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Aims Cryoballoon pulmonary vein isolation (PVI) is a safe and effective treatment for atrial fibrillation (AF). Current limitations include incomplete vein occlusion due to balloon rigidity and inconsistent electrogram recording, which impairs identification of isolation. We aimed to evaluate the acute safety and performance of a novel cryoballoon system. Methods and results The system includes a steerable sheath, mapping catheter, and a balloon that maintains uniform inflation pressure and size following initiation of ablation. Protocol-directed cryoablation was delivered for 180 s for isolation documented in ≤60 s, otherwise freeze duration was 240 s. Primary endpoints were acute safety and vein isolation. Pulmonary vein isolation was confirmed at ≥30 min post-isolation. Data were compared across vein locations. Thirty patients with paroxysmal AF were enrolled at two centres and underwent PVI. Pulmonary vein isolation was achieved with cryoablation only in 100% of veins (120/120). Nadir temperature was −53.1 ± 5.3°C. The number of applications to achieve PVI was 1.4 ± 0.4 per vein. Of the 120 veins, 89 were isolated with a single cryothermal application (10/30 patients required only 4 total cryoablations). There were no procedural- or device-related serious adverse events at 30 days post-procedure. A subset (24/30) of patients was followed for 1-year and 71% (17/24) remained free of atrial arrhythmias. Six patients with arrhythmia recurrence were remapped and three had durable PVI for all four veins. Conclusion In this first human experience, the novel cryoballoon platform was safe, efficacious, and demonstrated a high proportion of successful single ablation isolation.

Permanent pacemakers are usually implanted using the venous tributaries of the arms. There are clinical situations where this approach may not be ideal or even possible. In these situations, techniques for permanent pacing via the tributaries of the legs can be used. We describe a method of pacing via a femoral venous approach using a subcutaneous pocket. This technique provides a safe alternative pacing site when avoiding the chest and neck regions.

Purpose: To describe our experience in performing biopsy of post-septal orbital masses with core needle under computerized tomography guidance (CT-CNB). Methods: The medical records of all patients who underwent this procedure were reviewed. The procedure was performed under local anesthesia on a day case basis under a peribulbar block. A planning non-contrast computerized tomography (CT) scan of the orbits was performed to localise the mass. A 6-cm 18-G Temno Evolution® semi-automated biopsy needle was inserted through the skin into the orbit. Prior to further advancement of the needle, a low-dose CT limited to the previously determined plane was performed to confirm its position. The needle was then advanced, and the cutting needle was deployed to obtain the biopsy. Results: Five patients who underwent CT-CNB were identified. The CNB was successful in 4 patients and revealed a metastatic prostate adenocarcinoma, diffuse large B-cell lymphoma, a metastatic neuroendocrine tumour, and orbital inflammatory disease. The biopsy failed in the fifth patient when the needle failed to penetrate the tumour despite good localisation on CT. He was eventually diagnosed with fibrous meningioma of the greater wing of sphenoid on open biopsy. None of the patients had any complications other than peri-ocular bruising which was present in all of them. Conclusion: CT-CNB of mass lesions located in the lateral aspect of the orbit can be an alternative to open biopsy in selected cases. It avoids major surgery and allows the use of radiotherapy, if required, without any delay.

The thyroid gland secretes thyroxine (T4) and triiodothyronine (T3) in response to thyroid-stimulating hormone (TSH) released from the anterior pituitary gland. Iodine is essential for the synthesis of thyroid hormones. T4 and T3 increase basal metabolic rate, heat production and help to maintain normal growth and development. The parathyroid glands are essential for maintaining normal levels of serum calcium, which is necessary to maintain normal cellular function via calcium acting as a secondary messenger. Calcium is also involved in the coagulation of blood, transmission of nerve impulses and muscular contraction. Calcium is provided by various dietary sources and plasma levels are altered by varying absorption in the gut, mobilization from bone and excretion by the kidney.

Mixed bandgap and bandgap tunability in semiconductors is critical in expanding their use. Composition alterations through single-crystal epitaxial growth and formation of multi-layer tandem struct...

Background We meta‐analyzed the efficacy and safety of catheter (CA) vs thoracoscopic (TA) ablation for atrial fibrillation (AF). Methods PubMed, Embase, and Cochrane databases were searched until 31/12/2019 for relevant randomized trials and subsequent pooled analyses. Results In six trials totaling 465 patients (254 CA/211 TA), 1‐year AF recurrences were higher for CA (46% vs 26%, odds ratio 2.90 [95% CI 1.32‐6.38]), whereas total adverse events were lower (10% vs 25%, 0.35 [0.14‐0.86], respectively). Conclusion CA has lower efficacy but higher safety than TA. CA should remain the first‐line AF ablation strategy, and TA reserved for selected CA‐resistant patients where rhythm control is clinically necessary., This meta‐analysis of six randomized trials and 465 patients found that thoracoscopic ablation not only has significantly higher efficacy but also higher rates of adverse events, especially thoracic complications, compared to catheter ablation. Catheter ablation should remain the first‐line AF ablation strategy, and thoracoscopic ablation reserved for selected catheter ablation‐resistant patients after careful evaluation of relative benefits and risks by an AF Heart team.

