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Sample records for severe refractory status

  1. Refractory and severe status epilepticus in a patient with ring chromosome 20 syndrome.

    PubMed

    Hirano, Yoshiko; Oguni, Hirokazu; Nagata, Satoru

    2016-09-01

    Ring chromosome 20 [r(20)] syndrome is a rare chromosomal disorder that is characterized by the development of refractory epilepsy during childhood with gradual declines in cognitive performance and behavior. Although the prognoses of seizures and intellectual disability associated with this condition are poor, life-threatening complications have rarely been described. We herein presented a case of a 17-year-old female with [r(20)] syndrome who developed recurrent status epilepticus (SE) at 14years of age that evolved into unremitting SE in spite of vigorous antiepileptic treatments. She was administered thiopental anesthesia for 1year, and was subsequently left in severe neurological sequelae. It is important to note that patients with this syndrome not only have severe epileptic encephalopathy persisting into adulthood, but are also at risk of fatal SE. PMID:26980640

  2. Status Epilepticus and Refractory Status Epilepticus Management

    PubMed Central

    Abend, Nicholas S.; Bearden, David; Helbig, Ingo; McGuire, Jennifer; Narula, Sona; Panzer, Jessica A.; Topjian, Alexis; Dlugos, Dennis J.

    2014-01-01

    Status epilepticus (SE) describes persistent or recurring seizures without a return to baseline mental status, and is a common neurologic emergency. SE can occur in the context of epilepsy or may be symptomatic of a wide range of underlying etiologies. The clinician’s aim is to rapidly institute care that simultaneously stabilizes the patient medically, identifies and manages any precipitant conditions, and terminates seizures. Seizure management involves “emergent” treatment with benzodiazepines followed by “urgent” therapy with other anti-seizure medications. If seizures persist then refractory SE is diagnosed and management options include additional anti-seizure medications or infusions of midazolam or pentobarbital. This paper reviews the management of pediatric SE and RSE. PMID:25727508

  3. Management of refractory status epilepticus in adults

    PubMed Central

    Rossetti, Andrea O.; Lowenstein, Daniel H.

    2011-01-01

    Summary Refractory status epilepticus (RSE) can be defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug. RSE should be treated promptly to prevent morbidity and mortality; however, scarce evidence is available to support the choice of specific treatments. Major independent outcome predictors are age (not modifiable) and etiology (that should be actively targeted). Recent recommendations for adults, relying upon limited evidence, suggest that RSE treatment aggressiveness should be tailored to the clinical situation: to minimize ICU-related complications, focal RSE without major consciousness impairment might initially be approached more conservatively; conversely, early induction of pharmacological coma is advisable in generalized-convulsive forms. At this stage, midazolam, propofol or barbiturates represent the most used alternatives. Several other treatments, such as additional anesthetics, other antiepileptic or immunomodulatory compounds, or non-pharmacological approaches (electroconvulsive treatment, hypothermia), have been used in protracted RSE. Treatment lasting weeks or months may sometimes result in a good outcome, as in selected cases after cerebral anoxia and encephalitis. Well-designed prospective studies of this condition are urgently needed. PMID:21939901

  4. Propofol Infusion Syndrome in Refractory Status Epilepticus

    PubMed Central

    Hwang, Woo Sub; Gwak, Hye Min; Seo, Dae-Won

    2013-01-01

    Background and Purpose: Propofol is used for treating refractory status epilepticus, which has high rate of mortality. Propofol infusion syndrome is a rare but often fatal syndrome, characterized by lactic acidosis, lipidemia, and cardiac failure, associated with propofol infusion over prolonged periods of time. We investigated the clinical factors that characterize propofol infusion syndrome to know the risk of them in refractory status epilepticus. Methods: This retrospective observation study was conducted in Samsung medical center from Jan. 2005 to Dec. 2009. Thirty two patients (19 males, 13 females, aged between 16 and 64 years), with refractory status epilepsy were included. Their clinical findings and treatment outcomes were evaluated retrospectively. We divided our patients into established status epilepticus (ESE) and refractory status epilepticus (RSE). And then the patients with RSE was further subdivided into propofol treatment group (RSE-P) and the other anesthetics treatment group (RSE-O). We analyzed the clinical characteristics by comparison of the groups. Results: There were significant differences of hypotension and lipid change between ESE and RSE (p<0.05). However, there was no significant difference between RSE-P and RSE-O groups. The hospital days were longer in RSE than in ESE (p=0.012) and treatment outcome was also worse in RSE than in ESE (p=0.007) but there were no significant differences of hospital stays and treatment outcome between RSE-P and RSE-O. Conclusions: RSE is very critical disease with high mortality, which may show as many clinical changes as propofol infusion syndrome. Therefore propofol infusion syndrome might be considered as one of the clinical manifestations of RSE. PMID:24649467

  5. Pediatric Super-Refractory Status Epilepticus Treated with Allopregnanolone

    PubMed Central

    Broomall, Eileen; Natale, JoAnne E.; Grimason, Michele; Goldstein, Joshua; Smith, Craig M.; Chang, Celia; Kanes, Stephen; Rogawski, Michael A.; Wainwright, Mark S.

    2015-01-01

    Super-refractory status epilepticus is a life-threatening condition. Resistance to benzodiazepine and barbiturate treatment for this disorder is thought to be due to internalization of synaptic γ-aminobutyric acid (GABA)A receptors, and withdrawal of benzodiazepines and barbiturates during treatment often triggers seizure recurrence. The neurosteroid allopregnanolone acts as a positive allosteric modulator of synaptic and extrasynaptic GABAA receptors. Here we describe the use of allopregnanolone in 2 pediatric patients with super-refractory status epilepticus. This treatment allowed the general anesthetic infusions to be weaned with resolution of status epilepticus. This is the first report of allopregnanolone use to treat status epilepticus in children. PMID:25363147

  6. Severe refractory hypertension during shoulder arthroscopy

    PubMed Central

    Abrons, RO; Ellis, SE

    2016-01-01

    The use of epinephrine-containing saline irrigating solutions during arthroscopic shoulder surgery gained popularity after it was reported that the addition of epinephrine reduced bleeding and improved visualization without adverse cardiovascular effects. We share a case of a patient undergoing shoulder arthroscopy who received a standard intra-articular infusion of epinephrine-containing normal saline (1 mcg/mL) and experienced severe hemodynamic consequences. PMID:27051380

  7. Targeted therapeutics for severe refractory asthma: monoclonal antibodies.

    PubMed

    Grainge, Christopher L; Maltby, Steven; Gibson, Peter G; Wark, Peter A B; McDonald, Vanessa M

    2016-07-01

    Severe asthma is a complex multifactorial disease that requires specialist multidisciplinary input for optimal clinical outcomes. Following multidimensional assessment for optimisation of current therapy, self-management skills and comorbidities, all patients should be accurately phenotyped. Only after this assessment has been completed should new monoclonal antibody therapies be considered. In this review, we summarise the new antibody approaches targeting identified pathological pathways in severe refractory asthma. PMID:27018798

  8. Severe and refractory hypertension in a young woman.

    PubMed

    Cuadra, René H; White, William B

    2016-06-01

    Refractory hypertension in a young person is an uncommon clinical problem, but one that may be referred to hypertension specialists. Factitious hypertension is fortunately quite rare but should be considered when evaluating patients who are refractory to numerous classes of antihypertensive therapies and have failed to achieve control despite input from multiple providers. A 19-year-old woman was referred to us after failing to achieve blood pressure control by a primary physician and two subspecialists in nephrology and hypertension; she also had numerous emergency department visits for symptomatic and severe hypertension. Exhaustive diagnostic testing for secondary causes and witnessed medication dosing in an outpatient setting was unrevealing. Subsequent inpatient admission demonstrated normalization of BPs with small doses of intravenous antihypertensive agents. During the hospitalization, she was observed "pocketing" her oral medications in the buccal folds and then discarding them in a trash container. Confrontation by psychiatrists and the hypertension specialists led to the admission that she had learned to start and stop beta-blockers and clonidine to induce severe, rebound hypertension. Factitious and induced hypertension is a rare cause of resistant or refractory hypertension. Nevertheless, hypertension specialists should suspect the diagnosis when there is a history of visits to multiple institutions and physicians, negative secondary workup, absence of overt target organ damage, history of psychiatric illness, and employment in the medical field. PMID:27160032

  9. Volatile anesthetic for the control of posthypoxic refractory myoclonic status

    PubMed Central

    Rayadurg, Vivek; Muthuchellappan, Radhakrishnan; Rao, Umamaheshwara

    2016-01-01

    Posthypoxic myoclonus (Lance–Adams syndrome) is characterized by myoclonus involving multiple muscle groups which is resistant to most conventional antiepileptic drugs. We present a case of hypoxic brain injury-induced myoclonic status epilepticus successfully controlled with isoflurane. The antimyoclonic effects of isoflurane are likely due to potentiation of inhibitory postsynaptic GABAA receptor–mediated currents and its effects on thalamocortical pathways. It is effective even when intravenous agents fail to control myoclonus. It may be a useful alternative to intravenous anesthetics as a third tier therapy in patients with refractory status myoclonus.

  10. Ketogenic diet for adults in super-refractory status epilepticus

    PubMed Central

    Thakur, Kiran T.; Probasco, John C.; Hocker, Sara E.; Roehl, Kelly; Henry, Bobbie; Kossoff, Eric H.; Kaplan, Peter W.; Geocadin, Romergryko G.; Hartman, Adam L.; Venkatesan, Arun

    2014-01-01

    Objective: To describe a case series of adult patients in the intensive care unit in super-refractory status epilepticus (SRSE; refractory status lasting 24 hours or more despite appropriate anesthetic treatment) who received treatment with the ketogenic diet (KD). Methods: We performed a retrospective case review at 4 medical centers of adult patients with SRSE treated with the KD. Data collected included demographic features, clinical presentation, diagnosis, EEG data, anticonvulsant treatment, and timing and duration of the KD. Primary outcome measures were resolution of status epilepticus (SE) after initiation of KD and ability to wean from anesthetic agents. Results: Ten adult patients at 4 medical centers were started on the KD for SRSE. The median age was 33 years (interquartile range [IQR] 21), 4 patients (40%) were male, and 7 (70%) had encephalitis. The median duration of SE before initiation of KD was 21.5 days (IQR 28) and the median number of antiepileptic medications used before initiation of KD was 7 (IQR 7). Ninety percent of patients achieved ketosis, and SE ceased in all patients achieving ketosis in a median of 3 days (IQR 8). Three patients had minor complications of the KD including transient acidosis and hypertriglyceridemia and 2 patients ultimately died of causes unrelated to the KD. Conclusion: We describe treatment of critically ill adult patients with SRSE with the KD, with 90% of patients achieving resolution of SE. Prospective trials are warranted to examine the efficacy of the KD in adults with refractory SE. Classification of evidence: This study provides Class IV evidence that for intensive care unit patients with refractory SE, a KD leads to resolution of the SE. PMID:24453083

  11. Treatment of severe, refractory and rapidly evolving thrombotic thrombocytopenic purpura.

    PubMed

    Acedillo, Rey R; Govind, Mayur; Kashgary, Abdullah; Clark, William F

    2016-01-01

    A 36-year-old man presented to hospital with gross haematuria and evidence of severe, refractory thrombotic thrombocytopenic purpura. Initial treatment with high-volume plasma exchange therapy and early administration of rituximab failed to achieve a sustained clinical response. His clinical course was complicated by left hemianopsia and despite an urgent splenectomy he developed a large right-sided stroke with malignant cerebral oedema that required an emergent decompressive craniotomy. He also had numerous infectious complications as a consequence of an aggressive immunosuppressive strategy. While the patient did not respond to cyclophosphamide, cyclosporine, N-acetylcysteine, and one course of bortezomib, he eventually responded to a second course of bortezomib. One year later, the patient remains in remission and maintains excellent cognitive function. However, he has not completely recovered from his stroke and continues to participate in rehabilitation for his residual physical deficits. PMID:27284100

  12. New-Onset Refractory Status Epilepticus: More Investigations, More Questions

    PubMed Central

    Dillien, Philippe; Ferrao Santos, Susana; van Pesch, Vincent; Suin, Vanessa; Lamoral, Sophie; Hantson, Philippe

    2016-01-01

    A 27-year-old previously healthy woman was admitted to the hospital with recurrent seizures. Status epilepticus developed that became refractory to third-line therapy with propofol and barbiturates. The patient had a very extensive diagnostic workup including autoimmune, viral and genetic investigations. A tentative immune therapy was proposed with high doses of steroids and plasma exchanges. Our patient had an inherited heterozygous single nucleotide variant in the sequence c.1280A>G [p.Lys427Arg] of the SMC3 gene that was insufficient to explain the seizures. Surprisingly, IgM antibodies against Japanese encephalitis virus were positive on the serum drawn 11 days after symptom onset, as detected by ELISA and the immunofluorescence antibody (IFA) technique. IgG antibodies were also positive using the IFA technique, but not with ELISA. The same investigations as well as the detection of the viral genome by the q-RT-PCR technique were negative on cerebrospinal fluid. Despite the suspicion of a viral infection, we concluded that our patient had a new-onset refractory status epilepticus of cryptogenic origin. Termination of the status epilepticus was obtained after 47 days, with a possible benefit from the introduction of ketamine. PMID:27462243

  13. New-Onset Refractory Status Epilepticus: More Investigations, More Questions.

    PubMed

    Dillien, Philippe; Ferrao Santos, Susana; van Pesch, Vincent; Suin, Vanessa; Lamoral, Sophie; Hantson, Philippe

    2016-01-01

    A 27-year-old previously healthy woman was admitted to the hospital with recurrent seizures. Status epilepticus developed that became refractory to third-line therapy with propofol and barbiturates. The patient had a very extensive diagnostic workup including autoimmune, viral and genetic investigations. A tentative immune therapy was proposed with high doses of steroids and plasma exchanges. Our patient had an inherited heterozygous single nucleotide variant in the sequence c.1280A>G [p.Lys427Arg] of the SMC3 gene that was insufficient to explain the seizures. Surprisingly, IgM antibodies against Japanese encephalitis virus were positive on the serum drawn 11 days after symptom onset, as detected by ELISA and the immunofluorescence antibody (IFA) technique. IgG antibodies were also positive using the IFA technique, but not with ELISA. The same investigations as well as the detection of the viral genome by the q-RT-PCR technique were negative on cerebrospinal fluid. Despite the suspicion of a viral infection, we concluded that our patient had a new-onset refractory status epilepticus of cryptogenic origin. Termination of the status epilepticus was obtained after 47 days, with a possible benefit from the introduction of ketamine. PMID:27462243

  14. Supra-recommendation Treatment of Super-refractory Status Epilepticus

    PubMed Central

    Vyas, Devashish Dhiren; Dash, Gopal Krishna

    2016-01-01

    A 28-year old female was admitted with recurrent seizures following 2 days of febrile illness, after which she developed status epilepticus. Midazolam and later thiopentone infusions were started after failure of regular intravenous antiepileptics. Burst suppression was achieved at doses of 3 mg/kg/hr for midazolam and 6 mg/kg/hr of thiopentone. Adjunctive medications included methylprednisolone, intravenous immunoglobulin and acyclovir. Imaging and biochemical parameters were normal. She required 3 cycles of midazolam and 2 cycles of thiopentone for complete cessation of seizures. She recovered with mild attentional and recent memory deficits on follow up. Treatment of super-refractory status epilepticus requires individualized regimens and may need doses beyond conventional limits. To the best of our knowledge, there is no such reported case from India. PMID:27390680

  15. Severe Refractory Coeliac Disease with Response Only to Parenteral Nutrition

    PubMed Central

    Ng, Ka Ying Bonnie; Mehta, Ravi; Mohamed, Salma; Mohamed, Zameer; Arnold, Jayantha

    2014-01-01

    Refractory coeliac disease (RCD) is characterised by recurrent or persistent malabsorptive symptoms and villous atrophy, despite strict adherence to a gluten-free diet for at least 6 months and where other causes of malabsorption including malignancy have been excluded. There is limited evidence and guidance on the effective management of these patients. We describe a case of severe RCD in our hospital, with symptoms controlled effectively only by total parenteral nutrition (TPN). This 68-year-old woman initially presented to the clinic with persistent non-bloody diarrhoea and vomiting. A diagnosis of coeliac disease was confirmed with a positive tissue transglutaminase assay and histology. A strict gluten-free diet was ineffective and she represented 6 months later with 13 kg weight loss (16.7%), ongoing abdominal pain and diarrhoea, with bowels opening 16 times a day. She was oedematous, had an albumin of 12 g/l and required hospital admission. She was treated for pancreatic insufficiency and presumptively for small bowel bacterial overgrowth with no resolution of symptoms. We ruled out infectious causes and investigated for small bowel malignancy; all results were negative. Small bowel enteroscopy showed ulcerative jejunitis. She was given 5 days of TPN, following which her symptoms improved and albumin normalised. This was sustained with symptom resolution and weight gain seen at follow-up. TPN successfully and rapidly induced remission in this case. Thus, a short period of TPN should be considered as a potential component of management in patients with severe RCD. PMID:25473387

