Membrane-based therapeutic plasma exchange: Proposed techniques for preventing filter failure.

BACKGROUND AND OBJECTIVES: Therapeutic plasma exchange (TPE) is commonly performed using membrane-based TPE (mTPE) and is prone to filter failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We report on 46 patients, with a total of 321 mTPE treatments using the NxStage machine. This was a retrospective study with an aim to evaluate the effect of heparin, pre-filter saline dilution and the impact of total plasma volume exchanged (< 3 L vs. ≥3 L) on the rate of filter failure. Primary outcome was the overall rate of filter failure. Secondary outcomes included factors that may have indirectly influenced the rate of filter failure, including hematocrit, platelet count, replacement fluid (Fresh Frozen Plasma vs. albumin), and access type. RESULTS: We found that treatments that received both pre-filter heparin and saline had a statistically significant decrease in filter failure rate as compared to those that received neither (28.6% vs. 5.3%, P = .001), and compared to the treatments that received pre-filter heparin alone (14.2% vs. 5.3%, P = .015). In treatments that received both pre-filter heparin and saline predilution, we noted a significantly higher filter failure rate when the plasma volume exchanged was ≥3 L as compared to those that had <3 L exchanged (12.2% vs. 0.9%, P = .001). CONCLUSIONS: Rate of filter failure in mTPE can be reduced by implementing several therapeutic interventions including pre-filter heparin and pre-filter saline solution. These interventions were not associated with any clinically significant adverse events. Despite the above-mentioned interventions, large plasma volume exchanges of ≥3 L can negatively impact filter life.

Membrane-based therapeutic plasma exchange: Hemodynamics and operational characteristics leading to procedure failure.

BACKGROUND AND OBJECTIVES: Therapeutic plasma exchange (TPE) is a blood purification treatment capable of removing large molecular weight substances from plasma. It is commonly used for the removal of circulating pathogenic immunoglobulins presumed to be the cause of many autoimmune diseases. TPE can be performed with a membrane-based system (mTPE) or a centrifugal-based system (cTPE). When plasma separation is performed with a membrane, filter clotting can lead to longer treatment time, higher cost and can negatively impact patient satisfaction. In this study, we examine the operational characteristics that might influence filter life. DESIGN, SETTING, PARTICIPANTS, & MEASURES: We report on 24 patients, with a total of 135 mTPE treatments in a single tertiary care academic center using the NxStage machine. The study focuses on treatment specific parameters that may lead to procedure failure. The main parameters of interest were transmembrane pressure (TMP) and the filtration fraction as displayed on the machine (FFd) compared to the calculated filtration fraction (FFc). Primary outcome was to measure whether TMP, FFc, and FFd influenced filter survival. Secondary outcomes included factors that might have indirectly resulted in filter failure, including hematocrit (Hct), platelet count, heparin use, and intra-treatment calcium administration. RESULTS: In this study, we demonstrated that machine displayed filtration fractions (FFd) were lower than FFc and this difference was significantly larger in TPE sessions that experienced a clotting event (7.58 vs 6.22, P = .031). TPE sessions that clotted had a higher mean TMP (57.48 mmHg vs 44.43 mmHg, P = .001) and clotting events tended to have a lower mean blood flow rate (175.83 mL/min vs 189.55 mL/min, P = .002). In TPE sessions that received prefilter calcium administration, a higher mean dose of calcium gluconate was found in the sessions that experienced clotting (3.27 g vs 2.70 g, P = .013). Patients who experienced at least one clotting event were noted to be heavier than those patients without any clotting events (91.52 kg vs 72.15 kg, P = .040). Prefilter heparin administration was not associated with a lower incidence of filter clotting. We did not find a statistically significant difference in clotting events based upon type of intravenous access, pretreatment hematocrit, or pretreatment platelet counts. CONCLUSION: Among patients undergoing mTPE, machine FFd on the NxStage system are consistently lower than FFc. Treatments where there was a greater difference between displayed and FFc had a greater likelihood of filter clotting. Treatments with higher TMP were associated with failed treatments. Prefilter calcium administration during treatment was associated with increased filter clotting. Lower blood flow rates and higher patient weight were also associated with increased filter clotting. Prefilter heparin administration did not reduce the incidence of filter clotting.

Millimeter-wave emissivity as a metric for the non-contact diagnosis of human skin conditions.

