Challenges in the management of a child with yolk sac tumour of the nasal cavity presenting with epistaxis and progressive respiratory distress

Yolk Sac tumour (YST) of the nasal cavity is extremely rare with only less than five previously reported cases in the English literature. Due to its rarity, the diagnosis is not one that is considered at initial presentation until tissue biopsies are sent for histopathological examination. Serum α-fetoprotein levels aid in diagnosis and in monitoring progression of the tumour. Being a very uncommon tumour of germ cell origin presenting as localized disease in the nasal cavity, prognosis and survival rates are difficult to determine. We are reporting a rare yolk sac tumour case in an infant and the challenges encountered in its management

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC)

Objective: Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs. Design: Prospective cohort study. Setting: This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries. Participants: The study included patients admitted to ICUs across 24 years. Results: In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16-1.28; P <.0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07-1.08; P <.0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23-1.31; P <.0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57-15.48; P <.0001)Revisión por pare

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Polymer electrolyte blends of mono-carboxylic acid-modified epoxidized natural rubber and poly(ethyleneoxide)

Natural rubber with 50% of isoprene units epoxidized (ENR50) was treated with excess of mono-carboxylic acids to completely ring open the epoxide groups. The reaction was carried out by heating ENR50 dissolved in toluene with each of acetic and benzoic acid separately at 105 °C. The ring-opening reaction has produced hydroxyl-OH and ester-O-COR groups, leading to an increase in Tg. The products were characterized by Fourier transform infrared spectroscopy, nuclear magnetic resonance spectroscopy, thermal gravimetric analysis, and differential scanning calorimetry. By the solution casting method, each of the modified ENR50s was blended with poly(ethylene oxide) (PEO) in various ratios in toluene, and 2% lithium perchlorate (LiCIO4) was added as the dopant. Results show that the modified ENR and PEO formed incompatible blends. The PEO spherulite growth rate in the blends increased with PEO content. The electrical conductivity was found to increase with the weight fraction of PEO in the blend. At the ratio of 25/75, the acetic acid-modified ENR50/ PEO blend exhibits a conductivity value of 3.1 3 10 × 8 S cm × 1. The benzoic acid-modified ENR50/PEO achieved conductivity of 5.8310 × 7 S cm × 1 at the ratio of 30/70. These blends form conducting polymer electrolytes with potential application in batteries

Bickerstaff’s brainstem encephalitis with overlapping Guillain-Barré syndrome: Usefulness of sequential nerve conduction studies

Bickerstaff's brainstem encephalitis (BBE) is a rare immune-mediated disorder characterized by ophthalmoplegia, ataxia and disturbance of consciousness, which may overlap with Guillain-Barré syndrome (GBS) if there is additional limb weakness. We report a 7-month-old boy presented with ophthalmoplegia followed by a rapidly ascending paralysis of all four limbs and disturbance of consciousness. The initial impression was BBE with overlapping GBS. This was supported by sequential nerve conduction study (NCS) findings compatible with an acute inflammatory demyelinating polyneuropathy (AIDP). He received intravenous pulse methylprednisolone, intravenous immunoglobulin and plasmapharesis with complete clinical recovery after 6 weeks of illness and improved NCS findings from week 16. This is the first case of paediatric BBE with overlapping GBS with an AIDP subtype of GBS. It expands the clinical spectrum of this condition in children. Our case highlights the importance of sequential NCS in paediatric BBE with overlapping GBS for accurate electrophysiological diagnosis and prognosis particularly if the first NCS findings are not informative

A two-stage optimization method for Vehicle to Grid coordination considering building and Electric Vehicle user expectations

The formulation of the Vehicle to Grid (V2G) scheme should ideally consider both Electric Vehicle (EV) and building owners’ viewpoints. From the building owner’s viewpoint, the EVs should be present in the building and participate consistently to deliver the required power. From the EV owners’ viewpoint, participating in the V2G scheme should provide economic incentives while not compromising their travel needs. However, those proposed V2G algorithms up to this point in time had not considered any corrections required in response to unplanned changes in the EV travel plan. In this paper, a Two-stage optimization technique is proposed to determine the charging and discharging schedule for EVs participating in a vehicle-to-grid (V2G) programme at an office building. The EV owners’ travel convenience is focused with more attention in the proposed model by giving them two V2G options. Firstly, day-ahead optimization (DAO) is applied, based on the expected building load profile and EV behaviour, the optimal charging or discharging control of the EVs is obtained in order to save electricity bills by minimizing the maximum demand of the building. Subsequently, a real-time optimization (RTO) is performed to adjust the V2G operation based on actual vehicle behaviours which usually deviate from their estimations. Simulations are conducted and the preliminary results show that the proposed technique is able to adjust the EV charging or discharging in real-time with the aid of the day-ahead stage. The proposed model manages to capture a new ideal optimal maximum demand point and maintain the EV SOC profile as planned from the DAO stage in real-time when prediction deviation occurs. In addition, a comprehensive cost–benefit analysis in utilizing V2G in peak load reduction is also performed to gain insight into the potential savings and discharging rewards attributable to the building and EV owner respectively

Physiochemical and in vitro cytotoxicity properties of biocompatible palm fatty acid-based polyesters

With the sharp rise in global interest in sustainability and environmental concerns, there is a growing demand in replacing petroleum-derived raw materials with renewable plant-based raw materials in the production of polymers. In this study, two palm fatty acid polyesters were synthesized from palmitic and stearic acids. Their chemical structures were identified by FTIR and 1H-NMR analysis. Both polyesters showed a moderately high conversion rate from the acid value determination. DSC analysis showed that the palmitic acid polyester (PAP) had a lower Tg than that of stearic acid polyester (SAP), where PAP had a Tg of 1.8 °C, while SAP had a Tg of 31.9 °C. TGA demonstrated that thermal decomposition of both polyesters took place via two-stage processes, which occurred above 200 °C. GPC analysis showed that PAP (1031 g/mol) had a higher Mn value than SAP (972 g/mol). MTT assays were performed to determine the cytotoxicity of these polyesters against human keratinocytes (HaCaT), mouse fibroblasts (3T3), mouse hepatocytes (H2.35), and canine kidney cells (MDCK) in both dose- and time-dependent manners, with SDS serving as the experimental benchmark. Comparative cytotoxicity test showed that both PAP and SAP were biocompatibility and non-cytotoxic with the cell viability well above 80%, except SAP demonstrated a moderately low cytotoxicity on fibroblasts with cell viability remaining as 50.4% following 72 h exposure at 100 μg/mL of concentration. These findings suggest that the natural-sourced palm fatty acid polyesters have high potential to be used in pharmaceutical and nutraceutical applications