Urgent Replacement Research Articles

Pressure-Stabilized Flexible End-Effector for Selective Picking of Agaricus bisporus

Agaricus bisporus is widely cultivated worldwide due to its considerable economic benefits. The increasingly prominent contradiction between production and labor shortage necessitates the urgent replacement of human workers with intelligent picking technology and equipment. Therefore, a pressure-stabilized flexible end-effector was designed to achieve the rapid and low-loss picking of Agaricus bisporus. The dimensions of the end-effector were determined by measuring the external parameters of Agaricus bisporus. A mechanics model of the end-effector was constructed to analyze the picking process theoretically, and the pre-experiments identified the key performance factors of the end-effector: the thickness of the flexible membrane, the particle filler material, and the pressure stability. A series of experiments were conducted to investigate the factors mentioned above concerning the performance of the end-effector. The results show that the adsorption effect is best when the thickness of the flexible membrane is 0.9 mm, and the particle diameter is 200 mesh quartz. To control the adsorption force of the end-effector accurately during the picking process, a low-cost adsorption force-adjustment system was designed, and the stability of the system was verified. The experimental results showed that the device improved the stability of the adsorption force during the operation of the picking system by 84.71%. An experiment was conducted on the picking of Agaricus bisporus using the designed end-effector. The success rate of picking with the end-effector was 98.50%, and the picking damage rate was 2.50%.

Eco-friendly design of complex refractory aggregates as alternatives to the magnesia-chromite ones

Besides the good performance of electrofused magnesia-chromite aggregate (EMCA) in ceramic refractories, the generation of toxic Cr+6 after working conditions is driving its urgent replacement. Aiming at optimizing the search towards eco-friendly options, this work applied multiple electron-microscope-based techniques to assess its key microstructural features. BSE/EDS imaging coupled with thermodynamic calculations (CALPHAD) indicated that these aggregates were comprised of a periclase matrix where spinel precipitates (d50≈15μm) were embedded, inducing microcracking due to the thermal expansion mismatch. EBSD technique highlighted its pattern, revealing a good fit with {110} planes, which agrees with the Zener-Stroh crack mechanism. Designing concepts of compositionally complex ceramics were applied to find eco-friendly EMCA alternatives. From the 154 simulated systems, the four most promising ones were experimentally produced and characterized. Although kinetics aspects must be addressed, Cr-free EMCA-inspired microstructures were obtained, highlighting that this design approach can be used to support the development of novel raw materials.

An Early Prosthetic Valve Endocarditis in Presence of COVID-19-Associated Pneumonia

Introduction. Coronavirus disease (COVID-19)-associated pneumonia was a dangerous disease at the beginning of 2021. However, there are almost no records of early infectious endocarditis of prosthetic heart valve in the presence of such a disease. We present an interesting clinical case of successful treatment of complicated pathology.
 The COVID-19 outbreak involved unique clinical complications that were superimposed on the progressive heart failure due to prosthetic mitral valve dysfunction (its detachment) which did not allow time for active antiinflammatory therapy. Urgent replacement of the prosthesis made it possible to eliminate the infection and paved the way for successful long-term antibacterial, antifungal and antiviral therapy.
 The aim. To determine the features of management of patients with complex clinical pathology: prosthetic valve endocarditis associated with COVID-19 and severe lung inflammation in the early postoperative period.
 Case report. This work presents rare clinical case. A 46-year old male patient underwent successful surgery (mitral valve replacement with posterior leaflet preservation and left atrium resection) at the Department of Surgical Treatment of Acquired Heart Diseases of the National Amosov Institute of Cardiovascular Surgery and was discharged in satisfactory condition. One month later, he was hospitalized again and diagnosed with an early infectious endocarditis of prosthetic mitral valve and bilateral polysegmental COVID-19-associated pneumonia. After a week of medicinal preparation (antibacterial therapy), the patient underwent repeat mitral valve replacement in the presence of progressive heart insufficiency due to increasing paravalvular insufficiency. Postoperative period elapsed without significant complications. The patient was discharged in satisfactory condition on day 15 after surgery and primary rehabilitation.
 Conclusion. Having a specific etiology, pneumonia significantly damaged mitral prosthesis structures by increasing paravalvular insufficiency. Consequently, the patient underwent life-saving repeat mitral valve replacement in the presence of COVID-19-associated pneumonia and under massive antibacterial treatment which continued for 60 days after the patient’s discharge. An important element of successful treatment of COVID-19-associated pneumonia is the selection of adequate antibacterial, antifungal and antiviral drugs.

