Effective treatment of 2,4,6-trinitrotoluene from aqueous media using a sono-photo-Fenton-like process with a zero-valent iron nanoparticle (nZVI) catalyst.

In this study, we examine the effectiveness of using a combination of a sono-photo-Fenton-like procedure and nano zero-valent iron catalyst (nZVI) to treat 2,4,6-trinitrotoluene (TNT) in an aquatic environment. Zero-valent iron particles were generated by a chemical reduction technique. nZVI nanoparticles were analyzed using scanning electron microscopy (SEM) and X-ray diffraction (XRD) to characterize the nanocatalyst. The resulting nZVI nanoparticles were used as an addition in a sono-photo-Fenton method to remediate an aqueous solution contaminated with TNT. Furthermore, influences of operational factors such as temperature, catalyst dosage, wavelength, ultraviolet power, ultrasonic frequency and power, pH level, H2O2/nZVI ratio, initial TNT concentration, and reaction duration on the treatment of TNT were investigated. Under the conditions of an ideal pH of 3, temperature range of 40-45 °C, concentration of 50 mg per L TNT, dose of 2 mM of nZVI, and ratio of H2O2/Fe0 of 20, a treatment efficiency of 95.2% was achieved after a duration of 30 minutes. The sono-photo-Fenton process combined with nZVI showed a higher TNT removal efficiency compared to the Fenton, sono-Fenton, and photo-Fenton processes under the same conditions. Moreover, it promises a potential solution to treat TNT at the pilot scale while allowing reuse of the nZVI catalyst and the limitation of sludge.

Hepatectomy using a combination of extrafascial extrahepatic (Takasaki approach) and extrafascial intrahepatic pedicle approaches (Ton That Tung approach).

Selective pedicle control and anatomical liver resection are considered standard techniques in hepatectomy for hepatocellular carcinoma. In 1963, Ton That Tung made significant improvements in hepatectomy techniques with the principle of locating and ligation of Glissonean pedicle in the liver parenchyma based on precise knowledge of vascular and biliary anatomy (Tung TT, Quang ND. A new technique for operating on the liver. Lancet 1963;281:192-3). In 1986, the extrafascial Glissonean dissection was first introduced by Takasaki in 1986. This is a simple and safe technique that helps to identify the exact borders between liver sections for anatomic liver resection (Takasaki K. Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation. J Hepatobiliary Pancreat Surg 1998;5:286-91). The combination of two techniques helps minimize complications, reduce ischemic time of future liver remnant, intraoperative blood loss and avoid migration of cancer cells into other segments.

A case of Wilson disease with the ATP7B mutation presenting movement disorders.

BACKGROUND: Wilson disease is an autosomal recessive condition manifested when abnormal copper accumulation in the body particularly involving many organs such as brain, liver, and cornea. Diagnosis is challenging with the completion of tests in blood and urine, a liver biopsy, and clinical evaluation. ATP7B mutations with more than 600 identified variants are the genetic disorders of Wilson disease. CASE DESCRIPTION: We report an adolescent case with no family history presented with extrapyramidal dyskinesia. Other symptoms include liver cirrhosis and Kayser-Fleischer ring. The typical presentation of blood test results and brain MRI images helps us to suspect Wilson disease in this case. We confirmed to have a p.R778L form and a p.S105X form in ATP7B mutations. After combining therapy with trihexyphenidyl and trientine, the patient's medical condition was stable and no side effects were observed. CONCLUSION: Screening for the diagnosis of Wilson disease is essential in helping patients benefit from early treatment and genetic counseling.

Cellulitis in older people over 75 years - are there differences?

AIM: To examine differences in risk factors, clinical features and outcomes of cellulitis between those 75 + years and those <75 years admitted to a metropolitan hospital. METHODS: A prospective study of patients with limb cellulitis requiring intravenous antibiotics conducted at Bankstown-Lidcombe Hospital, Australia from June 2014 to April 2015. RESULTS: Thirty one patients were 75 + years and 69 less than 75 years. A greater proportion of older patients resided in nursing home (25.8% vs 2.9% respectively, p = 0.001) and mobilized with walking aid(s) (58.1% vs 11.6% respectively, p < 0.001). Significantly more older patients had documented hypertension (45.2% vs 23.2% respectively p = 0.035), atrial fibrillation (33.5% vs 5.8% respectively, p < 0.001), dementia (22.6% vs 1.4% respectively, p = 0.001) and malignancy (16.1% vs 1.4% respectively, p = 0.010). The clinical presentation of cellulitis and cellulitis severity (Eron classification) did not significantly differ in both groups; however older patients were more likely to have dependent edema (OR 4.0, 95%CI 1.3-12.6, p = 0.018) and less likely to be obese (OR 0.3, 95%CI 0.1-0.8, p = 0.012) or had a past history of cellulitis (OR 0.3, 95%CI 0.1-1.0, p = 0.044) on presentation. Despite the age difference, there were no major differences in intravenous antibiotic choice, hospital length of stay, and hospital readmission rates in both groups. Older patients however, were more likely to experience complications such as falls and/or decreased mobility (38.7% vs 15.9% respectively, p = 0.020) during the cellulitis episode. CONCLUSION: There are minor differences in the risk factors and clinical features of cellulitis in older patients as compared to the young. Outcomes are similar except for a higher incidence of hospital related complications.