Introduction Raised intracranial pressure (ICP) headache is rarely caused by spinal cord lesions. We present two patients with rare presentations of uncommon malignancies surrounding the cauda equina resulting in raised ICP headache. Cases Patient 1, a 54-year-old man, presented with two months of headache, blurred vision and 9kg weight loss. Fundoscopy revealed papilloedema. Shortly after presentation he developed lower limb weakness with absent tendon reflexes. MRI brain was unremarkable. MRI spine showed diffuse nerve root thickening and effacement of the CSF spaces around the cauda equina. Patient 2, a 51-year-old man, presented with four months of headache and blurred vision, progressive lower limb weakness and 20kg weight loss over 12 months. MRI brain showed two small lesions insufficient to cause raised ICP. MRI spine showed extensive lower spinal cord infiltration with diffuse thickening of the cauda equina. Pathological assessments revealed malignant histiocytosis in patient 1 and primary leptomeningeal gliomatosis in patient 2. Discussion These cases demonstrate the rare presentation of raised ICP headache resulting from spinal lesions. In both cases the original presentation with raised ICP headache and absent lower limb signs led to diagnostic delay. Malignant lesions in the spinal column can increase ICP, though the mechanism is debated. These cases emphasise the importance of a broader search for the aetiology of raised ICP headache in the absence of a causative lesion on primary brain imaging. Further, these cases highlight rare presentations of two uncommon pathological entities.

Objectives To assess whether head CT with 3D reconstruction can replace skull radiographs (SXR) in the imaging investigation of suspected physical abuse (SPA)/abusive head trauma (AHT). Methods PACS was interrogated for antemortem skeletal surveys performed for SPA, patients younger than 2 years, SXR and CT performed within 4 days of each other. Paired SXR and CT were independently reviewed. One reviewer analysed CT without and (3 months later) with 3D reconstructions. SXR and CT expert consensus review formed the gold standard. Observer reliability was calculated. Results A total of 104 SXR/CT examination pairs were identified, mean age 6.75 months (range 4 days to 2 years); 21 (20%) had skull fractures; two fractures on CT were missed on SXR. There were no fractures on SXR that were not seen on CT. For SXR and CT, respectively: PPV reviewer 1, 95% confidence interval (CI) 48–82% and 85–100%; reviewer 2, 67–98% and 82–100%; and NPV reviewer 1, 95%, CI 88–98% and 96–100%; reviewer 2, 88–97% and 88–98%. Inter- and intra-observer reliability were respectively the following: SXR, excellent (kappa = 0.831) and good (kappa = 0.694); CT, excellent (kappa = 0.831) and perfect (kappa = 1). All results were statistically significant (p Conclusions CT has greater diagnostic accuracy than SXR in detecting skull fractures which is increased on concurrent review of 3D reconstructions and should be performed in every case of SPA/AHT. SXR does not add further diagnostic information and can be omitted from the skeletal survey when CT with 3D reconstruction is going to be, or has been, performed. Key Points • Head CT with 3D reconstruction is more sensitive and specific for the diagnosis of skull fractures. • Skull radiographs can be safely omitted from the initial skeletal survey performed for suspected physical abuse when head CT with 3D reconstruction is going to be, or has been, performed.

Over recent years with the development of increasingly efficient scanners, the computed tomography (CT) scan of the head has become one of the most commonly requested initial investigations, used to provide an overview of the brain and its surrounding structures. In particular, the CT head scan has become significant in the trauma setting. With short scanning time, an investigation to confirm or exclude intracranial haemorrhage, skull fracture or stroke can now be performed in a matter of seconds. This article provides physicians with a structure for reading a CT head scan, to help identify key findings that may warrant further specialist neurosurgical or stroke team referral.

Background: The many causes of Intracerebral Haemorrhage (IH) can be difficult to differentiate. However, there are imaging features that can provide useful clues. This paper aims to provide a pictorial review of the common causes of IH, to identify some distinguishing diagnostic features and to provide guidance on subsequent imaging and follow up. It is hoped that this review would benefit radiology and non-radiology consultants, multi-professional workers and trainees who are commonly exposed to unenhanced CT head studies but are not neuroradiology specialists. Discussion: In the absence of trauma, Spontaneous Intracerebral Haemorrhage (SIH) can be classified as idiopathic or secondary. Secondary causes of IH include hypertension and amyloid angiopathy (75-80%) and less common pathologies such as vascular malformations (arteriovenous malformations, aneurysms and cavernomas), malignancy , venous sinus thrombosis and infection. SIH causes between 10 to 15% of all strokes and has a higher mortality than ischaemic stroke. Trauma is another cause of IH with significant mortality and some of the radiological features will be reviewed. Conclusion: Unenhanced CT is a mainstay of acute phase imaging due to its availability and, sensitivity and specificity for detecting acute haemorrhage. Several imaging features can be identified on CT and, along with clinical information, can provide some certainty in diagnosis. For those suitable and where diagnostic uncertainty remains CT angiogram, time-resolved CT angiography and catheter angiography can help identify underlying AVMs, aneurysms, cavernomas and vasculitides. MRI is more sensitive for the detection of subacute and chronic haemorrhage and identification of underlying mass lesions.

Background Vascular complications are common during invasive cardiac electrophysiology procedures. This meta‐analysis compares outcomes following ultrasound and nonultrasound‐guided vascular access for these procedures. Methods PubMed, Embase and Cochrane 01/01/1980‐30/09/2018 were searched for relevant studies to meta‐analyse. Results Seven studies (6269 patients) were included. Pooled rates and odds ratio(95% confidence interval) for ultrasound and nonultrasound subgroups were 1.2% vs 3.0%, 0.32 (0.21‐0.49) for all vascular complications, with less hematomas and arterial punctures but similar arteriovenous fistulas, pseudoaneurysms or retroperitoneal bleeds. Conclusion Ultrasound guidance had less complications due to less hematoma and arterial puncture, and is generally recommended for electrophysiology procedures., We meta‐analysed the vascular complications' rates for ultrasound versus non‐ultrasound guidance for vascular access of electrophysiological procedures from 7 studies totalling 6,269 patients. We found ultrasound guidance was associated with significantly lower rates of composite vascular complications, including less haematomas and arterial punctures, and should be generally encouraged for these procedures.

