Hydrogen from sewage sludge: Production methods, influencing factors, challenges, and prospects.

The rising global population and rapid industrialization have frequently resulted in a significant escalation in energy requirements. Hydrogen, renowned for its eco-friendly and renewable characteristics, has garnered substantial interest as a fuel alternative to address the energy needs currently fulfilled by fossil fuels. Embracing such energy substitutes holds pivotal importance in advancing environmental sustainability, aiding in the reduction of greenhouse gas emissions - the primary catalysts of global warming and climate fluctuations. This study elucidates recent trends in sewage sludge (SS)-derived hydrogen through diverse production pathways and critically evaluates the impact of varying parameters on hydrogen yield. Furthermore, a detailed analysis of the breakdown of the hydrogen generation process from SS is provided, along with an assessment of its economic dimensions. The review culminates by illuminating key obstacles in the adoption of this innovative technology, accompanied by practical recommendations to surmount these challenges. This comprehensive analysis is expected to attract considerable interest from stakeholders within the hydrogen production domain, fostering substantial engagement.

Long-term retroperitoneal lymph node dissection outcomes for nonseminomatous germ cell tumors with postchemotherapy retroperitoneal residual tumors, in a specialized hospital of Saudi Arabia.

Background: In men under the age of 35 years, testicular cancer is the most prevalent solid tumor. Additional treatment is necessary for many people with nonseminomatus germ cell tumors (NSGCTs). Whether in conjunction with chemotherapy or as a stand-alone procedure, retroperitoneal lymph node dissection (RPLND) continues to play a critical role in the treatment of these patients. There is a lack of information in Saudi Arabian literature about the long-term oncologic outcome of NSGCT following RPLND surgery. Objective: The study's goals were to identify clinical and pathological characteristics related with long-term survival following NSGCT for RPLND, as well as to assess the surgical and oncological results of this treatment. Methodology: From January 2010 to April 2021, nine adults who had had orchidectomy for testicular cancer and RPLND following treatment for the evidence of persistent NSGCT disease at our hospital were included in this retrospective research. Demographic information, laboratory results, radiological findings, staging, chemotherapy and radiotherapy status, surgical procedure details, perioperative problems, morbidity, and mortality were all acquired from patients' medical records. Rates of disease return and overall survival. SPSS was utilized for the data analysis. Results: During the study period, nine patients with NSGCT underwent RPLND, with a mean age of 28 years (5.4: standard deviation). The most common diseases were yolk sac and embryonal cell cancer. In addition to receiving neoadjuvant chemotherapy, all patients had a Clavien-Dindo score of 2, and there was no mortality after RPLND. Overall median survival time was 26, and disease-free survival time was 21 months. Overall survival at 1 year was 86%, and at 5 years, it was 66%. The prognosis of embryonal cell cancer was more optimistic than that of a tumor of the yolk sac. Conclusion: We have shown that RPLND has an extremely low rate of morbidity and postoperative problems. In terms of oncology, it results in adequate overall and disease-free survival rates, with low morbidity and postoperative complications.

Pharmacoepidemiological evaluation of off label and unlicensed prescription in pediatric intensive care units at tertiary care hospitals of Peshawar, Pakistan.

Population of pediatric intensive care units are at high risk of receiving off label and unlicensed drug use. Little is known about the characteristics and prevalence of unlicensed and off label prescriptions in pediatric intensive care units (PICUs) at tertiary care settings of Pakistan. Case notes of 420 children were reviewed for unlicensed and off label prescriptions during the one year. Medication profiles were assessed using Micromedex. Logistic regression was applied to calculate the odds-ratios for predictors of unlicensed and off label prescriptions. of the total prescriptions, 29.8% prescriptions were unlicensed from FDA and 42.27% prescriptions were off labelled. Dose (32.79%) was the most common reason for off label prescriptions followed by the indication (26.13%) and indication-dose (13.98%). Multivariate regression analysis revealed no significant association between the unlicensed prescriptions with their predictors. In reference to corresponding category, prescribed medications less than 5 (OR 0.280, 95%CL 0.137-0.570) were significantly less likely to receive off label prescriptions as compared to patients received 6 or more medications. Substantial numbers of children are exposed to unlicensed and off label prescriptions. Standards of drug quality, safety and efficacy should apply equally in adults and in pediatrics under ethical perspective. Suitable clinical interventions must be established by drug manufactures and government agencies for improved pediatric pharmacotherapy.