Global Warming, Air Pollution and Health

A new field of biomedical ethics is opening up, concerning what should be done to reduce the direct and indirect impacts of greenhouse gas emissions on human health. Some of these impacts could be described as ‘direct’, in the form of fatalities and illnesses due to the increasingly frequent heatwaves in many countries of recent years, ascribable to anthropogenic climate change. Other impacts are mediated through the air pollution that results from emissions from vehicles in the form of a cocktail of carbon oxides including carbon monoxide, nitrogen dioxide and particulates. Most of the world’s cities have streets with unsafe pollution levels, and one child’s death in Britain has been officially ascribed to air pollution (BBC 2020). This presentation aims to validate the above claims about the impacts of emissions on health, and to suggest remedies. The early phasing out of vehicles powered by internal combustion engines is the ultimate remedy for the latter set of impacts, while the urgent replacement of energy generated from fossil-fuel sources with renewable energy is the best way to remediate the former set. More immediate remedies for air pollution include restricting the use of roads and streets in urbanised areas by vehicles to bicycles and light vehicles with small engines. Medical and nursing education should include the diagnosis and treatment of pulmonary conditions resulting from increased levels of carbon oxides, nitrogen oxides and particulates. Medical and nursing practice should focus on the early identification of vulnerable adults and children at risk from air pollution, and warnings against walking, running or cycling along the most polluted thoroughfares.

Exploring the Transtheoretical Model of Change, Barriers, and Motives to Telemedicine Adoption in Athletic Training

Purpose: The delivery of healthcare services by athletic trainers (ATs) has evolved over the past two years as a result of the COVID-19 pandemic. Previous research has identified an integration of telemedicine as a necessary, urgent replacement for face-to-face patient encounters in athletic training; however, there is a lack of data to support the habitual and intentional change to one’s clinical practice that includes telemedicine. Therefore, the purpose of this study was to identify and analyze ATs respective stages of change related to telemedicine adoption, as well as explore motivating factors and barriers related to the adoption of telemedicine. Methods: We performed a cross-sectional study of 883 credentialed ATs. The survey contained a modified TTM stages of change assessment and 51-item telemedicine barriers and motives tool adapted from previous literature. A logistic regression was performed to assess highest level of education with telemedicine adoption status. Results: Overall, most ATs were categorized in the action, maintenance, and termination stage (n=551/882, 62.4%) for telemedicine adoption. Other participants were categorized in the stages as unaware (n=8, 0.9%), precontemplation (n=82, 9.3%), contemplation (n=78, 8.8%), and preparation (n=164, 18.6%). The logistic regression model was statistically significant (pConclusions: The results of the study suggest that most ATs have recently changed their delivery of healthcare in the last 6+ months and intend to maintain telemedicine use as part of their clinical practice. Additionally, telemedicine success was hampered by a lack of exposure but did feel that telemedicine fills gaps in patient care and addresses improved patient satisfaction. Additionally, increasing an ATs highest level of degree earned was associated with an increased likelihood of being in stage five on the modified-TTM assessment suggesting focused, professional development could sustain telemedicine use in athletic training.