Efficacy of the BNT162b2 mRNA Vaccine in Qatar As of March 31, 2021, more than 265,000 people in Qatar had received both doses of the BNT162b2 vaccine. Viral sequencing indicated that 50.0% of infe...

Background During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19. Methods A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates. Results A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred. Conclusions Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.

Airway management is fundamental to anaesthesia, and technology may help with the safety of this procedure. Videolaryngoscopy is a developing area, which is becoming commonplace in anaesthesia practice.

Renewable energy polygeneration systems are a viable alternative to fossil-fuel based systems, but storage solutions may be necessary when aiming for high sustainability and autonomy. As each storage technology has different strengths and weaknesses, combinations of various storage solutions may lead to better techno-economic performance than singular approaches. To this purpose, an optimization model including a novel dispatch control strategy for a hybrid energy storage system (HESS) is proposed, which uses biogas for long-term and batteries for short-term storage. The model optimizes for minimum lifetime costs while exploiting the biomass resources with maximum efficiency and quantifying the additional solar and battery capacities needed. It is applied in a case study with an innovative biomass-based polygeneration system in a rural locality of Bolivia to serve electricity, potable water, and bio-slurry as fertilizer. The results indicate that even with maximized efficiency of the biomass resource conversion, large PV and battery capacities are necessary to satisfy the electricity demand of the locality. Despite of the high investment costs, the biomass-based polygeneration system would cost 22% less over the project lifetime than the fossil-fuel based reference system while being less dependent on fuel price changes. It would also reduce CO2-emissions by over 98%. This research has been conducted in collaboration between UPC (Universitat Politècnica de Catalunya) and KTH Royal Institute of Technology, funded through Erasmus Mundus Joint Doctoral Programme SELECT+, the support of which is gratefully acknowledged. The project STandUP for Energy provided resources for supervision of this study. AI acknowledges support from Spanish project MOET_BIA2016-77675-R.

Biomass-based, small-scale Combined Cooling, Heating and Power (CCHP) systems can increase the energy autonomy of building complexes while reducing their Greenhouse Gases (GHG) emissions. In combination with air-to-water Heat Pumps (HP), highly efficient energy systems can be designed, which allow for high flexibility in serving thermal and electric demands. This study presents an exergy evaluation of such a small-scale CCHP/HP system using a dynamic modelling approach based on gasification of various types of woody biomass. The transient model takes into account the effects of the biomass chemical composition as well as of ambient temperatures on the exergy performance of all key components for various CCHP system sizes supporting an HP system. The model has been applied in a case study for a historic building complex, where the CCHP sub-system would support an HP-subsystem allowing for downsizing the latter. The results show that smaller CCHP systems operate with higher exergy efficiency, because for larger systems the heat transfer from the engine and the operation of the absorption chiller are less exergy efficient. The electric load-following CCHP subsystem reaches exergy efficiencies of up to 13.3%, indicating huge improvement potential for system and sub-system design. It was also found that the biomass composition heavily influences the exergy efficiency of the gasifier and in turn changes the exergy efficiency of the syngas engine and the entire CCHP sub-system. Objectius de Desenvolupament Sostenible::9 - Indústria, Innovació i Infraestructura Objectius de Desenvolupament Sostenible::7 - Energia Assequible i No Contaminant Objectius de Desenvolupament Sostenible::12 - Producció i Consum Responsables Objectius de Desenvolupament Sostenible::13 - Acció per al Clima

Background Recently, a novel cryoballoon (CB; POLARx) has been developed with increased steerability which maintains size and pressure throughout the ablation. Initial clinical data has demonstrated acute procedural safety and efficacy in de novo pulmonary vein isolation (PVI) procedures in patients with paroxysmal atrial fibrillation (AF). However, there are limited studies demonstrating the long-term efficacy of the CB. Purpose To evaluate the long-term safety and efficacy of the novel CB in treating paroxysmal AF. Methods This was a non-randomized, prospective, multi-center study. Fifty-eight consecutive patients with paroxysmal AF were enrolled at 4 centers for de novo PVI procedures. Cryoablation was delivered for 180s if time to isolation was ≤60s. Otherwise a 240s cryoablation was performed. PVI was confirmed with entrance and exit block testing. Patients were followed for 1 year with 24-hour Holter monitoring at 3, 6, and 12 months. After a 3-month blanking period, recurrence was defined as having any documented, symptomatic episode(s) of AF or atrial tachycardia. Results Acute isolation with the CB was achieved in 230 of 231 pulmonary veins (99.6%) with 5.2±1.5 cryoapplications per patient (1.3±0.6 cryoapplications per vein). There were 4 patients (6.9%) with phrenic nerve injury (3 resolved during the index procedure; 1 resolved at 6 months follow-up). One serious adverse device event was reported: femoral arterial embolism event occurring 2 weeks post index procedure (1.7%). Of the 56 patients that had complete 12-month follow-up, 43 (76.8%) were free from recurrent atrial arrhythmias. Conclusion Initial multicenter clinical experience with the novel CB has demonstrated long-term safety and efficacy of PVI in patients with paroxysmal AF. Further studies are underway to confirm these findings. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boston Scientific

In the wake of the September 11 terrorist attacks, law enforcement in the United States began to employ powers and tactics that infringe upon the civil liberties of the suspects that they targeted. Though some of these uses have been challenged and reversed in the courts, there is still a portion of the population that believes that tactics like these, even up to torture, have been justified to combat terrorism. This study seeks to use General Social Survey data about people’s views of the use of expanded police and surveillance powers to combat terrorism to compare these with people’s age, sex, race, education, political ideology, and trust in different branches of the government. This will improve our understanding of who puts more emphasis on security over civil liberties when it comes to terrorist suspects. Through this analysis, it is found that political ideology was not as important as was thought in the literature. It was found that confidence in the military was the strongest indicator of people favoring policies that expanded surveillance and gave increased power to go after terrorist suspects.

