Transient Diabetes Insipidus After Vasopressin Discontinuation.

Vasopressin infusion is commonly used in intensive care settings during states of advanced vasodilatory shock for its vasoconstrictive properties. Vasopressin also acts on renal tubular cell receptors in the collecting ducts of kidneys to allow for water reabsorption. The sudden discontinuation of vasopressin infusion can lead to the development of transient diabetes insipidus (DI) with classic findings of polyuria, dilute urine, and hypernatremia. We report the case of a 59-year-old male who underwent an emergent bedside cricothyrotomy procedure secondary to papillary carcinoma of the thyroid and subsequently developed septic shock requiring initiation of vasopressin infusion for hemodynamic support. He remained on vasopressin for five days before the infusion was discontinued after clinical improvement. Within 12 hours of vasopressin discontinuation, the patient developed polyuria (> 3 L/day urine output) with volumes as high as 1 L per hour. His serum sodium levels increased more than 10 mmol/L from 137 to 149 mmol/L. This case is unique from prior reports, as our patient was without any neurological or neurosurgical comorbidities that would predispose him to an organic central cause of DI. Furthermore, the patient's large-volume diuresis and serum abnormalities spontaneously self-improved within 24 hours without significant medical intervention. In conclusion, this case adds to a growing number of reports of transient DI following vasopressin withdrawal, demonstrating the need to formally recognize this occurrence as a potential consequence of vasopressin use in intensive care settings.

Causes of Death Among Medical ICU Patients With Pneumonia Due to COVID-19 in a Safety-Net Hospital.

We sought to identify the primary causes of death of adult patients admitted to the medical ICU with symptomatic COVID-19 who ultimately suffered in-hospital mortality over the span of three major waves of COVID-19: Wild-type, alpha/epsilon, and delta. DESIGN: Retrospective single-center cohort study from March 2020 to December 2021. SETTING: One medical ICU in a 600-bed Tertiary Care Hospital in Los Angeles, CA. PATIENTS: Adult (n = 306) ICU patients admitted with symptomatic COVID-19 who suffered in-hospital mortality. INTERVENTIONS: None. MAIN RESULTS: Of the 306 patients with COVID-19 who died in the hospital, 86.3% were Hispanic/Latino. The leading cause of death was respiratory failure, occurring in 57.8% of patients. There was no significant change in the rate of pulmonary deaths across the three waves of COVID-19 in our study period. The mean time from symptom onset to admission was 6.5 days, with an average hospital length of stay of 18 days. This did not differ between pulmonary and other causes of death. Sepsis was the second most common cause of death at 23.9% with a significant decrease from the wild-type wave to the delta wave. Among patients with sepsis as the cause of death, 22% (n = 16) were associated with fungemia. There was no significant association between steroid administration and cause of death. Lastly, the alpha/epsilon wave from December 2020 to May 2021 had the highest mortality rate when compared with wild-type or delta waves. CONCLUSIONS: We found the primary cause of death in ICU patients with COVID-19 was acute respiratory failure, without significant changes over the span of three waves of COVID-19. This finding contrasts with reported causes of death for patients with non-COVID-19 acute respiratory distress syndrome, in which respiratory failure is an uncommon cause of death. In addition, we identified a subset of patients (5%) who died primarily due to fungemia, providing an area for further investigation.

Exploring the potential of thermophilic anaerobic co-digestion between agro-industrial waste and water hyacinth: operational performance, kinetic study and degradation pathway.

