Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement

Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement. SHIGEKI TABATA, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Division of Cardiothoracic Surgery Thomas Jefferson University Hospital, Philadelphia, PA Introduction: Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for the patients with cardiogenic shock. We present a patient who developed severe complications while on ECMO. Case presentation: A 49-year-old female presented with severe heart failure and was placed on veno-arterial ECMO for bridge to decision. While on ECMO, the patient developed massive hemoptysis after Swan-Ganz catheter manipulation. After the endotracheal tube was clamped and the patient relied on full ECMO support for 36 hours, the hemoptysis resolved. The patient also developed liver failure with peak total bilirubin of 56 mg/dl. The molecular adsorbents recirculating system (MARS) device was performed from ECMO day 9 to ECMO day 14. Liver function improved and the value of total bilirubin decreased to 9.9 mg/dl on ECMO day 19. On ECMO day 20, the patient underwent a Heart Mate II LVAD placement and successful ECMO wean. During the course of surgical recovery, the patient had two episodes of sepsis and VAD pocket infection, which was finally controlled with antibiotic beads placement into the pocket. The patient was transferred to an acute rehabilitation facility on ECMO day 77. Discussion: Among the many possible hematologic complications, hemoptysis is often difficult to control. In our patient, the hemoptysis was not controllable by conventional treatment, thus the endotracheal tube was clamped to allow the entire airway to tamponade using the advantage of ECMO. Liver function is most important risk factors to determines patient survival. The MARS is a cell-free extracorporeal liver support device which eliminates albumin-bound substances, such as bilirubin. Using MARS, the patient recovered liver function to allow to perform LAD placement safely. While these mechanical circulatory support, control of sepsis isolating the source of infection was essential for patient survival

Successful management of severe liver failure on venoarterial extracorporeal membrane oxygenation using molecular adsorbent recirculating systeme.

A 49-year-old female with Adriamycin induced cardiomyopathy presented with decompensated biventricular congestive heart failure. Despite multiple Inotropes, the patient’s hemodynamics deteriorated and she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) placement as a bridge to decision. Pre-ECMO workup showed liver dysfunction with elevated total bilirubin of 5.9 mg/dl, normal liver enzymes and liver ultrasound image. Tentative diagnosis of “end-stage liver failure” was made without a biopsy. Shortly after initiation of ECMO, the patient developed massive hemoptysis which was successfully managed with continuation of ECMO and ventilator management. [i] The patient’s total bilirubin continued to increase to peak of 56 mg/dl on ECMO day #9 (Figure 1). Molecular adsorbent recirculating system (MARS) was initiated on ECMO day 9 thru 14. The bilirubin improved dramatically with MARS. Liver biopsy performed while on ECMO provided a definitive diagnosis of cholestasis without cirrhosis. The patient underwent Heart Mate II left ventricular assist device (LVAD) placement and ECMO removal on ECMO day 20. There was no further episode of liver failure, and the patient was eventually discharged from hospital. [i] Harrison M, Cowan S, Cavarocchi N, Hirose H. Massive hemoptysis on veno-arterial extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 2012 Mar 30. [Epub ahead of print]

X-ray elastic constant determination and residual stress estimation of spherical carbide in JIS SK3

After special surface treatments on specimens, residual stress behaviors of ferrite and cementite phases in two kind sizes of spheroidized JIS SK3 steels after tensile deformation were estimated by X-ray diffraction method. In the study, phase cementite X-ray elastic constant was obtained from composite X-ray elastic constants; compressive residual stresses were observed in ferrite and tensile residual stresses in cementite; the particle size of cementite has obvious affections on the residual stress behaviors of both cementite and ferrite; in order to well understand the interaction between cementite and matrix, the plastic strains of two phases and the misfit of plastic strain between them were analyzed based on Eshelby/Mori-Tanaka model. Copyright © 2006 by The International Society of Offshore and Polar Engineers

Sternal pain after rigid fixation: a pilot study of randomization rigid vs conventional wire closure.