  16. Preliminary results of the global audit of treatment of refractory status epilepticus.

    PubMed

    Ferlisi, M; Hocker, S; Grade, M; Trinka, E; Shorvon, S

    2015-08-01

    The treatment of refractory and super refractory status epilepticus is a "terra incognita" from the point of view of evidence-based medicine. As randomized or controlled studies that are sufficiently powered are not feasible in relation to the many therapies and treatment approaches available, we carried out an online multinational audit (registry) in which neurologists or intensivists caring for patients with status epilepticus may prospectively enter patients who required general anesthesia to control the status epilepticus (SE). To date, 488 cases from 44 different countries have been collected. Most of the patients had no history of epilepsy and had a cryptogenic etiology. First-line treatment was delayed and not in line with current guidelines. The most widely used anesthetic of first choice was midazolam (59%), followed by propofol and barbiturates. Ketamine was used in most severe cases. Other therapies were administered in 35% of the cases, mainly steroids and immunotherapy. Seizure control was achieved in 74% of the patients. Twenty-two percent of patients died during treatment, and four percent had treatment actively withdrawn because of an anticipated poor outcome. The neurological outcome was good in 36% and poor in 39.3% of cases, while 25% died during hospitalization. Factors that positively influenced outcome were younger age, history of epilepsy, and low number of different anesthetics tried. This article is part of a Special Issue entitled "Status Epilepticus". PMID:25952268

  17. Refractory status epilepticus following self-poisoning with the organochlorine pesticide endosulfan.

    PubMed

    Roberts, Darren M; Dissanayake, Wasantha; Rezvi Sheriff, M H; Eddleston, Michael

    2004-09-01

    We describe a case of refractory status epilepticus presenting to a rural general hospital in Sri Lanka. This patient's condition was precipitated by intentional self-poisoning with the organochlorine insecticide endosulfan. Although rarely seen in developed countries, pesticide poisoning particularly with endosulfan is an important cause of difficult-to-manage seizures in Asian countries. In this case report, we discuss the management of status epilepticus and refractory status epilepticus. Further, we specifically discuss the clinical pharmacology and toxicology of endosulfan. PMID:15337143

  18. A Comparison of Intravenous Levetiracetam and Valproate for the Treatment of Refractory Status Epilepticus in Children.

    PubMed

    İşgüder, Rana; Güzel, Orkide; Ceylan, Gökhan; Yılmaz, Ünsal; Ağın, Hasan

    2016-08-01

    Because of the lack of studies comparing the efficacy and safety of levetiracetam and valproate before the induction of general anesthesia in the treatment of convulsive refractory status epilepticus in children, we aimed to compare the effectiveness of these antiepileptic drugs in patients with convulsive status epilepticus admitted to the Pediatric Intensive Care Unit between 2011 and 2014. Forty-six (59%) of the 78 patients received levetiracetam, and 32 (41%) received valproate for the treatment of refractory status epilepticus. The response rate was not significantly different between the 2 groups. Although no adverse event was noted in patients who received levetiracetam, 4 (12.5%) patients in the valproate group experienced liver dysfunction (P = .025). According to our results, levetiracetam and valproate may be used in the treatment of refractory status epilepticus before the induction of general anesthesia. Levetiracetam appears as effective as valproate, and also safer. PMID:27080042

  19. Effect of music on the recovery of a patient with refractory nonconvulsive status epilepticus.

    PubMed

    Kuester, Gisela; Rios, Loreto; Ortiz, Armando; Miranda, Marcelo

    2010-08-01

    The effect of music in epilepsy has been reported as beneficial but mainly in the interictal condition. There are no reports of the effect of music in an acute condition such as status epilepticus. Herein, we report a remarkable response to music in a patient with medically refractory nonconvulsive status epilepticus. PMID:20637708

  20. Treatment of severe refractory erythema nodosum leprosum with tumor necrosis factor inhibitor Etanercept.

    PubMed

    Chowdhry, Sundeep; Shukla, Akhilesh; D'souza, Paschal; Dhali, Tapan; Jaiswal, Prashansa

    2016-06-01

    Erythema nodosum leprosum (ENL) is a common complication of lepromatous leprosy. Some patients unresponsive to conventional, first-line therapeutics develop recurrent, recalcitrant ENL. Here, we report a case of severe refractory ENL that was successfully treated with Etanercept. Biologics may be considered as therapeutic alternatives in management of severe, recalcitrant ENL. PMID:27242236

  1. Refractory status epilepticus and glutamic acid decarboxylase antibodies in adults: presentation, treatment and outcomes.

    PubMed

    Khawaja, Ayaz M; Vines, Brannon L; Miller, David W; Szaflarski, Jerzy P; Amara, Amy W

    2016-03-01

    Glutamic acid decarboxylase antibodies (GAD-Abs) have been implicated in refractory epilepsy. The association with refractory status epilepticus in adults has been rarely described. We discuss our experience in managing three adult patients who presented with refractory status epilepticus associated with GAD-Abs. Case series with retrospective chart and literature review. Three patients without pre-existing epilepsy who presented to our institution with generalized seizures between 2013 and 2014 were identified. Seizures proved refractory to first and second-line therapies and persisted beyond 24 hours. Patient 1 was a 22-year-old female who had elevated serum GAD-Ab titres at 0.49 mmol/l (normal: <0.02) and was treated with multiple immuno- and chemotherapies, with eventual partial seizure control. Patient 2 was a 61-year-old black female whose serum GAD-Ab titre was 0.08 mmol/l. EEG showed persistent generalized periodic discharges despite maximized therapy with anticonvulsants but no immunotherapy, resulting in withdrawal of care and discharge to nursing home. Patient 3 was a 50-year-old black female whose serum GAD-Ab titre was 0.08 mmol/l, and was discovered to have pulmonary sarcoidosis. Treatment with steroids and intravenous immunoglobulin resulted in seizure resolution. Due to the responsiveness to immunotherapy, there may be an association between GAD-Abs and refractory seizures, including refractory status epilepticus. Causation cannot be established since GAD-Abs may be elevated secondary to concurrent autoimmune diseases or formed de novo in response to GAD antigen exposure by neuronal injury. Based on this report and available literature, there may be a role for immuno- and chemotherapy in the management of refractory status epilepticus associated with GAD-Abs. PMID:26878120

  2. Use of ustekinumab for severe refractory atopic dermatitis in a young teenager.

    PubMed

    Wlodek, C; Hewitt, H; Kennedy, C T

    2016-08-01

    When conventional systemic immunosuppressive treatments fail in the setting of severe eczema, unlike in psoriasis, there are limited treatment options and only anecdotal evidence to help guide clinicians. There is a growing body of evidence for the use of certain biologic agents for moderate to severe eczema. We report the youngest case to date successfully and safely treated with ustekinumab for severe refractory atopic dermatitis. PMID:27079289

  3. Propofol Infusion Syndrome in Refractory Status Epilepticus: A Case Report and Topical Review.

    PubMed

    Walli, Akil; Poulsen, Troels Dirch; Dam, Mette; Børglum, Jens

    2016-01-01

    Propofol infusion syndrome (PRIS) is a fatal complication when doses of propofol administration exceed 4 mg/kg/h for more than 48 hours. Propofol overdosage is not uncommon in patients with refractory status epilepticus (RSE). We describe a case of refractory status epilepticus complicated by propofol infusion syndrome and collect from 5 databases all reports of refractory status epilepticus cases that were treated by propofol and developed the syndrome and outline whether refractory status epilepticus treatment with propofol is standardized according to international recommendations, compare it with alternative medications, and discuss how this syndrome can be treated and prevented. A total of 21 patients who developed this syndrome reported arrhythmia in all cases (100%), rhabdomyolysis in 9 cases (42%), lactic acidosis in 13 cases (62%), renal failure in 8 cases (38%), lipemia in 7 cases (33%), and elevated hepatic enzymes in 6 cases (28%). 13 patients died (66%). Propofol is still given in a dosage higher than what is internationally recommended, and new treatment modalities such as renal replacement therapy, blood exchange, and extracorporeal membrane oxygenation seem to be promising. In conclusion, propofol should be carefully titrated, the maximal infusion rate needs to be reassessed, and combination of different sedative agents may be considered. PMID:27493812

  4. Propofol Infusion Syndrome in Refractory Status Epilepticus: A Case Report and Topical Review

    PubMed Central

    Dam, Mette

    2016-01-01

    Propofol infusion syndrome (PRIS) is a fatal complication when doses of propofol administration exceed 4 mg/kg/h for more than 48 hours. Propofol overdosage is not uncommon in patients with refractory status epilepticus (RSE). We describe a case of refractory status epilepticus complicated by propofol infusion syndrome and collect from 5 databases all reports of refractory status epilepticus cases that were treated by propofol and developed the syndrome and outline whether refractory status epilepticus treatment with propofol is standardized according to international recommendations, compare it with alternative medications, and discuss how this syndrome can be treated and prevented. A total of 21 patients who developed this syndrome reported arrhythmia in all cases (100%), rhabdomyolysis in 9 cases (42%), lactic acidosis in 13 cases (62%), renal failure in 8 cases (38%), lipemia in 7 cases (33%), and elevated hepatic enzymes in 6 cases (28%). 13 patients died (66%). Propofol is still given in a dosage higher than what is internationally recommended, and new treatment modalities such as renal replacement therapy, blood exchange, and extracorporeal membrane oxygenation seem to be promising. In conclusion, propofol should be carefully titrated, the maximal infusion rate needs to be reassessed, and combination of different sedative agents may be considered. PMID:27493812

  5. Management of Super-Refractory Status Epilepticus with Isoflurane and Hypothermia

    PubMed Central

    Zhumadilov, Agzam; Gilman, Charles P.; Viderman, Dmitriy

    2015-01-01

    Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction. We describe the presentation and successful management of a male patient with SRSE using the inhaled anesthetic isoflurane, and mild hypothermia (HT). The potential utility of combined HT and volatile anesthesia is discussed. PMID:25674075

  6. Intravenous ketamine for treatment of super-refractory convulsive status epilepticus with septic shock: A report of two cases

    PubMed Central

    Shrestha, Gentle Sunder; Joshi, Pankaj; Chhetri, Santosh; Karn, Ragesh; Acharya, Subhash Prasad

    2015-01-01

    Refractory and super-refractory status epilepticus is a life-threatening neurological emergency, associated with high morbidity and mortality. Treatment should be aimed to stop seizure and to avoid cerebral damage and another morbidity. Published data about effectiveness, safety and outcome of various therapies and treatment approaches are sparse and are mainly based on small case series and retrospective data. Here we report successful management of two cases of super-refractory status epilepticus refractory to anesthetic therapy with midazolam and complicated by septic shock, managed successfully with ketamine infusion. PMID:25983437

  7. Early Use of the NMDA Receptor Antagonist Ketamine in Refractory and Superrefractory Status Epilepticus

    PubMed Central

    Zeiler, F. A.

    2015-01-01

    Refractory status epilepticus (RSE) and superrefractory status epilepticus (SRSE) pose a difficult clinical challenge. Multiple cerebral receptor and transporter changes occur with prolonged status epilepticus leading to pharmacoresistance patterns unfavorable for conventional antiepileptics. In particular, n-methyl-d-aspartate (NMDA) receptor upregulation leads to glutamate mediated excitotoxicity. Targeting these NMDA receptors may provide a novel approach to otherwise refractory seizures. Ketamine has been utilized in RSE. Recent systematic review indicates 56.5% and 63.5% cessation in seizures in adults and pediatrics, respectively. No complications were described. We should consider earlier implementation of ketamine or other NMDA receptor antagonists, for RSE. Prospective study of early implementation of ketamine should shed light on the role of such medications in RSE. PMID:25649724

  8. Surgical treatment of focal symptomatic refractory status epilepticus with and without invasive EEG

    PubMed Central

    Oderiz, Carolina Cuello; Aberastury, Marina; Besocke, Ana Gabriela; Sinner, Jorge; Comas-Guerrero, Betiana; Ciraolo, Carlos Alberto; Pasteris, Maria Concepción; Silva, Walter Horacio; García, María del Carmen

    2015-01-01

    Purpose Neurosurgery appears to be a reasonable alternative in carefully selected patients with refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE). We discuss the optimal timing of the surgery and the use of previous stereoelectroencephalography (SEEG) invasive evaluation. Methods We identified 3 patients (two pediatric and one adult) who underwent epilepsy surgery because of RSE or SRSE from our epilepsy surgery database, one of them with previous SEEG. Results Status epilepticus resolved acutely in all of them with no mortality and no substantial morbidity. At follow-up (median: 2 years), 1 patient was seizure-free, and 2 had significant improvement. Conclusion Surgery should be considered in all cases of RSE and SRSE early in the course of the evolution of the disease. PMID:26543817

  9. Severe Refractory Immune Thrombocytopenia Successfully Treated with High-Dose Pulse Cyclophosphamide and Eltrombopag

    PubMed Central

    Anwer, Faiz; Yun, Seongseok; Nair, Anju; Ahmad, Yusuf; Krishnadashan, Ravitharan; Deeg, H. Joachim

    2015-01-01

    Severe refractory ITP is clinically challenging and a variety of single or combination chemotherapies have been tried with limited outcome. We report a case of ITP that was unresponsive to multiple agents including high-dose steroid, IVIG, Rho(D) immune globulin, rituximab, cyclosporine, azathioprine, vincristine, mycophenolate mofetil, romiplostim, and eltrombopag; however, it achieved complete remission with combination treatment of cyclophosphamide and eltrombopag. PMID:26180646

  10. Severe Refractory Immune Thrombocytopenia Successfully Treated with High-Dose Pulse Cyclophosphamide and Eltrombopag.

    PubMed

    Anwer, Faiz; Yun, Seongseok; Nair, Anju; Ahmad, Yusuf; Krishnadashan, Ravitharan; Deeg, H Joachim

    2015-01-01

    Severe refractory ITP is clinically challenging and a variety of single or combination chemotherapies have been tried with limited outcome. We report a case of ITP that was unresponsive to multiple agents including high-dose steroid, IVIG, Rho(D) immune globulin, rituximab, cyclosporine, azathioprine, vincristine, mycophenolate mofetil, romiplostim, and eltrombopag; however, it achieved complete remission with combination treatment of cyclophosphamide and eltrombopag. PMID:26180646

  11. Clinical Significance of Human Metapneumovirus in Refractory Status Epilepticus and Encephalitis: Case Report and Review of the Literature

    PubMed Central

    Vehapoglu, Aysel; Turel, Ozden; Uygur Sahin, Turkan; Kutlu, Nurettin Onur; Iscan, Akın

    2015-01-01

    Encephalitis is a complex neurological disease that is associated with significant morbidity and mortality, and the etiology of the disease is often not identified. Human metapneumovirus (hMPV) is a common cause of upper and lower respiratory tract infections in children. Few reports are available showing possible involvement of hMPV in development of neurologic complications. Here, we describe an infant, the youngest case in literature, with refractory status epilepticus and severe encephalitis in whom hMPV was detected in respiratory samples and review diagnostic workup of patient with encephalitis. PMID:26664779

  12. Efficacy of Anti-TNFα in Severe and Refractory Neuro-Behcet Disease

    PubMed Central

    Desbois, Anne Claire; Addimanda, Olga; Bertrand, Anne; Deroux, Alban; Pérard, Laurent; Depaz, Raphael; Hachulla, Eric; Lambert, Marc; Launay, David; Subran, Benjamin; Ackerman, Felix; Mariette, Xavier; Cohen, Fleur; Marie, Isabelle; Salvarini, Carlo; Cacoub, Patrice; Saadoun, David

    2016-01-01

    Abstract To report the safety and efficacy of anti-tumor necrosis factor α (TNFα) therapy in severe and refractory neuro-Behçet disease (NBD) patients. Observational, multicenter study including 17 BD patients (70.6% of male, with a median age of 39.3 [24–60] years), with symptomatic parenchymal NBD, refractory to previous immunosuppressant and treated with anti-TNFα (infliximab 5 mg/kg [n = 13] or adalimumab [n = 4]). Complete remission was defined by the disappearance of all neurological symptoms and by the improvement of radiological abnormalities at 12 months. Overall improvement following anti-TNF was evidenced in 16/17 (94.1%) patients including 6 (35.3%) complete response and 10 (58.8%) partial response. The median time to achieve remission was 3 months (1–6). The median Rankin score was 2 (1–4) at the initiation of anti-TNFα versus 1 (0–4) at the time of remission (P = 0.01). Corticosteroids have been stopped in 4 (23.5%) patients, and reduced by more than 50% as compared with the dosage at baseline in 10 (58.8%) patients. Side effects occurred in 23.5% of patients and required treatment discontinuation in 17% of cases. TNF blockade represents an effective therapeutic approach for patients with severe and refractory NBD, a difficult to treat population. PMID:27281066