Evaluating humidity sensing response of graphene quantum dots synthesized by hydrothermal treatment of glucose.

Graphene quantum dots (GQDs) were prepared using a single-step hydrothermal treatment of glucose (C6H12O6) powder. X-ray diffraction patterns confirmed the random stacking or amorphous character of GQDs. Additionally, the UV-vis spectra confirmed the formation of GQDs with evident absorption peaks at 237 and 305 nm, which is attributed toπ-π* andn-π* transitions correspondingly. The average size and surface roughness of graphene quantum dots were estimated by atomic force microscopy images and found to be 27.0 ± 1.0 and 2.3 nm, respectively. Afterwards, the effect of increasing relative humidity (RH) from 0%-95%, and frequency, was analyzed using the capacitive and resistive responses of synthesized GQDs. The capacitive output at 0.1 kHz revealed that initially capacitance remains constant (15.0 ± 1.0 pF) up to a humidity level ranging between 0%-50%. Likewise, capacitance also displayed stabilized behavior after frequency levels were increased i.e., 1.0 and 10 kHz, at a humidity ranging from 0%-55%. Moreover, capacitance showed a 115,455, 22,480 and 3,620% improvement from their stable values at each respective frequency level i.e., 0.1, 1.0 and 10 kHz. The capacitive sensitivity decreased to 84.20 and 96.83% at greater frequencies (1.0 and 10 kHz) in comparison to the sensitivity at 0.1 kHz facing similar variations in a humid environment. In contrast, resistance displayed an exponential decline by 99.9900, 99.9796 and 99.9925%, accordingly, when RH increases from 0 to 95% at 0.1, 1.0 and 10 kHz, respectively. However, with the rise in frequency level from 0.1 to 1.0 kHz, resistive sensitivity increased considerably to 69 and 158.5%, respectively, in two prominent humidity ranges i.e., 0 ≤ RH ≤ 25% and 25% ≤ RH ≤ 50%. A further increase in testing frequency to 10 kHz enhances the resistive sensitivity by 598.5 and 178.5% when compared with the lowest sensitivity values at two noticeable humidity levels, 0%-25% and 25%-50%. The response and recovery times of our specimen were better than most of previously fabricated GQDs and other carbon-derived nanomaterials, which makes the nano-GQDs of our study more suitable for RH sensor application.

Survival And Progression After Radical Nephrectomy In A Cohort Of Non-Metastatic Renal Cell Carcinoma Treated With Curative Intent.

BACKGROUND: Radical nephrectomy (RN) is a standard treatment of cure for non-metastatic renal cell carcinoma (NMRCC). Long-term outcome data are limited for Pakistani population. Our aim was to assess the long-term outcomes of RCC treated with curative intent with radical nephrectomy (RN) and to study the 5 & 10years survival outcomes in patients with NMRCC who underwent radical nephrectomy. METHODS: This is a retrospective review and analysis of the data between December 2006 and February 2017. We included all the adult patients (age ≥18 years) with NMRCC from both genders irrespective of their histologic subtypes who underwent radical nephrectomy (RN) with a curative intent. The data was analysed for overall survival and recurrence rates at 5- and 10-years using Kaplan-Meier survival analysis. Multivariate analysis was performed using Cox-regression to identify risk factors associated with poor overall outcome in terms of recurrence and mortality. RESULTS: Three hundred and forty-four patients with 195 (55.5%) males and 149 (44.2%) females with a mean age of 53.5±14.1 years were monitored for a mean follow-up of 31.1±26.77 months (range: 3-132 months). Overall there were 46 (13.4%) deaths. Forty-nine 14.2%) cases had disease recurrence with 33 (9.5%) deaths from disease progression. The 5-year progression-free survival was 37% (95% CI: 49.04-72.76) with the median time to recurrence of 33 months (95% CI: 27.6-38.4) and the median overall survival was 103.7 months (95% CI: 95.7-111.7). The 5-year overall survival was 76.1% (95% CI: 75.2-77) while 10-year survival was 70.8%. There was a significant median survival difference for cases with and without recurrence (log-rank χ2: 117.5, p<0.001), T stage, Fuhrman's grade, and early postoperative recurrence. CONCLUSIONS: Radical nephrectomy offers the best survival for nonmetastatic renal cell carcinoma patients with excellent postoperative survival and progression-free profile. Although renal cell cancer presents in younger age group but the long-term survival after radical nephrectomy in Pakistani population is similar to the rest of the world.