Venous thromboembolism in psychogeriatric in-patients--a study of risk assessment, incidence, and current prophylaxis prescribing.

BACKGROUND: While venous thromboembolism (VTE) risk assessment and prophylaxis is well established for medical and surgical in-patients, there is a paucity of evidence, and therefore guidelines, in this area for psychogeriatric in-patients. We wished to determine VTE incidence, risk, and use of prophylaxis, in a psychogeriatric in-patient population. METHODS: Retrospective audit of consecutive psychogeriatric patients aged 65 years and over admitted to Bankstown Hospital over a 3-year period, 2007-2009. Using an adapted VTE risk scoring system, patients were assigned as low, medium, or high VTE risk. RESULTS: A total of 192 patients were included in the study. Mean age was 79.1 ± 7.0 years. Out of the total, 55.2% of patients had diagnosis of dementia, and 33.3% had depression. Overall, 81.8% (157/192) were assessed as low risk, and 18.2% (35/192) as medium risk. Also, 16.7% (32/192) received VTE prophylaxis. Four new VTE events occurred in medium-risk group, and one in low-risk group (p = 0.004). Overall VTE incidence was 10.5/10,000 patient-days, but 44.2 per 10,000 in medium-risk group. VTE risk score was predictive of VTE events - IRR 6.02 (95% Confidence Intervals (CI) = 1.76-20.7, p = 0.004) for every one-point increment in risk. Depression was associated with significantly higher VTE occurrence (6.3% in those with diagnosis vs. 0.8% without, p = 0.043). CONCLUSION: Using a VTE risk scoring system adapted for psychogeriatric in-patients, those assessed to be at medium risk had a significantly increased rate of VTE. On this basis, we would recommend VTE prophylaxis be prescribed for psychogeriatric in-patients assessed to be at medium and high level of risk.

Pilot study into impaired judgement, self-toileting behaviour in fallers and non-fallers.

Falls are a significant cause of morbidity and mortality in older people. There is an increased frequency of falls in older adults with cognitive impairment and dementia which may be due to impaired judgement of self capability to mobilise safely. This case control study assessed 53 Aged Care subjects aged 75+ years that were hospitalised post fall, from January 2008-December 2009, and compared these subjects' responses to those of 26 non-fallers to a standard question: 'While you are in the hospital, what would you do if you need to go to the toilet later?' This hypothetical scenario question was designed to assess judgement based on self-toileting behaviour and mobility. The study group and control group were similar in age (83.9 ± 4.7 vs. 82.0 ± 4.6 years respectively, p = 0.081) but the study group had statistically lower MMSE results when compared to controls (median 23 vs. 26.5 respectively, p = 0.031). Impaired judgement, defined as an unsafe/inappropriate response to the scenario question, was significantly more prevalent in the study group (fallers) compared to the control group (non-fallers) (41.5 vs. 15.4 %, p = 0.020). Impaired judgement was also more common with lower MMSE scores with 80.9 % of unsafe/inappropriate responses given by participants with MMSE of ≤20. The authors suggest there may be an association between impaired judgement, evidenced by responses to a standardised question, and falls history in older subjects, particularly in those with cognitive impairment or dementia. Ultimately, this may lead to identification of people at increased risk of falls and possibly effective falls prevention strategies in this population.

Medical Assessment Units and the older patient: a retrospective case-control study.

OBJECTIVE: To evaluate the effect of a Medical Assessment Unit (MAU) on older patients. METHODS: Retrospective case-control study of patients 65 years and above admitted to the MAU (study group) and the general medical wards (control group) in Bankstown-Lidcombe Hospital from 1 October 2008 to 31 March 2009 with four most common Diagnosis-Related Groups (DRG) ('falls and gait disorder', 'chronic obstructive pulmonary disease (COPD)', 'other major respiratory diseases and 'cellulitis'). MAIN OUTCOME MEASURES: Length of stay (LOS) in Emergency Department (ED) and in the hospital, mortality, readmissions within 1 month, and discharge destination. RESULTS: Eighty-nine patients were studied; 47 in the MAU group and 42 in the non-MAU group. The MAU cohort was significantly older (84.1 ± 7.9 years v. 80.4 ± 7.8 years, respectively, P=0.03); and had shorter ED LOS (4.9 ± 3.0h v. 6.5 ± 2.8h, P=0.012). Overall hospital LOS did not differ except for patients with 'cellulitis', (5.7 ± 4.9 days for MAU cohort v. 14.8 ± 6.8 days for non-MAU cohort, P=0.022). There was no significant difference in mortality, readmission rate or discharge destination. Conclusions. The MAU can be an effective service model for older patients. More research is required to confirm this and to define the key elements that are essential for its effectiveness.

