial Data and Safety Monitoring Committee, outside of the submitted work. JDN reports grants from NIAID, NIH, and Leidos Biomedical, outside of the submitted work. HCL reports employment from NIAID, during the conduct of the study. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR., Methods: The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome., Results: From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs., Conclusion: We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection., Objective: To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone., Design: Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978)., Setting: Multinational, multicenter trial., Participants: Adults hospitalized with COVID-19., Intervention: Intravenous ensovibep, 600 mg, or placebo., Measurements: Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90., Results: An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep ( n  = 247) or placebo ( n  = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P  = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep)., Limitation: The trial was prematurely stopped because of futility, limiting power for the primary outcome., Conclusion: Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified., Primary Funding Source: National Institutes of Health.

Introduction: Opioid analgesics are often used to treat moderate-to-severe acute non-cancer pain; however, there is little high-quality evidence to guide clinician prescribing. An essential element to developing evidence-based guidelines is a better understanding of pain management and pain control among individuals experiencing acute pain for various common diagnoses., Methods and Analysis: This multicentre prospective observational study will recruit 1550 opioid-naïve participants with acute pain seen in diverse clinical settings including primary/urgent care, emergency departments and dental clinics. Participants will be followed for 6 months with the aid of a patient-centred health data aggregating platform that consolidates data from study questionnaires, electronic health record data on healthcare services received, prescription fill data from pharmacies, and activity and sleep data from a Fitbit activity tracker. Participants will be enrolled to represent diverse races and ethnicities and pain conditions, as well as geographical diversity. Data analysis will focus on assessing patients' patterns of pain and opioid analgesic use, along with other pain treatments; associations between patient and condition characteristics and patient-centred outcomes including resolution of pain, satisfaction with care and long-term use of opioid analgesics; and descriptive analyses of patient management of leftover opioids., Ethics and Dissemination: This study has received approval from IRBs at each site. Results will be made available to participants, funders, the research community and the public., Trial Registration Number: NCT04509115., Competing Interests: Competing interests: In the past three years, Dr. Jeffery has received unrelated grant funding from the Agency for Healthcare Research and Quality, the National Institute on Drug Abuse, the National Heart, Lung, and Blood Institute, the American Cancer Society and the US Food and Drug Administration for the Yale-Mayo Clinic Center of Excellence in Regulatory Science and Innovation (CERSI) (U01FD005938). Dr. Ross currently receives research support through Yale University from Johnson and Johnson to develop methods of clinical trial data sharing, from the Medical Device Innovation Consortium as part of the National Evaluation System for Health Technology (NEST), from the Food and Drug Administration for the Yale-Mayo Clinic Center of Excellence in Regulatory Science and Innovation (CERSI) (U01FD005938), from the Agency for Healthcare Research and Quality (R01HS022882), from the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) (R01HS025164, R01HL144644), and from the Laura and John Arnold Foundation to establish the Good Pharma Scorecard at Bioethics International; in addition, Dr. Ross is an expert witness at the request of Relator's attorneys, the Greene Law Firm, in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen Inc. Ms. Ritchie currently receives research support through Yale University from Johnson & Johnson to develop methods of clinical trial data sharing, from the Medical Device Innovation Consortium as part of the National Evaluation System for Health Technology (NEST), and from the US Food and Drug Administration for the Yale-Mayo Clinic Center of Excellence in Regulatory Science and Innovation (CERSI) (U01FD005938). Ms. Emanuel received research support from the Medical Device Innovation Consortium as part of the National Evaluation System for Health Technology (NEST) and from the US Food and Drug Administration for the Yale-Mayo Clinic Center of Excellence in Regulatory Science and Innovation (CERSI) (U01FD005938). Dr. Gilbert currently receives research support from the National Institutes of Health (U19DE028717). Dr. Bellolio received funding from the National Center for Complementary and Integrative Health, the National Institute on Aging, and Diagnostic Robotics. Dr. Heckmann reported receiving salary support from CMS to develop, implement, and maintain hospital performance outcome measures that are publicly reported, in addition to receiving research support through Yale as part of a Centers for Disease Control and Prevention project designed to strengthen prescription drug overdose prevention efforts, from Connecticut Department of Public Health as part of a public health project designed to assess the impact of Good Samaritan Laws, and from the Community Health Network of Connecticut for her work as a medical consultant. Dr Lipkind serves on the Pfizer independent external data monitoring committee for the COVID-19 vaccine. Since leaving the Yale-New Haven Center for Outcomes Research and Evaluation, Ms. Ciaccio has been employed part-time at Hugo Health., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Pulmonary hypertension (PH), a chronic and complex medical condition affecting 1% of the global population, requires clinical evaluation of right ventricular maladaptation patterns under various conditions. A particular challenge for clinicians is a proper quantitative assessment of the right ventricle (RV) owing to its intimate coupling to the left ventricle (LV). We, thus, proposed a patient-specific computational approach to simulate PH caused by left heart disease and its main adverse functional and structural effects on the whole heart. Information obtained from both prospective and retrospective studies of two patients with severe PH, a 72-year-old female and a 61-year-old male, is used to present patient-specific versions of the Living Heart Human Model (LHHM) for the pre-operative and post-operative cardiac surgery. Our findings suggest that before mitral and tricuspid valve repair, the patients were at risk of right ventricular dilatation which may progress to right ventricular failure secondary to their mitral valve disease and left ventricular dysfunction. Our analysis provides detailed evidence that mitral valve replacement and subsequent chamber pressure unloading are associated with a significant decrease in failure risk post-operatively in the context of pulmonary hypertension. In particular, right-sided strain markers, such as tricuspid annular plane systolic excursion (TAPSE) and circumferential and longitudinal strains, indicate a transition from a range representative of disease to within typical values after surgery. Furthermore, the wall stresses across the RV and the interventricular septum showed a notable decrease during the systolic phase after surgery, lessening the drive for further RV maladaptation and significantly reducing the risk of RV failure., (© 2022. International Federation for Medical and Biological Engineering.)