Objective: Rigid sternal fixation may provide better sternal closure than conventional sternal wire closure. We performed a prospective randomized study to investigate if rigid closure reduces postoperative sternal pain. Methods: Patients undergoing CABG ± valve surgery between July 2011 and January 2012 were prospectively randomized into conventional wire closure (group C) or rigid fixation using sternal plates (group R). Pain scores were determined at 6 AM using a numeric rating scale (0 no pain, 5 moderate pain, 10 worst possible pain). Narcotic pain medication requirement from day 1 to 5 was collected and converted into intravenous morphine equivalent. Results: Among the total of 26 patients, 11 patients were in Group R (10 male and 1 female, age 67 ± 8.0) and 15 patients were in Group C (13 male and 2 female, age 66 ± 9.9). Preoperative risk factors and procedure were identical between the two groups. Pain scores were not significantly different between 2 groups. Narcotic requirement was smaller in group R (15.7 mg intravenous morphine equivalent in group R in day 1vs 18.4 mg intravenous morphine equivalent in day 1 in group C in day 1, 13.1 mg vs 12.5 mg in day 2, 9.4 mg vs 10.5 mg in day 3, 6.9 mg vs 7.7 mg in day 4, and 6.2 mg vs 6.9 mg in day 5) than group C. Total iv narcotic given over 5 days was 24 ± 41 mg in group R and 34 mg ± 54 mg in group C (p=0.60). Conclusion: Randomized data rom this ongoing study showed a trend of fewer narcotic requirement especially intravenous narcotics in group R than in group C. Implications: Rigid fixation may potentially improve immediate sternal pain after open heart surgery. Less narcotic requirement potentially facilitate early return to the daily activity

Correlation of Blood Platelet Count and Petechiae on the Visible Mucous Membrane in Grazing Cattle