Membrane distillation (MD) is a promising separation technology for the treatment of chemical mechanical planarization (CMP) wastewater releasing from nano-electronics industries. In order to determine the feasibility of the process at industrial scale, the most important factors are large-scale system evaluation and related economics. Since membrane distillation is a thermally driven process, therefore, different integration possibilities between an air gap membrane distillation (AGMD) system and low-grade heat sources are identified and analyzed in this work. Global mass and energy balances are conducted around AGMD system for CMP wastewater treatment in a typical nano-electronics manufacturing facility. It is determined that around 100 GWh of thermal energy can be readily recovered via internal sources and reused to treat 120,000 m(3) CMP wastewater/ year with MD feed temperature of 80 degrees C. Along with the technical feasibility of the system, the detailed economic evaluation has also been performed. Annual capital investment and operating cost showed that the expected CMP wastewater treatment cost can be as low as 3 $/m(3), which is estimated to be nearly 95% lower than the wastewater treatment cost using electro-chemical systems.

Background Microscopic colitis is a form of inflammatory bowel disease characterized by profuse non-bloody watery diarrhea. Macroscopic abnormality is not present on colonoscopy, and it requires biopsy for diagnosis. Few cases have been attributed to levodopa/dopa-decarboxylase inhibitor therapy. Method A retrospective cohort study of 21 patients on levodopa/benserazide and one patient on levodopa-carbidopa intestinal gel with clinically suspected or biopsy proven microscopic colitis. Results All 21 patients on oral levodopa/benserazide had resolution of diarrhea with cessation of the medication. Four patients discontinued levodopa permanently. Two were rechallenged with levodopa/benserazide without symptom recurrence. One patient on oral levodopa/carbidopa developed diarrhea only with intermittent dispersible levodopa/benserazide. 14 were switched to levodopa/carbidopa with resolution of diarrhea in 9 but symptom recurrence in 5. One patient on oral levodopa/benserazide developed profuse diarrhea when switched to levodopa-carbidopa intestinal gel. Of 7/22 patients who had colonoscopy and biopsy, 5 had histopathological proven microscopic colitis. Conclusion levodopa/dopa-decarboxylase inhibitor induced microscopic colitis may be more common than previously suspected, with the potential to affect treatment compliance and therapeutic options.

Background Pulmonary vein isolation using cryotherapy is an established treatment for the management of patients with paroxysmal atrial fibrillation. Ablation using the commercially available balloon cryocatheter has been shown to create wide antral pulmonary vein isolation. A novel balloon cryocatheter (BCC) has been designed to maintain uniform pressure and size during ablation, potentially improving contact with the antral anatomy. The extent of ablation created using the novel BCC has not previously been established. Purpose To determine the anatomical extent of pulmonary vein isolation using electroanatomical mapping when performing catheter ablation for paroxysmal atrial fibrillation using the novel BCC. Methods Nine consecutive patients underwent pre-procedure computed tomography angiography of the left atrium to quantify the chamber dimensions. An electroanatomical map was created using the cryoablation system mapping catheter and a high definition mapping system. A bipolar voltage map was obtained following ablation to determine the extent of pulmonary vein isolation ablation. A volumetric technique was used to quantify the extent of vein and posterior wall electrical isolation in addition to traditional techniques for proving entrance and exit block. Results All patients had paroxysmal atrial fibrillation, mean age 56 years, 7 (78%) male. Electrical isolation was achieved for 100% of the pulmonary veins; mean total procedure time was 109 min (+/- 26 SD), and fluoroscopy time 14.9 min (+/- 2.4 SD). The median treatment applications per vein was one (range one - four), and median treatment duration 180 sec (range 180 -240). Left atrial volume 32 mL/m2 (+/- 7 SD), and mean left atrial posterior wall area 22 cm2 (+/- 4 SD). Data was available for quantitative assessment of the extent of ablation for eight patients. No lesions (0 of 32) were ostial in nature. The antral surface area of ablation was not statistically different between the left and right sided pulmonary veins (p 0.63), which were 5.9 (1.6 SD) and 5.4 (2.1 SD) cm2 respectively. In total 50% of the posterior left atrial wall was ablated. Conclusion Pulmonary vein isolation using a novel BCC provides a wide and antral lesion set. There is significant debulking of the posterior wall of the left atrium. Abstract Figure.