Emergency department (ED) psychiatrists face the consequential decision to pursue involuntary inpatient psychiatric admission. Research on the relationship between patient characteristics and the decision to pursue involuntary psychiatric admission is limited. Using data from 2017 to 2018 at an urban Los Angeles hospital, we used generalized linear mixed effects models to compare patients who were involuntarily admitted to inpatient psychiatry to patients who were discharged from the ED. Of 2,448 patients included in the study, 1,217 (49.7%) were involuntarily admitted to inpatient psychiatry and 1,231 (50.3%) were discharged. After controlling for sociodemographic characteristics, admitted patients were more likely to have been brought in by police, have had an organized suicide plan or recent attempt, physical signs of harm, psychosis, depression or hopelessness, lack social support, have diagnoses of schizophrenia or bipolar disorder, and be administered injectable psychotropic medications. Stimulant use, a diagnosis of anxiety or developmental disorders, and recent medical ED utilization were associated with discharge. Psychiatrists pursued involuntarily psychiatric hospitalization based on factors potentially indicative of dangerousness, leaving patients, particularly those with recent substance use, without immediate access to treatment. Policies should focus on increasing follow up to high quality, voluntary outpatient mental health care., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: During protests following the death of George Floyd, kinetic impact projectiles (KIP) were used by law enforcement as a method of crowd control. We describe the injuries seen at a single Level 1 trauma center in Los Angeles over a two-day period of protests to add to the collective understanding of the public health ramifications of crowd-control weapons used in the setting of protests., Case Series: We reviewed the emergency department visits of 14 patients who presented to our facility due to injuries sustained from KIPs over a 48-hour period during civil protests after the death of George Floyd., Conclusion: Less lethal weapons can cause significant injuries and may not be appropriate for the purposes of crowd control, especially when used outside of established guidelines.

Introduction: Post-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient., Case Series: Eight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED., Conclusion: Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention. Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site.