Diethylstilbestrol in the Treatment of Castration-resistant Prostate Cancer: A Lower-middle-income Country Experience.

INTRODUCTION:  Prostate cancer is the second most common cancer and the fifth leading cause of death worldwide. Its metastatic stage is associated with considerable morbidity and may lead to death. In Pakistan, given the high levels of economic constraint, patients with castration-resistant metastatic prostate cancer can be treated with cost-effective medications like diethylstilbestrol (DES). OBJECTIVES:  The goal of this study was to assess the efficacy and adverse effects of DES when used in patients with castration-resistant prostate cancer (CRPC). MATERIALS AND METHODS:  From January 2011 to December 2016, all medical records of patients with a diagnosis of prostate cancer resistant to the effects of castration presenting at Shaukat Khanum Cancer Hospital and Research Centre, Lahore, were reviewed. All patients were treated with DES (2.5 mg) initially, but the dose was increased for some patients to 5 mg in combination with aspirin (75 mg). The patients were followed clinically with prostate-specific antigen (PSA) value assessment. The PSA response to treatment, time to disease progression, and adverse events were recorded and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). RESULTS: A total of 91 patients were included in the study, and the mean patient age was 66 ± 8 years. The median baseline PSA was 150 ng/mL (range: 56-626 ng/mL), and the median Gleason's score was eight. A total of 90.1% of patients had metastatic disease at the time of diagnosis. Hormonal ablation was provided with bilateral orchiectomy for 71 patients (78.0%), and luteinizing hormone-releasing hormone (LHRH) analog was provided for 20 patients (22.0%). With this treatment, the median time to PSA progression was 597 days. After DES treatment was started, 78 patients (87.7%) showed a PSA response, and median time to progression was 212 days. In 24 patients (26.4%), the PSA response was maintained for more than a year. The PSA response was quantified as a good response (i.e., ≥50% PSA drop) or as a partial response (i.e., <50% PSA drop). The good PSA response was observed in 56 patients (61.5%) with a median time to progression of 273 days, and 22 patients (24.2%) had a partial response maintained for 109 days. Thirteen patients (14.3%) did not respond to DES treatment. The median percent change in PSA was -55.52% (range: -99.9 to +422). Thromboembolic complication was observed in eight patients (8.7%) patients while two patients suffered from liver toxicity. CONCLUSION:  DES is an effective, economical, and relatively safe drug in patients with CRPC.

Outcomes of Nephron Sparing in a Specialist Cancer Hospital of a Developing Country.

Introduction Nephron-sparing surgery in the form of partial nephrectomy (PN) is currently considered the standard treatment for relatively small localized renal cell tumors. Objectives This study aimed to determine outcomes of PN regarding complications, recurrence, and survival rates at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Methods We assessed the data of patients older than 18 years undergoing PN from January 2010 to June 2017 who met our inclusion criteria. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). Results A total of 35 patients were studied, with a male to female ratio of 2.5:1 with median age of 50 years. The median hospital stay was four days (range: 3-7), and the median RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior location relative to polar lines) Score was five (range: 4-10). The most common pathological tumor stage was T1 (94%), and the median size was 3.5 cm. On histopathology, clear-cell carcinoma was the most common tumor (incidence, 71%). The median Fuhrman's grade was two. On final histopathology, four patients had positive margins. Among them, two patients showed a progressive deterioration in renal functions and were found to have residual disease six months later. Only one patient developed metastasis in the lung. Wound infection was observed in one patient while another had wound dehiscence. Urine leakage was noted in two patients. The median follow-up duration was 18 months (range: 3-84). Mean cancer-free survival was 78.6 months, and overall survival was 79.2 months. The projected three-year and five-year disease-free and overall survival was 96% and 94%, respectively. Conclusion PN is a viable option with excellent outcomes regarding the complication profile, recurrence-free, and overall survival in patients with relatively small localized renal tumors.