Purpose: This study aimed to evaluate the impact of Patient As Teacher (PAT) sessions on the knowledge, communication skills, and participation of pharmacy students in the United Kingdom.Methods: During the academic year 2019–2020, year 1 and 2 pharmacy students at the University of Central Lancashire were invited to complete a questionnaire following PAT sessions. Data were analyzed by means of descriptive statistics, including mean and standard deviation for: continuous variables and reliability analysis. Pearson’s chi-square or Fisher exact test, odds ratio, and phi were used for analyzing dichotomous variables. Thematic analysis was used for free text comments.Results: Sixty eight of 228 students participated (response rate of 29.8%). No statistical difference was found between gender (P=0.090); a statistically significant difference was found between year (P=0.008). Cronbach’s α (0.809) confirmed a good internal consistency. Ninety-seven percent of the students learned a lot, and 85.3% appreciated and valued the PAT sessions; 89.7% wanted more sessions. Ninety-two point seven percent perceived the sessions to contextualize their learning. Five questions were dichotomized by grouping the responses into negative and positive; 90.3% of responses were positive and did not show statistically significant differences in gender and year of study. Overall students’ free text comments were positive, but active listening and consultation appeared in the positive and negative domains, highlighting the need for more student engagement.Conclusion: PAT sessions had a positive impact on students’ knowledge, communication skills and participation, and contextualized learning. They provide a valuable contribution to the pharmacy students’ experience in the United Kingdom.

Wastewater from chemical mechanical planarization (CMP) processes in nano-electronics industries must be treated properly in order to fulfil local and international environmental regulations. This study is focused on a performance assessment of membrane distillation (MD) technology for CMP wastewater treatment. A new prototype of air gap membrane distillation (AGMD) module was utilized, with feed water consisting of CMP wastewater collected from imec, Belgium. The module was tested at different operating conditions (temperatures, flow rates and filtration time) and responses in terms of separation efficiency, permeate water quality, transmembrane flux, specific heat demand and exergy efficiency were determined. High quality permeate was produced in all trials, i.e. conductivity ~2.11 µS/cm, pH ~5.4, TOC ~1.13 ppm, IC ~0.24 ppm, TDS ~1.18 ppm and COD ~ 1.9 ppm; for most of the contaminants the separation efficiency was >99%. These findings clearly show that the resulting MD permeate does not exceed environmental regulations for release to recipient, and the permeate can even be considered for reuse. Moreover, the determined specific heat demand at different operating conditions was varying between 1390 and 2170 kWh/m3 whereas; the achievable exergy efficiency was ~19%. QC 20191202

BACKGROUND/PURPOSE: Blood type has become an increasingly recognized risk factor for coagulopathy. We explored the association between blood type and hematoma expansion (HE) after intracerebral hemorrhage (ICH). METHODS: Spontaneous ICH patients prospectively enrolled in an ongoing ICH cohort study at Columbia University Irving Medical Center from 2009 to 2016 were evaluated. Primary ICH patients with admission blood type testing were evaluated for HE differences, defined as > 33% relative HE. The association of blood type with radiographic HE outcomes was assessed using multivariable logistic regression models. The association of blood type and poor clinical outcomes using modified Rankin Scale (mRS 4–6) was additionally explored. RESULTS: Of 272 ICH patients with blood type data and neuroimaging available to determine HE, there were 146 (54%) type-O, 82 (30%) type-A, 34 (13%) type-B, and 10 (3%) type-AB patients. No significant baseline demographic, clinical, or radiographic differences were noted between blood types. Type-B blood was associated with more HE compared to other blood types (OR 2.82; 95% CI 1.23–6.45) after adjusting for known covariates of HE (anticoagulant use, time to admission computed tomography scan, and baseline hematoma volume). No associations with blood type and poor 3 month mRS were identified, but these analyses were limited secondary to our smaller cohort. CONCLUSIONS: There may be differences in HE after ICH in patients with different blood types. Further work is required to replicate these findings and identify the pathophysiologic mechanisms behind coagulopathy between blood types after ICH.

Membrane distillation (MD) integrated with a district heating network (DHN) to supply the heat demand has been investigated in a bioethanol production plant (BP). The specific application considered here is ethanol recovery from fermentation off-gas (CO2) scrubber water, where the main objective of this study was to develop an air gap MD system that is driven by heat from DHN, thereby offloading the steam-driven distillation column. Experiments conducted on an MD laboratory facility combined with data from the bioethanol industry were used to assess the technological and economic feasibility of this integrated MD-DHN-BP system. Comparisons were also made between the distillation column and MD units regarding heat demand and economic savings. Results of the study showed that MD could be a competitive technology for ethanol recovery given that low-grade heat such as from district heating network or waste heat is accessible.

In this study, energy-related operational parameters for modern and traditional (conventional) sugar mills are analyzed, with the goals of identifying improvements in energy efficiency and potential for surplus electricity export. Results show that the power-to-heat ratio of modern and traditional mills is clearly distinct, lying in the ranges of 0.3–0.5 and 0.04–0.07, respectively. Modifications under consideration for the traditional mills include the following upgrades: electric drives and higher capacity back-pressure turbine (case 1); high-pressure boiler, condensing extraction steam turbine and electric drives (case 2); and improvements in case 2 plus bagasse drying (case 3). The thermodynamic impact of these modifications shows that more power is generated as the modification becomes more advanced. Case 1 exhibits a modest increase in cogeneration efficiency (4%) as compared to the base case, while the cogeneration efficiency increase is more marked for cases 2 and 3 (21% and 31%, respectively). Surplus power was studied in a regional context, where it was found that the contribution of 19 retrofitted sugar mills in nine Brazilian regions could supply 30% or more power as compared to current installed power capacity. The economic analysis showed that levelized cost of electricity (LCOE) was lowest for case 1 (11 USD/MWh) and highest for cases 2 and 3 (58 USD/kWh).