Dredged sediments as a plant-growing substrate: Estimation of health risk index

Dredging of sediments is conducted worldwide to maintain harbours and water bodies. As a result, large amounts of materials generated require proper management and could have useful applications in a circular economy context. The current use of peat as organic material in cultivating plants requires urgent replacement by more sustainable alternatives. In this context, using nutrient-rich sediments generated by dredging could be an attractive option. However, due to contaminants in dredged sediments, more investigations are required. The present study investigated the potential to employ dredged material as a plant-growing substrate to cultivate lettuce (Lactuca sativa). The study employed compost and dredged sediments from Malmfjärden Bay, Sweden, with low and high nutritional content (LN and HN, respectively), with and without polymer (PO) used for dewatering. The tests were carried out under controlled conditions in a greenhouse, and the studied substrates were (% vol): (1) 100 % sediment (100SHN); (2) 50 % sediment +50 % compost (50SLN-50C); (3) 70 % sediment +30 % compost (70SLN-30C); (4) 50 % polymer sediment +50 % compost (50SPO-50C); and (5) 100 % compost (100C). Fertilisers were added to 50SLN-50C and 70SLN-30C during the experiment. Lettuces with the highest weight were harvested from substrates 100C, 50SPO-50C and 50SLN-50C. However, the lettuces only reached a weight of 18.57 ± 4.67 g. The results showed that a main limitation of the growth was probably a lack of aeration of the sediments during sampling and development of the experiment. The low aeration possibly caused a lack of available forms of N in the substrates, hindering the growth. Lettuces harvested from substrates containing sediments presented Cd concentrations slightly overpassing the Swedish thresholds, and the health risk index was marginally exceeding 1. Hence, sediments need to be pre-treated before using them to cultivate edible crops, or they could be employed to cultivate ornamental or bioenergy plants.

Stuck mechanical valve complication in non-COVID-19 patients during COVID-19 pandemic: single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Background Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. Purpose We wanted to explore how did the COVID-19 pandemic restrictions impacted mechanical valve replacement patients on chronic anticoagulation and the long-term consequences of limiting their access to health service. Methods We present a series of 10 patients on warfarin anticoagulation therapy who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Results Eight patients were female, two of whom were pregnant at the first trimester and eventually went on to receive an abortion; six patients received urgent valve replacement cardiac surgery; four patients were managed medically e.g. with heparin; none had thrombolytic therapy. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization including intensive care admission, with high in-hospital mortality rates and high costs were necessary. Mean hospital admission time was 27.5 ± 18.5 days. The cost of treatment, as average estimated reimbursement, was 11,000 USD for medical admission only, and 43,200 USD when surgery was required, up to 64,000 USD when ECMO was part of patient management. Conclusion Despite governments’ efforts to implement telemedicine and virtual clinics, COVID-19 restrictions and health-messaging affected the routine follow-up of non-COVID-19 patients. We report dramatic consequences to this drastic change in healthcare: clinical complications, lost lives and inflated healthcare costs in patients with a prosthetic valve. We believe that non-COVID-19 patients have paid, and will continue to pay in the future, a price that is much greater than those patients who have suffered from COVID-19. Active engagement of patients should be implemented in a time of emergencies, and further studies should address the efficacy and cost-effectiveness of public policies aimed to decrease the burden of avoidable complications and missed diagnoses. Abstract Figure. Fluoroscopy in a 70 years old patient

Loss of engagement in controlling chronic anticoagulation therapy during Covid-19 stringency measures. A single center experience of disproportioned increase of stuck mechanical valves.

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.