FREQUENCY AND FACTORS EFFECTING NON CLEARANCE OF LOWER POLE RENAL STONES.

BACKGROUND: Renal stone disease is a major health hazard in Pakistan and extra-corporeal shockwave lithofripsy is one of comprehensive method used to treat these stones. The aim of this study is to determine the frequency of factors affecting the non-clearance of stone fragments of lower pole renalstone after extra corporeal shockwave lithotripsy. The study was done with the objective to determine the frequency the spatial anatomical factors which can influence the non-clearance of lower pole stone fragments after ESWL. METHODS: One and nineteen (119) patients with lower pole renal stone less than 10 mm were subjected to maximum 3 sessions of extracorporeal shock wave lithotripsy. KUB radiographs, ultrasonography and intravenous urography were used as investigative tools for lower pole renal calyceal anatomy. X ray KUB and ultrasound were done after a week for clearance. Data was analysed with the help of SPSS version 10.0 and presented in the forms of tables and graphs. RESULTS: There were 77 (64.71%) males and 42 (35.29%) females. Infundibulo-pelvic angle (IPA)>40' was present in 93 (78.15%), Infundibular length (IL) <22 mm in 107 (89.92%) and Infundibular width (W) >4 mm was present in 100 (84.03%) patients. The frequency of stone non clearance was noted in 31 (26.05%). Infundibulo-pelvic angle (IPA)>40 degrees (p=0.000), Infundibular length (IL)<22 mm (p=0.001) and Infundibular width (IW)>4 mm (p=0.046) were significant variables affecting stone clearance. CONCLUSION: The frequency of non-clearance of lower calyx of kidney stone is 26.05%. The clearance of fragments of the lower calyx kidney stones is affected by. three spatial anatomical factors, i.e., Infundibulopelvic angle, Infundibular width and infundibular length.

The effects of protamine overdose on coagulation parameters as measured by the thrombelastograph.

BACKGROUND AND OBJECTIVE: Protamine is routinely administered following cardiopulmonary bypass in order to neutralize the effects of heparin. An excess of protamine can contribute to coagulopathy, hence predisposing to bleeding with associated morbidity and mortality. Thromboelastography (TEG) is recognized as an invaluable bedside tool to detect coagulation parameters; however, the effects of protamine overdose on TEG parameters have not been fully established. METHODS: Forty-six patients undergoing cardiac surgery using cardiopulmonary bypass were recruited in the study. Following heparinization, the patient's blood heparin level was measured using Hepcon HMS. Incremental doses of protamine [at a protamine-to-Hepcon-derived heparin ratio (PHR) of 1:1, 2:1 and 3:1] were added to patients' blood samples in vitro and four TEG coagulation parameters, including R (time to clot initiation), K (clot kinetics), alpha (clot kinetics) and maximum amplitude (ultimate clot strength), were monitored. Statistical analysis was performed using NCSS software. RESULTS: Protamine caused dose-dependent worsening of coagulation parameters on TEG; K was significantly elevated, whereas alpha and maximum amplitude showed significant reduction (P < 0.001) compared with baseline at a PHR of 2:1 and 3:1, respectively. R was significantly prolonged compared with baseline (P < 0.001) at a PHR of 3:1. CONCLUSION: Protamine adversely affects clot initiation time, clot kinetics and platelet function in a dose-dependent manner, which can predispose to bleeding.

Segmental mediolytic arteriopathy with post-transplant lymphoproliferative disorder of the lung: case report and review of the literature.

Segmental mediolytic arteriopathy (SMA) is an extremely rare condition of uncertain etiology causing degeneration of arterial media, intramural dissection or the rupture of aneurysms. It is recognized as a rare cause of fatal intra-abdominal bleeding. We report the first case of recurrent intra-abdominal bleeding secondary to SMA in a lung transplant patient, with a further complication of lymphoproliferative disease in the transplanted lung. We discuss the pathogenesis, clinical presentation, imaging characteristics and the complexities of management in this case.

Does preoperative computed tomography reduce the risks associated with re-do cardiac surgery?