  13. Efficacy of Anti-TNFα in Severe and Refractory Neuro-Behcet Disease: An Observational Study.

    PubMed

    Desbois, Anne Claire; Addimanda, Olga; Bertrand, Anne; Deroux, Alban; Pérard, Laurent; Depaz, Raphael; Hachulla, Eric; Lambert, Marc; Launay, David; Subran, Benjamin; Ackerman, Felix; Mariette, Xavier; Cohen, Fleur; Marie, Isabelle; Salvarini, Carlo; Cacoub, Patrice; Saadoun, David

    2016-06-01

    To report the safety and efficacy of anti-tumor necrosis factor α (TNFα) therapy in severe and refractory neuro-Behçet disease (NBD) patients.Observational, multicenter study including 17 BD patients (70.6% of male, with a median age of 39.3 [24-60] years), with symptomatic parenchymal NBD, refractory to previous immunosuppressant and treated with anti-TNFα (infliximab 5 mg/kg [n = 13] or adalimumab [n = 4]). Complete remission was defined by the disappearance of all neurological symptoms and by the improvement of radiological abnormalities at 12 months.Overall improvement following anti-TNF was evidenced in 16/17 (94.1%) patients including 6 (35.3%) complete response and 10 (58.8%) partial response. The median time to achieve remission was 3 months (1-6). The median Rankin score was 2 (1-4) at the initiation of anti-TNFα versus 1 (0-4) at the time of remission (P = 0.01). Corticosteroids have been stopped in 4 (23.5%) patients, and reduced by more than 50% as compared with the dosage at baseline in 10 (58.8%) patients. Side effects occurred in 23.5% of patients and required treatment discontinuation in 17% of cases.TNF blockade represents an effective therapeutic approach for patients with severe and refractory NBD, a difficult to treat population. PMID:27281066

  14. Refractory status epilepticus due to pneumococcal meningitis in an infant with congenital immunodeficiency

    PubMed Central

    Prasanth, Sudhakaran; Shaji, Velayudhan Cheruvallil; Lyla, Chacko; Jayalakshmi, Vasudevapanicker

    2016-01-01

    Pneumococcal meningitis remains a life-threatening infection, with varied presentations. A 3 month-old-baby with pneumococcal meningitis presented with clusters of seizures evolving into refractory status epilepticus despite standard antibiotic and aggressive anticonvulsant therapy. Progressive illness despite antibiotic initially suggested possible antibiotic resistance and resulted in addition of another antibiotic. Nonresponse to standard treatment and previous history of abscess in the back of neck pointed to some underlying congenital immunodeficiency. Further evaluation showed a deficiency of complement factor C3. This case underlines the need to consider underlying immunodeficiency in cases of refractory status epilepticus due to bacterial meningitis. Gram-staining of cerebrospinal fluid sample showing plenty of Gram-positive bacteria and comparatively fewer pus cells is a clue regarding some underlying immunodeficiency. PMID:27606021

  15. Refractory status epilepticus due to pneumococcal meningitis in an infant with congenital immunodeficiency.

    PubMed

    Prasanth, Sudhakaran; Shaji, Velayudhan Cheruvallil; Lyla, Chacko; Jayalakshmi, Vasudevapanicker

    2016-01-01

    Pneumococcal meningitis remains a life-threatening infection, with varied presentations. A 3 month-old-baby with pneumococcal meningitis presented with clusters of seizures evolving into refractory status epilepticus despite standard antibiotic and aggressive anticonvulsant therapy. Progressive illness despite antibiotic initially suggested possible antibiotic resistance and resulted in addition of another antibiotic. Nonresponse to standard treatment and previous history of abscess in the back of neck pointed to some underlying congenital immunodeficiency. Further evaluation showed a deficiency of complement factor C3. This case underlines the need to consider underlying immunodeficiency in cases of refractory status epilepticus due to bacterial meningitis. Gram-staining of cerebrospinal fluid sample showing plenty of Gram-positive bacteria and comparatively fewer pus cells is a clue regarding some underlying immunodeficiency. PMID:27606021

  16. Seizures, refractory status epilepticus, and depolarization block as endogenous brain activities

    NASA Astrophysics Data System (ADS)

    El Houssaini, Kenza; Ivanov, Anton I.; Bernard, Christophe; Jirsa, Viktor K.

    2015-01-01

    Epilepsy, refractory status epilepticus, and depolarization block are pathological brain activities whose mechanisms are poorly understood. Using a generic mathematical model of seizure activity, we show that these activities coexist under certain conditions spanning the range of possible brain activities. We perform a detailed bifurcation analysis and predict strategies to escape from some of the pathological states. Experimental results using rodent data provide support of the model, highlighting the concept that these pathological activities belong to the endogenous repertoire of brain activities.

  17. Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate.

    PubMed

    Hatch, D M; Atito-Narh, E; Herschmiller, E J; Olufolabi, A J; Owen, M D

    2016-05-01

    We present a case of accidental injection of tranexamic acid during spinal anesthesia for an elective cesarean delivery. Immediately following intrathecal injection of 2mL of solution, the patient complained of severe back pain, followed by muscle spasm and tetany. As there was no evidence of spinal block, the medications given were checked and a 'used' ampoule of tranexamic acid was found on the spinal tray. General anesthesia was induced but muscle spasm and tetany persisted despite administration of a non-depolarizing muscle relaxant. Hemodynamic instability, ventricular tachycardia, and status epilepticus developed, which were refractory to phenytoin, diazepam, and infusions of thiopental, midazolam and amiodarone. Magnesium sulfate was administered postoperatively in the intensive care unit, following which the frequency of seizures decreased, eventually stopping. Unfortunately, on postoperative day three the patient died from cardiopulmonary arrest after an oxygen supply failure that was not associated with the initial event. This report underlines the importance of double-checking medications before injection in order to avoid a drug error. As well, it suggests that magnesium sulfate may be useful in stopping seizures caused by the intrathecal injection of tranexamic acid. PMID:26775897

  18. Comparison of Intravenous Anesthetic Agents for the Treatment of Refractory Status Epilepticus.

    PubMed

    Reznik, Michael E; Berger, Karen; Claassen, Jan

    2016-01-01

    Status epilepticus that cannot be controlled with first- and second-line agents is called refractory status epilepticus (RSE), a condition that is associated with significant morbidity and mortality. Most experts agree that treatment of RSE necessitates the use of continuous infusion intravenous anesthetic drugs such as midazolam, propofol, pentobarbital, thiopental, and ketamine, each of which has its own unique characteristics. This review compares the various anesthetic agents while providing an approach to their use in adult patients, along with possible associated complications. PMID:27213459

  19. Comparison of Intravenous Anesthetic Agents for the Treatment of Refractory Status Epilepticus

    PubMed Central

    Reznik, Michael E.; Berger, Karen; Claassen, Jan

    2016-01-01

    Status epilepticus that cannot be controlled with first- and second-line agents is called refractory status epilepticus (RSE), a condition that is associated with significant morbidity and mortality. Most experts agree that treatment of RSE necessitates the use of continuous infusion intravenous anesthetic drugs such as midazolam, propofol, pentobarbital, thiopental, and ketamine, each of which has its own unique characteristics. This review compares the various anesthetic agents while providing an approach to their use in adult patients, along with possible associated complications. PMID:27213459

  20. Aplastic anaemia in pregnancy with severe thrombocytopenia refractory to platelet transfusion: a case and management plan

    PubMed Central

    Smolinsky, Adi; Carson, Michael P; Guzman, Edwin R; Ranzini, Angela; Toscano, Joanne; Bukhari, Amar

    2009-01-01

    Aplastic anaemia is a rare haematological disorder during pregnancy, which when complicated by severe thrombocytopenia poses a significant maternal risk. A woman with aplastic anaemia and a platelet (PLT) count of 11 × 109/L refractory to PLT transfusion required caesarean delivery. Proactive planning by a multidisciplinary team, large volume PLT transfusion prior to surgery and postoperative uterine artery embolization resulted in avoidance of mortality. Maternal preferences should be discussed in detail due to the high risk of maternal morbidity and mortality associated with severe aplastic anaemia. This report outlines a management plan to address the medical and ethical issues faced when caring for a pregnant patient with severe aplastic anaemia and severe thrombocytopenia. We credit the good outcome to our proactive multidisciplinary approach.

  1. Drug-refractory aggression, self-injurious behavior, and severe tantrums in autism spectrum disorders: a chart review study.

    PubMed

    Adler, Benjamin A; Wink, Logan K; Early, Maureen; Shaffer, Rebecca; Minshawi, Noha; McDougle, Christopher J; Erickson, Craig A

    2015-01-01

    Aggression, self-injurious behavior, and severe tantrums are impairing symptoms frequently experienced by individuals with autism spectrum disorders. Despite US Food and Drug Administration approval of two atypical antipsychotics targeting these symptoms in youth with autistic disorder, they remain frequently drug refractory. We define drug-refractory aggression, self-injurious behavior, and severe tantrums in people with autism spectrum disorders as behavioral symptoms requiring medication adjustment despite previous trials of risperidone and aripiprazole or previous trials of three psychotropic drugs targeting the symptom cluster, one of which was risperidone or aripiprazole. We reviewed the medical records of individuals of all ages referred to our clinic for autism spectrum disorder diagnostic evaluation, as well as pharmacotherapy follow-up notes for all people meeting autism spectrum disorder criteria, for drug-refractory symptoms. Among 250 consecutively referred individuals, 135 met autism spectrum disorder and enrollment criteria, and 53 of these individuals met drug-refractory symptom criteria. Factors associated with drug-refractory symptoms included age 12 years or older (p < 0.0001), diagnosis of autistic disorder (p = 0.0139), and presence of intellectual disability (p = 0.0273). This pilot report underscores the significance of drug-refractory aggression, self-injurious behavior, and severe tantrums; suggests the need for future study clarifying factors related to symptom development; and identifies the need for focused treatment study of this impairing symptom domain. PMID:24571823

  2. Chapter 14: Acute severe asthma (status asthmaticus).

    PubMed

    Shah, Rachna; Saltoun, Carol A

    2012-01-01

    Acute severe asthma, formerly known as status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy such as inhaled albuterol, levalbuterol, or subcutaneous epinephrine. It is a medical emergency that requires immediate recognition and treatment. Oral or parenteral corticosteroids should be administered to all patients with acute severe asthma as early as possible because clinical benefits may not occur for a minimum of 6-12 hours. Approximately 50% of episodes are attributable to upper respiratory infections, and other causes include medical nonadherence, nonsteroidal anti-inflammatory exposure in aspirin-allergic patients, allergen exposure (especially pets) in severely atopic individuals, irritant inhalation (smoke, paint, etc.), exercise, and insufficient use of inhaled or oral corticosteroids. The patient history should be focused on acute severe asthma including current use of oral or inhaled corticosteroids, number of hospitalizations, emergency room visits, intensive-care unit admissions and intubations, the frequency of albuterol use, the presence of nighttime symptoms, exercise intolerance, current medications or illicit drug use, exposure to allergens, and other significant medical conditions. Severe airflow obstruction may be predicted by accessory muscle use, pulsus paradoxus, refusal to recline below 30°, a pulse >120 beats/min, and decreased breath sounds. Physicians' subjective assessments of airway obstruction are often inaccurate. More objective measures of airway obstruction via peak flow (or forced expiratory volume in 1 second) and pulse oximetry before oxygen administration usually are helpful. Pulse oximetry values >90% are less commonly associated with problems although CO(2) retention and a low Pao(2) may be missed. PMID:22794687

  3. Successful management of severe refractory acquired immune bleeding disorder: Prior to insisting surgery

    PubMed Central

    Al-Jafar, Hassan; Al-Barjas, H.; Hashem, Raed A.; Refaii, Thanaa M.K.; AlSaeed, Ahmad M.

    2014-01-01

    INTRODUCTION Acquired bleeding disorders are rare and may be missed before surgery. Additionally, they may be refractory to conventional treatments. PRESENTATION OF CASE A 50-year-old patient experienced prolonged post-operative bleeding when his bleeding disorder was missed prior to his undergoing inguinal herniorrhaphy. Post-operative investigations revealed severe acquired von Willebrand syndrome associated with a monoclonal gammopathy of undetermined significance. A few months later, he required umbilical herniorrhaphy, but he did not respond to attempts to raise his von Willebrand factor antigen and activity levels using conventional therapies, including desmopressin, cryoprecipitate, intravenous immunoglobulin, and Von Willebrand factor concentrate. A triple therapy combination of dexamethasone, intravenous immunoglobulin, and mycophenolate mofetil was administered, with a successful and sustained response, lasting about 2 months. The surgery was performed safely, without any complications. DISCUSSION Conventional acquired von Willebrand syndrome treatment is usually aimed at replacing von Willebrand factor or stimulating its secretion from storage in endothelial cells. In the present case, the alternative treatment was directed against both the humoral and cell-mediated immune mechanisms. CONCLUSION This case of acquired bleeding disorder showed that more attention must be given to a patient's coagulation profile, even if only very minor laboratory coagulation derangements are detected prior to surgery, to avoid missing such rare disorders. The described triple therapy demonstrated good effects and may be considered for inclusion in a controlled randomized study to determine its usefulness for other surgeries delayed due to severe acquired bleeding disorders. To the best of our knowledge, this triple combination treatment has not been previously used for the treatment of severe acquired bleeding disorders that are refractory to conventional therapies. PMID

  4. Deep Brain Stimulation for the Treatment of Severe, Medically Refractory Obsessive-Compulsive Disorder

    PubMed Central

    Sedrak, Mark; Wong, William; Wilson, Paul; Bruce, Diana; Bernstein, Ivan; Khandhar, Suketu; Pappas, Conrad; Heit, Gary; Sabelman, Eric

    2013-01-01

    Deep brain stimulation is a rapidly expanding therapy initially designed for the treatment of movement disorders and pain syndromes. The therapy includes implantation of electrodes in specific targets of the brain, delivering programmable small and safe electric impulses, like a pacemaker, that modulates both local and broad neurologic networks. The effects are thought to primarily involve a focus in the brain, probably inhibitory, which then restores a network of neural circuitry. Psychiatric diseases can be refractory and severe, leading to high medical costs, significant morbidity, and even death. Whereas surgery for psychiatric disease used to include destructive procedures, deep brain stimulation allows safe, reversible, and adjustable treatment that can be tailored for each patient. Deep brain stimulation offers new hope for these unfortunate patients, and the preliminary results are promising. PMID:24361021

  5. RISK OF SEVERE AND REFRACTORY POSTOPERATIVE NAUSEA AND VOMITING IN PATIENTS UNDERGOING DIEP FLAP BREAST RECONSTRUCTION

    PubMed Central

    MANAHAN, MICHELE A.; BASDAG, BASAK; KALMAR, CHRISTOPHER L.; SHRIDHARANI, SACHIN M.; MAGARAKIS, MICHAEL; JACOBS, LISA K.; THOMSEN, ROBERT W.; ROSSON, GEDGE D.