Association of hemodynamic factors and progressive aortic dilatation following type A aortic dissection surgical repair

Type A aortic dissection (TAAD) involves the ascending aorta or the arch. Acute TAAD usually requires urgent replacement of the ascending aorta. However, a subset of these patients develops aortic rupture due to further dilatation of the residual dissected aorta. There is currently no reliable means to predict the risk of dilatation following TAAD repair. In this study, we performed a comprehensive morphological and hemodynamic analysis for patients with and without progressive aortic dilatation following surgical replacement of the ascending aorta. Patient-specific models of repaired TAAD were reconstructed from post-surgery computed tomography images for detailed computational fluid dynamic analysis. Geometric and hemodynamic parameters were evaluated and compared between patients with stable aortic diameters (N = 9) and those with aortic dilatation (N = 8). Our results showed that the number of re-entry tears and true/false lumen pressure difference were significantly different between the two groups. Patients with progressive aortic dilatation had higher luminal pressure difference (6.7 [4.6, 10.9] vs. 0.9 [0.5, 2.3] mmHg; P = 0.001) and fewer re-entry tears (1.5 [1, 2.8] vs. 5 [3.3, 7.5]; P = 0.02) compared to patients with stable aortic diameters, suggesting that these factors may serve as potential predictors of aneurysmal dilatation following surgical repair of TAAD.

MO868CLINICAL OUTCOMES FOR INTRAVENOUS DRUG USERS REQUIRING HAEMODIALYSIS

Abstract Background and Aims Intravenous drug users (IVDU) face significant challenges when requiring long-term therapies such as dialysis and pose management dilemma to clinicians. Many patients present late, complicated by erratic lifestyles and complex mental health needs, often requiring urgent renal replacement therapy (RRT). Decisions regarding modality can be difficult due to the lack of evidence for outcomes in this cohort. We investigated the clinical outcomes of patients with history of IVDU in our service who presented with ESRD. Method A single-centre retrospective analysis of ESRD patients with a background of IVDU. Incidence of hospital and ICU admission, length of stay and frequency of culture positive sepsis following the initiation of RRT were investigated. Primary outcome was days admitted versus days spent in the community, frequency of life-threatening sepsis and tunnelled catheter replacement. Data was collected from the date of first RRT (earliest April 2015 and latest November 2019) to last follow-up in September 2020 or patient death. An admission was included when the patient was admitted for at least an overnight stay in hospital. Admission days calculated do not include attendance for outpatient haemodialysis. Bacteraemia’s were included when a report confirming a positive culture associated with clinical features of infection; paired samples were counted as a single episode. Results Six patients initiated RRT during the study period and included four males and two females. Mean age of 46.6 years (32-54 years). Cause of ESRD was Amyloid AA in 5) and IgA nephropathy in 1). Mean follow-up was 677 days till censor (range 313 to 932 days). There was an average of nine inpatient admissions (range 3 to 17) averaging 280 inpatient days (range 29 to 637 days) across the cohort. At last follow-up, three patients died with an average time to death of 833 days from initiation of RRT (range 664 to 932 days). Four patients required at least one admission to the Intensive Care Unit (ITU) with an average length of stay of 10.3 days (range 1 to 47 days). All patients experienced at least two episodes of culture positive sepsis with a total of 72 bacteraemia’s across the cohort (range 2 to 41). Four patients required tunnelled catheter replacement ranging from 2 to 7 catheters. Results are summarised in Table 1. Conclusion IVDU patients represent a challenging patient population to manage with limited options available for RRT. This study highlights these difficulties particularly with the use of tunnelled catheters for haemodialysis. Our results indicate RRT in IVDUs is associated with frequent and prolonged hospital stays with multiple bacteraemia’s, ICU admissions and significant mortality. Clinicians are faced with a significant ethical dilemma as tunnelled catheters represent both a lifeline for continued survival and a perfect access to recreational drugs. If patients are to be offered haemodialysis via tunnelled access, more intensive and earlier multidisciplinary planning and counselling needs to be employed to ensure patients are aware of the significance of the associated risks. Psychological therapy and social care input would be essential to help reduce morbidity and mortality.