A persistent hypoglossal artery was first described in 1889 and is one of the more common anatomical variations arising from aberration in normal development. Endovascular coiling has been recognised as a robust treatment for acutely ruptured intracranial arterial aneurysms, although specific data regarding an aneurysm arising from a persistent hypoglossal artery is lacking due to the low incidence. Here we report both the oldest patient reported to be treated with a persistent hypoglossal artery-associated aneurysm and also explicitly report endovascular treatment of a persistent hypoglossal artery aneurysm arising at the posterior inferior cerebellar artery origin. Qualitative systematic review of the available medical literature demonstrates limited evidence regarding treatment of persistent hypoglossal artery-associated aneurysms with the majority being carried out via open surgery. Ruptured posterior inferior cerebellar artery aneurysm arising from a persistent hypoglossal artery can be successfully and safely treated by endovascular therapy via the persistent hypoglossal artery. Randomised study of this situation is unlikely to be feasible; however, qualitative review of the literature reveals six such aneurysms that have been treated surgically, and this case appears to be the first via an endovascular means.

The growing demand for energy and the accelerating threats from climate change call for innovative and sustainable solutions to decrease dependency on fossil fuels. Biomass -based, small-scale Combined Cooling, Heating and Power (CCHP) systems are one of these solutions, because they can satisfy the energy demands of the consumer with enhanced flexibility, l ower losses, less costs and less environmental pollution as compared to centralized facilities. Due to recent advances in several scientific subfields with relevance to small-scale CCHP, a rapidly increasing amount of literature is now available. Therefore, a structural overview is essential for engineers and researchers. This paper presents a review of the current investigations in small-scale CCHP systems covering biomass-fired concepts and solar extensions. To this end, critical system components are described and analysed according to their specific advantages and drawbacks. Recent case studies have been collected and key findings are highlighted according to each type of prime mover. The results indicate a scientific bias towards the economic viability of such systems and the need for real-life and experiment system data. However, the potential of biomass-fired CCHP systems and of such systems with solar extensions has clearly been recognised. Based on the results, future policy implementations should focus on fostering such systems in areas with high energy costs and to increase energy resilience in developed regions. Additionally research and industry applying novel prime mover technologies should be financially supported.

Infantile neuroaxonal dystrophy (INAD) is a rare autosomal recessive disorder that is associated with developmental delay and regression. A female patient of consanguineous parents presented with gross motor delay at 15 months. She was known to have two paternal uncles who had died with a diagnosis of INAD. Over the next 15 months, she exhibited regression in several domains and following genetic testing was diagnosed with a PLA2G6 mutation in keeping with INAD. The cerebellar vermis demonstrated a significant reduction in the N-acetylaspartate/creatinine (NAA/Cr) ratio of 0.69. This case highlights what we believe to be a new imaging feature of a low NAA/Cr ratio in the cerebellar vermis with normal ratios in the cerebellar hemispheres and basal ganglia in a patient with genetically confirmed diagnosis of INAD.

Impact of a reduction in heating, cooling and electricity loads on the performance of a polygeneration district heating and cooling system based on waste gasification

A novel integrated renewable-based energy system for production of synthetic diesel is proposed and simulated in this study. This system merges solid oxide electrolyser (SOE), entrained gasification (EG) and Fischer-Tropsch (FT) technologies. Two case scenarios are considered here. In the first case, the electrolyser unite produce syngas through co-electrolysis of steam and carbon dioxide, while in the second case only steam is electrolyzed. The effects of SOEC and EG operating pressure and temperatures on the system performance in each case are investigated and compared. It is shown that the operating condition of electrolyser subsystem has a more considerable effect on the performance of the integrated system as compared to the gasification subsystem. Also waste heat recovery results in about 43 and 2 percentage point increase in energy and exergy efficiency, respectively. It is also shown that internal recovering of oxygen has the best effect on the system performance.

In this study, a novel integrated system for production of advanced synthetic diesel is proposed and analyzed from thermodynamic, economic, and environmental perspectives. This system consists of solid oxide electrolyser (SOEC), entrained gasification (EG), Fischer-Tropsch (FT), and upgrading processes. Eleven different combinations of precursor syngas production through steam and CO2 co-electrolysis and biomass gasification are investigated. Results show that increasing share of produced syngas in electrolyser unit results in higher system efficiencies, emission savings, and levelized cost of FT diesel. Moreover, different options of heat and mass flow recovery are considered. It is concluded that recovery of produced medium pressure steam in the system is highly beneficial and recommended. Besides, it is shown that while oxygen recovery is the best choice of mass recovery, hydrogen recovery for internal use has adverse effect on the system performance. Although CO2 and water recovery do not show any pro...

Biogas upgrading to synthetic natural gas (SNG) is a viable and appealing route for power-to-gas because it combines waste management with the use of the surplus electricity that might arise in energy systems having a considerable share of renewable energy sources in their production mix. In this work, the exergo-economic performance of a biogas upgrading process through integrated electrolysis and methanation is assessed in connection with the current market status to test which conditions could make the proposed option economically viable. Two different configurations, which differ mainly for the operating pressure of the electrolyser, are compared. The exergy efficiencies are high (>80%) and exergo-economic costs of the produced bio-SNG in the two analyzed configurations are 5.62 and 4.87 c€/kWhexergy, for low- and high-pressure respectively. Lower values would be required for the bio-SNG to compete with fossil natural gas. We show how both the input electricity price and the capacity factor have a substantial impact on the economic sustainability of the process. Eventually, the monetary exploitation of the oxygen produced by electrolysis and the participation to the emission trading scheme could contribute further to improve the economic attractiveness of the process.

Conventional district heating and cooling (DHC) systems are compelled to reduce their fossil fuel dependency while ensuring profitability as cooling and heating demands decline. One solution is to ...