Anaerobic co-digestion (co-AD) of agro-industrial waste, namely, palm oil mill effluent (POME) and sugarcane vinasse (Vn), with water hyacinth (WH) as co-substrate was carried out in two separate Anaerobic Suspended Growth Closed Bioreactors (ASGCBs) under thermophilic (55 °C) conditions. The highest chemical oxygen demand (COD) and soluble COD reduction in co-AD of POME-WH (78.61%, 78.86%) is slightly higher than co-AD of Vn-WH (75.75%, 78.24%). However, VFA reduction in co-AD of POME-WH (96.41%) is higher compared to co-AD of Vn-WH (85.94%). Subsequently, biogas production peaked at 13438 mL/day values and 16122 mL/day for co-AD of POME-WH and Vn-WH, respectively. However, the methane content was higher in the co-AD of POME-WH (72.04%) than in the co-AD of Vn-WH (69.86%). Growth yield (YG), maximum specific substrate utilization rate (rx,max) and maximum specific biomass growth rate (µmax) are higher in co-AD of POME-WH, as supported by the higher mixed liquor volatile suspended solids (MLVSS) and COD reduction efficiency compared to co-AD of Vn-WH. However, methane yield ([Formula: see text]) reported in the co-AD of POME-WH and Vn-WH are 0.2748 and 0.3112 L CH4/g CODreduction, respectively, which suggests that WH is a more suitable co-substrate for Vn compared to POME.

Chemical and biological combined treatment for sugarcane vinasse: selection of parameters and performance studies.

Sugarcane vinasse has been reported as a high strength industrial wastewater that could cause severe environmental pollution due to its complex and bio-refractory compounds. Thus, the combined coagulation and sequencing batch biofilm reactor (SBBR) system was employed for the sugarcane vinasse treatment. This study aims to determine the recommended conditions of various parameters under coagulation and SBBR and investigate the effectiveness of combined processes. First, the approach of the coagulation process could achieve the maximum COD reduction and decolorization efficiencies of 79.0 ± 3.4% and 94.1 ± 1.9%, respectively, under the recommended conditions. Next, SBBR as an integrated biofilm reactor showed excellent synergistic biodegradability, removing 86.6 ± 4.3% COD concentration and 94.6 ± 3.8% color concentration at 3.0 g·COD/L of substrate loading concentration. The kinetic studies of SBBR revealed that the first-order kinetic model was the best fit for COD reduction efficiency. In contrast, the second-order kinetic model was the best fit for decolorization efficiency. The SBBR reaction was further investigated by ultraviolet-visible spectrophotometry (UV-Vis). In the combined processes, SBBR followed by the coagulation process (SBBR-CP) showed greater COD reduction and decolorization efficiencies (97.5 ± 0.3 and 99.4 ± 0.1%) when compared to the coagulation process followed by SBBR (CP-SBBR). This study demonstrated the removal performance and potential application of the combined sequential process to produce effluent that can be reused for bioethanol production and fertigation. This finding provides additional insight for developing effective vinasse treatment using combined chemical and biological processes.

Spontaneous hemothorax in a 48-year-old man with COVID-19 acute respiratory distress syndrome.

A 48-year-old man presented with gradually worsening dyspnea three days after testing positive for COVID-19. He was admitted to the intensive care unit on maximum high flow nasal cannula settings and subsequently intubated for hypoxic respiratory failure due to COVID-19 pneumonia. Two weeks into the patient's hospital course, he unexpectedly developed worsening hypotension with multiple vasopressor requirements. Labs revealed an unexpected hemoglobin drop from 12.5 to 7.9 g/dL. Chest radiograph showed near complete opacification of the right hemithorax concerning for hemothorax. This case presentation describes a rare phenomenon of spontaneous hemothorax in a patient with COVID-19.

Kinetic model discrimination on the biogas production in thermophilic co-digestion of sugarcane vinasse and water hyacinth.