    2014-01-01

    Background Postoperative nausea and vomiting (PONV) are commonly feared after general anesthesia and can impact results. The primary aim of our study was to examine incidence and severity of PONV by investigating complete response, or absence of PONV, to prophylaxis used in patients undergoing DIEP flaps. Our secondary aims were definition of the magnitude of risk, state of the art of interventions, clinical sequelae of PONV, and interaction between these variables, specifically for DIEP patients. Methods A retrospective chart review occurred for 29 patients undergoing DIEP flap breast reconstruction from September 2007 to February 2008. We assessed known patient and procedure-specific risks for PONV after DIEPs, prophylactic antiemetic regimens, incidence, and severity of PONV, postoperative antiemetic rescues, and effects of risks and treatments on symptoms. Results Three or more established risks existed in all patients, with up to seven risks per patient. Although 90% of patients received diverse prophylaxis, 76% of patients experienced PONV, and 66% experienced its severe form, emesis. Early PONV (73%) was frequent; symptoms were long lasting (average 20 hours for nausea and emesis); and multiple rescue medications were frequently required (55% for nausea, 58% for emesis). Length of surgery and nonsmoking statistically significantly impacted PONV. Conclusion We identify previously undocumented high risks for PONV in DIEP patients. High frequency, severity, and refractoriness of PONV occur despite standard prophylaxis. Plastic surgeons and anesthesiologists should further investigate methods to optimize PONV prophylaxis and treatment in DIEP flap patients. PMID:24038427

  6. Oxycodone/Naloxone PR: A Review in Severe Refractory Restless Legs Syndrome.

    PubMed

    Frampton, James E

    2015-06-01

    An oral, fixed-dose combination of prolonged-release (PR) oxycodone with PR naloxone (Targin(®), Targiniq(®), Targinact(®); hereafter referred to as oxycodone/naloxone PR) is approved in Europe for the second-line symptomatic treatment of patients with severe to very severe idiopathic restless legs syndrome (RLS), after failure of dopaminergic therapy. Coadministration of naloxone represents a targeted approach to counteracting opioid-induced bowel dysfunction without compromising therapeutic efficacy; because of its very low oral bioavailability, naloxone blocks the action of oxycodone at opioid receptors locally in the gut. The efficacy of oxycodone/naloxone PR in patients with severe RLS inadequately controlled by previous (mainly dopaminergic) treatment has been demonstrated in RELOXYN, a 12-week, randomized, double-blind study with a 40-week open-label extension. In this pivotal study, oxycodone/naloxone PR significantly improved RLS symptoms compared with placebo from week 2 onwards; a beneficial effect of oxycodone/naloxone PR was maintained through 1 year of treatment. Furthermore, improvements in RLS symptoms in oxycodone/naloxone PR recipients were accompanied by similarly sustained improvements in disease-specific quality of life and subjective sleep variables. Oxycodone/naloxone PR was generally well tolerated, with a treatment-related adverse event profile (e.g. gastrointestinal disorders, CNS disorders, fatigue and pruritus) that was consistent with that expected for opioid therapy. Notably, there were no confirmed cases of augmentation among oxycodone/naloxone PR recipients throughout the course of the study. Results from the well-designed RELOXYN trial have thus demonstrated the value of oxycodone/naloxone PR as a second-line therapy for severe refractory RLS; further investigation of this combination product as a first-line treatment for severe RLS is now warranted. PMID:26135898

  7. Drug-Refractory Aggression, Self-Injurious Behavior, and Severe Tantrums in Autism Spectrum Disorders: A Chart Review Study

    ERIC Educational Resources Information Center

    Adler, Benjamin A.; Wink, Logan K.; Early, Maureen; Shaffer, Rebecca; Minshawi, Noha; McDougle, Christopher J.; Erickson, Craig A.

    2015-01-01

    Aggression, self-injurious behavior, and severe tantrums are impairing symptoms frequently experienced by individuals with autism spectrum disorders. Despite US Food and Drug Administration approval of two atypical antipsychotics targeting these symptoms in youth with autistic disorder, they remain frequently drug refractory. We define…

  8. Is dengue severity related to nutritional status?

    PubMed

    Kalayanarooj, Siripen; Nimmannitya, Suchitra

    2005-03-01

    A retrospective review of dengue patients admitted to Queen Sirikit National Institute of Child Health (previously known as Children's Hospital) from 1995 to 1999 revealed 4,532 confirmed cases of dengue infection; 80.9% were dengue hemorrhagic fever (DHF) and 19.1% were dengue fever cases (DF). Among the DHF patients; 30.6% had shock. The majority of them, 66.6%, had a normal nutritional status, while 9.3% were malnourished and 24.2% had obesity as classified by weight for age. Compared with control patients with other diagnoses (excluding HIV/AIDS patients), malnourished children had a lower risk of contracting dengue infection (odds ratio = 0.48, 95% Cl = 0.39-0.60, p = 0.000) while obese children had a greater risk of infection with dengue viruses (odds ratio = 1.96, 95% Cl = 1.55-2.5, p = 0.000). The clinical signs, symptoms and laboratory findings of dengue were almost the same among the 3 groups of malnourished, normal, and obese patients. The minor differences observed were that in obese children liver enlargement was found less often; maculopapular/convalescence rash and elevations of alanine aminotransferase were found more often. Malnourished patients had a higher risk of developing shock (37.8%) than normal (29.9%) and obese patients (30.2%) (p = 0.000). Obese patients had more unusual presentations: encephalopathy (1.3%) and associated infections (4.8%), than normal (0.5% and 2.7%) and malnourished patients (1.2% and 3.1%). Complications of fluid overload were found more in obese patients (6.5%) compared to normal (3.2%) and malnourished patients (2.1%) (p = 0.000). The case-fatality rates (CFR) in malnourished patients and obese patients were 0.5% and 0.4%, respectively, while in normal patients the CFR was 0.07%. Under and over nutrition DHF patients had either a greater risk of shock or unusual presentations and complications, which can lead to severe disease or complications and probably a higher CFR. PMID:15916044

  9. Long-term captopril therapy in severe refractory congestive heart failure

    PubMed Central

    Steingo, L.; Pocock, W. A.; Flax, H.; Stein, M.; Barlow, J. B.

    1982-01-01

    1 The favourable haemodynamic effects of captopril in patients with congestive heart failure have been reported. 2 We have treated 25 patients with severe chronic congestive heart failure with captopril in doses of 75-450 mg daily. Before entering the study all patients remained in New York Heart Association functional class IV despite high-dose diuretic and vasodilator therapy. 3 Mean cardiothoracic ratio was 60%, and all patients had a shortening fraction of 18% or less on echocardiography (normal 25 to 40%). 4 Five patients died within one month of captopril and five between four and seven months, three of whom had improved to class IIM and one to IIS before death. 5 Of the 15 survivors one was referred for a heart transplant when he had improved to class IIM. The remaining 14 patients were followed for 8-16 months. Ten improved to New York Heart Association class I or IIS and four to class IIM or III. Diuretic requirements were decreased considerably in all 14. Side effects were common but captopril did not have to be withdrawn. Captopril is a highly effective drug in the treatment of patients with congestive heart failure refractory to currently accepted therapy. PMID:6753902

  10. Measurements of Total Hemispherical Emissivity of Several Stably Oxidized Metals and Some Refractory Oxide Coatings

    NASA Technical Reports Server (NTRS)

    Wade, William R.

    1959-01-01

    A description of the apparatus and methods used for obtaining total hemispherical emissivity is presented, and data for several stably oxidized metals are included. The metals which were tested included type 347 stainless steel, tungsten, and Haynes alloys B, C, X, and 25. No values of emissivity were obtained for tungsten or Haynes alloy B because of the nature of the oxides produced. The refractory oxide coatings tested were flame-sprayed alumina and zirconia. The results of the investigation indicate that strongly adherent, oxidized surfaces of a high stable emissivity can be produced on type 347 stainless steel for which the total hemispherical emissivity varied from 0.87 to 0.91 for temperatures from 600 F to 2,000 F. For this same temperature range, the Haynes alloys tested showed values of total hemispherical emissivity from 0.90 to 0.96 for alloy C, from 0.85 to 0.88 for alloy X, and from 0.85 to 0.89 for alloy 25. Haynes alloy B and tungsten formed nonadherent oxides at elevated temperatures and, therefore, stable emissivities were not obtained. The results obtained for the flame-sprayed ceramics (alumina and zirconia) showed considerably higher values of total emissivity than those measured for coatings applied by other methods. Emissivity values ranging from 0.69 to 0.44 for aluminum oxide and from 0.62 to 0.44 for zirconium oxide were measured for temperatures from 800 F to 2,000 F.

  11. Interleukin-1 receptor is a target for adjunctive control of diazepam-refractory status epilepticus in mice.

    PubMed

    Xu, Zheng-Hao; Wang, Yi; Tao, An-Feng; Yu, Jie; Wang, Xiao-Yu; Zu, Yun-Yun; Zhang, Shi-Hong; Chen, Zhong

    2016-07-22

    Proinflammatory cytokine interleukin-1 beta (IL-1β) may accumulate in the brain during status epilepticus, but whether it contributes to the progressive refractoriness of SE remains unclear. By using a kainic acid-induced SE mice model, we tested whether pharmacological blockade or knock-out of interleukin-1 receptor type 1 (IL-1R1) could influence the diazepam-refractory phenomenon of prolonged SE. We confirmed diazepam failed to terminate prolonged SE (allowed to continue for 40min before diazepam administration). The expression level of IL-1β in the hippocampus during prolonged SE was significantly higher than that of baseline. Interestingly, prolonged SE was not diazepam-refractory in IL-1R1 knock-out mice. Moreover, administration of interleukin-1 receptor antagonist (IL-1RA) combined with diazepam terminated established prolonged SE, while IL-1RA alone is not capable to terminate prolonged SE. On the contrary, administration of recombinant human IL-1β weakens the efficacy of diazepam by prolonging its latency to terminate non-prolonged SE. Thus, the present study provides direct evidence that accumulated IL-1β contributed to the diazepam refractoriness of prolonged SE, and suggests that interleukin-1 receptor is a target for adjunctive control of diazepam-refractory SE. PMID:27133574

  12. Fecal Microbiota Transplantation Using Upper Gastrointestinal Tract for the Treatment of Refractory or Severe Complicated Clostridium difficile Infection in Elderly Patients in Poor Medical Condition: The First Study in an Asian Country

    PubMed Central

    Gweon, Tae-Geun; Kim, Jinsu; Lim, Chul-Hyun; Park, Jae Myung; Lee, Dong-Gun; Lee, In Seok; Cho, Young-Seok; Kim, Sang Woo; Choi, Myung-Gyu

    2016-01-01

    Background and Aims. Fecal microbiota transplantation (FMT) is a highly effective treatment option for refractory Clostridium difficile infection (CDI). FMT may be challenging in patients with a low performance status, because of their poor medical condition. The aims of this study were to describe our experience treating patients in poor medical condition with refractory or severe complicated CDI using FMT via the upper GI tract route. Methods. This study was a retrospective review of seven elderly patients with refractory or severe complicated CDI and a poor medical condition who were treated with FMT through the upper GI tract route from May 2012 through August 2013. The outcomes studied included the cure rate of CDI and adverse events. Results. Of these seven patients who received FMT via the upper GI tract route, all patients were cured. During the 11-month follow-up period, CDI recurrence was observed in two patients; rescue FMT was performed in these patients, which led to a full cure. Vomiting was observed in two patients. Conclusions. FMT via the upper gastrointestinal tract route may be effective for the treatment of refractory or severe complicated CDI in patients with a low performance status. Physicians should be aware of adverse events, especially vomiting. PMID:27127501

  13. Refractory Convulsive Status Epilepticus in Children: Etiology, Associated Risk Factors and Outcome

    PubMed Central

    BARZEGAR, Mohammad; MAHDAVI, Mohammad; GALEGOLAB BEHBEHANI, Afshin; TABRIZI, Aidin

    2015-01-01

    Objective Refractory status epilepticus (RSE) is a life-threatening disease in children wherein the patient’s convulsive seizures do not respond to adequate initial anticonvulsants. RSE is associated with high rate of mortality and morbidity. This study was aimed to survey the risk factors leading status epilepticus (SE) to RSE in children, and their early outcome. Materials & Methods Patients with SE hospitalized in Tabriz Children’s Hospital, Iran were studied during the years 2007 and 2008 with regard to their clinical profile, etiology, the treatment methods available to them and their outcome upon release from the hospital. Results Among 132 patients with SE, 53 patients (40.15%) suffered from RSE. Acute symptomatic etiology was a risk factor responsible for developing RSE in the patient (P=0.004). Encephalitis was the most common etiology of acute symptomatic SE. There was no significant relationship observed between RSE and the patients’ age, gender, date of initial drug intake and type of seizure. The mortality rate was 8.3% and a new neurological deficit occurred in 25.7% of cases. None of RSE with encephalitis returned to the baseline status. Mortality and morbidity rates were significantly higher in children with RSE than in those with SE (P=0.006). Conclusion Etiology of SE significantly influenced prognosis of it with significant incidence of RSE in acute symptomatic group. Because acute neurological insult such as encephalitis and meningitis are common causes of RSE in children, properly management of them is necessary to avoid permanent brain damage. PMID:26664438

  14. Feasibility Study Evaluating Therapeutic Hypothermia for Refractory Status Epilepticus in Children.

    PubMed

    Buttram, Sandra D W; Au, Alicia K; Koch, Joshua; Lidsky, Karen; McBain, Kristin; O'Brien, Nicole; Zielinski, Brandon A; Bell, Michael J

    2015-12-01

    Pediatric refractory status epilepticus (RSE) is a neurological emergency with significant morbidity and mortality, which lacks consensus regarding diagnosis and treatment(s). Therapeutic hypothermia (TH) is an effective treatment for RSE in preclinical models and small series. In addition, TH is a standard care for adults after cardiac arrest and neonates with hypoxic-ischemic encephalopathy. The purpose of this study was to identify the feasibility of a study of pediatric RSE within a research group (Pediatric Neurocritical Care Research Group [PNCRG]). Pediatric intensive care unit (PICU) admissions at seven centers were prospectively screened from October 2012 to July 2013 for RSE. Experts within the PNCRG estimated that clinicians would be unwilling to enroll a child, unless the child required at least two different antiepileptic medications and a continuous infusion of another antiepileptic medication with ongoing electrographic seizure activity for ≥2 hours after continuous infusion initiation. Data for children meeting the above inclusion criteria were collected, including the etiology of RSE, history of epilepsy, and maximum dose of continuous antiepileptic infusions. There were 8113 PICU admissions over a cumulative 52 months (October 2012-July 2013) at seven centers. Of these, 69 (0.85%) children met inclusion criteria. Twenty children were excluded due to acute diagnoses affected by TH, contraindications to TH, or lack of commitment to aggressive therapies. Sixteen patients had seizure cessation within 2 hours, resulting in 33 patients who had inadequate seizure control after 2 hours and a continuous antiepileptic infusion. Midazolam (21/33, 64%) and pentobarbital (5/33, 15%) were the most common infusions with a wide maximum dose range. More than one infusion was required for seizure control in four patients. There are substantial numbers of subjects at clinical sites within the PNCRG with RSE that would meet the proposed inclusion criteria for a

  15. Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multi-center study

    PubMed Central

    Gaspard, Nicolas; Foreman, Brandon; Judd, Lilith M.; Brenton, James N.; Nathan, Barnett R.; McCoy, Blathnaid M.; Al-Otaibi, Ali; Kilbride, Ronan; Fernández, Ivan Sánchez; Mendoza, Lucy; Samuel, Sophie; Zakaria, Asma; Kalamangalam, Giridhar P.; Legros, Benjamin; Szaflarski, Jerzy P.; Loddenkemper, Tobias; Hahn, Cecil D.; Goodkin, Howard P.; Claassen, Jan; Hirsch, Lawrence J.; LaRoche, Suzette M.

    2013-01-01

    Summary Purpose To examine patterns of use, efficacy and safety of intravenous ketamine for the treatment of refractory status epilepticus (RSE). Methods Multicenter retrospective review of medical records and EEG reports in ten academic medical centers in North America and Europe, including 58 subjects, representing 60 episodes of RSE were identified between 1999 and 2012. Seven episodes occurred after anoxic brain injury. Key findings Permanent control of RSE was achieved in 57% (34/60) of episodes. Ketamine was felt to have contributed to permanent control (“possible” or “likely” responses) in 32% (19/60) including seven (12%) in which ketamine was the last drug added (likely responses). Four of the seven likely responses, but none of the 12 possible ones, occurred in patients with post-anoxic brain injury. No likely responses were observed when infusion rates were lower than 0.9mg/kg/h; when ketamine was introduced at least eight days after SE onset; or after failure of seven or more drugs. Ketamine was discontinued due to possible adverse events in five patients. Complications were mostly attributed to concurrent drugs, especially other anesthetics. Mortality rate was 43% (26/60), but was lower when SE was controlled within 24h of ketamine initiation (16% vs. 56%, p=0.0047). Significance Ketamine appears to be a relatively effective and safe drug for the treatment of RSE. This retrospective series provides preliminary data on effective dose and appropriate time of intervention to aid in the design of a prospective trial to further define the role of ketamine in the treatment of RSE. PMID:23758557

  16. Remission of refractory pyoderma gangrenosum, severe acne, and hidradenitis suppurativa (PASH) syndrome using targeted antibiotic therapy in 4 patients.