Orientadora: Profª. Drª. Ruth BohunovskyCoorientadora: Drª. Carmen SchierDissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências Humanas, Programa de Pós-Graduação em Letras e Universidade de Leipzig. Defesa : Curitiba, 17/12/2019Inclui referências: p. 87-90Área de concentração: Estudos LinguísticosResumo: O presente trabalho tem como objetivo uma análise acerca da representação da mulher em letras de rap feministas e como essas poderiam ser didatizadas para o contexto brasileiro de ensino de Alemão como Língua Estrangeira (ALE). Entre as letras de rap escolhidas para a análise - "Die Gretchenfrage" da rapper austríaca Yasmo, "Die Freundin von" da rapper alemã Sookee, "Sand in die Augen" do rapper alemão Danger Dan e "Gelernt" da banda Käptn Peng & Die Tentakel von Delphi - há algumas cantadas a partir de uma perspectiva masculina. Após uma discussão teórica sobre as particularidades do gênero textual rap e dos questionamentos atuais sobre a inserção desse gênero em livros didáticos e em sala de aula, apresenta-se uma análise das quatro letras de rap que compõem o corpus. Essa análise leva em consideração discursos feministas da atualidade e baseia-se no método de análise discursiva de textos em língua alemã proposto por Claus Altmayer (2007), assim como no conceito de Letramento Crítico. Baseado na análise realizada, o trabalho mostra que as mulheres são retratadas em situação de vulnerabilidade e ao mesmo tempo também de empoderamento. O presente trabalho almeja responder às seguintes perguntas de pesquisa: Que relevância didática possuem letras de raps feministas para o ensino de ALE em contexto brasileiro? Quais padrões de interpretação da imagem das mulheres podem ser reconstruídos em letras de rap feministas? De que forma as letras de rap feministas podem ser usadas para tematizar a igualdade de gênero em sala de aula de ALE? Por fim, propõe-se alguns exercícios para a inserção das letras de rap analisadas no presente trabalho no ensino de ALE em contexto brasileiro. Palavras-chave: Alemão como Língua Estrangeira. Estudos culturais. Padrão de interpretação cultural. Estudos de gênero. Imagem da mulher. Hip-hop. Rap.Abstract: The present work aims to analyze the representation of women in feminist rap lyrics and how these could be taught in the Brazilian context of teaching German as a Foreign Language (GFL). Among the rap lyrics chosen for analysis - "Die Gretchenfrage" from Austrian Rapper Yasmo, "Die Freundin von" from German Rapper Sookee, "Sand in die Augen" from German Rapper Danger Dan and "Gelernt" from the diverse band Käptn Peng & Die Tentakel von Delphi - there are some sung from a male perspective. After a theoretical discussion about the particularities of the rap as a textual genre and the current questions about the insertion of this genre in textbooks and in the classroom, an analysis of the four rap lyrics that make up the corpus is presented. This analysis considers feminist discourses today and is based on the method of discursive analysis of texts in German language proposed by Claus Altmayer (2007), as well as on the concept of Critical Literacy. Based on the analysis performed, the present work shows that women are portrayed in a situation of vulnerability and empowerment at the same time. This work aims to answer the following research questions: What didactic relevance do feminist rap lyrics have for teaching GFL in the Brazilian context? What patterns of women's image interpretation can be reconstructed in feminist rap lyrics? How can feminist rap lyrics be used to address gender equality in the GFL classroom? Finally, some exercises for the insertion of rap lyrics analyzed in the present work in the teaching of GFL in a Brazilian context are proposed. Keywords: German as a foreign language. Cultural studies. Cultural interpretation pattern. Gender studies. Perception of women. Hip-hop. RapZUSAMMENFASSUNG: Im Rahmen der vorliegenden Arbeit soll untersucht werden, wie Frauen in feministischen Raptexten vertreten sind und wie diese Texte für den brasilianischen Kontext des Unterrichts von Deutsch als Fremdsprache (DaF) verwendet werden können. Unter den für die Analyse ausgewählten Raptexten "Die Gretchenfrage" der österreichischen Rapperin Yasmo, "Die Freundin von" der deutschen Rapperin Sookee, "Sand in die Augen" des deutschen Rapper Danger Dan und "Gelernt" der Band Käptn Peng & Die Tentakel von Delphi gibt es einige, die aus einer männlichen Sicht gesungen sind. Nach einer theoretischen Diskussion über die Besonderheiten des Rap als Textsorte und die aktuellen Fragen zur Einfügung dieser Textsorte in Lehrwerken und im Klassenzimmer folgt eine Analyse der vier Raptexte, aus denen das Korpus dieser Masterarbeit besteht. Diese Analyse berücksichtigt die heutigen feministischen Debatten und basiert auf dem von Claus Altmayer (2007) vorgeschlagenen Verfahren der diskursiven Analyse von Texten in deutscher Sprache sowie auf dem Konzept des "Letramento Crítico". Basierend auf der durchgeführten Analyse zeigt die Arbeit, dass Frauen oft als verletztlich und gleichzeitig machtvoll dargestellt werden. Die vorliegende Arbeit zielt darauf ab, die folgenden Forschungsfragen zu beantworten: Welchen didaktischen Mehrwert haben feministische deutschsprachige Raptexte für den DaFUnterricht im brasilianischen Raum? Welche Deutungsmuster zum Frauenbild lassen sich in feministischen deutschsprachigen Raptexten rekonstruieren? Inwiefern können feministische Raptexte dazu beitragen, die Debatte über Geschlechtergleichstellung im DaF-Unterricht zu thematisieren? Anschließend werden einige Möglichkeiten zum Einsatz von Raptexten vorgeschlagen, die in der vorliegenden Arbeit zum DaF-Unterricht im brasilianischen Kontext analysiert wurden. Stichwörter: Deutsch als Fremdsprache. Kulturstudien. Kulturelles Deutungsmuster. Genderforschung. Frauenbild. Hip-Hop. Rap

心臓血管外科領域におけるゼラチンシートの止血効果、癒着防止効果の検討

BACKGROUND:The bi1ayer gelatin sealing sheet was developed as a safe, effective, easy-to-handle and low-cost hemostatic agent. OBJECTIVE:To examine the feasibility of gelatin sealing sheets using a canine aterial hemorrhage mode1. METHODS:In vivo degradation of gelatin sealing sheets was examined by implanting subcutaneously in rats. For the hemostatic and anti-adhesion efficacy investigations, femoral arteries of dogs were pricked with syringe needle to make as mall hole, and a gelatin(i.e. experimental group) or fibrin glue sealing sheet (i.e. control group) was applied on the hole to stop bleeding (n=8). After discontinuation of the bleeding, the skin incisions were closed and re-examined 4 weeks postoperatively. RESULTS:From the degradation study, 4h thermally treated gelatin sheet which degraded within 3 weeks in vivo was chosen for the further hemostatic study. In all cases of gelatin and fibrin glue sealing sheets, bleeding from the needle hole on canine femoral arteries was effectively stopped. Postoperative adhesions and inflammation at the site in the experimental group were significantly less than those in the control group (P<0.01 for adhesion scores). CONCLUSIONS:The gelatin sealing sheet was found to be as effective as the fibrin glue sealing sheet as a surgical hemostatic agent, and more effective in preventing postoperative adhesions.博士（医学）・甲第632号・平成27年3月16日Copyright ©2015 IOS Pres