A half-space electromagnetic model of human skin over the band 30-300 GHz was constructed and used to model radiometric emissivity. The model showed that the radiometric emissivity rose from 0.4 to 0.8 over this band, with emission being localized to a layer approximately one millimeter deep in the skin. Simulations of skin with differing water contents associated with psoriasis, eczema, malignancy, and thermal burn wounds indicated radiometry could be used as a non-contact technique to detect and monitor these conditions. The skin emissivity of a sample of 30 healthy volunteers, measured using a 95 GHz radiometer, was found to range from 0.2 to 0.7, and the experimental measurement uncertainty was ±0.002. Men on average were found to have an emissivity 0.046 higher than those of women, a measurement consistent with men having thicker skin than women. The regions of outer wrist and dorsal forearm, where skin is thicker, had emissivities 0.06-0.08 higher than the inner wrist and volar forearms where skin is generally thinner. Recommendations are made to develop a more sophisticated model of the skin and to collect larger data sets to obtain a deeper understanding of the signatures of human skin in the millimeter wave band. Bioelectromagnetics. 38:559-569, 2017. © 2017 The Authors. Bioelectromagnetics published by Wiley Periodicals, Inc.

Self-inflicted enucleations: Clinical features of seven cases.

We report the clinical presentation, radiography, and management outcomes of autoenucleations (AE). Charts of 7 patients evaluated at 4 institutions with AE were reviewed. Four males and three females had a mean age of 50 years (range 26-72 years). The etiologies were psychosis secondary to underlying mental illness (6, 88%) and substance use (1, 12%), and the mechanism was largely blunt digital injury (6, 88%). Three (43%) AE patients suffered bilateral enucleations. Common concomitant injuries included eyelid lacerations (5, 71%) and optic nerve avulsion (3, 43%). Radiography was utilized for all of the study patients with computed tomography as the most common (5, 71%), followed by ultrasound (1, 14%), and magnetic resonance imaging with CT angiography (1, 14). Orbital exploration was performed in the management of all patients. Orbital implants were placed in 4 (57%) patients. Patients were followed for a mean of 1.9 months (range 1-4 months). Autoenucleation affects both genders and is commonly associated with eyelid lacerations, optic nerve avulsion, and intracranial hemorrhage. The association with intracranial hemorrhage is consistent with prior reports of internal carotid artery injury following shearing of the optic nerve. Autoenucleation cases were seen secondary to mental or substance induced psychosis, and these patients may be at risk for future injuries such as AE of the contralateral globe. The common causes for psychosis reported our patient group include schizophrenia, depression, schizoaffective disorder, and methamphetamine-induced psychosis, which corroborates with similar cases in the literature. Two of three cases of bilateral AE suffered sequential AE where the contralateral globe was enucleated days apart. All patients suffering AE should have full medical, psychiatric, neurologic, and radiologic evaluation and monitoring while under care. When evaluating patients with obvious ocular injury, accompanying intracranial injuries should be ruled out in a timely fashion before pursuing surgical intervention.

Concomitant lung and brain abscesses: a rare presentation of a common bacteria.

Streptococcusanginosusis a member of the Streptococcus millerigroup, known to cause suppurative infections of the deep tissues. There have been very few case reports of the bacteria presenting with concomitant lung and brain abscesses. We describe a patient with new, onset seizures, subsequently diagnosed with S. anginosuslungandbrain abscesses.

Respiratory failure due to lung involvement with adult T-cell leukemia/lymphoma: case report and review of literature.

Acute adult T-cellleukemia/lymphoma (ATLL) is a hematologic malignancy that usually entails a poor prognosis; median survival is only six months. Significant immunosuppression is commonly seen in these patients. Lung involvement in ATLL is usually documented either radiographically or as an autopsy finding. Few proven cases of ante mortem extensive lung infiltration have been described in the scientific literature. We present a fatal case of acute respiratory failure as a result of histologically proven lung infiltration by malignant lymphocytes in a patientwith acuteATLL. Although the most common cause of death i n patients with ATLL is respiratory failure in the setting of an infectious process, it should be kept in mind that patients with ATLL with acute respiratory failure may have malignant lung infiltration as a potential cause.

Acute respiratory distress syndrome in human granulocytic ehrlichiosis.

The ehrlichioses are emerging zoonotic infections. They have a very nonspecific clinical presentation. The diseases generally present as undifferentiated fever, but thrombocytopenia, leucopenia, and transaminitis are important laboratory features. Ehrlichiosis as a cause of acute respiratory distress syndrome (ARDS) has been infrequently described in the literature. Physicians should be aware of this life-threatening but treatable entity. We present a patient who developed ARDS shortly after being diagnosed with and initiating treatment for human granulocytic ehrlichiosis (HGE). A 54-year-old woman presented with fever, hypotension, and pancytopenia, with peripheral smear diagnostic of ehrlichiosis. She was started on doxycycline therapy following which she developed ARDS which resolved with methylprednisone. The fatality for HGE has been estimated as 7-10%. ARDS secondary to Ehrlichia has been shown to respond dramatically to steroids.