Co-digestion between sugarcane vinasse (Vn) and water hyacinth (WH) at various mixing ratios of 0:1, 1:0, 1:3, 3:1, and 1:1 was carried out under thermophilic conditions (55 °C) for 60 days. The effect of various mixing ratios on the pH changes, soluble chemical oxygen demand (sCOD) reduction, and cumulative biogas production was investigated. The first order, modified Gompertz, and logistic function kinetic models were selected to fit the experimental data. Model discrimination was conducted through the Akaike Information Criterion (AIC). The study revealed that co-digestion shows better performance compared to the mono-digestion of both substrates. Vn:WH mixing ratio 1:1 with inoculum to substrate ratio (ISR) of 0.38 g VSinoculum/g VSsubstrate is the most favorable ratio, achieving sCOD reduction efficiency and cumulative biogas production of 71.6% and 1229 mL, respectively. Model selection through AIC revealed that ratio 1:1 was best fitted to the logistic function kinetic model (R2 = 0.9897) with Ym and K values of 1232 mL and 31 mL/day, respectively.

Photocatalytic Degradation of Sugarcane Vinasse Using ZnO Photocatalyst: Operating Parameters, Kinetic Studies, Phytotoxicity Assessments, and Reusability.

ABSTRACT: Photocatalytic degradation performance is highly related to optimized operating parameters such as initial concentration, pH value, and catalyst dosage. In this study, the impact of various parameters on the photocatalytic degradation of anaerobically digested vinasse (AnVE) has been determined through decolourization and chemical oxygen demand (COD) reduction efficiency using zinc oxide (ZnO) photocatalyst. In this context, the application of photocatalytic degradation in treating sugarcane vinasse using ZnO is yet to be explored. The COD reduction efficiency and decolourization achieved 83.40% and 99.29%, respectively, under the conditions of 250 mg/L initial COD concentration, pH 10, and 2.0 g/L catalyst dosage. The phytotoxicity assessment was also conducted to determine the toxicity of AnVE before and after treatment using mung bean (Vigna radiata). The reduction of root length and the weight of mung bean indicated that the sugarcane vinasse contains enormous amounts of organic substances that affect the plant's growth. The toxicity reduction in the AnVE solution can be proved by UV-Vis absorption spectra. Furthermore, the catalyst recovery achieved 93% in the reusability test. However, the COD reduction efficiency and decolourization were reduced every cycle. It was due to the depletion of the active sites in the catalyst with the adsorption of organic molecules. Thus, it can be concluded that the photocatalytic degradation in the treatment of AnVE was effective in organic degradation, decolorization, toxicity reduction and can be reused after the recovery process.

Critical iron deficiency anemia with record low hemoglobin: a case report.

BACKGROUND: Anemia is a serious global health problem that affects individuals of all ages but particularly women of reproductive age. Iron deficiency anemia is one of the most common causes of anemia seen in women, with menstruation being one of the leading causes. Excessive, prolonged, and irregular uterine bleeding, also known as menometrorrhagia, can lead to severe anemia. In this case report, we present a case of a premenopausal woman with menometrorrhagia leading to severe iron deficiency anemia with record low hemoglobin. CASE PRESENTATION: A 42-year-old Hispanic woman with no known past medical history presented with a chief complaint of increasing fatigue and dizziness for 2 weeks. Initial vitals revealed temperature of 36.1 °C, blood pressure 107/47 mmHg, heart rate 87 beats/minute, respiratory rate 17 breaths/minute, and oxygen saturation 100% on room air. She was fully alert and oriented without any neurological deficits. Physical examination was otherwise notable for findings typical of anemia, including: marked pallor with pale mucous membranes and conjunctiva, a systolic flow murmur, and koilonychia of her fingernails. Her initial laboratory results showed a critically low hemoglobin of 1.4 g/dL and severe iron deficiency. After further diagnostic workup, her profound anemia was likely attributed to a long history of menometrorrhagia, and her remarkably stable presentation was due to impressive, years-long compensation. Over the course of her hospital stay, she received blood transfusions and intravenous iron repletion. Her symptoms of fatigue and dizziness resolved by the end of her hospital course, and she returned to her baseline ambulatory and activity level upon discharge. CONCLUSIONS: Critically low hemoglobin levels are typically associated with significant symptoms, physical examination findings, and hemodynamic instability. To our knowledge, this is the lowest recorded hemoglobin in a hemodynamically stable patient not requiring cardiac or supplemental oxygen support.