Background:Simulation-based education (SBE) has become commonplace in healthcare education within hospitals, higher education institutions, the private healthcare sector, and private education providers. The standards and quality of delivery vary across the UK [1], leading to differing degrees of learning for healthcare professionals. This variance in standards makes research into the impact of SBE on the end user (the patient) difficult to measure.Review:The delivery of SBE needs to be of a high standard if learningviathis pedagogy is to be maximised and benefits to patients are to be accurately assessed. This article aims to summarise the importance of quality within clinical SBE and how it can be achieved and maintained to produce a measurable impact on patient care. The current progress of the implementation of UK national standards for SBE is included to highlight the need for standardisation and guidance to support simulation centres and individuals to benchmark practice and work towards accreditation through quality measurement and monitoring processes. Suggestions are made on how such standards will affect the future of SBE and all those involved.Conclusion:There is a clear need for the development of national standards for SBE delivery and for a stepped approach [i.e. minimum, intermediate, and advanced standards] depending on the size, capacity, and frequency of SBE education delivery. Considerable financial outlay will be required to monitor standards effectively. The enhanced use of current and future technologies should be considered with regards to monitoring standards as well as data collection for future research opportunities.

Here, we presented a novel industrial application for membrane distillation (MD) in a pharmaceutical production facility’s wastewater treatment plant (WWTP). Two semicommercial air gap MD module designs (Xzero and Elixir500) were studied for comparison, with experimental results of product yield and heat demand up-scaled for inclusion in system simulations. District heating was considered to drive the 3 m3/h capacity MD process, with heat recovery employed in various process streams and for heating purposes in offices. The selected configurations show a high degree of thermal integration with an increase of yearly district heating purchases of 2–13%. Economic assessments of the full-scale MD system indicate that unit costs of purification would be $1.3/m3 and $7/m3 for Elixier500 and Xzero MD modules, respectively. Module heat losses should be considered in the future design of MD systems since the heat demand contributed to up to 77% of the specific costs.

Membrane distillation is a novel process that could be adapted effectively for many water purification applications. In recent years, several bench, pilot and commercial scale membrane distillation ...

District heating and cooling (DHC) systems, modified or retrofitted with integration of gasifiers and gas upgrading equipment, represent promising alternatives to traditional approaches since vario ...

The aim of this paper is to evaluate optimum design criteria for developing solar thermal integrated membrane distillation system for cogeneration of pure water and heat. The temporal and seasonal ...

Background The relative proportion of each cardiac inherited disease (CID) causing resuscitated sudden cardiac arrest (RSCA) on a population basis is unknown. Objectives This study describes the profile of patients with CIDs presenting with RSCA; their data were collected by the national Cardiac Inherited Diseases Registry New Zealand (CIDRNZ). Methods Data were collated from CIDRNZ probands presenting with RSCA (2002 to 2018). Results CID was identified in 115 (51%) of 225 RSCA cases: long QT syndrome (LQTS) (n = 48 [42%]), hypertrophic cardiomyopathy (HCM) (n = 28 [24%]), Brugada syndrome (BrS) (n = 16 [14%]), catecholaminergic polymorphic ventricular tachycardia (CPVT) (n = 9 [8%]), arrhythmogenic right ventricular cardiomyopathy (ARVC) (n = 9 [8%]), and dilated cardiomyopathy (n = 5 [4%]). Seventy-one (62%) of 115 were male. Of 725 probands from the CIDRNZ with CID, the proportion presenting with RSCA was: CPVT, 9 (53%) of 17; BrS, 16 (33%) of 49; ARVC, 9 (25%) of 36; LQTS, 48 (20%) of 238; dilated cardiomyopathy, 5 (9%) of 58; and HCM, 28 (8%) of 354. Incident activity was: normal everyday activities, 44 (40%); exercising, 33 (30%); concurrent illness, 13 (12%); sleeping, 10 (9%); drugs/medication, 9 (8%); and emotion, 2 (2%). LQTS and CPVT predominated in those 24 years of age, 49 (64%) of 76. For those >40 years of age, HCM was the most common (33%) CID. A genetic diagnosis in patients with CID was made in 48 (49%) of 98 tested. Diagnosis by age range was as follows: age 1 to 14 years, 78%; age 15 to 24 years, 53%; age 25 to 39 years, 54%; and age >40 years, 26%. Conclusions The commonest CID identified after RSCA was LQTS; the most common CID cause of RSCA for those >40 years of age was HCM. CPVT was the CID most likely to present with RSCA and HCM the least. Genetic yield decreases with age. Only one-third of RSCA cases due to CID occurred while exercising.

This study presents a comparative techno-economic feasibility analysis for two polygeneration plant solutions, applied to low-income dairy farms in Bolivia. The first option considers an internally fired microturbine (IFMT) and, the second, an internal combustion engine (ICE). They are integrated with an absorption refrigeration system and a fertilizer dryer. Biogas, produced with farms waste, fuels these power generators. The levelized costs of biogas for cooking, electricity, cooling and fertilizers were determined. The cost of biogas, for both options, was found to be 0.020 USD/kWh, which is lower than the subsidized price of LPG. The most competitive cost of electricity was determined for the ICE plant option; it was found to be 0.082 USD/kWh and is lower than the subsidized cost of fossil fuel-based electricity. The cost of cooling was found to be around 0.082 USD/kWh, which is slightly higher than the cost of cooling supplied by using grid electricity. In a realistic scenario, the shorter payback period was found to be 4.4 years for the ICE plant option. From this, the ICE-based plant was found as the most feasible option. Additionally, if no subsidies are applied to the fossil fuel-based services, the proposed polygeneration systems are a highly competitive alternative.