    PubMed

    Join-Lambert, Olivier; Duchatelet, Sabine; Delage, Maïa; Miskinyte, Snaigune; Coignard, Hélène; Lemarchand, Nicolas; Alemy-Carreau, Murielle; Lortholary, Olivier; Nassif, Xavier; Hovnanian, Alain; Nassif, Aude

    2015-11-01

    Pyoderma gangrenosum, severe acne, and suppurative hidradenitis (PASH) syndrome can prove refractory to treatment and is characterized by relapses and recurrences. The combination of antibiotic therapy and surgery can produce success in the management of the syndrome. Acute treatment is required, but maintenance therapy is also necessary to prevent disease relapse. The response to antibiotic therapy is hypothesis generating, raising the issue of a modified host response. To date, anecdotal reports support the use of surgery and medical therapy, but controlled investigations with extended follow-up are necessary to substantiate preliminary data observed with individual cases. PMID:26470620

  17. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study

    PubMed Central

    2014-01-01

    Introduction Seizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE. Methods We retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year. Results Thirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5

  18. Reversal of Severe and Refractory Humoral Hypercalcemia With 177Lu-Octreotate Peptide Receptor Radionuclide Therapy for Neuroendocrine Tumor of the Pancreas.

    PubMed

    Iliuta, Ioan-Andrei; Beauregard, Jean-Mathieu; Couture, Félix; Douville, Pierre; Mac-Way, Fabrice

    2015-09-01

    A 48-year-old Caucasian male patient with newly diagnosed neuroendocrine tumor of the pancreas with multiple liver metastases developed severe and refractory hypercalcemia. Complementary investigations were compatible with humoral hypercalcemia with high parathyroid hormone-related peptide (PTHrP) levels. Hypercalcemia was refractory to medical treatments for more than 2 years. Serum calcium returned to normal values only after 4 cycles of peptide receptor radionuclide therapy with Lu-octreotate, with concomitant reduction of PTHrP level and tumor regression. The use of radionuclide therapy could be an option for the management of severe humoral hypercalcemia in patients with inoperable metastatic pancreatic neuroendocrine tumor. PMID:26053724

  19. Differential Diagnosis of Genetic Disorders Associated with Moderate to Severe Refractory Eczema and Elevated Immunoglobulin E.

    PubMed

    Arjona Aguilera, C; Albarrán Planelles, C; Tercedor Sánchez, J

    2016-03-01

    The association of moderate to severe eczema and elevated plasma levels of immunoglobulin E is a characteristic not only of atopic dermatitis but also of various genodermatoses: hyperimmunoglobulin E syndromes, Omenn syndrome, Netherton syndrome, peeling skin syndrome type B, severe dermatitis, multiple allergies, and metabolic wasting syndrome, Wiskott-Aldrich syndrome, prolidase deficiency, Loeys-Dietz syndrome, IPEX syndrome, STAT5B deficiency, and pentasomy X. The clinical presentation of these genodermatoses -typically in children- is consistent with severe atopic dermatitis. Immunoglobulin E is elevated from birth and response to conventional treatments is poor. Diagnosis is further complicated by the fact that these genodermatoses often share other clinical manifestations and laboratory findings. We present practical guidelines for differentiating among these various entities, with the aim of helping physicians decide what type of genetic test should be carried out -and when- in order to establish a definitive diagnosis. PMID:26593686

  20. Severe Acute Pulmonary Toxicity Associated with Brentuximab in a Patient with Refractory Hodgkin's Lymphoma

    PubMed Central

    Sabet, Yasmin; Ramirez, Saul; Rosell Cespedes, Elizabeth; Rensoli Velasquez, Marimer; Porres-Muñoz, Mateo; Gaur, Sumit; Figueroa-Casas, Juan B.; Porres-Aguilar, Mateo

    2016-01-01

    Acute pulmonary toxicity associated with brentuximab appears to be a rare but serious adverse effect that can be potentially fatal. We report the case of a twenty-nine-year-old female with Hodgkin's lymphoma who was treated with brentuximab and later presented with severe acute pulmonary toxicity; she improved after the discontinuation of brentuximab and administration of antibiotics and glucocorticoid therapy. Currently there is very little data in the literature in regard to the clinical manifestations and characteristics of patients taking brentuximab and the potential development of acute severe pulmonary toxicity, as well as the appropriate therapeutic approach, making this particular case of successful treatment and resolution unique. PMID:27190667

  1. Labetalol infusion for refractory hypertension causing severe hypotension and bradycardia: an issue of patient safety.

    PubMed

    Fahed, Samir; Grum, Daniel F; Papadimos, Thomas J

    2008-01-01

    Incremental doses of intravenous labetalol are safe and effective and, at times, such therapy may need to be augmented by a continuous infusion of labetalol to control severe hypertension. Continuous infusions of labetalol may exceed the recommended maximum daily dose of 300 mg on occasion. We report a case in which hypertension occurring after an abdominal aortic aneurysm repair, initially responsive to intermittent intravenous beta-blockade, became resistant to this therapy leading to the choice of an intravenous labetalol infusion as the therapeutic option. The labetalol infusion resulted in a profound cardiovascular compromise in this postoperative critically ill patient. While infusions of labetalol have successfully been used, prolonged administration in the intensive care unit requires vigilance and the establishment of a therapeutic rationale/policy for interventions, such as the ready availability of glucagon, beta-agonists, phosphodiesterase inhibitors, insulin, and vasopressin when severe cardiovascular depression occurs. PMID:18505576

  2. High-dose cyclophosphamide for moderate to severe refractory multiple sclerosis: 2-year follow-up (investigational new drug No. 65863).

    PubMed

    Gladstone, Douglas E; Peyster, Robert; Baron, Edward; Friedman-Urevich, Sharon; Sibony, Patrick; Melville, Patricia; Gottesman, Malcolm

    2011-01-01

    High-dose cyclophosphamide (HDC) is a chemotherapy treatment designed to eradicate autoreative B- and T-cells responsible for lymphocyte-mediated autoimmune illness while sparing the pluripotent blood stem cell of any ill effects. Multiple sclerosis (MS) is the most common inflammatory and demyelinating immune-mediated disorder of the central nervous system in young adults. Patients with moderate to severe, refractory MS, defined as an Expanded Disability Status Scale (EDSS) score of 3.5 or higher after two or more Food and Drug Administration-approved disease-modifying agents, received 200 mg/kg of cyclophosphamide over 4 days. For the next 2 years, quarterly EDSS score evaluations and biannual brain magnetic resonance imaging and neuro-ophthalmologic evaluations were obtained. Fifteen patients were evaluated for clinical response. During follow-up, one patient increased their baseline EDSS score by 1.0. EDSS score stability of decrease was realized in five of seven (71%) patients with relapsing-remitting MS and six of eight (75%) patients with secondary progressive MS. Four patients required additional immunomodulatory treatment after treatment. Treatment response was seen regardless of the baseline presence or absence of contrast lesion activity. HDC can effectively decrease symptoms, stop disease progression, and allow for disability regression in relapsing-remitting MS and secondary progressive MS patients. The most appropriate candidates for HDC, its duration of benefit, and the potential need for prophylactic preventative immune manipulation after HDC all require further investigation. PMID:19770795

  3. A case of refractory IgG4-related peripheral neuropathy with severe axonal damage.

    PubMed

    Suzuki, Yu; Shiraishi, Makoto; Yamada, Koji; Doi, Masatomo; Kato, Masayuki; Hasegawa, Yasuhiro

    2016-05-31

    A 78-year-old man presented complaining of tingling and pain. Neurological examination revealed dysesthesia and hypothermesthesia below both knees and areflexia in the lower extremities. Laboratory data revealed elevated serum levels of immunoglobulin IgG4 and para-aortic, and mesenteric lymphadenopathy was evident on plain computed tomography of the abdomen. Microscopic findings of a bone marrow biopsy specimen showed occlusion of blood vessels with IgG4-positive plasma cells. IgG4-related disease was diagnosed because the bone marrow biopsy exhibited > 10 IgG4-positive plasma cells per high-power field. Treatment was initiated with prednisolone starting at 30 mg/day, but no improvement in neurological symptoms was achieved. Sural nerve biopsy demonstrated obstructive thromboangiitis with severe loss of myelin and axons. Further investigations are needed to elucidate the relationship between obstructive thromboangiitis and steroid-resistant IgG4-related peripheral neuropathy. PMID:27098901

  4. Successful Treatment of Severe Carbon Monoxide Poisoning and Refractory Shock Using Extracorporeal Membrane Oxygenation.

    PubMed

    Teerapuncharoen, Krittika; Sharma, Nirmal S; Barker, Andrew B; Wille, Keith M; Diaz-Guzman, Enrique

    2015-09-01

    Carbon monoxide (CO) is the most common cause of poisoning and poisoning-related death in the United States. It is a tasteless and odorless poisonous gas produced from incomplete combustion of hydrocarbons, such as those produced by cars and heating systems. CO rapidly binds to hemoglobin to form carboxyhemoglobin, leading to tissue hypoxia, multiple-organ failure, and cardiovascular collapse. CO also binds to myocardial myoglobin, preventing oxidative phosphorylation in cardiac mitochondria and resulting in cardiac ischemia or stunning and cardiogenic pulmonary edema. Treatment of CO poisoning is mainly supportive, and supplemental oxygen remains the cornerstone of therapy, whereas hyperbaric oxygen therapy is considered for patients with evidence of neurological and myocardial injury. Extracorporeal membrane oxygenation (ECMO) has been utilized effectively in patients with respiratory failure and hemodynamic instability, but its use has rarely been reported in patients with CO poisoning. We report the successful use of venoarterial ECMO in a patient with severe CO poisoning and multiple-organ failure. PMID:25922545

  5. Dorsal anterior cingulotomy and anterior capsulotomy for severe, refractory obsessive-compulsive disorder: a systematic review of observational studies.

    PubMed

    Brown, Lauren T; Mikell, Charles B; Youngerman, Brett E; Zhang, Yuan; McKhann, Guy M; Sheth, Sameer A

    2016-01-01

    OBJECT The object of this study was to perform a systematic review, according to Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) and Agency for Healthcare Research and Quality (AHRQ) guidelines, of the clinical efficacy and adverse effect profile of dorsal anterior cingulotomy compared with anterior capsulotomy for the treatment of severe, refractory obsessive-compulsive disorder (OCD). METHODS The authors included studies comparing objective clinical measures before and after cingulotomy or capsulotomy (surgical and radiosurgical) in patients with OCD. Only papers reporting the most current follow-up data for each group of investigators were included. Studies reporting results on patients undergoing one or more procedures other than cingulotomy or capsulotomy were excluded. Case reports and studies with a mean follow-up shorter than 12 months were excluded. Clinical response was defined in terms of a change in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. The authors searched MEDLINE, PubMed, PsycINFO, Scopus, and Web of Knowledge through October 2013. English and non-English articles and abstracts were reviewed. RESULTS Ten studies involving 193 participants evaluated the length of follow-up, change in the Y-BOCS score, and postoperative adverse events (AEs) after cingulotomy (n = 2 studies, n = 81 participants) or capsulotomy (n = 8 studies, n = 112 participants). The average time to the last follow-up was 47 months for cingulotomy and 60 months for capsulotomy. The mean reduction in the Y-BOCS score at 12 months' follow-up was 37% for cingulotomy and 55% for capsulotomy. At the last follow-up, the mean reduction in Y-BOCS score was 37% for cingulotomy and 57% for capsulotomy. The average full response rate to cingulotomy at the last follow-up was 41% (range 38%-47%, n = 2 studies, n = 51 participants), and to capsulotomy was 54% (range 37%-80%, n = 5 studies, n = 50 participants). The rate of transient AEs was 14.3% across

  6. Severe cefepime-induced status epilepticus treated with haemofiltration.

    PubMed

    Suarez-de-la-Rica, A; Hernández-Gancedo, C; López-Tofiño, A; Maseda, E; Gilsanz, F

    2016-01-01

    Neurotoxicity caused by cefepime may occur predominantly in patients with impaired renal function. A case of a cefepime-induced non-convulsive status epilepticus (NCSE) is presented. A 65-year-old woman suffered a severe NCSE due to cefepime in the presence of acute renal failure, requiring coma induction with sodium thiopental. A serious interaction between valproic acid (VPA) and meropenem was also produced after changing cefepime to meropenem. Continuous veno-venous haemofiltration was employed to improve cefepime clearance, and the patient progressively regained her previous mental condition. In conclusion, the cefepime dose must be adjusted according to renal function in order to avoid toxicity in patients with renal failure. Electroencephalogram should be considered in cases of acute confusional state in patients receiving cefepime, to achieve early detection of NCSE. Continuous renal replacement therapy may be successfully employed in severe cases in order to accelerate cefepime removal. Likewise, meropenem should not be used concomitantly with VPA. PMID:26633605

  7. Squamous Cell Lung Carcinoma Presenting With Refractory Status Epilepticus: A Case Report of Paraneoplastic Limbic Encephalitis.

    PubMed

    Hurley, Killian; Herron, Malcolm; McDermott, Sean; Farrell, Terence; O'Riordan, Deirdre

    2015-08-01

    Lung cancer-associated paraneoplastic syndromes affecting the central nervous system present significant diagnostic and treatment challenges. In this case, the patient presented with personality change, cognitive impairment, complex partial seizures, ataxia, dyspraxia, and dysphasia. Shortly after admission, the patient suffered refractory generalized tonic-clonic seizures and a decreased level of consciousness and required intubation, ventilation, and admission to the ICU. He was subsequently diagnosed with paraneoplastic limbic encephalitis based on recognized criteria, including a compatible clinical picture, elevated protein content in his cerebrospinal fluid with negative cytology, a positive positron emission tomography-computed tomography scan showing a right upper lobe tumor, and the exclusion of other neuro-oncological complications. Histopathology confirmed the tissue diagnosis as squamous cell cancer. Initial immunotherapy with steroids and intravenous immunoglobulin and subsequent lobectomy and adjuvant chemotherapy were partially successful, leading to partial resolution of his cognitive impairment. This report highlights the diagnostic and therapeutic challenges of lung-related paraneoplastic syndromes. In addition, it illustrates the poor outcomes for patients and identifies squamous cell cancer as an extremely rare cause of paraneoplastic limbic encephalitis. PMID:25784771

  8. Use of Longitudinal Dose–Response Modeling to Support the Efficacy and Tolerability of Alitretinoin in Severe Refractory Chronic Hand Eczema (CHE)

    PubMed Central

    Schmith, GD; Singh, R; Gomeni, R; Graff, O; Hamedani, AG; Troughton, JS; Learned, SM

    2015-01-01

    Longitudinal dose–response analyses of alitretinoin (an investigational agent in the US) were conducted to supplement results from phase III studies in severe, refractory chronic hand eczema, with objectives to address several outstanding development issues (e.g., optimal dose, possible factors affecting efficacy and/or tolerability). Models were fitted to the physicians' global assessment score and triglycerides over time. Five hundred trials were simulated to evaluate the relevance of findings. Analyses clarified that the optimal dose of alitretinoin was 30 mg once daily, where response rates were ∼10% over placebo at 12 weeks and increased by 5–7% over placebo for every 4 weeks thereafter, for up to 24 weeks. Elderly subjects had higher magnitudes of efficacy and an increased probability of high triglycerides. Results from analyses sufficiently addressed the development issues, thereby adding to the weight of evidence supporting the efficacy and safety of alitretinoin in the treatment of severe, refractory chronic hand eczema. PMID:26225249

  9. Liver transplantation for refractory severe pruritus related to widespread multifocal hepatic focal nodular hyperplasia (FNH) in a child: case report and review of literature.

    PubMed

    Merli, L; Grimaldi, C; Monti, L; Nobili, V; Francalanci, P; de Ville de Goyet, J

    2012-11-01

    FNH is a rare and benign tumor of the liver. It is not a conventional indication for liver transplantation, and no transplant for FNH in a child has been reported to date. Multifocal FNH growing in adolescent age to a widespread tumor invading the whole liver and associated with severe refractory pruritus was an unusual indication for transplantation in a 13-yr-old girl. The operation and the follow-up were uneventful, allowing full recovery and disappearance of pruritus. PMID:22093884

  10. Atypical auditory refractory periods in children from lower socio-economic status backgrounds: ERP evidence for a role of selective attention.