A Self-Empowered Upper Limb Repetitive Engagement Program to Improve Upper Limb Recovery Early Post-Stroke: Phase II Pilot Randomized Controlled Trial.

Background. Time outside therapy provides an opportunity to increase upper limb (UL) use during post-stroke hospitalization. Objective. To determine if a self-directed UL program outside therapy (Self-Empowered UL Repetitive Engagement, SURE) was feasible and to explore the potential effect of the SURE program on UL use and recovery. Methods. Twenty-three patients from an inpatient rehabilitation center who were ≤21 days post-stroke and had a Fugl Meyer UL (FMUL) score ≤50 and a positive motor evoked potential (MEP+) response were randomized (stratified by impairment) to either experimental group (SURE: individualized, UL self-exercise and use outside therapy for 6 hours/week for 4 weeks) or control group (education booklet). Feasibility was evaluated by program adherence, dropout rate, adverse events, and satisfaction. Potential effect was measured by paretic UL use via accelerometry weekly during the intervention, FMUL and Action Research Arm Test (ARAT) at baseline (Week 0), post-intervention (Week 4), and follow-up (Week 8 and Week 16). Results. Adherence to SURE was high: 87% program completion (mean 313±75 repetitions/day). There were no dropouts, no adverse events related to SURE, and patient satisfaction averaged 7.8/10. Experimental participants achieved an additional hour of UL use daily (range: .3-1.2 hours/day) compared to control. Significant improvements in FMUL and ARAT were observed in both groups from Week 0 to Week 4 and to Week 8 (P ≤ .002), which were maintained to Week 16. There were no differences between groups (P ≥ .119). Conclusions. SURE was a feasible self-directed program that increased UL use in MEP+ individuals with moderate-severe impairment early post-stroke. Further studies with larger sample sizes and potentially higher dose are required to determine efficacy.

Haldane-Andrews substrate inhibition kinetics for pilot scale thermophilic anaerobic degradation of sugarcane vinasse.

A pilot scale anaerobic degradation of sugarcane vinasse was carried out at various hydraulic retention time (HRT) in the Anaerobic Suspended Growth Closed Bioreactor (ASGCB) under thermophilic temperature. The performance and kinetics were evaluated through the Haldane-Andrews model to investigate the substrate inhibition potential of sugarcane vinasse. All parameters show great performance between HRT 35 and 25 days: chemical oxygen demand (COD) reduction efficiency (81.6 to 86.8%), volatile fatty acids (VFA) reduction efficiency (92.4 to 98.5%), maximum methane yield (70%) and maximum biogas production (19.35 L/day). Furthermore, steady state values from various HRT were obtained in the kinetic evaluation for: rXmax (1.20 /day), Ks (19.95 gCOD/L), Ki (7.00 gCOD/L) and [Formula: see text] (0.33 LCH4/gCOD reduction). This study shows that anaerobic degradation of sugarcane vinasse through ASGCB could perform well at high HRT and provides a low degree of substrate inhibition as compared to existing studies from literature.

A Nationwide Survey Study on Medical Student Experience in Acute Care Surgery.