Characteristics associated with recurrent falls among the elderly within aged-care wards in a tertiary hospital: the effect of cognitive impairment.

In this study, we aimed to determine the factors associated with recurrent falls in aged-care inpatients at a tertiary hospital, with a focus on the cognitive domains of recurrent fallers. We retrospectively examined the characteristics of 70 aged-care inpatients who sustained ≥ 2 falls; 269 patients who sustained 1 fall; and 69 non-fallers during their hospital admission. We also analyzed the available Mini-Mental State Examination (MMSE) scores and sub-scores of 37 recurrent fallers, 163 single fallers, and 37 non-fallers. The independent risk factors for recurrent falls were a history of dementia, stroke, or atrial fibrillation; and patients' hospital length of stay >5 weeks. Protective factors were the patients' ability to speak English and a history of depression. Recurrent fallers had significantly lower MMSE scores than single fallers and non-fallers (17.3 ± 6.7, 20.2 ± 6.2, 24.0 ± 5.1, respectively, p < 0.01); and a larger proportion of recurrent fallers had MMSE <18 than in the other two groups (54.1%, 34.4% and 10.8%, respectively, p < 0.01). In addition, patients with recurrent falls were more likely to have significantly lower scores in the 'registration', 'attention and calculation', 'recall' and 'praxis' domains of the MMSE than single fallers. The findings from this study suggest that cognitive impairment particularly affecting short-term memory, recall and visuospatial perception may contribute to recurrent falls in the inpatient population. Prospective studies to elucidate a causal relationship may be worthwhile.

Characteristics associated with falls among the elderly within aged care wards in a tertiary hospital: a retrospective.

BACKGROUND: Falls are the most frequently reported adverse events in inpatient settings. We conducted a retrospective case-control study of inpatient falls within aged care wards in a tertiary hospital to investigate the associated characteristics of elderly patients suffering from falls and fall-related characteristics. METHODS: Consecutive retrospective cross-sectional design spanned July 2006 to December 2008. PATIENT GROUP: Information on all aged care inpatients who suffered from 1 or more falls was extracted from Incident Information Management System (IIMS). Further details about the particular admission(s) were obtained from patients' medical records, e.g., patients' characteristics and circumstances surrounding the falls. Randomly selected aged care patients who did not suffer from a fall and who were discharged from the hospital in the same period served control group. Characteristics among patients with single fall and recurrent falls, as well as non-fallers were compared. RESULTS: Of the 438 falls evaluated, 71.9% occurred in patients' room and 18.9% in patients' bathroom/toilet. The common activities were moving/transferring and taking shower/toileting, respectively, 70.3%, 12.1% while occurring falls; and time of falls had a high peak during 9:00-11:00 a.m. Many were unassisted while falling. The common contributing factors for fall were intrinsic factors. Patients with recurrent falls were more likely to have lower Mini-Mental State Examination (MMSE) score. Logistic regression analysis showed length of stay longer than five weeks, dementia and stroke were independent risk factors for recurrent falls; and living in hostel/nursing home preadmission, needing assistance with mobility, cognitive impairment, stroke, incontinence and arthritis/osteoporosis were independent risk factors for fall. CONCLUSIONS: In an aged care ward, falls are independently associated with recurrent factors. Cognitive impairment/dementia was a strong risk factor for falls, and main causes leading to fall were intrinsic factors. For patients with cognitive impairment/dementia and behavioral disorder providing special and effective interventions is of paramount importance for reducing the incidence of fall in an aged care ward in hospital settings.

Serum C-reactive protein as a biomarker for early detection of bacterial infection in the older patient.

BACKGROUND: although C-reactive protein (CRP) is widely used in younger populations, its value for diagnosing bacterial infection in older population is not well established. This study examined the usefulness of serum CRP level in the early detection of bacterial infection in older patients. METHODS: in a prospective cohort study, consecutive patients aged 70 years or over admitted to Aged Care wards were recruited. CRP levels were measured within 24 h of presentation, and their significance in predicting bacterial infections was analysed. The relationship between CRP and other clinical features of diagnosing bacterial infections (e.g. temperature, white cell count, neutrophil count, oxygen saturation, blood pressure and heart rate) was also examined. RESULTS: a total of 232 patients were recruited over a period of 3 months. CRP levels were 21.3 +/- 36.0 and 150.5 +/- 114.1 mg/l (mean +/- SD) in the non-infection and infection groups, respectively (P < 0.001). We found that the CRP cut-off value of 60 mg/l had the best combination of sensitivity and specificity. At this level, the sensitivity of diagnosing bacterial infection was 80.7%, specificity 96.0%, positive predictive value 91.9% and negative predictive value 89.8%. CRP and temperature had higher sensitivity and specificity than white cell count and neutrophil count in the diagnosis of infection. For every 1-mg/l increment in CRP, the risk of bacterial infection increases by 2.9%. CONCLUSION: CRP is a convenient and useful biomarker to predict early bacterial infection in older patients especially when other markers are atypical or not present.