A best evidence topic was written according to the structured protocol. The question addressed was whether preoperative computed tomography (CT) scan reduces the risk associated with re-do cardiac surgery. A Medline search revealed 412 papers, of which seven were deemed relevant to the topic. We conclude that preoperative CT angiography using ECG-gated multi-detector scan enables excellent anatomical details of heart, aorta and previous grafts, and highlights high-risk cases due to adherent grafts or ventricle or aortic atherosclerosis. This allows for better risk stratification and change of surgical strategy to reduce the potential risk in patients coming for re-do cardiac surgery. According to published reports, high-risk CT-scan findings in these patients caused clinicians to cancel surgery in up to 13% of cases, while preventive surgical strategies including non-midline approach, peripheral vascular exposure or establishing cardiopulmonary bypass prior to re-sternotomy have been reported in over two-thirds of patients with significant reduction in the operative risk. The risk of damage to vital structures, including previous grafts, heart or larger vessels is generally reported fewer than 10%, with evidence of significantly lower incidence of intra-operative injuries in patients who had prior CT-scans compared to those who did not. Hence, adequate preoperative imaging using ECG-gated multi-slice CT is essential for optimum planning of re-do cardiac surgery.

Early experience with the Levitronix Centrimag device for extra-corporeal membrane oxygenation following lung transplantation.

Extra-corporeal membrane oxygenation (ECMO) is accepted as a salvage therapy to treat life-threatening complications following lung transplantation such as primary graft dysfunction, acute rejection or airway dehiscence. Levitronix Centrimag (Levitronix LLC, Waltham, MA) is a centrifugal pump that consists of a magnetically levitated bearing-less rotor designed to reduce blood friction. ECMO using the Levitronix Centrimag pump may be an ideal medium-term support for lung transplant recipients suffering these serious complications. We describe our early experience of using ECMO with Levitronix Centrimag device and the Hilite hollow fibre membrane oxygenator (Medos Hilite LT, Medos Medizintechnik AG) in three cases following lung transplantation. The device is technically easy to implant and manage with a low complication rate on minimal anticoagulation.

Alteration in transthoracic impedance following cardiac surgery.

INTRODUCTION: Haemodynamically significant ventricular tachyarrhythmias are a frequent complication in the immediate post-operative period after cardiac surgery. Successful cardioversion depends on delivery of sufficient current, which in turn is dependent on transthoracic impedance (TTI). However, it is uncertain if there is a change in TTI immediately following cardiac surgery using cardiopulmonary bypass (CPB). METHODS: TTI was measured on 40 patients undergoing first time isolated cardiac surgery using CPB. TTI was recorded at 30 kHz using Bodystat Multiscan 5000 equipment before operation (with and without a positive end-expiratory pressure (PEEP) of 5 cm of H(2)O) and then at 1, 4 and 24 h after the operation. Data was analyzed to determine the relationship between pre- and post-operative variables and TTI values. RESULTS: Mean pre-operative TTI was 54.5+/-10.55 ohms without PEEP and 61.8+/-15.4 ohms on a PEEP of 5 cm of H(2)O. TTI dropped significantly (p<0.001) after the operation to 47.2+/-10.6 ohms at 1 h, 42.6+/-10.2 ohms at 4 h and 41.8+/-10.4 ohms at 24 h. A positive correlation was noted between duration of operation and TTI change at 1 h (r=0.38; p=0.016). There was no significant correlation between the duration of bypass and change in TTI. CONCLUSION: TTI decreases by more than 30% in the immediate post-operative period following cardiac surgery. This state may favour defibrillation at lower energy levels.

Extracorporeal membrane oxygenator as a bridge to successful surgical repair of bronchopleural fistula following bilateral sequential lung transplantation: a case report and review of literature.

BACKGROUND: Lung transplantation (LTx) is widely accepted as a therapeutic option for end-stage respiratory failure in cystic fibrosis. However, airway complications remain a major cause of morbidity and mortality in these patients, serious airway complications like bronchopleural fistula (BPF) are rare, and their management is very difficult. CASE PRESENTATION: A 47-year-old man with end-stage respiratory failure due to cystic fibrosis underwent bilateral sequential lung transplantation. Severe post-operative bleeding occurred due to dense intrapleural adhesions of the native lungs. He was re-explored and packed leading to satisfactory haemostasis. He developed a bronchopleural fistula on the 14th post-operative day. The fistula was successfully repaired using pericardial and intercostal vascular flaps with veno-venous extracorporeal membrane oxygenator (VV-ECMO) support. Subsequently his recovery was uneventful. CONCLUSION: The combination of pedicled intercostal and pericardial flaps provide adequate vascular tissue for sealing a large BPF following LTx. Veno-venous ECMO allows a feasible bridge to recovery.