Feasibility study of treatment of mixed astigmatism with small-incision lenticule extraction (SMILE) by using research software.

PURPOSE: To report the preliminary experience and initial clinical results following SMILE for the treatment of mixed astigmatism. METHODS: Thirteen eyes of nine patients with a mean age of 27 ± 4.36 years were included in the series. In 8/13 eyes, myopic SMILE license and in 4/13 eyes, hyperopic SMILE license (available as part of an open/research software) was used for the treatment. The mean follow-up was 9.5 ± 8.7 (0.5-24) months, and the median follow-up was 6 months. SETTING: Nethradhama Superspeciality Eye Hospital, Bangalore, India. DESIGN: Exploratory study. RESULTS: The mean preoperative sphere, cylinder, and spherical equivalent (SE) were 1.44 ± 1.63, -2.70 ± 2.30, and -0.24 ± 1.14 D, which changed to -0.03 ± 0.30, -0.28 ± 0.48, and -0.18 ± 0.49 D, respectively, 6 months postoperatively. Furthermore, 85% (11/13) eyes were within ± 0.50 D, 92% (12/13) eyes were within ± 1.00 D, while all eyes were within ± 1.50 D of SE correction. All eyes were within ± 1.00 D of cylinder correction. In addition, 92% (12/13) eyes had UDVA better than 20/32, with 54% (7/13) eyes having UDVA 20/20 or better. Safety and efficacy indices were 1.08 and 0.92, respectively. No eyes lost more than 1 line of CDVA. The mean corneal higher order aberrations (HOA) increased from 0.111 ± 0.048 to 0.209 ± 0.056 (P < 0.001). The mean objective scatter index (OSI) did not show a significant change (pre = 0.71 ± 0.69, 6 months = 0.89 ± 0.20; P = 0.35). CONCLUSION: Early experience showed that SMILE was feasible for the management of eyes with mixed astigmatism, without any intraoperative complications, unique to the procedure.

Virtual Reality Simulation in a Health Assessment Laboratory Course: A Mixed-methods Explanatory Study Examining Student Satisfaction and Self-confidence.

BACKGROUND: The purpose of this mixed-methods study was to examine the relationship between virtual reality simulation (VRS) and student satisfaction and self-confidence in a health assessment laboratory course. METHODS: Second-year students (n = 37) completed a postoperative respiratory distress scenario using Elsevier's Simulation Learning System with Virtual Reality. All participants completed the Satisfaction and Self-Confidence in Learning Scale; a subset participated in 1:1 semistructured interviews. RESULTS: Satisfaction and self-confidence scores were strongly correlated. VRS experiences of fidelity, communication confidence and competence, learning with peers, integrated learning and critical thinking, and a safe space to learn were related to students' satisfaction and self-confidence. CONCLUSIONS: VRS experiences are correlated with high student satisfaction and self-confidence.

Quality control methods for fruit extracts of Kigelia africana using high performance thin layer chromatography.

Kigelia africana is a tree native to Africa but also found in eastern and southern parts of India with reported anti-bacterial, anti-inflammatory, and immunomodulatory activities. Verbascoside, caffeic acid and ferulic acid are important markers for the quality control of the plant. Two different HPTLC methods were developed and validated; method - 1 for estimation of verbascoside and caffeic acid while method - 2 for estimation of caffeic acid and ferulic acid. Developed methods were applied to the methanolic fruit extract to determine the quantities of markers. Both methods were found to be linear, specific, precise, accurate, sensitive and robust. Results indicated that both methods can be used for quantitative determination of verbascoside, caffeic acid and ferulic acid in fruit extract. The developed methods may be utilised as a part of the quality control and standardisation for the raw material and extracts of Kigelia africana and can also aid to chromatographic fingerprinting of the plant.

Repigmentation of cutaneous scars depends on original wound type.