Unusual complications following left ventricular assisted device implantation: case series

BackgroundWhile left ventricular assisted devices (LVAD) have revolutionized the treatment of advanced heart failure, they are associated with a wide range of complications, including bleeding and infection which are the most common complications reported in the literature. Our case series report four unusual complications not related to gastrointestinal bleeding and infections and their management.Case presentationA 61 year old female after LVAD implantation with late onset of severe symptomatic aortic regurgitation treated by transfemoral transcatheter valve implantation (TAVI) with good long term results.A 75 year old male patient with acute pump failure secondary to cable damage, who underwent urgent pump replacement. A 49 year old female patient with a history of myoma who developed massive uterine bleeding which was treated with emergent open hysterectomy after failed gonadotropin-releasing hormone therapy replacement. A 57 year old male patient with device display failure 1 month after LVAD implantation without the ability to monitor speed, power consumption and blood flow.ConclusionsLVAD patients can be presented with a great variety of complications. Physicians should be aware of their manifestations and the management options.

High sensitivity troponin and COVID-19 outcomes

Background Recent reports have demonstrated high troponin levels in patients affected with COVID-19. In the present study, we aimed to determine the association between admission and peak troponin levels and COVID-19 outcomes. Methods This was an observational multi-ethnic multi-centre study in a UK cohort of 434 patients admitted and diagnosed COVID-19 positive, across six hospitals in London, UK during the second half of March 2020. Results Myocardial injury, defined as positive troponin during admission was observed in 288 (66.4%) patients. Age (OR: 1.68 [1.49–1.88], p < .001), hypertension (OR: 1.81 [1.10–2.99], p = .020) and moderate chronic kidney disease (OR: 9.12 [95% CI: 4.24–19.64], p < .001) independently predicted myocardial injury. After adjustment, patients with positive peak troponin were more likely to need non-invasive and mechanical ventilation (OR: 2.40 [95% CI: 1.27–4.56], p = .007, and OR: 6.81 [95% CI: 3.40–13.62], p < .001, respectively) and urgent renal replacement therapy (OR: 4.14 [95% CI: 1.34–12.78], p = .013). With regards to events, and after adjustment, positive peak troponin levels were independently associated with acute kidney injury (OR: 6.76 [95% CI: 3.40–13.47], p < .001), venous thromboembolism (OR: 11.99 [95% CI: 3.20–44.88], p < .001), development of atrial fibrillation (OR: 10.66 [95% CI: 1.33–85.32], p = .026) and death during admission (OR: 2.40 [95% CI: 1.34–4.29], p = .003). Similar associations were observed for admission troponin. In addition, median length of stay in days was shorter for patients with negative troponin levels: 8 (5–13) negative, 14 (7–23) low-positive levels and 16 (10–23) high-positive (p < .001). Conclusions Admission and peak troponin appear to be predictors for cardiovascular and non-cardiovascular events and outcomes in COVID-19 patients, and their utilisation may have an impact on patient management.

Experience in inspection of loading structures of boiler frame BBP 210-140 with determination of their technical state and development of recommendations for further operation

Formulation of the problem. The boiler unit is lined in order to protect the surfaces of the supporting frame (columns, beams) from possible mechanical, thermal, physical and chemical damage. The importance of high-quality lining of thermal units has been known for a long time and there is a huge amount of information on this topic. It should be noted that the main load falls on the lining − this is the effect of high temperatures, aggressive chemical environment, mechanical stress and other factors during the operation of the heating unit. Particular attention should be paid to the lining device if the unit is metal, since the thermal expansion of the metal is much greater than that of the brick, which must be taken into account. There must be a gap for thermal expansion between the lining layer and the metal walls of the heating unit, otherwise the lining may simply collapse when the metal is heated. The gap is sealed with basalt wool in the form of bundles or sheets. The efficiency of the thermal boiler equipment fully depends on how durable, heat-resistant, energy-efficient, and repairable the lining will be. During operation, under the influence of high temperatures and chemical slags, the boiler lining gradually wears out. A timely high-quality repair of the boiler lining will protect the equipment from serious damage to the frame structures and urgent replacement of individual elements of the boiler equipment. The purpose of the article is to work on the technical inspection of the elements of the boiler frame BBP 210-140 due to the need to determine their actual technical condition and the development of recommendations for further safe operation. Assessment of technical condition is carried out on the basis of technical inspection (visual and instrumental) and verification calculations. To determine the stress strain state that occurs in the columns of the frame, test calculations were perform using the software package "Lira – Windows". Conclusion. Based on the results of technical inspection and verification calculations, it was found that the columns of the frame, due to the presence of significant plastic deformations in certain areas, caused in turn by the action of local high-temperature exposure, are no longer able to perceive the maximum operational loads. A variant of strengthening the columns of the boiler frame BBP 210-140 by the method of increasing the cross section is proposed.