BACKGROUND: There is little known about medical student education in acute care surgery (ACS)-how much and what type of exposure students receive in the specialty. The aim of this study was to investigate the current status of ACS education provided to students in U.S. medical schools. MATERIALS AND METHODS: We created an online survey tool covering the surgical clerkship and ACS curriculum and distributed this survey to the official email list of the Association for Surgical Education Committee on Clerkship Directors. RESULTS: A total of 57 of 294 (19.4%) responses were received. All respondents reported that at least some of their major teaching hospitals are affiliated with an ACS service and have a level 1 or 2 trauma center. Although almost two-thirds (61.8%) of respondents believe that medical students should have formal ACS education in the form of a clinical rotation, an ACS rotation is mandatory at only 16.4% of programs and is optional at 69.1% of programs as part of the surgical clerkship curriculum. The duration of ACS rotations ranges from 1 to 6 wk, and half of programs require students to take overnight call (most often 1-2 nights/wk). The most common pathologies that students see on ACS include appendicitis, biliary disease and cholecystitis, intestinal obstruction, and trauma. CONCLUSIONS: Medical students across the nation have varying exposure to ACS during their clinical training. With the continued growth of the ACS specialty, further study is warranted to examine the impact of undergraduate ACS education on student career planning.

Acute Care Surgery Education in US Medical Schools: A Systematic Review of the Current Literature and Report of a Medical Student Experience.

OBJECTIVE: There is currently little known about acute care surgery (ACS) education in US medical schools. The purpose of this paper was to systematically review the state of the literature describing ACS training at the medical school level and introduce an ACS education model provided to medical students at our institution. DESIGN: We conducted a comprehensive literature review using the PubMed database to identify all articles related to ACS (trauma surgery, emergency general surgery, and surgical critical care) and undergraduate medical education. PARTICIPANTS: A total of 376 articles were captured with our search strategy. The articles were reviewed for eligibility by 2 separate reviewers. RESULTS: We identified 3 relevant articles for our literature review. All studies were performed at level 1 trauma centers. The duration of ACS rotations ranges from 1 to 4 weeks with variable night call schedules. While several curricular changes have improved student perceptions on ACS education, none of the studies have thoroughly evaluated the impact on students' readiness or career choices for their postgraduate training. CONCLUSIONS: The current lack of information on ACS education in medical school has left us with a need to better understand this area in order to improve students' experience and exposure to the specialty. Future efforts should be placed on addressing current issues in ACS education and evaluating its impact on career choice of medical students.

Incidence and treatment of severe primary mitral regurgitation in contemporary clinical practice.

BACKGROUND: Mitral regurgitation (MR) is a common valvular disorder, occurring in up to 10% of the general population. Although surgery is the established treatment for primary MR, many patients do not receive appropriate therapy. The objective of this study was to determine the incidence and treatment pattern of patients with severe MR evaluated at a tertiary medical center and determine factors associated with receiving surgery. METHODS: All patients with moderate-severe and severe MR undergoing transthoracic echocardiography from 2011 to 2016 were identified. Patients with prior mitral valve surgery were excluded. Treatment recommendations were classified as referral to cardiology, referral to cardiothoracic surgery (CTS), receiving mitral valve surgery or receiving MitraClip. A multivariate logistic regression model was used to evaluate factors associated with referral to CTS or receiving surgery. RESULTS: During the study period, 1918 transthoracic echocardiogram were performed and 412 patients with moderate-severe or severe MR were identified. One hundred sixty-six patients (40%) had primary MR and 246 patients (60%) had secondary MR. For those with primary MR, 75 patients (45%) received treatment (surgery, n = 60 and MitraClip, n = 15) and 91 patients (55%) did not receive treatment. One hundred patients (60%) were referred to CTS and 128 patients (77%) were referred to cardiology. Patients undergoing surgery were younger (62.6 ±â€¯14.2 years vs 72.0 ±â€¯14 years, p < 0.001), with a higher prevalence of heart failure (57% vs 40%, p = 0.044) and a lower prevalence of stroke (3% vs 24%, p < 0.001) and hypertension (54% vs 74%, p = 0.012), compared to patients not undergoing surgery, respectively. Ejection fraction (60.4 ±â€¯10.9% vs 56.3 ±â€¯11.6%, p = 0.034), left ventricular end diastolic diameter (53.2 ±â€¯10.3 mm vs 48.7 ±â€¯10.9 mm, p = 0.040) and effective regurgitant orifice area (0.5 ±â€¯0.4 cm2 vs 0.3 ±â€¯0.1 cm2) were higher in patients undergoing surgery, compared to patients not undergoing surgery, respectively. The most common reason for not receiving surgery was that MR was not addressed by the treating physician and lost to clinical follow-up. Over 50% of patients that did not receive surgery had at least 1 indication based upon current practice guidelines. CONCLUSIONS: In contemporary clinical practice, less than half of patients with moderate-severe and severe primary MR received surgery and many were not referred for surgical consultation.