Introduction: EDs are often the first line of contact with individuals infected with COVID-19 and play a key role in triage. However, there is currently little specific guidance for deciding when patients with COVID-19 require hospitalisation and when they may be safely observed as an outpatient., Methods: In this retrospective study, we characterised all patients with COVID-19 discharged home from EDs in our US multisite healthcare system from March 2020 to August 2020, focusing on individuals who returned within 2 weeks and required hospital admission. We restricted analyses to first-encounter data that do not depend on laboratory or imaging diagnostics in order to inform point-of-care assessments in resource-limited environments. Vitals and comorbidities were extracted from the electronic health record. We performed ordinal logistic regression analyses to identify predictors of inpatient admission, intensive care and intubation., Results: Of n=923 patients who were COVID-19 positive discharged from the ED, n=107 (11.6%) returned within 2 weeks and were admitted. In a multivariable-adjusted model including n=788 patients with complete risk factor information, history of hypertension increased odds of hospitalisation and severe illness by 1.92-fold (95% CI 1.07 to 3.41), diabetes by 2.20-fold (1.18 to 4.02), chronic lung disease by 2.21-fold (1.22 to 3.92) and fever by 2.89-fold (1.71 to 4.82). Having at least two of these risk factors increased the odds of future hospitalisation by 6.68-fold (3.54 to 12.70). Patients with hypertension, diabetes, chronic lung disease or fever had significantly longer hospital stays (median 5.92 days, 3.08-10.95 vs 3.21, 1.10-5.75, p<0.01) with numerically higher but not significantly different rates of intensive care unit admission (27.02% vs 14.30%, p=0.27) and intubation (12.16% vs 7.14%, p=0.71)., Discussion: Patients infected with COVID-19 may appear clinically safe for home convalescence. However, those with hypertension, diabetes, chronic lung disease and fever may in fact be only 'pseudo-safe' and are most at risk for subsequent hospitalisation with more severe illness and longer hospital stays., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

In this study, the preparation and characterization of haloxyfop-R-methyl herbicide loaded in poly(methylmethacrylate) (PMMA) nano-capsules by emulsion polymerization and its release behavior were investigated. The chemical characterizations of PMMA/haloxyfop-R-methyl nano-capsules were confirmed by FT-IR spectroscopy method, and the surface morphology was studied by field emission scanning electron microscopy and transmission electron microscopy. Also, the herbicide loading and encapsulation efficiency were analyzed for the herbicide-loaded nano-capsules. The release rate of PMMA/haloxyfop-R-methyl nano-capsules was determined by UV-visible spectroscopy. The thermal properties and thermal stability of nano-capsules were explored by the thermal gravimetric analysis method. The diameter of the nano-capsules was in the range of 100-300 nm. Increasing the amount of herbicide in nano-formulations significantly affected the surface of the nano-capsules and reduced their surface smoothness. Triton-X100 was identified as the best surfactant for the preparation of nano-capsules, and the sample containing the lowest herbicide content showed the best performance in terms of encapsulation and loading efficiency. This sample showed a steady-state release rate during the six days.

In the present study, the ability of duckweed (Lemna minor L.) in the decolorization of Acid Bordeaux B (ABB), as an aminoazo benzene dye, from polluted waters was evaluated. It was found that the rise of temperature and enhancement of the plant initial weight led to increasing the dye removal efficiency, but raising the initial dye concentration and pH reduced it. However, in the optimum conditions, the plant exhibited a considerable potential for the phytoremediation of ABB by 94%. The comparison of the experimental dye removal efficiency with its predicted amounts from ANN (R 2 = 0.99) showed that ANN supplied the appropriate predictive performance. Inhibition of the plant growth and reduction of the chlorophyll (Chl) a, b, and a+b content (around 26%, 32.4%, and 28.6%, respectively) after plant treatment with 40 mg/L of ABB confirmed its toxic effects on the plant in high concentrations. Antioxidant enzyme activities and contents of malondialdehyde, phenol, and flavonoids were also raised by the augmentation of the ABB concentration. As a result of the ABB biodegradation pathway, seven intermediate compounds were identified using GC-MS analysis.