Формалізовані критерії раціональності програми розвитку системи озброєння тактичної авіації Повітряних Сил Збройних Сил України на довгостроковій перспективі (прогнозованій) загрозі

Розглянуто основні можливі випадки нестачі бойової спроможності тактичної авіації Повітряних Сил Збройних Сил України на початку довгострокового періоду планування розвитку її системи озброєння та пов’язані з ними можливі варіанти обрання стратегій переоснащення авіаційних частин на нову бойову авіаційну техніку для ліквідації наявної нестачі. Названі варіанти стратегій пропонується звести у три основні групи, а саме стратегію сталого розвитку, коли необхідна спроможність досягається наприкінці періоду планування, стратегію постійної ліквідації нестачі спроможності вздовж всього періоду планування, та стратегію швидкої ліквідації нестачі спроможності за мінімально можливий час. Запропоновано формалізовані, із застосуванням методу бойових потенціалів, критерії раціональності програми розвитку системи озброєння тактичної авіації Повітряних Сил Збройних Сил України, за допомогою використання яких, на відміну від відомих методичних підходів, можливо здійснити синтез такої раціональної програми у зворотній постановці математичної задачі оптимізації.

A Case of Endogenous Endophthalmitis in COVID- 19 Pandemic

The home isolation from lockdown has limited the exchange of microflora in community. It benefits in limiting 2019 nCOV but collateral depletion in memory-based immunity has its own devastating consequences. It triggers subclinical infections, by reactivation of dormant pathogens or evolution of normal microflora into multidrug-resistant strains, which may escalate to endogenous infections. With the following case report, as a consequence of such unfortunate circumstances, we emphasize upon timely management of endophthalmitis, an ocular emergency, on promptly ruling out inflammatory etiologies, with modifications in protocol and due precautions as per the current COVID situation. The case demonstrates rapid response to acute endophthalmitis in a tertiary eye hospital with 24 h emergency services in a megacity amidst lockdown. The condition masqueraded as uveitis initially hence appropriate treatment got delayed by a week. Immediate aqueous sample collection for microbiological investigation and medical treatment with intravitreal injection antibiotics and steroid followed by intensive therapy with topical steroids and fortified drops aided in local delivery of drugs in better concentration than commercially available vials. Further surgical intervention, provided vitreous sample for microbial testing, debulked infection from vitreous. Growth of Enterobacter hormaechi was observed in vitreous sample, uncommon in endogenous endophthalmitis. Blood sample revealed drug-resistant Staphylococcus hominis. The patient regained vision successfully from mere perception of light to 6/60 within a few weeks. Such endogenous infections are highly alarming and necessitate urgent replacement of antibiotic abuse, over the counter treatments, approaching quacks, and fear of going to hospital with meticulous management by concerned specialists under updated protocols.

Percutaneous Nephrostomy Catheter Misplacement into Inferior Vena Cava in a Patient with a Horseshoe Kidney.

