Anterior pericardial tracheoplasty for long-segment tracheal stenosis: Long-term outcomes

ObjectiveAlthough several techniques have been described for the treatment of tracheal stenosis, including slide tracheoplasty, tracheal autograft, rib grafting, and use of a pericardial patch, the optimal repair remains controversial because of a lack of long-term follow-up data. The purpose of this study is to examine the long-term results of anterior pericardial tracheoplasty.MethodsTo assess the long-term outcomes of patients who underwent repair of tracheal stenosis with anterior pericardial tracheoplasty, we reviewed the case histories of 26 consecutive patients (1984–present). All but 5 had long-segment tracheal stenosis with more than 10 complete tracheal rings. Twenty-one had significant cardiac disease, and 10 had their cardiac lesions repaired at the time of their tracheoplasty. The median age was 6 months (range, 2 days–25 years). All patients underwent anterior pericardial tracheoplasty through a median sternotomy during normothermic cardiopulmonary bypass. We have previously described our tracheoplasty technique. An average of 14 tracheal rings (range, 5–22) was divided anteriorly, and a patch of fresh autologous pericardium was used to enlarge the trachea to 1.5 times the predicted diameter for age and weight.ResultsThere were 3 hospital deaths (at 1, 2, and 7 months, respectively) and 2 late deaths (at 2 and 13 years postoperatively, respectively). No deaths were related to airway obstruction. Two survivors required tracheostomy postoperatively, one after formation of granulation tissue and stenosis and the other after failure to wean from mechanical ventilation. All survivors remain asymptomatic, with minimal to no evidence of airway obstruction. Median follow-up is 11 years (range, 3 months–22 years).ConclusionAnterior pericardial tracheoplasty for tracheal stenosis provides excellent results in the majority of patients at long-term follow-up

Improving Outcomes for Infants with Single Ventricle Physiology through Standardized Feeding during the Interstage

Congenital heart disease is identified as the most common birth defect with single ventricle physiology carrying the highest mortality. Staged surgical palliation is required for treatment, with mortality historically as high as 22% in the four- to six-month period from the first- to second-stage surgical palliation, known as the interstage. A standardized postoperative feeding approach was implemented through an evidence-based protocol, parent engagement, and interprofessional team rounds. Five infants with single ventricle physiology preprotocol were compared with five infants who received the standardized feeding approach. Mann- Whitney tests were conducted to evaluate the hypotheses that infants in the intervention condition would consume more calories and have a positive change inweight-to-age -score (WAZ) and shorter length of stay (LOS) following the first and second surgeries compared to infants in the control condition. After the protocol, the change inWAZ during the interstage increased by virtually one standard deviation from 0.05 to 0.91.Median LOS dropped 32% after the first surgery and 43% after the second surgery. Since firstand second-stage palliative surgeries occur within the same year of life, this represents savings of $500,000 to$800,000 per year in a 10-infant model.The standardized feeding approach improved growth in single ventricle infants while concurrently lowering hospital costs

A randomized, double-blind, placebo-controlled trial of oral montelukast in acute asthma exacerbation.

Background: Leukotriene receptor antagonists (LTRAs) are well established in the management of outpatient asthma. However, there is very little information as to their role in acute asthma exacerbations. We hypothesized that LTRAs may accelerate lung function recovery when given in an acute exacerbation. Methods: A randomized, double blind, placebo-controlled trial was conducted at the Aga Khan University Hospital to assess the efficacy of oral montelukast on patients of 16 years of age and above who were hospitalized with acute asthma exacerbation. The patients were given either montelukast or placebo along with standard therapy throughout the hospital stay for acute asthma. Improvements in lung function and duration of hospital stay were monitored. Results: 100 patients were randomized; their mean age was 52 years (SD +/− 18.50). The majority were females (79%) and non-smokers (89%). The mean hospital stay was 3.70 ± 1.93 days with 80% of patients discharged in 3 days. There was no significant difference in clinical symptoms, PEF over the course of hospital stay (p = 0.20 at day 2 and p = 0.47 at day 3) and discharge (p = 0.15), FEV1 at discharge (p = 0.29) or length of hospital stay (p = 0.90) between the two groups. No serious adverse effects were noted during the course of the study. Conclusion: Our study suggests that there is no benefit of addition of oral montelukast over conventional treatment in the management of acute asthma attack