Cutaneous scarring is currently an inevitable outcome following skin injury. Abnormal pigmentation within scars makes them more noticeable, causing distress for patients, particularly as there is no reliable and effective treatment available to date. The Duroc pig, known to scar badly, was used to investigate repigmentation of scars resulting from three different wound types: incisional, partial thickness excisional and full thickness excisional. Wounds were created on the backs of Duroc pigs and the resulting scars harvested at days 35, 56, 70 and 90 days post-injury. Scars were processed for histology and immunohistochemistry, quantitatively analysed using image analysis software and subjected to statistical analysis. Photographs of the macroscopic appearance of scars were scored for pigmentation using a visual analogue scale. Results demonstrated temporal and spatial differences in melanocyte repopulation and function within scars from different wound types. The microscopic pigment deposition did not correlate with macroscopic appearances in mature scars. Pigmentation of scars is dependent on the width and depth of wounds. This study has provided important information on which we can base future studies to investigate factors controlling the repigmentation of scars.

Tattoos: ancient body art may assist in medical emergencies.

Tattooing, like medicine, is an ancient art form. However, in the UK, tattooing of minors is illegal except when performed for medical reasons. We present a 15-year-old type I diabetic, who being prone to hypoglycaemic attacks, had a permanent medical alert tattoo on his forearm, with his parents' consent, whilst on holiday abroad. Tattooing to convey a medical message is employed by many adults for reasons as diverse as anaphylaxis to do not resuscitate orders. We present the patient and propose that clinicians may wish to consider supporting tattooing to convey a medical alert in young people, particularly those at risk of life-threatening complications, such as hypoglycaemia.

Thyrotoxic hypokalemic periodic paralysis: two case reports and a brief review of literature.

Thyrotoxic Hypokalemic Periodic Paralysis (THPP) is a rare complication of thyrotoxicosis and can sometimes be fatal. It needs early recognition for proper management and prevention of recurrences. Here we describe two cases presenting with acute onset of paresis, low potassium levels, low levels of thyroid-stimulating hormones (TSH), and elevated thyroid hormone levels.

A prospective, randomized, comparative clinical study to compare the safety and efficacy of different hydrophobic aspheric monofocal intraocular lenses.

Purpose: To report the 1-year clinical outcomes related to safety, efficacy, predictability, contrast sensitivity, patient satisfaction, complications, and overall results with Optiflex Genesis and Eyecryl Plus (ASHFY 600) monofocal aspheric intraocular lenses (IOLs) and compare the same with Tecnis-1 monofocal IOL. Methods: This prospective, single-center, single-surgeon, randomized, three-arm study included 159 eyes of 140 eligible patients who underwent cataract extraction with IOL implantation with any of the three study lenses. Clinical outcomes related to safety, efficacy, predictability, contrast sensitivity, patient satisfaction, complications, and overall results were compared at a mean follow-up of 1 year (12 ± 1.20 months). Results: Preoperatively, age and baseline ocular parameters of all the three groups were matched. At 12 months post-op, no significant differences were noted among the groups in terms of mean postoperative uncorrected and corrected distance visual acuity (UDVA and CDVA, respectively) sphere, cylinder, and spherical equivalent (SE; P > 0.05 for all parameters). Eighty-nine percent eyes in the Optiflex Genesis group as against 96% eyes in the Tecnis-1 and Eyecryl Plus (ASHFY 600) groups were within ± 0.5 D, and 100% of eyes in all the three groups were within ± 1.00 D of SE accuracy. Postoperative internal higher-order aberrations (HOAs) and coma, and mesopic contrast sensitivity at all spatial frequencies were comparable across all the three groups. Two eyes in the Tecnis-1 group, two eyes in the Optiflex group, and one eye in the Eyecryl Plus (ASHFY 600) group underwent YAG capsulotomy at the last follow-up. No eye in any of the groups showed glistenings or required IOL exchange due to any reason. Conclusion: At 1-year post-op, all the three aspheric lenses showed comparable results in visual and refractive parameters, post-op aberrations, contrast sensitivity, and posterior capsule opacification (PCO) behavior. Further follow-up is needed to evaluate the long-term behavior for refractive stability and PCO rates of these lenses. Trial registry: CTRI/2019/08/020754 (www.ctri.nic.in).

Altered color of plasma component - Unnecessary wastage of a precious resource.

