Noninvasive ventilatory support in morbid obesity

BACKGROUND

In the conventional management of the morbidly obese that normalizes the apnea-hypopnea index (AHI), CO2 levels often remain elevated.

METHODS

A retrospective review of morbidly obese patients using volume preset settings up to 1800ml to positive inspiratory pressures (PIPs) of 25-55cm H2O, or pressure control at 25-50cm H2O pressure via noninvasive interfaces up to continuously (CNVS).

RESULTS

Twenty-six patients, mean 55.6±14.8 years of age, weight 108-229kg, mean BMI 56.1 (35.5-77)kg/m², mean AHI 69.0±24.9, depended on up to CNVS for 3 weeks to up to 66 years. There were eleven extubations and seven decannulations to CNVS despite failure to pass spontaneous breathing trials. Thirteen were CNVS dependent for 92.2 patient-years with little to no ventilator free breathing ability (VFBA). Six used NVS from 10 to 23h a day, and others only for sleep. Fifteen patients with cough peak flows (CPF) less than 270L/m had access to mechanical insufflation-exsufflation (MIE) in the peri-extubation/decannulation period and long-term. The daytime end-tidal (Et)CO2 of 14 who were placed on sleep NVS without extubation or decannulation to it decreased from mean EtCO2 61.0±9.3-38.5±3.6mm Hg and AHI normalized to 2.2. Blood gas levels were normal while using NVS/CNVS. Pre-intubation PaCO2 levels, when measured, were as high as 183mm Hg before extubation to CNVS.

CONCLUSIONS

Ventilator unweanable morbidly obese patients can be safely extubated/decannulated and maintained indefinitely using up to CNVS rather than resort to tracheotomies.

Telediagnosis of oral lesions in primary care: The EstomatoNet Program

OBJECTIVE

The diagnosis of oral lesions is often challenging for primary healthcare providers, which explains the high number of referrals to specialist care. This favors increases in waiting lines and delays in diagnosis, contributing to high mortality rates from oral cancer. This study aimed to summarize the experience of the EstomatoNet, a telediagnosis program catering to primary care dentists and physicians from southern Brazil.

STUDY DESIGN

This exploratory study included all queries received by EstomatoNet from June 2015 to December 2016. Health providers (71 dentists and 18 physicians from primary care) submitted requests including clinical information and photographs of oral lesions by means of a cloud-based platform. Specialized oral medicine teleconsultants received the data, conveyed a diagnostic hypothesis, and conveyed management recommendations.

RESULTS

Actinic cheilitis (n = 41, 15.8%), squamous cell carcinoma (n = 22, 8.5%), and inflammatory hyperplasia (21, 8.1%) were the most frequent diagnoses. Teleconsultants recommended referral to specialists in 42.9% of the cases, total biopsy in 23.6%, and follow-up in 16.2%. After the EstomatoNet use, the intention to refer the patients to face-to-face consultation reduced from 96.9% to 35.1%.

CONCLUSION

Telediagnosis for oral lesions is feasible and has potential to improve the quality of primary health care by bridging the gap between primary and specialized health care.

Strong dipole-quadrupole coupling and Fano resonance in H-like metallic nanostructures

Under certain conditions of the incident light polarization direction a Fano resonance arises in small gold nanorods arranged in a H-like configuration. This stems from the coupling between a bright dipole plasmon mode excited in the horizontal rod and dark quadrupole plasmon modes in both vertical rods. We investigate these surface plasmon modes, and analyze the dependence of the Fano resonance on the geometry parameters such as rod size and interparticle separation, and refractive index of embedding medium. To describe the degree of this energy transfer, we introduce a new parameter: the Fano resonance efficiency. We calculate absorption cross-sections for visible and NIR spectrum in each element of the structure, and near-field distributions at different wavelengths. We show that Fano resonance in small H-like structures exhibits high sensitivity with respect to the refractive index of the host medium, outperforming the values for larger plasmonic structures based on nanorods already investigated.

Electrochemical mineralization of anaerobically digested olive mill wastewater

A novel approach was developed for the energetic valorisation and treatment of olive mill wastewater (OMW), combining anaerobic digestion and electrochemical oxidation. The electrochemical treatment was proposed as the final step to mineralize the remaining OMW fraction from the anaerobic reactor. The electrooxidation of anaerobically digested OMW was investigated over dimensionally stable anodes (DSAs). RuO(2) based anode was significantly more efficient than IrO(2)-type DSA, mainly for the COD removal. IrO(2) based anode promoted a selective oxidation of phenols and colour removal. For instance, after an electrolysis charge of 10.4 × 10(4) C L(-1), COD removals of 14 and 99%, phenols removals of 91 and 100% and colour removals of 85 and 100% were obtained for IrO(2) and RuO(2) DSAs-type, respectively. The electrochemical post-treatment was effectively performed without using a supporting electrolyte and in the presence of the solids that remained from the anaerobic process. The achievement of the required effluent quality for sewer systems disposal depends on the operating conditions of the anaerobic process. Consequently, special care must be taken with the chloride and nitrogen levels that may surpass the legal discharge limits. The electrochemical oxidation over RuO(2) based DSA is an appropriate second-step treatment for OMW disposal, after the recovery of its energetic potential.