    PubMed

    Stevens, Courtney; Paulsen, David; Yasen, Alia; Neville, Helen

    2015-02-01

    Previous neuroimaging studies indicate that lower socio-economic status (SES) is associated with reduced effects of selective attention on auditory processing. Here, we investigated whether lower SES is also associated with differences in a stimulus-driven aspect of auditory processing: the neural refractory period, or reduced amplitude response at faster rates of stimulus presentation. Thirty-two children aged 3 to 8 years participated, and were divided into two SES groups based on maternal education. Event-related brain potentials were recorded to probe stimuli presented at interstimulus intervals (ISIs) of 200, 500, or 1000 ms. These probes were superimposed on story narratives when attended and ignored, permitting a simultaneous experimental manipulation of selective attention. Results indicated that group differences in refractory periods differed as a function of attention condition. Children from higher SES backgrounds showed full neural recovery by 500 ms for attended stimuli, but required at least 1000 ms for unattended stimuli. In contrast, children from lower SES backgrounds showed similar refractory effects to attended and unattended stimuli, with full neural recovery by 500 ms. Thus, in higher SES children only, one functional consequence of selective attention is attenuation of the response to unattended stimuli, particularly at rapid ISIs, altering basic properties of the auditory refractory period. Together, these data indicate that differences in selective attention impact basic aspects of auditory processing in children from lower SES backgrounds. PMID:25003553

  11. Infliximab versus Cyclosporine Treatment for Severe Corticosteroid-Refractory Ulcerative Colitis: A Korean, Retrospective, Single Center Study

    PubMed Central

    Kim, Eun Hye; Kim, Duk Hwan; Park, Soo Jung; Hong, Sung Pil; Kim, Tae Il; Kim, Won Ho; Cheon, Jae Hee

    2015-01-01

    Background/Aims In patients with corticosteroid-refractory ulcerative colitis (UC), cyclosporine or infliximab may be added to the treatment regimen to induce remission. Here, we aimed to compare the efficacy of cyclosporine and infliximab. Methods Between January 1995 and May 2012, the medical records of 43 patients with corticosteroid-refractory UC who received either infliximab or cyclosporine as a rescue therapy at a tertiary care hospital in Korea were reviewed. Results Among the 43 patients, 10 underwent rescue therapy with cyclosporine and the remaining 33 patients received infliximab. A follow-up of 12 months was completed for all patients. The colectomy rate at 12 months was 30% and 3% in the cyclosporine and the infliximab groups, respectively (p=0.034). However, the Cox proportional hazard model indicated that the treatment of rescue therapy was not an independent associate factor for preventing colectomy (p=0.164). In the subgroup analysis, infliximab with azathioprine was superior to cyclosporine for preventing colectomy (hazard ratio of infliximab with azathioprine compared with cyclosporine only, 0.073; 95% confidence interval, 0.008 to 0.629). Conclusions No difference between infliximab and cyclosporine with respect to preventing colectomy was noted. However, infliximab with azathioprine may be more effective than cyclosporine alone for preventing colectomy. PMID:25473080

  12. Use of Recombinant Factor VIIa in a Pediatric Patient With Initial Presentation of Refractory Acute Immune Thrombocytopenic Purpura and Severe Bleeding

    PubMed Central

    Gurion, Reut; Siu, Anita; Weiss, Aaron R.; Masterson, Margaret

    2012-01-01

    Severe bleeding in acute immune thrombocytopenic purpura (ITP) is rare but can cause significant complications to the patient. Here we report the case of a pediatric patient with acute ITP and hematuria refractory to anti-D immune globulin, high dose intravenous immunoglobulin G, and high dose steroids. Her hematuria was successfully treated with recombinant factor VIIa (rFVIIa). While further investigation on the use of rFVIIa in ITP is warranted, this case report contributes to the pediatric literature for its use during the course of an initial presentation of ITP with hemorrhagic complications. PMID:23258971

  13. Therapeutic Hypothermia for Refractory Status Epilepticus in a Child with Malignant Migrating Partial Seizures of Infancy and SCN1A Mutation: A Case Report

    PubMed Central

    Shein, Steven L.; Reynolds, Thomas Q.; Gedela, Satyanarayana; Kochanek, Patrick M.

    2012-01-01

    Status epilepticus (SE) is a common indication for neurocritical care and can be refractory to standard measures. Refractory SE (RSE) is associated with high morbidity and mortality. Unconventional therapies may be utilized in certain cases, including therapeutic hypothermia (TH), bumetanide, and the ketogenic diet. However, the literature describing the use of such therapies in RSE is limited. Details of a case of TH for RSE in an infant with malignant migrating partial seizures of infancy were obtained from the medical record. A 4-month-old child developed SE that was refractory to treatment with concurrent midazolam, phenobarbital, fosphenytoin, topiramate, levetiracetam, folinic acid, and pyridoxal-5-phosphate. This led to progressive implementation of three unconventional therapies: TH, bumetanide, and the ketogentic diet. Electrographic seizures ceased for the entirety of a 43-hour period of TH with a target rectal temperature of 33.0°C–34.0°C. No adverse effects of hypothermia were noted other than a single episode of asymptomatic hypokalemia. Seizures recurred 10 hours after rewarming was begun and did not abate with reinstitution of hypothermia. No effect was seen with administration of bumetanide. Seizures were controlled long-term within 48 hours of institution of the ketogenic diet. TH and the ketogenic diet may be effective for treating RSE in children. PMID:23667778

  14. Levofloxacin for the treatment of severe refractory BK virus-associated hemorrhagic cystitis in hematopoietic stem cell transplantation recipients: A report of three cases

    PubMed Central

    TOPTAS, TAYFUR; KAYGUSUZ-ATAGUNDUZ, ISIK; KANI, HALUK TARIK; ADIGUZEL, CAFER; FIRATLI-TUGLULAR, TULIN

    2014-01-01

    BK-virus (BKV) is an important etiological agent for late-onset hemorrhagic cystitis (HC) in patients undergoing hematopoietic stem cell transplantation. Late-onset HC causes significant morbidity among these patients. Therapeutic approaches remain predominantly symptomatic. Several treatment options have been used with variable success rates. Cidofovir has the highest specificity against BKV; however, its lack of availability in the majority of countries, high costs and potential nephrotoxic effects limit its use. The present study reports three cases of severe and prolonged BKV-associated HC (BKHC). HC was resolved in all three of the patients using oral levofloxacin. Thus, levofloxacin may be an effective treatment modality for achieving complete clinical and molecular response in patients with refractory, severe BKHC. PMID:25202408

  15. Complete recovery after severe myxoedema coma complicated by status epilepticus.

    PubMed

    Fjølner, Jesper; Søndergaard, Esben; Kampmann, Ulla; Nielsen, Søren

    2015-01-01

    We report a case of life-threatening myxoedema presenting with hypothermia, hypotension, bradycardia, pericardial effusion and deep coma. The condition was complicated by prolonged status epilepticus. The optimal treatment strategy has been debated over the years and the literature is briefly reviewed. Treatment with l-thyroxine (LT4) monotherapy without initial loading dose and with no l-triiodothyronine (LT3) treatment was successful with full recovery after hospitalisation for more than a month. Myxoedema coma is a rare, reversible condition with a high mortality and should be considered as a differential diagnosis in medical emergencies. PMID:25809434

  16. Survey made of refractory metals

    NASA Technical Reports Server (NTRS)

    Ault, G. M.

    1968-01-01

    Survey reviews the structural applications of refractory metals and the special problems they present in manufacture, evaluation, and application. The unique facilities required for their processing and evaluation, a summary of accomplishments in achieving commercial products, and the present status of the most advanced refractory materials are presented.

  17. [Refractory hypoxia].

    PubMed

    Cuchard, P; Guillemin, P

    2011-04-27

    We report a case of refractory hypoxia in an 85 years old smoker patient, who is known for cardiac and pulmonary comorbidities. The whole clinical picture at the time of his admission to hospital was pointing to a cardiac failure or a pneumonia that were causing the respiratory insufficiency. Despite an optimal treatment which stabilised these conditions, the patient remained severely hypoxic, but with relatively few symptoms. The non response to the oxygen and the worsening of the oxygen saturation when changing from the lying to the sitting (or supine) position finally evoke the syndrome of platypnea-orthodeoxia caused by a cardiac right to left shunt; that diagnosis was confirmed by a cardiac ultrasound with contrast which revealed an important inter-auricular shunt. The patient didn't wish to undertake the curative treatment (shunt closure). PMID:21526473

  18. Sudden severe hyperammonemia and status epilepticus -a case report-

    PubMed Central

    Shin, Woo-Kyung; Jang, Young-Eun; Lee, Hannah; Min, Se-Hee

    2013-01-01

    There are various causes to a low level of consciousness in patients in the intensive care unit. Neurological injury, infection, and metabolic disarray are considered as some of the causes. A 39 year-old female patient was transferred to our hospital with septic shock due to ascending colon perforation. The patient had previously received ovarian cancer surgery and a cycle of chemotherapy at another hospital. Emergent operation for colon perforation was successful. After the operation, she was treated in the intensive care unit for infectious and pulmonary complications. She suddenly showed deterioration in her level of consciousness and had a generalized seizure. At the time of her seizure, she had severe hyperammonemia. Brain CT showed severe cerebral edema that was absent in the CT scan taken 2 days before. Continuous renal replacement therapy was conducted but was ineffective in lowering the level of serum ammonia and the patient subsequently died. PMID:24101963

  19. Ethnic Background, Socioeconomic Status, and Problem Severity as Dropout Risk Factors in Psychotherapy with Youth

    ERIC Educational Resources Information Center

    de Haan, Anna M.; Boon, Albert E.; Vermeiren, Robert R. J. M.; Hoeve, Machteld; de Jong, Joop T. V. M.

    2015-01-01

    Background: Dropout from child and adolescent psychotherapy is a common phenomenon which can have negative consequences for the individual later in life. It is therefore important to gain insight on dropout risk factors. Objective: Several potential risk factors [ethnic minority status, a lower socioeconomic status (SES), and higher problem…

  20. Pre-operative fibrous osteodystrophy and severe, refractory, post-operative hypocalcemia following parathyroidectomy in a dog

    PubMed Central

    Reinhart, Jennifer M.; Nuth, Ellie K.; Byers, Christopher G.; Thoesen, Mike; Armbrust, Laura J.; Biller, David S.; Harkin, Kenneth R.

    2015-01-01

    A 13-year-old dog exhibited dramatic, radiographic osteopenia consistent with fibrous osteodystrophy secondary to primary hyperparathyroidism. Following parathyroidectomy, the dog developed severe, prolonged hypocalcemia, but was successfully treated and discharged 32 d after surgery. A variety of factors may have contributed to this dog’s hypocalcemia including hypoparathyroidism and hungry bone syndrome. PMID:26246635

  1. Severe and irreversible myelopathy after concurrent systemic and intrathecal nucleoside analogue treatment for refractory diffuse large B-cell lymphoma: A case report and review of the literature.

    PubMed

    Alsdorf, Winfried H; Schmitz, Michael; Schieferdecker, Aneta; Dierlamm, Judith; Bokemeyer, Carsten; Binder, Mascha

    2016-06-01

    We report a patient with refractory diffuse large B-cell lymphoma who developed irreversible, severe spinal neurotoxicity after concurrent treatment with intrathecal and systemic cytarabine. Shortly after concomitant administration of intrathecal triple therapy (MTX, dexamethasone and cytarabine) and high-dose systemic cytarabin (R-DHAP protocol) the patient lost control of bowel and bladder function and developed an ascending, irreversible paraplegia. Infectious or neoplastic diseases of the spinal cord were ruled out. A magnetic resonance imaging scan of the spine resulted in a diagnosis of toxic myelitis. Previously observed cases of spinal neurotoxicity after cytarabine treatment are reviewed as well as current guidelines for the use of intrathecal chemotherapy in high-grade non-Hodgkin lymphoma. In summary, severe spinal neurotoxicity of intrathecal chemotherapy is a rare side-effect, however several studies suggest that the neurotoxicity of cytarabine is significantly enhanced by concurrent intrathecal and high-dose systemic administration. Simultaneous high-dose systemic and intrathecal chemotherapy with cytarabine should therefore be avoided. PMID:25655468

  2. Profile of anti-IL-5 mAb mepolizumab in the treatment of severe refractory asthma and hypereosinophilic diseases

    PubMed Central

    Menzella, Francesco; Lusuardi, Mirco; Galeone, Carla; Taddei, Sofia; Zucchi, Luigi

    2015-01-01

    Asthma is a complex disorder frequently associated with a poor symptom control, concomitant morbidity, mortality, and significant health care costs due to lack of compliance or inadequate therapeutic options. Interleukin-5 (IL-5) plays a key role in the pathogenesis of eosinophilic disorders, and in the latest years has become a definite target for treatment. Besides asthma, other hypereosinophilic disorders include the hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis, sinonasal polyposis, COPD with eosinophilic airway inflammation, allergic rhinitis, atopic dermatitis, eosinophilic esophagitis. The introduction of mepolizumab, a fully humanized monoclonal antibody that binds to IL-5, may represent a useful therapeutic option to control exacerbations and improve asthma-related quality of life in a subgroup of patients with persistent airway eosinophilia and moderate to severe asthma. Several studies carried out in recent years allow, at present, a careful patient selection for appropriate individualized treatment in severe asthma. Further research is anyway needed in order to better understand the pathogenetic mechanisms of asthma and to find new biomarkers. The high costs of biological agents as compared with standard drugs may be largely offset by increased clinical efficacy and good safety profile in selected patients. PMID:26504401

  3. Theoretical and practical issues related to the management of severe and refractory psychotic illness complicated by pulmonary embolism

    PubMed Central

    Chandele, Payal H.; Cholera, Rashmin; Kale, Sanjiv; Ramakrishnan, Aparna; Ross, Cecil R.; Andrade, Chittaranjan

    2015-01-01

    Pulmonary embolism (PE) is a potentially fatal condition. We describe the educative case of a young adult male, with a longstanding history of schizophrenia, who was receiving anticoagulant treatment because of repeated episodes of PE in the past. He presented with severe exacerbation of psychosis and did not respond to oral and parenteral antipsychotic medication during inpatient treatment. He was taken up for electroconvulsive therapy (ECT) and received a single ECT uneventfully. The ECT course had to be interrupted because of the unexpected development of a 4-day febrile illness, after which he experienced sudden onset breathlessness, which was diagnosed as acute-on-chronic PE. After the crisis resolved with 4 days of intensive care, he was managed with clozapine. We discuss concerns associated with the psychiatric management of patients with PE; special issues include the use of restraints, parenteral antipsychotic medications, anticoagulants, and ECT. PMID:26816433

  4. Theoretical and practical issues related to the management of severe and refractory psychotic illness complicated by pulmonary embolism.

    PubMed

    Chandele, Payal H; Cholera, Rashmin; Kale, Sanjiv; Ramakrishnan, Aparna; Ross, Cecil R; Andrade, Chittaranjan

    2015-01-01

    Pulmonary embolism (PE) is a potentially fatal condition. We describe the educative case of a young adult male, with a longstanding history of schizophrenia, who was receiving anticoagulant treatment because of repeated episodes of PE in the past. He presented with severe exacerbation of psychosis and did not respond to oral and parenteral antipsychotic medication during inpatient treatment. He was taken up for electroconvulsive therapy (ECT) and received a single ECT uneventfully. The ECT course had to be interrupted because of the unexpected development of a 4-day febrile illness, after which he experienced sudden onset breathlessness, which was diagnosed as acute-on-chronic PE. After the crisis resolved with 4 days of intensive care, he was managed with clozapine. We discuss concerns associated with the psychiatric management of patients with PE; special issues include the use of restraints, parenteral antipsychotic medications, anticoagulants, and ECT. PMID:26816433

  5. -C Refractories

    NASA Astrophysics Data System (ADS)

    Xu, Yibiao; Sang, Shaobai; Li, Yawei; Ren, Bo; Zhao, Lei; Li, Yuanbing; Li, Shujing

    2014-06-01

    Al2O3-C refractories were first fabricated in a coke bed at 1673 K (1400 °C) using tabular corundum, reactive alumina, carbon black, silicon, and microsilica as the starting materials and phenol resin as the binder. Then the alkali attack resistance of those materials was conducted in the powder mixture of carbon black and potassium carbonate (1:1 wt pct) in a graphite crucible at 1273 K (1000 °C) for 10 hours. The correlation between pore size, permeability of Al2O3-C refractories, and their alkali (K2CO3) attack was investigated by means of mercury intrusion porosimetry, X-ray diffraction (XRD), and scanning electron microscopy (SEM). The results showed that the pore structure of Al2O3-C refractories was controlled by the addition of silicon, ultrafine reactive alumina, and microsilica to in-situ form SiC whiskers and mullite in the preparation process. The mean pore size of Al2O3-C refractories was strongly associated with permeability. With the decrease of the mean pore size, the permeability of the Al2O3-C refractories reduced constantly. The alkali attack test also verified that the Al2O3-C refractories with lower permeability had better alkali corrosion resistance, because the penetration of K vapor into the materials could be restricted effectively. The corrosion mechanism of Al2O3-C refractories supposes that (1) K2CO3 was reduced to K vapor and penetrated into the specimen through the open pores and (2) K vapor reacted with SiC, SiO2, and alumina to form KAlSi2O6 and KAlSiO4, which is in agreement with the thermodynamic prediction.