Efficacy of a Virtual Reality Commercial Gaming Device in Upper Limb Recovery after Stroke: A Randomized, Controlled Study.

OBJECTIVE: To compare the efficacy of a virtual reality commercial gaming device, Nintendo wii (NW) with conventional therapy and customary care in facilitating upper limb recovery after stroke. DESIGN: Randomized, controlled, single-blinded study. SETTING: Tertiary rehabilitation center. PARTICIPANTS: 105 subjects admitted to in inpatient rehabilitation program within 6 weeks of stroke onset. INTERVENTIONS: Subjects were randomly assigned to one of three groups of upper limb exercises: (1) NW gaming; (2) conventional therapy; (3) control. NW gaming and conventional therapy were provided fourtimes a week for 3 weeks. MAIN OUTCOME MEASURE(S): The main outcome measure was Fugl-Meyer assessment (FMA) of upper limb function. Secondary outcome measures included Action Research Arm Test, Functional Independence Measure, and Stroke Impact Scale. These measures were assessed at baseline, completion of intervention (week 3) and at 4 weeks and 8 weeks after completion of intervention. The primary outcome measure was the change in FMA scores at completion of intervention. RESULTS: The mean age was 57.5±9.8 years, and subjects were enrolled at a mean of 13.7±8.9 days after stroke. The mean baseline FMA score was 16.4±14.2. There was no difference in FMA scores between all 3 groups at the end of intervention, and at 4 and 8 weeks after completion of intervention. Similar findings were also noted for the secondary outcome measures. CONCLUSION(S): Twelve sessions of augmented upper limb exercises via NW gaming or conventional therapy over a 3-week period was not effective in enhancing upper limb motor recovery compared to control.

Sympathetic arousal increases a negative memory bias in young women with low sex hormone levels.

Emotionally arousing events are typically better attended to and remembered than neutral ones. Current theories propose that arousal-induced increases in norepinephrine during encoding bias attention and memory in favor of affectively salient stimuli. Here, we tested this hypothesis by manipulating levels of physiological arousal prior to encoding and examining how it influenced memory for emotionally salient images, particularly those that are negative rather than positive in valence. We also tested whether sex steroid hormones interact with noradrenergic activity to influence these emotional memory biases in women. Healthy naturally cycling women and women on hormonal contraception completed one of the following physiological arousal manipulations prior to viewing a series of negative, positive and neutral images: (1) immediate handgrip arousal-isometric handgrip immediately prior to encoding, (2) residual handgrip arousal-isometric handgrip 15min prior to encoding, or (3) no handgrip. Sympathetic arousal was measured throughout the session via pupil diameter changes. Levels of 17ß-estradiol and progesterone were measured via salivary samples. Memory performance was assessed approximately 10min after encoding using a surprise free recall test. The results indicated that handgrip successfully increased sympathetic arousal compared to the control task. Under immediate handgrip arousal, women showed enhanced memory for negative images over positive images; this pattern was not observed in women assigned to the residual and no-handgrip arousal conditions. Additionally, under immediate handgrip arousal, both high estradiol and progesterone levels attenuated the memory bias for negative over positive images. Follow-up hierarchical linear models revealed consistent effects when accounting for trial-by-trial variability in normative International Affective Picture System valence and arousal ratings. These findings suggest that heightened sympathetic arousal interacts with estradiol and progesterone levels during encoding to increase the mnemonic advantage of negative over positive emotional material.