Strategies for lipids and phenolics degradation in the anaerobic treatment of olive mill wastewater

Strategies are proposed for the anaerobic treatment of lipid and phenolic-rich effluents, specifically the raw olive mill wastewater (OMW). Two reactors were operated under OMW influent concentrations from 5 to 48 g COD L(-1) and Hydraulic Retention Time between 10 and 5 days. An intermittent feeding was applied whenever the reactors showed a severe decay in the methane yield. This strategy improved the mineralization of oleate and palmitate, which were the main accumulated Long-Chain Fatty Acids (LCFA), and also promoted the removal of resilient phenolic compounds, reaching remarkable removal efficiencies of 60% and 81% for two parallel reactors at the end of a feed-less period. A maximum biogas production of 1.4m(3)m(-3)d(-1) at an Organic Loading Rate of 4.8 kg COD m(-3)d(-1) was obtained. Patterns of individual LCFA oxidation during the OMW anaerobic digestion are presented and discussed for the first time. The supplementation of a nitrogen source boosted immediately the methane yield from 21 and 18 to 76 and 93% in both reactors. The typical problems of sludge flotation and washout during the anaerobic treatment of this oily wastewater were overcome by biomass retention, according to the Inverted Anaerobic Sludge Blanket (IASB) reactor concepts. This work demonstrates that it is possible to avoid a previous detoxification step by implementing adequate operational strategies to the anaerobic treatment of OMW.

Anaerobic digestion challenge of raw olive mill wastewater

Olive mill wastewater (OMW) was digested in its original composition (100% v/v) in an anaerobic hybrid. High concentrations (54-55 kg COD m(-3)), acid pH (5.0) and lack of alkalinity and nitrogen are some OMW adverse characteristics. Loads of 8 kg COD m(-3) d(-1) provided 3.7-3.8 m3 biogas m(-3) d(-1) (63-64% CH4) and 81-82% COD removal. An effluent with basic pH (8.1) and high alkalinity was obtained. A good performance was also observed with weekly load shocks (2.7-4.1, 8.4-10.4 kg COD m(-3) d(-1)) by introducing piggery effluent and OMW alternately. Biogas of 3.0-3.4 m3 m(-3) d(-1) (63-69% CH4) was reached. Developed biomass (350 days) was neither affected by raw OMW nor by organic shocks. Through the effluents complementarity concept, a stable process able of degrading the original OMW alone was obtained. Unlike what is referred, OMW is an energy resource through anaerobiosis without additional expenses to correct it or decrease its concentration/toxicity.

Treatment of cervical dystonia with botulinum toxin in a patient with myasthenia gravis

We report the case of a 49-year-old woman who has the rare combination of myasthenia gravis and cervical dystonia. She was treated with botulinum toxin type A with good response and no evidence of deterioration of the myasthenic symptoms. We therefore conclude that it is possible to use botulinum toxin in the presence of defective neuromuscular transmission.

Identical twin discordance for the Brachmann-de Lange syndrome revisited

The only known twin pair evidently discordantly affected for the BDLS (Brachmann-de Lange syndrome) and who had been considered monozygotic (MZ) based on blood analysis remained a problem because biological zygosity determination needed further typing. In this report we review the clinical findings of this pair of twins at the age of 20. The use of DNA fingerprinting with three multilocus probes, F10, DNF24, and 33.6, allowed us to present evidence of monozygosity with a high degree of certainty. The significance of this confirmation of discordance in determining the cause of BDLS is discussed. Intensive comparative genomic studies of the discordant twin sisters may be useful to unravel the molecular genetics of this enigmatic pattern of malformation.

Mental scanning of visual images generated from verbal descriptions: towards a model of image accuracy

Recent mental scanning experiments have shown that subjects are not only able to construct mental images from verbal descriptions, but that these images have structural properties similar to those of images derived from perception. In addition, the specific sequencing of a description can affect the internal structure of images of described objects, in particular their metric properties. Discontinuous descriptions require additional exposure to achieve the structural coherence of images constructed from continuous descriptions. Thus, the capacity of images to reflect accurately the objects they refer to is not an all-or-nothing property, but rather results from stepwise elaboration. This study describes a quantitative model designed to account for the gradual process of image elaboration and the progressive increase in image accuracy. The model posits that the location of a landmark mentioned in a description is not represented as a sharp point in the mental image, but is instead associated with a region around this point. Learning the description essentially consists of progressively narrowing each 'region of uncertainty' associated with a landmark to its exact location. Additional experimental data were collected to provide a more finegrained understanding of image elaboration. Computations of the regions of uncertainty associated with each landmark were used to develop a computer program simulating the whole mental scanning protocol, which provided support for our account of image accuracy.