Objective: Among patients with status epilepticus, we sought to determine the rate of endotracheal intubation, identify the physician specialties responsible for endotracheal intubation, and characterize the trend in use of endotracheal intubation over the last 20 years. Methods: We performed a cross-sectional study using data from 2 sources. First, we used inpatient claims between 2009 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. Patients with status epilepticus were identified using International Classification of Diseases, 9th Revision, Clinical Modification ( ICD-9-CM) codes, and those who underwent endotracheal intubation were identified based on Current Procedural Terminology codes. Medical specialties of providers performing intubation were identified based on Healthcare Provider Taxonomy Codes. Second, we used claims data from the National Inpatient Sample (NIS) to estimate the annual rates and trends of endotracheal intubation and tracheostomy among patients with status epilepticus from 1995 to 2014. Results: Among 1971 Medicare beneficiaries with status epilepticus, 566 (29%) patients underwent endotracheal intubation. 375 (66%) patients were intubated on admission. The most common medical providers performing intubation in patients with status epilepticus were emergency medicine physicians (50.4%), anesthesiologists (16.4%), and pulmonary medicine physicians (10.1%). Neurologists accounted for 1.7% of all intubations. Among individuals with status epilepticus identified in the NIS, 248 681 (41.7%) were intubated. The proportion of patients intubated increased from 29.5% (95% confidence interval [CI]: 27.8%-31.3%, P = .018) in 1995 to 50.8% (95% CI: 49.6%-52%, P = .012) in 2014. The proportion of patients with status epilepticus who underwent tracheostomy increased from 2.2% (95% CI: 1.7%-2.7%, P = .005) in 1995 to 3.4% (95% CI: 3%-3.9%, P = .004) in 2014. Significance: Approximately 1 in 3 patients with status epilepticus undergo endotracheal intubation. Over the last 20 years, the proportion of patients with status epilepticus undergoing endotracheal intubation has almost doubled. Neurologists perform a small percentage of these intubations.

This paper presents a techno-economic feasibility study of a polygeneration plant proposed for an association of dairy farmers in Bolivia. The systems have been designed in an integrated approach and are based on the resource recovery utilizing available cow dung. The production of biogas is proposed using “low cost” tubular digesters. The biogas is used for the production of electricity and heat in a 40 kWel internal combustion engine. Heat from the exhaust gas is recovered to drive an absorption cooling system for milk refrigeration and for a bio-slurry drying system. The final services are biogas, electricity, cooling and fertilizers. The techno-economic analysis focuses on determining the levelized cost of the services and compare them with the subsidized and non-subsidized prices of other competitive services in the market. Sensitivity analyses for the services prices are carried out to see the influence of the feedstock handling cost and the subsidies on investment capital. Once the selling prices of the services are defined, the payback period of investment capital is determined. The results show that the biogas and electricity costs were found lower than the subsidized prices of similar services in the market while the cost of cooling was found slightly higher. From the sensitivity analysis we have that the feedstock handling cost can be increased from 10 to 18 USD/ton while maintaining the biogas price below the subsidized LPG price, and applying subsidies to the investment capital allows reducing the rest of the services costs. The payback period is around 3.5 years when a subsidy of 15% is applied in the investment capital and the services are sold at the subsidized prices of the conventional services. Our study has shown that under the conditions of the Bolivian market it is feasible the installation of a polygeneration plant. On the other hand, a market without or with reduced subsidies for the conventional services makes the proposed system more feasible and competitive.

Energy services are especially expensive on remote islands due to longer and more unstable fuel supply chains. In this paper, different renewable energy systems utilizing locally available biomass and solar energy are proposed as alternatives for a hotel resort on Neil Island, India. Based on local demand data, commercial information, and scientific literature, four cases are modelled with the simulation software HOMER and their economic, energetic, as well as ecological (3E) performances are compared. The robustness of each case configuration is tested with a sensitivity analysis. The results show that a biomass-based, solar-assisted combined cooling, heating, and power (CCHP) system offers an economic saving potential of more than 500,000 USD over twenty years and could decrease CO2 emissions by 365 t per year. When not applying CCHP measures, system performance is significantly worsened. A solar and battery-assisted diesel generator system shows similar economic outcomes as the CCHP system but worse ecological performance. Implementing the biomass-based CCHP system could improve the ecological footprint of the island, substantially decrease expenditure for the hotel owner, and generate a new source of income for surrounding farmers through biomass selling. QC 20190402

As governments and companies struggle to meet their own objectives for the energy transition, more innovative social and technological measures are needed to reduce Greenhouse Gas (GHG) emissions. For this purpose, an assessment of an off-grid polygeneration system, which can serve the electric and cooling demand of a neighbourhood in Hermosillo, Mexico, has been conducted. Energy computations have been done, the energy demand of one dwelling has been measured to ascertain the correctness of the computations, and a demand model for the entire neighbour-hood has been created. Based on the model, an off-grid polygeneration system has been designed, which uses a biodiesel engine, PV panels, and an absorption chiller. The system has been optimized for its economic performance and is compared to the currently used system. The results show that the polygeneration system with higher energy efficiency could reduce GHG emissions down to 14%. However, electricity in Hermosillo is heavily subsidized making it harder for innovative systems to compete. Moreover, even without the state subsidies to the end-user, the polygeneration system has still a nearly 30% higher Net Present Cost (NPC) than the conventional system over its project lifetime of 20 years. Nonetheless, with precise political incentives and further advances in the applied technologies, small-scale renewable polygeneration systems could become cost-efficient alternatives in the near future.