Background: Percutaneous nephrostomy (PCN) is commonly indicated for upper urinary tract drainage in case of obstruction or fistula. Only a few cases of PCN catheter misplacement into the inferior vena cava (IVC) have been published. Case Presentation: We report a case of a PCN catheter misplaced into the IVC through a fistula between the urinary tract and an ipsilateral renal vein in a patient with horseshoe kidney, after bedside urgent replacement for hemorrhage and hemorrhagic shock. Conclusion: Although a nephrostomy Foley catheter can be used for adequate urinary drainage and hemostatic purposes after percutaneous nephrolithotomy, its placement should be always verified through antegrade pyelography and particular care should be used for horseshoe kidneys. In case of massive hemorrhage, after temporary closure of the PCN catheter, the cause of bleeding should be investigated with urgent angiography or contrast-enhanced CT scan and promptly treated.

Impact of superimposed nephrological care to guidelines-directed management by primary care physicians of patients with stable chronic kidney disease: a randomized controlled trial

BackgroundOptimal clinical care of patients with chronic kidney disease (CKD) requires collaboration between primary care physicians (PCPs) and nephrologists. We undertook a randomised trial to determine the impact of superimposed nephrologist care compared to guidelines-directed management by PCPs in CKD patients after hospital discharge.MethodsStage 3b-4 CKD patients were enrolled during a hospitalization and randomised in two arms: Co-management by PCPs and nephrologists (interventional arm) versus management by PCPs with written instructions and consultations by nephrologists on demand (standard care). Our primary outcome was death or rehospitalisation within the 2 years post-randomisation. Secondary outcomes were: urgent renal replacement therapy (RRT), decline of renal function and decrease of quality of life at 2 years.ResultsFrom November 2009 to the end of June 2013, we randomised 242 patients. Mean follow-up was 51 + 20 months. Survival without rehospitalisation, GFR decline and elective dialysis initiation did not differ between the two arms. Quality of life was also similar in both groups. Compared to randomised patients, those who either declined to participate in the study or were previously known by nephrologists had a worse survival.ConclusionThese results do not demonstrate a benefit of a regular renal care compared to guided PCPs care in terms of survival or dialysis initiation in CKD patients. Increased awareness of renal disease management among PCPs may be as effective as a co-management by PCPs and nephrologists in order to improve the prognosis of moderate-to-severe CKD.Trial registrationThis study was registered on June 29, 2009 in clinicaltrials.gov (NCT00929760) and adheres to CONSORT 2010 guidelines.

Rhabdomyolysis requiring emergency dialysis as a consequence of simultaneous administration of simvastatin and clarithromycin

Iatrogenic complications from polypharmacy have significantly increased over the past decade and clinicians and pharmacists must remain aware of potentially dangerous drug interactions 1–3. Our case is a reminder of the potential for significant patient harm from drug interactions when additional medication that is seemingly innocuous is prescribed in addition to a patient’s regular long-term medications. Our case also highlights the diagnosis and management of rhabdomyolysis and acute kidney injury. A 75-year-old Caucasian male presented to the emergency department with nausea, bilateral calf tenderness and a reduced urine output. Creatinine Kinase (CK) levels demonstrated severe rhabdomyolysis and the patient’s creatinine was significantly elevated with a concurrent metabolic acidosis requiring urgent renal replacement therapy in the intensive care unit (ICU). He was recently prescribed clarithromycin 500mg twice daily as part of Helicobacter pylori eradication therapy in addition to his regular combination therapy of simvastatin 80 mg and ezetimibe 10 mg daily dose. Statins may cause dose dependent Statin Associated Myopathies (SAMs) such as myositis and rhabdomyolysis and are metabolised by the hepatic cytochrome P450 (CYP450) 3A4 enzyme4,5. Clarithromycin is a potent CYP450 3A4 hepatic enzyme inhibitor that leads to significantly elevated plasma levels of statin medications, increasing the risk of SAMs4,6–8. Our patient responded to the cessation of the offending medications and initiation of continuous renal replacement therapy. This case demonstrates the dangerous side effects and interactions of commonly prescribed medications.

