Neuro-fuzzy modelling of a continuous stirred tank bioreactor with ceramic membrane technology for treating petroleum refinery effluent: a case study from Assam, India.

A continuous stirred tank bioreactor (CSTB) with cell recycling combined with ceramic membrane technology and inoculated with Rhodococcus opacus PD630 was employed to treat petroleum refinery wastewater for simultaneous chemical oxygen demand (COD) removal and lipid production from the retentate obtained during wastewater treatment. In the present study, the COD removal efficiency (CODRE) (%) and lipid concentration (g/L) were predicted using two artificial intelligence models, i.e., an artificial neural network (ANN) and a neuro-fuzzy neural network (NF-NN) with a network topology of 6-25-2 being the best for NF-NN. The results revealed the superiority of NF-NN over ANN in terms of determination coefficient (R2), root mean square error (RMSE), and mean absolute percentage error (MAPE). Three learning algorithms were tested with NF-NN; among them, the Bayesian regularization backpropagation (BR-BP) outperformed others. The sensitivity analysis revealed that, if solid retention time and biomass concentrations were maintained between 35 and 75 h and 3.0 g/L and 3.5 g/L, respectively, high CODRE (93%) and lipid concentration (2.8 g/L) could be obtained consistently.

Idiopathic Pericardial Ossification Causing Chronic Constrictive Pericarditis.

BACKGROUND: Chronic constrictive pericarditis (CCP) is usually caused by the fibroinflammatory reaction of the visceral and parietal pericardium that encase the heart. The cause of CCP is various including tuberculosis, trauma, prior surgery, radiation, and malignancy. MATERIAL AND METHODS: We examined the pericardiectomy specimen of a case of CCP in a 17-year-old boy. RESULTS: The histopathology of the pericardium revealed pericardial ossification bony remodeling and hematopoiesis within the intertrabecular marrow spaces. No granulomatous or neoplastic etiology was identified. CONCLUSION: Idiopathic pericardial ossification can cause CCP in pediatric patients.

Hydrogen peroxide assisted endoscopic necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Endoscopic necrosectomy (EN) is the preferred approach for management of symptomatic or infected walled-off pancreatic necrosis (WOPN). Hydrogen peroxide (H2O2) has been reported to be a good adjunctive therapy for EN. We performed a systematic review and meta-analysis to evaluate effectiveness and safety of H2O2 assisted EN for WOPN. METHODS: A comprehensive search of multiple databases (through December 2020) was performed to identify studies that reported outcomes of H2O2 assisted EN for WOPN. Outcomes assessed included clinical success, technical success, and adverse events. RESULTS: A total of 454 patients with mean age (47.3 ± 7.9 years) and WOPN size (12.4 ± 3.1 cm) were included from 15 studies. The median H2O2 concentration was 3% (range 0.1-3%), with dilution and volume ranging from 1:1 to 10:1 and 20 ml to 1 L, respectively. The rates of technical success, clinical success and adverse events was 97.3% (95% confidence interval [CI]: 94.8-98.6, I2 = 0), 89.8% (95% CI: 86.3-92.5, I2 = 0) and 17.9% (95% CI: 12.6-24.7, I2 = 38), respectively. The most common adverse event was bleeding (7.1%) followed by stent migration (5.3%). On meta-regression, WOPN size, patient age, use of metal stent, number of necrosectomies and transgastric access were not significant predictor for technical success, clinical success or adverse events. CONCLUSION: H2O2 assisted EN is effective and safe for management of WOPN. Its use may be encouraged, and future randomized controlled studies are needed to study the optimal technique, concentration and best predictors of success.

Improvement of laboratory turnaround time using lean methodology.

Purpose The purpose of this paper is to discuss the implementation of lean methodology to reduce the turnaround time (TAT) of a clinical laboratory in a super speciality hospital. Delays in report delivery lead to delayed diagnosis increased waiting time and decreased customer satisfaction. The reduction in TAT will lead to increased patient satisfaction, quality of care, employee satisfaction and ultimately the hospital's revenue. Design/methodology/approach The generic causes resulting in increasing TAT of clinical laboratories were identified using lean tools and techniques such as value stream mapping (VSM), Gemba, Pareto Analysis and Root Cause Analysis. VSM was used as a tool to analyze the current state of the process and further VSM was used to design the future state with suggestions for process improvements. Findings This study identified 12 major non-value added factors for the hematology laboratory and 5 major non-value added factors for the biochemistry lab which were acting as bottlenecks resulting in limiting throughput. A four-month research study by the authors together with hospital quality department and laboratory staff members led to reduction of the average TAT from 180 to 95minutes in the hematology lab and from 268 to 208 minutes in the biochemistry lab. Practical implications Very few improvement initiatives in Indian healthcare are based on industrial engineering tools and techniques, which might be due to a lack of interaction between healthcare and engineering. The study provides a positive outcome in terms of improving the efficiency of services in hospitals and identifies a scope for lean in the Indian healthcare sector. Social implications Applying lean in the Indian healthcare sector gives its own potential solution to the problem caused, due to a wide gap between lean accessibility and lean implementation. Lean helped in changing the mindset of an organization toward providing the highest quality of services with faster delivery at an optimal cost. Originality/value This paper is an effort to reduce the gap between healthcare and industrial engineering and enhancing the use of lean practices in Indian healthcare. The study is motivated toward implementing lean methodology successfully in services.