Predictors of new malignant ventricular arrhythmias after coronary surgery: a case-control study.

OBJECTIVES: We sought to investigate the relationship between perioperative factors and the occurrence of ventricular tachycardia (VT) and ventricular fibrillation (VF), as well as the impact of VT/VF on early and late mortality. BACKGROUND: Both VT and VF are rare but serious complications after coronary artery bypass graft surgery (CABG), and their etiology and implications remain uncertain. METHODS: Data on 4,411 consecutive patients undergoing CABG (1,154 [25.8%] had off-pump surgery) between April 1996 and September 2001 were extracted from a prospective database and analyzed. Odds ratios (ORs) describing associations between possible risk factors and VT/VF were estimated separately. Factors observed to be significantly associated with VT/VF were further investigated using multivariate logistic regression. RESULTS: Sixty-nine patients suffered VT/VF (1.6%). There were 61 (1.4%) in-hospital/30-day deaths, 15 among patients who had postoperative VT/VF (21.7%). Patient factors independently associated with an increase in the odds of VT/VF included age <65 years, female gender, body mass index <25 kg/m(2), unstable angina, moderate or poor ejection fraction, and the need for inotropes and an intra-aortic balloon pump (OR 1.72 to 4.47, p < 0.05). After adjustment, off-pump surgery was associated with a substantial but nonsignificant protective effect against VT/VF (OR 0.53, 95% confidence interval [CI] 0.25 to 1.13; p = 0.10). Actuarial survival at two years was 98.2% among patients who had VT/VF and who survived to discharge/30 days, compared with 97.0% for the control group (adjusted hazard ratio 0.96 (95% CI 0.40 to 2.31, p = 0.92). CONCLUSIONS: The incidence of VT/VF is low in patients undergoing coronary surgery but is associated with high in-hospital mortality. The late survival of the discharged VT/VF patients compares favorably with that of controls.

Clinical outcomes in coronary artery bypass graft surgery: comparison of off-pump and on-pump techniques.

BACKGROUND: A consecutive series of patients undergoing first-time coronary artery bypass graft (CABG) surgery were analyzed and the impact of off-pump surgery was evaluated. METHODS: From January 1, 2000 to December 31, 2000, 367 patients underwent isolated first-time CABG surgery. One hundred and twenty underwent off-pump CABG (Group A, 32.7%) and 247 underwent conventional on-pump CABG (Group B, 67.3%). Five patients were converted during operation and were included in Group A. The pre-operative characteristics, intra-operative details, and post-operative course were analyzed in the two groups. All patients were followed up between 11 and 23 months (median 18 months) after operation by telephone interviews or questionnaire survey. RESULTS: Early mortality was 2.1% (group A, 0.83%; group B, 2.83%), with the difference not being statistically significant. The incidence of post-op stroke (group A, 1.66%; group B, 3.66%), renal failure (group A, 2.5%; group B, 5.66%), and gastrointestinal complications (group A, 1.66%; group B, 1.21%) was likewise not significantly different in the two groups. However, the patients in group A had a statistically significant lower incidence of low cardiac-output (group A 13.3%; group B 29.5%; p = 0.002), atrial fibrillation (group A 11.66%; group B 30.36%; p<0.001), blood product transfusion (group A 39.66%; group B 89.87%; p<0.001), time on ventilator (group A, 5.96 hrs; group B, 10.31 hrs; p<0.001), and post-op hospital stay (group A, 7.79 days; group B, 9.81 days, p<0.001). Medium-term results (recurrence of angina, late mortality, cardiovascular events, and need for revascularization) were similar in the two groups. CONCLUSIONS: Off-pump CABG results in a decreased incidence of complications in the immediate post-op period with comparable results in the medium term.