Image-guided placement of percutaneous de novo low-profile gastrojejunostomy tubes in the pediatric population: a study of feasibility and efficacy.

De novo low-profile gastrojejunostomy tubes in pediatric patients offer less external catheter bulk and decreased propensity for dislodgement as children become more mobile. While small cohort studies have evaluated de novo placement of coaxial, adjustable-length, percutaneous gastrojejunostomy (GJ) tubes in children, placement of de novo low-profile GJ tubes in pediatric patients has not been analyzed. This study evaluates technical feasibility, safety and clinical efficacy of percutaneous, retrograde placement of de novo low-profile GJ tubes in infants and children. Following institutional review board approval, all de novo low-profile GJ tube placements in patients were retrospectively reviewed between May 2014 and May 2017. Technical parameters of fluoroscopy time, tube size, T-fasteners and complications were recorded. Clinical data, including age, indication, weight gain and complications, were analyzed. Thirty-four de novo low-profile GJ tubes were placed in 34 patients (median age: 9.4months, range: 2months-11.8years; median pre-procedural weight: 7.5kg, range: 2.9-31.6kg). Twenty-one 14-Fr and 13 16-Fr GJ tubes were placed with technical success rate of 100%. Average weight gain 3months' post procedure was 1.1kg (range: 0.3-4.8kg) and average weight percentile for age increase was 9.6% (range: -48.9% to 53.5%). One major complication occurred following balloon inflation within the tract causing pain requiring urgent replacement of the GJ tube. Minor complications occurred in 11 patients (32%): accidental dislodgement (n=9), skin irritation (n=4), tube dysfunction (n=2), leakage (n=2) and tube migration into the esophagus (n=1). Percutaneous, antegrade, image-guided placement of de novo low-profile GJ tubes is technically feasible, safe and clinically efficacious in appropriately selected pediatric patients.

DRUG PROVISION OF HIV INFECTED CRIMINALS IN INSTITUTIONS OF CRIMINAL-EXECUTIVE SYSTEM OF KRASNODAR REGION

The rapid spread of human immunodeficiency virus (HIV) leads not only to loss of health in persons held in penitentiary institutions, but also to an increase in material costs for drug coverage of the infected, causing the deficit in the budget of the Russian Federation. The aim of the study is the investigation of the problems in drug supply of HIV-infected people and to search for their solutions. Materials and methods . The investigation was conducted on the basis of statistic data, medical statements and accounting to reports of the penitentiary medical organization using methods of analysis, documentary observation, grouping and comparison of data. Results and discussion . It has been established that in institutions of the penal system the number of HIV-infected criminals continues to grow rapidly. It has been determined that currently in the criminal-executive system (CES) of Kuban’ only 5 classes of antiretroviral drugs out of the 10 classes represented on the Russian pharmacy market are used. Hereby the greatest number of drugs used in prison medical organization for conducting antiretroviral therapy (ARVT), are classified as “Nucleoside reverse transcriptase inhibitors” and “Protease Inhibitors”, and other classes of art drugs are represented by only one international nonproprietary name (raltegravir, enfuvirtide, etravirine). Drug treatment of socially significant infectious diseases is supplied centrally and completely satisfies regional needs. The structure of suppliers has been identified and determined. In 2016 the main suppliers were Joint-stock companies (JSC) “National Immunobiological Company” and “R-PHARM”. An acute shortage of drugs for opportunistic infections due to insufficient funding has also been determined. The necessity for urgent replacement of material-technical base in prison pharmacies for compliance with the rules of storage of medicines which can ensure their safety was identified. The imperfection of accounting medicines and urgent necessity of the centralization system of personified registration were revealed. Real needs in funding increasing and the establishment of Central pharmacy were identified. Conclusion. The revealed deficiencies indicate a critical need for opening Central pharmacy in the territorial bodies of the criminal-executive system and establishing a centralized system of personified registration of medical property, as well as improving the process of medical record keeping and the increase in funding.