Laparostomy management using the ABThera™ open abdomen negative pressure therapy system in a grade IV open abdomen secondary to acute pancreatitis.

Wound control in laparostomy for the treatment of intra-abdominal hypertension remains challenging and numerous techniques have been described. We report the first UK experience with a new commercially available device specifically designed to facilitate management of the open abdomen. A 44-year-old gentleman presented with a 3-day history of constant severe epigastric pain and associated vomiting. Amylase was markedly elevated and he was admitted for supportive management of pancreatitis, with subsequent transfer to intensive care due to severe systemic inflammatory syndrome. The patient decompensated, developing intra-abdominal hypertension with renal and respiratory failure. This was successfully managed by performing a laparostomy and using an ABThera™ Open Abdomen Negative Pressure Therapy System (KCI, San Antonio, TX). We describe its use to facilitate wound control, including enteroatmospheric fistula, allowing granulation and eventual restoration of gastrointestinal continuity 383-days after admission. We found the ABThera™ System proved to be a useful treatment adjunct, protecting intra-abdominal contents while removing large volumes of exudate and infected material from within the abdominal cavity. Complex cases such as this remain infrequent and this article provides a summary of our experience, including a review of indications for laparostomy and the underlying basic science in this difficult area.

Isolated ischaemic contracture of medial head of gastrocnemius.

A 47-year-old woman presented with a disabling fixed flexion deformity of the knee and an equinus deformity of the ankle following treatment in a cast for a minor flexion deformity following a tibial plateau fracture. Two years later, the cause was identified as an isolated ischaemic contracture involving the medial head of gastrocnemius. She made a good recovery following extensive corrective surgery and rehabilitation.

Artificial Intelligence Research and Development for Application in Video Capsule Endoscopy.

Artificial intelligence (AI) research for medical applications has expanded quickly. Advancements in computer processing now allow for the development of complex neural network architectures (eg, convolutional neural networks) that are capable of extracting and learning complex features from massive data sets, including large image databases. Gastroenterology and endoscopy are well suited for AI research. Video capsule endoscopy is an ideal platform for AI model research given the large amount of data produced by each capsule examination and the annotated databases that are already available. Studies have demonstrated high performance for applications of capsule-based AI models developed for various pathologic conditions.

A Rare Case of an Ectopic Liver Presenting as Right Atrial Mass.

Ectopic liver tissue is commonly observed in the abdominal cavity in adjacent organs. Extension of hepatic tissue into the intrathoracic cavity is rarely reported. We present the case of a 46-year-old woman with a 2.1 × 1.8 cm mass confirmed by transesophageal echocardiogram to be at the right atrial and inferior vena cava junction that was initially thought to be a myxoma which prompted surgical excision but subsequently identified as ectopic liver by histology.

When should cardiopulmonary bypass be used in the setting of severe hypothermic cardiac arrest?

A best evidence topic was written according to a structured protocol. The question addressed was regarding the indication and timing of the use of cardiopulmonary bypass (CPB), following severe hypothermic cardiac arrest. A total of 284 papers were found using the reported searches, of which nine represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were survival, rewarming speed, incidence of arrhythmia during rewarming, resolution of full neurological function, long-term neurological function, evidence of damage on neurological imaging and venous metabolic parameters in hypothermic patients. The most recent of the best evidence studies, a retrospective comparative study of 68 patients, demonstrated CPB rewarming to be far superior to conventional methods of rewarming, with mortality rates of 15.8 and 53.3%, respectively. Another study of similar size, comparing CPB with extracorporeal membrane oxygenation (ECMO) for rewarming, revealed superior survival rates with ECMO, 75 vs 34%. A systematic review of 68 patients demonstrated an overall survival of 60%, and 80% of survivors returning to a previous level of activity. Two smaller observational studies reported survival rates of 73.1 and 45.5%, respectively. A retrospective study analysing long-term neurological outcomes of survivors reported normal history and physical examination in 93.3%, normal neurovascular ultrasound in 100%, normal neuropsychological findings in 93.3% and normal brain magnetic resonance imaging in 86.7%. A small comparative study demonstrated a significant survival benefit when CPB was preceded with emergency thoracotomy, internal cardiac massage and warm mediastinal irrigation compared with CPB alone. We conclude that, following deep hypothermic circulatory arrest, the urgent use of cardiopulmonary bypass is widely indicated for rewarming where it has been shown to provide good survival and neurological outcomes far superior in comparison with conventional methods of rewarming.