  6. Allogeneic human mesenchymal stem cell therapy (remestemcel-L, Prochymal) as a rescue agent for severe refractory acute graft-versus-host disease in pediatric patients.

    PubMed

    Kurtzberg, Joanne; Prockop, Susan; Teira, Pierre; Bittencourt, Henrique; Lewis, Victor; Chan, Ka Wah; Horn, Biljana; Yu, Lolie; Talano, Julie-An; Nemecek, Eneida; Mills, Charles R; Chaudhury, Sonali

    2014-02-01

    Severe steroid-refractory acute graft-versus-host disease (aGVHD) is related to significant mortality and morbidity after allogeneic stem cell transplantation. Early clinical trials of therapy with human mesenchymal stem cells (hMSCs) in pediatric patients with severe aGVHD resistant to multiple immunosuppressive agents showed promising results. In this study, we evaluated the risk/benefit profile of remestemcel-L (Prochymal), a third-party, off-the-shelf source of hMSCs, as a rescue agent for treatment-resistant aGVHD in pediatric patients. Children with grade B-D aGVHD failing steroids and, in most cases, other immunosuppressive agents were eligible for enrollment. Patients received 8 biweekly i.v. infusions of 2 × 10(6) hMSCs/kg for 4 weeks, with an additional 4 weekly infusions after day +28 for patients who achieved either a partial or mixed response. The enrolled patients compose a very challenging population with severe disease that was nonresponsive to the standard of care, with 88% of the patients experiencing severe aGVHD (grade C or D). Seventy-five patients (median age, 8 yr; 58.7% male; and 61.3% Caucasian) were treated in this study. Sixty-four patients (85.3%) had received an unrelated hematopoietic stem cell graft, and 28 patients (37.3%) had received a cord blood graft. At baseline, the distribution of aGVHD grades B, C, and D was 12.0%, 28.0%, and 60.0%, respectively. The median duration of aGVHD before enrollment was 30 d (range, 2 to 1639 d), and patients failed a median of 3 immunosuppressive agents. Organ involvement at baseline was 86.7% gastrointestinal, 54.7% skin, and 36.0% liver. Thirty-six patients (48.0%) had 2 organs involved, and 11 patients (14.7%) had all 3 organs involved. When stratified by aGVHD grade at baseline, the rate of overall response (complete and partial response) at day +28 was 66.7% for aGVHD grade B, 76.2% for grade C, and 53.3% for grade D. Overall response for individual organs at day +28 was 58.5% for

  7. New-onset refractory status epilepticus in an adult with an atypical presentation of cat-scratch disease: successful treatment with high-dose corticosteroids.

    PubMed

    Laswell, Emily M; Chambers, Kasandra D; Whitsel, Danielle R; Poudel, Kiran

    2015-06-01

    New-onset refractory status epilepticus (NORSE) is defined as a sudden onset of refractory status epilepticus in patients who do not have a history of epilepsy. It is a neurologic emergency, and determining the underlying etiology is an important factor for effectively managing and predicting the prognosis of NORSE. We describe the case of a 28-year-old woman who was hospitalized with NORSE secondary to an unknown etiology. She did not respond to traditional anticonvulsant therapy, including benzodiazepines, fosphenytoin, propofol, and levetiracetam. The patient was placed on continuous electroencephalography (EEG) monitoring and was treated further with multiple antiepileptics, which were titrated aggressively based on EEG readings and therapeutic drug levels; despite this treatment, EEG monitoring revealed continued seizures. Thus, high-dose corticosteroids were started for seizure control. Her workup included computed tomography and magnetic resonance imaging of the head, a lumbar puncture, toxicology screening, and extensive testing for multiple infectious and inflammatory etiologies. The patient's history revealed recent exposure to a new cat. Serologic results were positive for Bartonella henselae, and she was diagnosed with cat-scratch disease (CSD). She did not have the typical presentation of symptoms of lymphadenopathy, however, which is common in CSD. Doxycycline 100 mg and rifampin 300 mg twice daily were added to the patient's anticonvulsant and corticosteroid therapy. She was hospitalized for a total of 26 days and discharged with only minor neurologic impairment (short-term memory deficits and minor cognitive problems). The patient was discharged receiving antiepileptics, antibiotics, and a corticosteroid taper. To our knowledge, this is the first clinically known case of NORSE secondary to CSD without typical CSD symptoms in the adult population. The patient failed to respond to traditional anticonvulsant therapy alone. With the addition of high

  8. DEVELOPMENT STATUS AND ENVIRONMENTAL HAZARDS OF SEVERAL CANDIDATE ADVANCED ENERGY SYSTEMS

    EPA Science Inventory

    The report gives a review of the development status of several advanced energy concepts and discusses the primary environmental hazards of each system. Systems reviewed include potential new sources of energy and improved energy conversion. Each system is evaluated with respect t...

  9. Refractory status epilepticus, serious rhabdomyolysis, acute liver injury, and pancytopenia after a massive intake of ethyl methanesulfonate: a case report

    PubMed Central

    Yamazaki, Hiroyuki; Tajima, Shogo; Takeuchi, Takahiro

    2015-01-01

    Ethyl methanesulfonate is a mutagenic, alkylating agent and considered harmful to humans at levels greater than a certain threshold; however, the toxicity at high doses remains unclear. We report a case of a Japanese man who presented with status epilepticus, rhabdomyolysis, pancytopenia, and hair loss after accidental ingestion of a massive amount of ethyl methanesulfonate. The patient completely recovered with critical care, including multiple antiepileptic drugs, renal replacement therapy, blood transfusion, granulocyte colony-stimulating factor therapy, and antibacterial/fungal prophylaxis. The case indicates that ethyl methanesulfonate causes neurotoxicity, hepatotoxicity, hematotoxicity, and renal toxicity, which can be successfully treated with appropriate palliative therapies. PMID:26629236

  10. Decreased Functional Status as a Risk Factor for Severe Clostridium difficile Infection among Hospitalized Older Adults

    PubMed Central

    Rao, Krishna; Micic, Dejan; Chenoweth, Elizabeth; Deng, Lili; Galecki, Andrzej T.; Ring, Cathrin; Young, Vincent B.; Aronoff, David M.; Malani, Preeti N.

    2013-01-01

    Background Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in hospitalized older adults, who are among the patients at highest risk of severe infection. The role of impaired functional status as a risk factor for severe CDI remains poorly understood. Design Prospective cohort study. Setting The University of Michigan Health System, a 930-bed tertiary care hospital. Participants Hospitalized patients with CDI, age ≥50 years. Measurements Included demographics; clinical characteristics; and a composite outcome, the CDI severity score: fever [T >38°C]; acute organ dysfunction; white blood cell count >15 000/mm3; lack of response to therapy; intensive care unit admission, need for colectomy, or death due to CDI. Pre-admission functional status was assessed by ability to perform activities of daily living (ADLs); patients were assigned to an ADL Class (independent, some assistance, or full assistance). Secondary outcomes included length of stay; 90-day mortality and readmission; and CDI recurrence. Results We identified 90 hospitalized patients with CDI (mean age 66.6 [± SD 10.2]). Fifty-eight patients (64.4%) had severe CDI as measured by a positive severity score. At baseline, 25 (27.8%) required assistance with ADLs. On univariate analysis, an ADL Class of “full assistance” was associated with severity score (OR 7, CI 95 1.83–26.79, P = .004). In a multivariable model which included age, ADL Class, congestive heart failure, diabetes mellitus, depression, weighted Charlson-Deyo comorbidity score, immunosuppression, prior CDI, and PPI use, an ADL Class of “full assistance” retained its association with severity score (OR 8.1, CI 95 1.24–52.95, P = .029). ADL Class was not associated with secondary outcomes. Conclusion Among this cohort of hospitalized older adults, impaired functional status was an independent risk factor for severe CDI. PMID:24083842

  11. Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care.

    PubMed

    Wharam, J Frank; Zhang, Fang; Landon, Bruce E; Soumerai, Stephen B; Ross-Degnan, Dennis

    2013-08-01

    One-third of US workers now have high-deductible health plans, and those numbers are expected to grow in 2014 as implementation of the Affordable Care Act continues. There is concern that high-deductible health plans might cause enrollees of low socioeconomic status to forgo emergency care as a result of burdensome out-of-pocket costs. We analyzed emergency department (ED) visits and hospitalizations over two years among enrollees insured in high-deductible plans through small employers in Massachusetts. We found that plan members of low socioeconomic status experienced 25-30 percent reductions in high-severity ED visits over both years, while hospitalizations declined by 23 percent in year 1 but rose again in year 2. Similar trends were not found among high-deductible plan members of high socioeconomic status. Our findings suggest that plan members of low socioeconomic status at small firms responded inappropriately to high-deductible plans and that initial reductions in high-severity ED visits might have increased the need for subsequent hospitalizations. Policy makers and employers should consider proactive strategies to educate high-deductible plan members about their benefit structures or identify members at higher risk of avoiding needed care. They should also consider implementing means-based deductibles. PMID:23918484

  12. Physical Activity, Health Status and Risk of Hospitalization in Patients with Severe Chronic Obstructive Pulmonary Disease

    PubMed Central

    Benzo, Roberto P.; Chang, Chung-Chou H.; Farrell, Max H.; Kaplan, Robert; Ries, Andrew; Martinez, Fernando J.; Wise, Robert; Make, Barry; Sciurba, Frank

    2010-01-01

    Background Chronic obstructive pulmonary disease (COPD) is a leading cause of death and 70% of the cost of COPD is due to hospitalizations. Self-reported daily physical activity and health status have been reported as predictors of a hospitalization in COPD but are not routinely assessed. Objectives We tested the hypothesis that self-reported daily physical activity and health status assessed by a simple question were predictors of a hospitalization in a well-characterized cohort of patients with severe emphysema. Methods Investigators gathered daily physical activity and health status data assessed by a simple question in 597 patients with severe emphysema and tested the association of those patient-reported outcomes to the occurrence of a hospitalization in the following year. Multiple logistic regression analyses were used to determine predictors of hospitalization during the first 12 months after randomization. Results The two variables tested in the hypothesis were significant predictors of a hospitalization after adjusting for all univariable significant predictors: >2 h of physical activity per week had a protective effect [odds ratio (OR) 0.60; 95% confidence interval (95% CI) 0.41–0.88] and self-reported health status as fair or poor had a deleterious effect (OR 1.57; 95% CI 1.10–2.23). In addition, two other variables became significant in the multivariate model: total lung capacity (every 10% increase) had a protective effect (OR 0.88; 95% CI 0.78–0.99) and self-reported anxiety had a deleterious effect (OR 1.75; 95% CI 1.13–2.70). Conclusion Self-reported daily physical activity and health status are independently associated with COPD hospitalizations. Our findings, assessed by simple questions, suggest the value of patient-reported outcomes in developing risk assessment tools that are easy to use. PMID:20234126

  13. Pharmacotherapy for Status Epilepticus.

    PubMed

    Trinka, Eugen; Höfler, Julia; Leitinger, Markus; Brigo, Francesco

    2015-09-01

    Status epilepticus (SE) represents the most severe form of epilepsy. It is one of the most common neurologic emergencies, with an incidence of up to 61 per 100,000 per year and an estimated mortality of 20 %. Clinically, tonic-clonic convulsive SE is divided into four subsequent stages: early, established, refractory, and super-refractory. Pharmacotherapy of status epilepticus, especially of its later stages, represents an "evidence-free zone," due to a lack of high-quality, controlled trials to inform clinical decisions. This comprehensive narrative review focuses on the pharmacotherapy of SE, presented according to the four-staged approach outlined above, and providing pharmacological properties and efficacy/safety data for each antiepileptic drug according to the strength of scientific evidence from the available literature. Data sources included MEDLINE and back-tracking of references in pertinent studies. Intravenous lorazepam or intramuscular midazolam effectively control early SE in approximately 63-73 % of patients. Despite a suboptimal safety profile, intravenous phenytoin or phenobarbital are widely used treatments for established SE; alternatives include valproate, levetiracetam, and lacosamide. Anesthetics are widely used in refractory and super-refractory SE, despite the current lack of trials in this field. Data on alternative treatments in the later stages are limited. Valproate and levetiracetam represent safe and effective alternatives to phenobarbital and phenytoin for treatment of established SE persisting despite first-line treatment with benzodiazepines. To date there are no class I data to support recommendations for most antiepileptic drugs for established, refractory, and super-refractory SE. Limiting the methodologic heterogeneity across studies is required and high-class randomized, controlled trials to inform clinicians about the best treatment in established and refractory status are needed. PMID:26310189

  14. Adult venovenous extracorporeal membrane oxygenation for severe respiratory failure: Current status and future perspectives.

    PubMed

    Sen, Ayan; Callisen, Hannelisa E; Alwardt, Cory M; Larson, Joel S; Lowell, Amelia A; Libricz, Stacy L; Tarwade, Pritee; Patel, Bhavesh M; Ramakrishna, Harish

    2016-01-01

    Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure was proposed more than 40 years ago. Despite the publication of the ARDSNet study and adoption of lung protective ventilation, the mortality for acute respiratory failure due to acute respiratory distress syndrome has continued to remain high. This technology has evolved over the past couple of decades and has been noted to be safe and successful, especially during the worldwide H1N1 influenza pandemic with good survival rates. The primary indications for ECMO in acute respiratory failure include severe refractory hypoxemic and hypercarbic respiratory failure in spite of maximum lung protective ventilatory support. Various triage criteria have been described and published. Contraindications exist when application of ECMO may be futile or technically impossible. Knowledge and appreciation of the circuit, cannulae, and the physiology of gas exchange with ECMO are necessary to ensure lung rest, efficiency of oxygenation, and ventilation as well as troubleshooting problems. Anticoagulation is a major concern with ECMO, and the evidence is evolving with respect to diagnostic testing and use of anticoagulants. Clinical management of the patient includes comprehensive critical care addressing sedation and neurologic issues, ensuring lung recruitment, diuresis, early enteral nutrition, treatment and surveillance of infections, and multisystem organ support. Newer technology that delinks oxygenation and ventilation by extracorporeal carbon dioxide removal may lead to ultra-lung protective ventilation, avoidance of endotracheal intubation in some situations, and ambulatory therapies as a bridge to lung transplantation. Risks, complications, and long-term outcomes and resources need to be considered and weighed in before widespread application. Ethical challenges are a reality and a multidisciplinary approach that should be adopted for every case in consideration. PMID:26750681

  15. Adult venovenous extracorporeal membrane oxygenation for severe respiratory failure: Current status and future perspectives

    PubMed Central

    Sen, Ayan; Callisen, Hannelisa E.; Alwardt, Cory M.; Larson, Joel S.; Lowell, Amelia A.; Libricz, Stacy L.; Tarwade, Pritee; Patel, Bhavesh M.; Ramakrishna, Harish

    2016-01-01

    Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure was proposed more than 40 years ago. Despite the publication of the ARDSNet study and adoption of lung protective ventilation, the mortality for acute respiratory failure due to acute respiratory distress syndrome has continued to remain high. This technology has evolved over the past couple of decades and has been noted to be safe and successful, especially during the worldwide H1N1 influenza pandemic with good survival rates. The primary indications for ECMO in acute respiratory failure include severe refractory hypoxemic and hypercarbic respiratory failure in spite of maximum lung protective ventilatory support. Various triage criteria have been described and published. Contraindications exist when application of ECMO may be futile or technically impossible. Knowledge and appreciation of the circuit, cannulae, and the physiology of gas exchange with ECMO are necessary to ensure lung rest, efficiency of oxygenation, and ventilation as well as troubleshooting problems. Anticoagulation is a major concern with ECMO, and the evidence is evolving with respect to diagnostic testing and use of anticoagulants. Clinical management of the patient includes comprehensive critical care addressing sedation and neurologic issues, ensuring lung recruitment, diuresis, early enteral nutrition, treatment and surveillance of infections, and multisystem organ support. Newer technology that delinks oxygenation and ventilation by extracorporeal carbon dioxide removal may lead to ultra-lung protective ventilation, avoidance of endotracheal intubation in some situations, and ambulatory therapies as a bridge to lung transplantation. Risks, complications, and long-term outcomes and resources need to be considered and weighed in before widespread application. Ethical challenges are a reality and a multidisciplinary approach that should be adopted for every case in consideration. PMID:26750681

  16. Relationship between dental caries status and anemia in children with severe early childhood caries.

    PubMed

    Tang, Ru-Shing; Huang, Meng-Chuan; Huang, Shun-Te

    2013-06-01

    Severe early childhood caries (SECC) is a public health problem among preschool children. Malnutrition is a condition commonly prevalent in children with SECC. This study investigated the nutritional status among preschool children with SECC. Children with SECC (n = 101) aged 2-5 years from the Division of Pediatric Dentistry in an academic hospital in Southern Taiwan were recruited for our cross-sectional study. The nutritional status of the children was assessed based on anthropometric measurements and clinical tests. By applying the criteria established by the World Health Organization, we found that 9% and 46% of the children with SECC were diagnosed as being anemic and iron deficient, respectively. Using national standards for the body mass index, 30% of children with SECC were classified as underweight. The relationship between the caries status of the children and anemia was examined using multivariable logistic regression analysis (p < 0.05). Our results show that SECC is strongly associated with anemia (7.25-fold), indicating that clinicians and dentists should provide treatment to improve both the oral hygiene and the nutritional status of children with SECC. PMID:23684139

  17. Functional design of refractories for slagging gasifiers

    SciTech Connect

    Kwong, Kyei-Sing; Dogan, Cynthia P.; Bennett, James P.; Chinn, Richard E.; Dahlin, Cheryl L.