Background: Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCL X ) remain a challenging problem. We examined the reasons for CCL X , clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCL X ., Methods and Results: We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCL X (n=866; 65%). Reasons for CCL X included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCL X (C statistic, 0.985). CCL X subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCL X ; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCL X was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009)., Conclusions: In this study, prehospital ECG without overreading or transmission lead to frequent CCL X . CCL X subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCL X patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCL X and influence clinical outcomes.

Background: The hydatidiform mole (HM) is a precancerous placenta considered as a gestational trophoblastic disease (GTD). It may convert to more invasive forms of gestational trophoblastic neoplasia (GTN), endangering women’s health by more severe complications. Most GTN cases originate from HM, which is associated with uterine bleeding, preeclampsia and thyroid problems. Its etiology has not been adequately explored, but some risk factors have been reported. The aim of the present study was to assess any relationships between molar pregnancy and factors including mothers’ and husbands’ occupations. Methods: In this case control study, seventy complete molar pregnancies (cases) were compared with 200 normal pregnancies (controls) in 5 educational hospitals affiliated to medical universities in Tehran, Iran. Data were analyzed using t-test, chi-square test, Fisher’s exact test and logistic regression modeling. Results: There was no significant relationship between the risk of molar pregnancy and age, education, blood RH, parity, duration of OCP use, intra-uterine device usage, smoking, consanguinity of woman and husband, ethnicity, history of infertility, history of moles in the family, and dwelling ownership. The two groups were statistically different regarding husbands’ jobs, history of abortion, use OCP, and ABO blood group. The odds ratio with a husband’s physical job having exposure to dust and soil was 18.2 (CI: 8.26-43.03, PV˂0.001). Logistic regression analysis only showed husband’s job and husband’s physical job exposure to dust and soil as predictors. Conclusion: Husband’s jobs and especially exposure to dust and soil could be a major risk factor for molar pregnancy. More studies on the epidemiology, occupational health, microbiology and genetics are warranted to shed more light on this abnormal pregnancy., (Creative Commons Attribution License)

Introduction: Extended stay in the emergency department (ED) is associated with worse outcomes in critically ill trauma patients. We conducted a human factors analysis to better understand impediments for patient flow when a surgical ICU (SICU bed is available in order to reduce ED LOS., Methods: This is a retrospective review of all trauma patients admitted to a protected SICU through the ED during 2011 and 2014. In 2010, a 24-hour protected SICU bed protocol was implemented to make a bed readily available. During 2013 human factors analysis helped to describe flow disruptions; related interventions were introduced to facilitate rapid transport from the ED to SICU. The interventions required the following prior to CT scanning: immediate ICU bed orders placed by the ED physician and ED to ICU personnel communication. Direct transport from the CT scanner to the ICU was mandated. Data including patient demographics, injury severity, ED LOS, ICU LOS, and hospital LOS was collected and compared between 2011 (PRE) and 2014 (POST)., Results: A total of 305 trauma patients admitted from the ED to the SICU were analyzed; 174 patients in 2011 (PRE) and 131 in 2014 (POST). Average age was 46 years and patients had a mean admission GCS and injury severity score (ISS) of 12.3 and 15.9, respectively. The cohorts were similar in age, mechanism of injury, initial vital signs, and injury severity. After implementing the human factors interventions, decreases were noted in the mean ED LOS (2.4 v. 3.0 hours, p=0.005) and ICU LOS (4.0 v. 4.8 days, p=0.023). No differences in hospital LOS or mortality were observed., Conclusions: While an open SICU bed protocol may facilitate rapid transport of trauma patients from the ED to the ICU, additional human factors interventions emphasizing improved communication and coordination can further reduce time spent in the ED., Level of Evidence: Level IV, Economic/Decision., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)