Renal manifestations of HIV infected highly active antiretroviral therapy naive children in India.

BACKGROUND: There are several studies on renal manifestations in human immunodeficiency virus (HIV) infected children from American and African regions, but similar studies from India are lacking. A cross-sectional study was carried out in 28 HIV infected antiretroviral therapy (ART) naïve children coming to the pediatric HIV clinic. METHODS: Demographic data of the children, clinical presentations including blood pressure, detailed laboratory investigations (serum creatinine, glomerular filtration rate), urine analysis (urine morphology, urine albumin, pus cells, and red blood cells), and CD4 counts were collected. RESULTS: Of the 28 children, 15 (53.6%) had renal manifestations with a male to female ratio of 1:1.5. The most common renal manifestation in our study was abnormal glomerular filtration rate (GFR) in 11 (44.0%) of 25 children. This was followed by pus cells in urine in 6 (21.4%) of the 28 children while 3 (10.7%) of them had proteinuria. The mean age of children with renal manifestations was 5.04±2.75 years as compared to those without renal manifestations who had a mean age of 7.38±2.95 years (P=0.0390). CDC class and sex were not associated with renal manifestations. CONCLUSIONS: Our study suggests that reduced GFR is the common renal manifestation, particularly in younger children. Other renal manifestations are related to proteinuria. The lack of correlation of CDC classification with renal manifestations mandates screening of children with HIV for renal disease. A more detailed study of renal manifestations in HIV-infected children is needed.

Screening approach, optimisation and scale-up for chiral liquid chromatography of cathinones.

Screening approaches adopted in pharmaceutical companies for chiral LC method development may be quite complicated and sophisticated in order to guarantee a high success rate. However in other environments it may be of more value to assess how simple a screen might be used to still have a good chance of achieving success. The genuine need to develop chiral separations for the former 'legal-high' drug mephedrone and related cathinones of topical interest presented a good opportunity to develop this theme. In initial work on mephedrone itself, no chiral separation was observed on Chirobiotic V, Cyclobond I 2000 DNP, Whelk-O1 and AmyCoat using reversed phase mobile phases. However, using normal phase solvents, chiral separation was observed on all the chiral stationary phases (CSP) used except Chiralcel OJ-H. Of the chiral separations observed on RegisPack, RegisCell and Whelk-O1, some optimisation work was carried out on the latter two which had showed the greatest enantioselectivity. Following optimisation, the best enantioselectivity (1.59) and enantioresolution (5.90) was found with a 250 mm × 4.6 mm I.D. Whelk-O1 column using a propan-2-ol (IPA)-hexane-trifluoroacetic acid (TFA)-triethylamine (TEA) (10:90:0.05:0.05, v/v/v/v) mobile phase. Subsequent screening on other cathinones was restricted to RegisPack, RegisCell and Whelk-O1 or equivalent phases with two mobile phases and this gave a very good success rate. Indeed it was possible to separate all six cathinones on one column, RegisCell, with one mobile phase, propan-2-ol-hexane-TFA (15:85:0.1, v/v/v) but obviously it had been necessary to go through the 3-column screen to arrive at this finding. While Whelk-O1 was not so successful, ease of optimisation on this phase was again a feature. To illustrate the applicability of these separations, it was shown that, as a basis for semi-preparative work, the optimsed mephedrone separation on Whelk-O1 could be scaled-up to a 2000µl injection of a 1.0 mg ml(-1) solution in mobile phase (2.0mg on-column) while still using the 250 mm × 4.6 mm I.D. analytical column.

Septic arthritis affecting pubic symphysis.

A 26-year-old man presented to accident and emergency with a 1-week history of fever, rigors and sudden onset of severe left testicular pain. The symptoms started without trauma and pain radiated to the abdomen and was worse on walking. He had raised temperature and inflammatory markers. He reattended 2 days later with progressive bilateral groin pain, night sweats and the blood cultures grew Staphylococcus aureus. Repeat cultures were sent and the patient was arranged to be followed up in clinic. He returned 5 days later with worsening symptoms. S aureus was grown from the second blood culture, so he was admitted for intravenous flucloxacillin. MRI of the pelvis showed a small fluid collection around the pubic symphysis and extensive periarticular bone marrow oedema consistent with septic arthritis and a retropubic abscess. He was treated with a 8-week course of flucloxacillin with complete resolution.