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

New Estimates for Csiszár Divergence and Zipf–Mandelbrot Entropy via Jensen–Mercer’s Inequality

Jensen’s inequality is one of the fundamental inequalities which has several applications in almost every field of science. In 2003, Mercer gave a variant of Jensen’s inequality which is known as Jensen–Mercer’s inequality. The purpose of this article is to propose new bounds for Csiszár and related divergences by means of Jensen–Mercer’s inequality. Also, we investigate several new bounds for Zipf–Mandelbrot entropy. The idea of this article may further stimulate research on information theory with the help of Jensen–Mercer’s inequality

Improving Outcomes for Infants with Single Ventricle Physiology through Standardized Feeding during the Interstage

Congenital heart disease is identified as the most common birth defect with single ventricle physiology carrying the highest mortality. Staged surgical palliation is required for treatment, with mortality historically as high as 22% in the four- to six-month period from the first- to second-stage surgical palliation, known as the interstage. A standardized postoperative feeding approach was implemented through an evidence-based protocol, parent engagement, and interprofessional team rounds. Five infants with single ventricle physiology preprotocol were compared with five infants who received the standardized feeding approach. Mann- Whitney tests were conducted to evaluate the hypotheses that infants in the intervention condition would consume more calories and have a positive change inweight-to-age -score (WAZ) and shorter length of stay (LOS) following the first and second surgeries compared to infants in the control condition. After the protocol, the change inWAZ during the interstage increased by virtually one standard deviation from 0.05 to 0.91.Median LOS dropped 32% after the first surgery and 43% after the second surgery. Since firstand second-stage palliative surgeries occur within the same year of life, this represents savings of $500,000 to$800,000 per year in a 10-infant model.The standardized feeding approach improved growth in single ventricle infants while concurrently lowering hospital costs

Effects of machining parameters, ultrasonic vibrations and cooling conditions on cutting forces and tool wear in meso scale ultrasonic vibrations assisted end-milling (UVAEM) of Ti–6Al–4V under dry, flooded, MQL and cryogenic environments – A statistical analysis

Ti–6Al–4V, an alloy of titanium has recently gained focus of research to overcome its machinability challenges. Miniaturization in devices has forced a shift towards micro and meso-scale machining. Sustainability and green manufacturing concepts have shifted focus in machining from cutting fluids towards modern cooling approaches to minimize or eliminate them. In present research, cutting forces & tool wear in Ultrasonic Vibrations Assisted End Milling of Ti–6Al–4V at meso-scale under Dry, Flooded, Minimum Quantity Lubrication & Cryogenic cooling have been analyzed to develop optimum machining parameters. Taguchi L16 orthogonal array was designed to perform experiments keeping Cutting Speed, Feed per tooth, Depth of cut, Ultrasonic vibrations amplitude & Cooling environment as inputs. ANOVA was used to analyze contribution ratios by these parameters towards cutting forces & tool wear. Results indicated that machining conditions, cooling environment and Ultrasonic Vibrations influence cutting forces & tool wear. Depth of cut had the highest influence with 63.41% contribution towards cutting forces while cutting speed remained the highest influencing factor with 39.86% contribution towards tool wear. Cutting forces were reduced by 33.49%, 16.93% and 4.91% while tool wear was reduced by 26.43%, 9.48% and 5.17% under Minimum Quantity Lubrication environment compared to dry, flooded and cryogenic cooling respectively. Cutting forces and tool wear under ultrasonic vibrations were reduced by 24.52% and 13.16% respectively as compared to Conventional Machining (CM). For optimum results, Minimum Quantity Lubrication with low Cutting Speed, Depth of cut, Feed per tooth and high amplitude of ultrasonic vibrations is recommended to machine Ti–6Al–4V