BACKGROUND AND OBJECTIVES: The present study was conducted to evaluate the etiology of altered color of plasma component of blood in transfusion practice. MATERIALS AND METHODS: The study was conducted at the blood center of a tertiary care teaching hospital in western India for a period of 6 months. After component separation, all the plasma units with altered color were segregated and samples were taken for further evaluation. Altered colored plasma units were divided into three - green discoloration, yellow discoloration, and lipemic plasma. Donors were called, their detailed history was taken, and necessary investigations were done accordingly. RESULTS: Forty plasma units out of 20,658 (0.19%) donations showed discoloration. Out of which, 3 plasma units showed green discoloration, 9 plasma units showed yellow discoloration, and the remaining 28 plasma units were lipemic. Among three donors whose plasma showed green discoloration, one female donor had a history of oral contraceptive pill usage and had higher values of copper and ceruloplasmin. All donors with yellow plasma had a higher value of unconjugated bilirubin. All the donors with lipemic plasma gave a history of intake of fatty meal prior to donating blood and showed higher values of triglyceride, cholesterol, and very-low-density lipoprotein. CONCLUSION: Plasma component with altered color restricts its issue to the patient and also for use in fractionation. In our study, many of the altered color plasma units were safe to transfuse, but the decision regarding transfusion was debatable on consultation with the treating doctor. Further studies with a large sample size are recommended for the use of these plasma components.

Bacteroides meningitis in a healthy child: A case report and review of the literature.

A 7-year-old male presented with meningitis. CSF gram stain showed gram negative rods, but the organism failed to grow on culture. 16 s rRNA sequencing identified the organism as Bacteroides fragilis. The patient fully recovered with antibiotic therapy targeting that organism.

Maternal allo anti-M antibody-induced hemolytic disease of newborn.

Hemolytic disease of the fetus and newborn is a syndrome associated with immune destruction of the fetal and newborn red cells by maternal red cell alloantibodies. The detection of anti-M in antenatal screening can be responsible for neonatal red cell aplasia. A 32-h-old full-term neonate admitted with inconsolable cry and mild fever. Laboratory tests revealed progressive anemia and hyperbilirubinemia on day 3. The peripheral blood smear showed evidence of hemolysis and reticulocyte count was reduced. Intensive phototherapy and antibiotics were started after ruling out other causes of hyperbilirubinemia. Blood group typing and advanced red cell serology workup were done. Antibody screening and identification was suggestive of the presence of anti-M antibody in both mother and baby. Intravenous immunoglobulin and red blood cell transfusions were given. Anti-M is capable of causing hemolytic disease of the fetus and newborn and prolonged anemia. Newborns with anemia should be evaluated for all the possible causes to establish a diagnosis.

Impact of prefilter dilution on IgG removal in membrane-based therapeutic plasma exchange.

INTRODUCTION: Previous studies have demonstrated that a "one plasma volume exchange" would result in an estimated 63% decline in pretreatment IgG levels. We evaluated the use of prefilter dilution with normal saline as a method to prevent filter failure without decreasing the efficiency of IgG removal. METHODS: Twenty-one treatment sessions were analyzed and all received prefilter dilution with normal saline. Primary outcome was to determine whether prefilter dilution resulted in decreased treatment efficiency in removing the targeted IgG. Secondary outcome was filter failure in conjunction with the combined use of prefilter heparin and saline infusions. RESULTS: All 21 treatments (100%) received prefilter dilution with saline solution and 19/21 (90.47%) also received prefilter heparin (bolus and/or hourly infusion). We demonstrated a 60%-70% decline in pretreatment IgG levels. CONCLUSION: Prefilter dilution during membrane-based therapeutic plasma exchange based treatment did not result in a demonstrable decrease in efficiency of IgG removal while maintaining filter patency.

NCLEX-RN readiness: HESI Exit Exam validity and nursing program policies.

BACKGROUND: The HESI® Exit Exam (E2) has been used to assess student readiness for the NCLEX-RN® examination for over two decades. PURPOSE: In this study, we examined the relationship between students' average E2 scores and their first time NCLEX-RN pass or fail outcomes to understand the validity of the E2 as a predictor of NCLEX-RN readiness. In addition, we examined the relationship between policies governing E2 use in programs and success on the NCLEX-RN. METHODS: Over 40 programs across the United States participated in the study, providing NCLEX-RN outcome information for 3686 students that took the E2 in 2018-2019 and information about policies. RESULTS: Students who achieved an average E2 score of 850 and above had a NCLEX-RN first-time pass rate (FTPR) of 96.33%. The NCLEX-RN FTPR was 97.29% for students whose average E2 score was 900 and above. Policies such as test preparation requirements and remediation for the E2 were associated with statistically significantly higher student NCLEX-RN FTPR. CONCLUSION: This study builds upon past evidence about the validity of the E2 and extends research in new directions by demonstrating the role of specific E2 policies in supporting students' success on the NCLEX-RN.

Early Laser for Burn Scars (ELABS): protocol for a multi-centre randomised, controlled trial of both the effectiveness and cost-effectiveness of the treatment of hypertrophic burn scars with Pulsed Dye Laser and standard care compared to standard care alone [version 1; peer review: 2 approved].

This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact. This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.