Utility of an alpha-1 adrenergic agonist in the management of chylothorax: a case series and management algorithm

Chylothorax is the accumulation of lymphatic fluid (chyle) within the pleural space. There are multiple causes, including traumatic and non-traumatic mechanisms. Trauma can cause disruption of the thoracic duct either by direct damage or indirect crushing or avulsion mechanisms. Non-traumatic causes include infections, inflammatory processes, malignancies, and iatrogenic injury (during surgery or central venous access). The traditional management of traumatic chylothorax has been either a conservative approach, including complete nil per os, or a low-fat diet with medium-chain triglyceride supplementation with the administration of somatostatin or its analog, octreotide, versus a surgical approach consisting of thoracic duct ligation. Recently a less invasive approach via thoracic duct embolization has gained popularity. There have been a few reports of the successful use of an alpha 1-adrenergic agonist (midodrine) as an adjunct in the conservative approach. We describe the utility of midodrine in three cases of chylothorax and propose a management algorithm

Optimization of Nozzle Design for Weight Reduction using Variable Wall Thickness

In various fields, including rockets, turbines, and engines, the critical role played by nozzles in achieving optimal performance is underscored. Within the domain of rocketry, particular attention is given to the weight of the nozzle, where even the slightest modifications in weight can lead to a profound impact on rocket performance. In this research, an endeavor is made to comprehensively investigate the intricate interplay of nozzle pressure ratio, nozzle thickness, and Mach number, to unveil the effects of these parameters on nozzle deformation, the development of equivalent stress, and the pivotal factor of safety. Material optimization strategies for a wide array of flow and geometrical parameters are also explored within the framework of this study. With each parameter considered at four levels, an exploration is conducted across Mach numbers of 1.5, 2.0, 2.5, and 3.0, alongside Nozzle Pressure Ratios of 2, 4, 6, and 8. The meticulous analysis of nozzle thicknesses at levels of 1 mm, 2 mm, 3 mm, and 4 mm is carried out. The computational fluid dynamics (CFD) analysis is systematically executed across all cases, with resultant pressure profiles on the internal surfaces of the nozzle serving as essential boundary conditions for static structural analysis. The presentation of findings entails a comprehensive discussion of the factor of safety values for all parameter combinations. Significantly, it is observed from our results that a direct correlation exists between nozzle thickness and factor of safety, with an increase in nozzle thickness corresponding to an enhancement in factor of safety

Intensive rehabilitation after pelvic and hip fractures: a comparative retrospective study

PurposePelvic fracture (PF) is common, especially among older patients, and its prevalence increases over time. In contrast to hip fracture (HF), the literature on rehabilitation after PF is scant, mandating a study of the outcomes of rehabilitation in patients with PF. The present study compared patients who underwent intensive rehabilitation following HF or PF.MethodsA retrospective study of patients 65 years of age and older who underwent intensive rehabilitation in the Geriatrics Department. Data were collected on patients with PF, while data on patients with HF were taken from an earlier study. All patients in both groups suffered from low-energy trauma. Rehabilitation outcomes were measured using the Montebello Rehabilitation Factor Score-revised (MRSF-R).Results144 PF patients were compared with 138 HF patients. The mean age of the patients in the HF group was 82.5 ± 7.1 compared to 81.5 ± 6.9 in the PF group (p = 0.230). Females comprised 77.5% of the patients in the HF group and 90.3% in the PF group (p = 0.04). All patients in the HF group underwent surgical repair of their fracture, while all patients in the PF group had non-surgical treatment. More patients in the HF sample had a nursing caregiver prior to the fracture (92.0% vs. 60.4%, p < 0.001), had a higher Charlson Co-morbidity Index total score (2.1 ± 1.9 vs. 1.6 ± 1.7, p = 0.13), developed more delirium (21.7% vs. 8.3%, p = 0.16), more infections (29.0% vs. 11.1%, p < 0.002), and more cardiovascular complications (23.9% vs. 5.6%, p < 0.001) during hospitalization. They had longer hospital stays (20.9 ± 7.5 vs. 18.2 ± 7.7 days, p = 0.0007), and had a higher mortality rate (13.8% vs. 6.3%, p = 0.037) over the first year following the fracture than the PF group. A similar rate of patients in both groups (64.5% vs. 60.4%, p = 0.483) had successful intensive rehabilitation. In the PF group only cognitive state was an independent predictor of successful rehabilitation, with each additional point in the Mini Mental State Examination (MMSE) increasing the patient’s chance of reaching an MRFS-R score ≥ 50 by 20.5%.ConclusionDespite slightly different characteristics in the two groups, the results of intensive rehabilitation were similar. Cognitive state was the only independent factor that affected achievement of a better rehabilitation outcome. With the increasing rate of PF, more studies should focus on rehabilitation in this patient population

Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center

Background: Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients. Methods: A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF). Results: A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062–16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157–1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance. Conclusion: The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies. Trial registration: ClinicalTrials.gov Identifier: NCT03846973

Early predictors of intensive care unit admission among COVID-19 patients in Qatar

BackgroundCOVID-19 is associated with significant morbidity and mortality. This study aimed to explore the early predictors of intensive care unit (ICU) admission among patients with COVID-19.MethodsThis was a case–control study of adult patients with confirmed COVID-19. Cases were defined as patients admitted to ICU during the period February 29–May 29, 2020. For each case enrolled, one control was matched by age and gender.ResultsA total of 1,560 patients with confirmed COVID-19 were included. Each group included 780 patients with a predominant male gender (89.7%) and a median age of 49 years (interquartile range = 18). Predictors independently associated with ICU admission were cardiovascular disease (adjusted odds ratio (aOR) = 1.64, 95% confidence interval (CI): 1.16–2.32, p = 0.005), diabetes (aOR = 1.52, 95% CI: 1.08–2.13, p = 0.016), obesity (aOR = 1.46, 95% CI: 1.03–2.08, p = 0.034), lymphopenia (aOR = 2.69, 95% CI: 1.80–4.02, p < 0.001), high AST (aOR = 2.59, 95% CI: 1.53–4.36, p < 0.001), high ferritin (aOR = 1.96, 95% CI: 1.40–2.74, p < 0.001), high CRP (aOR = 4.09, 95% CI: 2.81–5.96, p < 0.001), and dyspnea (aOR = 2.50, 95% CI: 1.77–3.54, p < 0.001).ConclusionHaving cardiovascular disease, diabetes, obesity, lymphopenia, dyspnea, and increased AST, ferritin, and CRP were independent predictors for ICU admission in patients with COVID-19

Gastroparesis and functional dyspepsia: excerpts from the AGA/ANMS meeting

Despite the relatively high prevelance of gastroparesis and functional dyspepsia, the aetiology and pathophysiology of these disorders remain incompletely understood. Similarly, the diagnostic and treatment options for these two disorders are relatively limited despite recent advances in our understanding of both disorders.This manuscript reviews the advances in the understanding of the epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and functional dyspepsia as discussed at a recent conference sponsored by the American Gastroenterological Association (AGA) and the American Neurogastroenterology and Motility Society (ANMS). Particular focus is placed on discussing unmet needs and areas for future research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78690/1/j.1365-2982.2009.01434.x.pd

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.

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2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.

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withdrawn 2017 hrs ehra ecas aphrs solaece expert consensus statement on catheter and surgical ablation of atrial fibrillation

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Alpha - Skew Pi - Armendariz Rings

In this article we introduce a new concept called Alpha-skew Pi-Armendariz rings (Alpha - S Pi - AR)as a generalization of the notion of Alpha-skew Armendariz rings.Another important goal behind studying this class of rings is to employ it in order to design a modern algorithm of an identification scheme according to the evolution of using modern algebra in the applications of the field of cryptography.We investigate general properties of this concept and give examples for illustration. Furthermore, this paperstudy the relationship between this concept and some previous notions related to Alpha-skew Armendariz rings. It clearly presents that every weak Alpha-skew Armendariz ring is Alpha-skew Pi-Armendariz (Alpha-S Pi-AR). Also, thisarticle showsthat the concepts of Alpha-skew Armendariz rings and Alpha-skew Pi- Armendariz rings are equivalent in case R is 2-primal and semiprime ring.Moreover, this paper proves for a semicommutative Alpha-compatible ringR that if R[x;Alpha] is nil-Armendariz, thenR is an Alpha-S Pi-AR. In addition, if R is an Alpha - S Pi -AR, 2-primal and semiprime ring, then N(R[x;Alpha])=N(R)[x;Alpha]. Finally, we look forwardthat Alpha-skew Pi-Armendariz rings (Alpha-S Pi-AR)be more effect (due to their properties) in the field of cryptography than Pi-Armendariz rings, weak Armendariz rings and others.For these properties and characterizations of the introduced concept Alpha-S Pi-AR, we aspire to design a novel algorithm of an identification scheme