Ixazomib が奏効している心アミロイドーシス合併多発性骨髄腫

　Ixazomib は，経口のプロテアソーム阻害薬であり，特に非注射薬の組み合わせが選択される多発性骨髄腫患者の再発難治例にとって有用な治療薬である．今回，我々はIxazomib が奏効している心アミロイドーシス合併多発性骨髄腫を経験したため報告する．症例は50歳代女性で，20XX 年10月心不全精査のため当院循環器内科入院となり，精査にて洞不全症候群（type3），心アミロイドーシスと診断された．洞不全症候群（type3）に対して心臓ペースメーカー移植術が施行され，血液検査にてM 蛋白を認めたため当科紹介となった．骨髄検査では形質細胞の増加を認め，AL アミロイドーシス（心臓，消化管）合併多発性骨髄腫（IgG‐λ with BJP）と診断した．20XX 年12月から治療を開始．VRD 療法を１コース施行中に，ペースメーカー波形ではない不整脈が多発し，うっ血性心不全の併発や，心源性脳梗塞による左完全片麻痺を発症した．VRD 療法は継続困難と判断し，elotuzumab 併用RD 療法に変更し治療を施行した．２コースでPD となったため，脳梗塞の発症によるADL の低下があることから，施設入所をふまえて外来通院頻度が少ない治療法として，Ixazomib 併用RD 療法を選択し治療を開始した．治療効果および忍容性は良好で，M 蛋白の順調な低下を認め，心不全の増悪なく経過している．心アミロイドーシス合併多発性骨髄腫は，治療に伴い致死性不整脈や心不全を併発することが多い．プロテアソーム阻害剤であるbortezomib 投与にて，不整脈や心不全の併発症状が出現していたが，経口プロテアソーム阻害剤であるixazomib の投与では，不整脈や心不全を併発させることなく，治療が継続し得た．　Ixazomib is an oral proteasome inhibitor that is useful for the treatment of recurrent refractory cases, particularly when a non-injection combination drug therapy is chosen for the patient. Here, we report a case of cardiac amyloidosis treated with ixazomib in a patient with multiple myeloma. The patient was a 50-year-old woman hospitalized in the cardiovascular medicine department of our hospital in October 20XX for close examination of cardiac failure. On the basis of the test findings, sick sinus syndrome (type 3) and cardiac amyloidosis were diagnosed. A heart pacemaker transplantation was performed for the sick sinus syndrome (type 3), and additional tests indicated M-protein expression; thus, the patient was referred to our department. A bone marrow test revealed increased plasma cells, which led to the diagnosis of immunoglobulin light chain amyloidosis (heart and digestive tract) secondary to multiple myeloma (IgG‐λ with BJP). Treatment was initiated in December 20XX. During the first course of VRD treatment, multiple non-pacemaker waveform arrhythmias and congestive heart failure occurred. Left total hemiplegia due to cardioembolic stroke occurred. We judged it difficult to continue the VRD treatment, so we switched the treatment to concomitant elotuzumab and RD therapy. After 2 courses, the patient became PD. With a decrease in ADL due to the onset of cerebral infarction and considering the possible need for institutionalization, ixazomib combined with RD therapy was initiated as treatment to reduce the frequency of outpatient visits. The treatment efficacy and tolerance were good, the M-protein expression level decreased gradually. Her progress was uneventful with no worsening of cardiac failure. Cardiac amyloidosis secondary to multiple myeloma is commonly associated with treatment-related lifethreatening arrhythmias and cardiac failure. Treatment with the proteasome inhibitor bortezomib is associated with the onset of arrhythmias and cardiac failure. However, treatment with the oral proteasome inhibitor ixazomib can be continued without onset of arrhythmia and cardiac failure

Open-source Software for Developing Anthropomorphic Spoken Dialog Agents

An architecture for highly-interactive human-like spoken-dialog agent is discussed in this paper. In order to easily integrate the modules of different characteristics including speech recognizer, speech synthesizer, facial-image synthesizer and dialog controller, each module is modeled as a virtual machine that has a simple common interface and is connected to each other through a broker (communication manager). The agent system under development is supported by the IPA and it will be publicly available as a software toolkit this year