    2002-09-01

    Refractories are used in coal slagging gasifiers to protect the outer steel shell from coal slag attack and to insulate it from heat. Corrosion by the aggressive coal slags and unexpected temperature shock severely shorten the service life of these refractories. Currently, the best refractories available for the slagging coal gasifiers last from 6 to 18 months. The down time for the installation of new refractory lining reduces on-line availability of the gasifier. Researchers at the Albany Research Center (ARC) have found that structural spalling by slag penetration into the refractory is responsible for the early failure of refractories in some gasifiers. The low melting point of coal slags, the low thermal gradient in the refractory, and the improper design of refractory microstructure contribute to promote slag penetration. Work at ARC has demonstrated that refractories with an improved functional design are more resistant to slag penetration. Cooperation with commercial refractory companies and gasifier designers/operators is underway to produce and test improved refractories.

  18. Association between Nutritional Status and Severity of Dengue Infection in Children in El Salvador

    PubMed Central

    Marón, Gabriela M.; Clará, A. Wilfrido; Diddle, John Wesley; Pleités, Ernesto B.; Miller, Laura; MacDonald, Gene; Adderson, Elisabeth E.

    2010-01-01

    Clinical observations and some studies suggest that dengue virus infection is more severe among children with better nutritional status. We examined the nutritional status of children in El Salvador and its relationship between this and the severity of dengue infection. Z-scores for weight-for-age, height-for-age, and body mass index (BMI)-for-age of children with dengue fever (66), dengue hemorrhagic fever (62), and healthy controls (74) were compared. There were no differences in weight-for-age or BMI-for-age Z-scores between the three groups. Children with dengue fever had a greater height-for-age than healthy controls but no significant differences in rates of stunting. There was no difference in height between children with dengue fever and dengue hemorrhagic fever. Excess nutrition does not appear to be a risk factor for severe forms of dengue infection in El Salvador, nor does malnutrition appear to be predictive of good outcomes. PMID:20134012

  19. Reversal of Refractory Ulcerative Colitis and Severe Chronic Fatigue Syndrome Symptoms Arising from Immune Disturbance in an HLA-DR/DQ Genetically Susceptible Individual with Multiple Biotoxin Exposures.

    PubMed

    Gunn, Shelly R; Gunn, G Gibson; Mueller, Francis W

    2016-01-01

    BACKGROUND Patients with multisymptom chronic conditions, such as refractory ulcerative colitis (RUC) and chronic fatigue syndrome (CFS), present diagnostic and management challenges for clinicians, as well as the opportunity to recognize and treat emerging disease entities. In the current case we report reversal of co-existing RUC and CFS symptoms arising from biotoxin exposures in a genetically susceptible individual. CASE REPORT A 25-year-old previously healthy male with new-onset refractory ulcerative colitis (RUC) and chronic fatigue syndrome (CFS) tested negative for autoimmune disease biomarkers. However, urine mycotoxin panel testing was positive for trichothecene group and air filter testing from the patient's water-damaged rental house identified the toxic mold Stachybotrys chartarum. HLA-DR/DQ testing revealed a multisusceptible haplotype for development of chronic inflammation, and serum chronic inflammatory response syndrome (CIRS) biomarker testing was positive for highly elevated TGF-beta and a clinically undetectable level of vasoactive intestinal peptide (VIP). Following elimination of biotoxin exposures, VIP replacement therapy, dental extractions, and implementation of a mind body intervention-relaxation response (MBI-RR) program, the patient's symptoms resolved. He is off medications, back to work, and resuming normal exercise. CONCLUSIONS This constellation of RUC and CFS symptoms in an HLA-DR/DQ genetically susceptible individual with biotoxin exposures is consistent with the recently described CIRS disease pathophysiology. Chronic immune disturbance (turbatio immuno) can be identified with clinically available CIRS biomarkers and may represent a treatable underlying disease etiology in a subset of genetically susceptible patients with RUC, CFS, and other immune disorders. PMID:27165859

  20. Reversal of Refractory Ulcerative Colitis and Severe Chronic Fatigue Syndrome Symptoms Arising from Immune Disturbance in an HLADR/DQ Genetically Susceptible Individual with Multiple Biotoxin Exposures

    PubMed Central

    Gunn, Shelly R.; Gibson Gunn, G.; Mueller, Francis W.

    2016-01-01

    Patient: Male, 25 Final Diagnosis: Ulcerative colitis and chronic fatigue syndrome Symptoms: Colitis • profound fatigue • multi-joint pain • cognitive impairment • corneal keratitis Medication: — Clinical Procedure: VIP replacement therapy Specialty: Family Medicine Objective: Unusual clinical course Background: Patients with multisymptom chronic conditions, such as refractory ulcerative colitis (RUC) and chronic fatigue syndrome (CFS), present diagnostic and management challenges for clinicians, as well as the opportunity to recognize and treat emerging disease entities. In the current case we report reversal of co-existing RUC and CFS symptoms arising from biotoxin exposures in a genetically susceptible individual. Case Report: A 25-year-old previously healthy male with new-onset refractory ulcerative colitis (RUC) and chronic fatigue syndrome (CFS) tested negative for autoimmune disease biomarkers. However, urine mycotoxin panel testing was positive for trichothecene group and air filter testing from the patient’s water-damaged rental house identified the toxic mold Stachybotrys chartarum. HLA-DR/DQ testing revealed a multisusceptible haplotype for development of chronic inflammation, and serum chronic inflammatory response syndrome (CIRS) biomarker testing was positive for highly elevated TGF-beta and a clinically undetectable level of vasoactive intestinal peptide (VIP). Following elimination of biotoxin exposures, VIP replacement therapy, dental extractions, and implementation of a mind body intervention-relaxation response (MBI-RR) program, the patient’s symptoms resolved. He is off medications, back to work, and resuming normal exercise. Conclusions: This constellation of RUC and CFS symptoms in an HLA-DR/DQ genetically susceptible individual with biotoxin exposures is consistent with the recently described CIRS disease pathophysiology. Chronic immune disturbance (turbatio immuno) can be identified with clinically available CIRS biomarkers and

  1. The present status of xeroderma pigmentosum in Japan and a tentative severity classification scale.

    PubMed

    Nakano, Eiji; Masaki, Taro; Kanda, Fumio; Ono, Ryusuke; Takeuchi, Seiji; Moriwaki, Shinichi; Nishigori, Chikako

    2016-08-01

    Xeroderma pigmentosum (XP) is a rare autosomal recessive hereditary disease. Patients with XP have severe hypersensitivity to sunlight, resulting in skin cancers, and some patients have neurological symptoms. In Japan, XP complementation group A (XP-A) is the most common form, and it is associated with severe neurological symptoms. We performed a nationwide survey on XP to determine the present status of XP in Japan. The distribution of complementation groups in Japan was considerably different from that in other countries, but there was a higher frequency in group A and the variant type, which is similar to previous reports in Japan. Basal cell carcinoma was the most frequent skin cancer that patients with XP developed, followed by squamous cell carcinoma and malignant melanoma. The frequency of these skin cancers in patients with XP-A has decreased, and these skin cancers have been occurring in much older people than those previously observed. Diagnosing XP in patients at younger ages seems to encourage patients and their parents to use sun protection, which helps prevent skin cancer. We also created a tentative scale for classifying the severity of XP, and we evaluated the neurological symptoms of XP-A using this severity scale. Our classification correlated well with patients' age, suggesting that it may be useful and feasible in clinical practice to assess the progression of symptoms of each patient with XP and evaluate the effects of treatment in the future. PMID:27539899

  2. Haematological profile in leprosy. Part II--Relationship to severity of disease and treament status.

    PubMed

    Karat, A B; Rao, P S

    1978-01-01

    321 adult male lepromatous leprosy patients were studied for relationship between haematological findings, severity of disease and duration of treatment. Significant changes were noticed in relation in haemoglobin concentration, serum vitamin B12 and serum folate levels, serum albumin and globulin. No significant changes were observed in serum iron levels in relation to disease and treatment status. With rising bacterial load, there was a trend towards lower haemoglobin concentration, higher vitamin B12 level and lowered serum folate levels. Serum albumin showed a significant decline, while serum globulin showed a significant rise. The findings are discussed in relation to replacement of bone marrow by lepromatous tissue as well as possible interference in the metabolism of haematinics by M. leprae. The exact mechanism of neurlogical deficit in leprosy in relation to deficiency of vitamin B12 and folic acid need to be further elucidated. PMID:651316

  3. Dynamic Testing of Gasifier Refractory

    SciTech Connect

    Michael D. Mann; John P. Hurley

    2002-09-27

    As DOE continues to advance new power systems, materials issues are often pivotal in determining the ultimate efficiency that can be reached in the system. Refractory performance in slagging gasification represents one of these issues. The University of North Dakota (UND) Chemical Engineering Department in conjunction with the UND Energy & Environmental Research Center (EERC) have initiated a program to thoroughly examine the combined chemical (reaction and phase change) and physical (erosion) effects experienced by a variety of refractory materials during both normal operation and thermal cycling under slagging coal gasification conditions. The goal of this work is to devise a mechanism of refractory loss under these conditions. The focus of the proposed work is to test the corrosion resistance of commercially available refractories to flowing coal slag, and propose the mechanisms of corrosion for the conditions studied. Corrosion is the degradation of material surfaces or grain boundaries by chemical reactions with melts, liquids, or gases, causing loss of material and consequently a decrease in strength of the structure. In order to develop methods of reducing corrosion, the microstructure that is attacked must be identified along with the mechanism and rates of attack. Once these are identified, methods for reducing corrosion rates can be developed. The work will take advantage of equipment and experimental techniques developed at the EERC under funding from several DOE programs. The controlled-atmospheric dynamic corrodent application furnace (CADCAF) will be utilized to simulate refractory/slag interactions under dynamic conditions that more realistically simulate the environment in a slagging coal gasifier than any of the static tests used previously by refractory manufacturers and researchers. To date, efforts have focused on final shakedown of the CADCAF and obtaining representative samples of slag and refractory for testing.

  4. Aquaporin 4 antibody [NMO Ab] status in patients with severe optic neuritis in India.

    PubMed

    Ambika, Selvakumar; Balasubramanian, Mahalakshmi; Theresa, Lily; Veeraputhiran, Akila; Arjundas, Deepak

    2015-12-01

    Neuromyelitis optica (NMO) is an inflammatory demyelinating disease of the central nervous system that causes attacks of optic neuritis and transverse myelitis. The discovery of a specific serum marker for NMO-IgG antibody [aquaporin 4 antibody/AQP4 Ab] has revolutionised the treatment of demyelinating diseases. Severe vision loss can be seen in optic neuritis (ON) associated with both multiple sclerosis (MS) and NMO. Identifying this antibody in optic neuritis patients can help us to establish the likelihood of these patients developing NMO (Jarius et al. Neurol Sci 298:158-162, 2010). It is important to differentiate these two entities as the treatment strategies of MS and NMO are different. To the best of our knowledge, there is no published literature regarding the importance of identifying this antibody in severe optic neuritis in Indian patients. Hence we decided to screen our severe optic neuritis patients for this AQP4 Ab. To investigate the presence of aquaporin 4 antibody and determine its prognostic value for visual and neurological outcome, in patients with bilateral and recurrent [severe] ON without any previous neurological manifestations presenting to a neuro-ophthalmology clinic in India. Single centre, prospective study. 40 patients (27 female patients and 13 male) with severe optic neuritis [patients with no visual improvement by 4 weeks from onset of vision loss] who presented either as recurrent attacks or as bilateral and severe optic neuritis between January 2010 and June 2011 were enrolled. Clinical features, visual outcome and sequential neurological events were compared between the seropositive and the seronegative groups. Aquaporin 4 antibodies were detected from serum using ELISA technique and IIF technique. Presence of this antibody in the serum was considered to be seropositive status and patients who did not have this antibody were considered seronegatives. AQP4 antibodies were detected in 8 of the 40 patients with severe ON (20 %).The

  5. Serum Vitamin D Status in Iranian Fibromyalgia Patients: according to the Symptom Severity and Illness Invalidation

    PubMed Central

    Maafi, Alireza Amir; Haghdoost, Afrooz; Aarabi, Yasaman; Hajiabbasi, Asghar; Shenavar Masooleh, Irandokht; Zayeni, Habib; Ghalebaghi, Babak; Hassankhani, Amir; Bidari, Ali

    2016-01-01

    Background This study was designed to assess serum vitamin D status (25-OHD) in the fibromyalgia (FM) patients and to compare it with a healthy control group. It also aimed to investigate the correlation of serum vitamin D level with FM symptom severity and invalidation experiences. Methods A total of 74 consecutive patients with FM and 68 healthy control participants were enrolled. The eligible FM patients completed the Illness Invalidation Inventory (3*I), the Revised Fibromyalgia Impact Questionnaire (FIQR) and a short-form health survey (SF-12). Venous blood samples were drawn from all participants to evaluate serum 25-OHD levels. Mann-Whitney tests and multiple logistic regression analyses were performed and Spearman's correlations were calculated. Results 88.4% of FM patients had low levels of serum 25-OHD. FM patients had significantly higher level of serum 25-OHD than the control group (17.24 ± 13.50 and 9.91 ± 6.47 respectively, P = 0.0001). There were no significant correlations between serum 25-OHD levels and the clinical measures of disease impact, invalidation dimensions, and health status. Multiple logistic regression analyses revealed that an increased discounting of the disease by the patient's spouse was associated with a 4-fold increased risk for vitamin D deficiency (OR = 4.36; 95% CI, 0.95–19.87, P = 0.05). Conclusions This study showed that although high rates of vitamin D insufficiency or deficiency were seen among FM patients and healthy non-FM participants, but it seems there was no intrinsic association between FM and vitamin D deficiency. Addressing of invalidation experience especially by the patient's spouse is important in management of FM. PMID:27413482

  6. Testing Requirements for Refractory Materials

    NASA Technical Reports Server (NTRS)

    Calle, Luz Marina; Hintze, Paul E.; Parlier, Christopher R.; Curran, Jerome P.; Kolody, Mark R.; Sampson, Jeffrey W,; Montgomery, Eliza M.

    2012-01-01

    Launch Pads 39A and 39B currently use refractory material (Fondu Fyre) in the flame trenches. This material was initially approved for the Saturn program. This material had a lifetime of 10years according to the manufacturer, and it has been used for over 40 years. As a consequence, the Fondu Fyre at Launch Complex 39 requires repair subsequent to almost every launch. A review of the literature indicates that the gunned Fondu Fyre refractory product (WA-1 G) was never tested prior to use. With the recent severe damage to the flame trenches, a new refractory material is sought to replace Fondu Fyre. In order to replace Fondu Fyre, a methodology to test and evaluate refractory products was developed. This paper outlines this methodology and discusses current testing requirements, as well as the laboratory testing that might be required. Furthermore, this report points out the necessity for subscale testing, the locations where this testing can be performed, and the parameters that will be necessary to qualify a product. The goal is to identify a more durable refractory material that has physical, chemical, and thermal properties suitable to withstand the harsh environment of the launch pads at KSC.

  7. Testing Requirements for Refractory Materials

    NASA Technical Reports Server (NTRS)

    Calle, Luz Marina; Hintze, Paul E.; Parlier, Christopher R.; Curran, Jerome P.; Kolody, Mark R.; Sampson, Jeffrey W.; Montgomery, Eliza M.

    2011-01-01

    Launch Pads 39A and 39B currently use refractory material (Fondu Fyre) in the flame trenches. This material was initially approved for the Saturn program. This material had a lifetime of 10 years according to the manufacturer, and it has been used for over 40 years. As a consequence, the Fondu Fyre at Launch Complex 39 requires repair subsequent to almost every launch. A review of the literature indicates that the gunned Fondu Fyre refractory product (WA-1G) was never tested prior to use. With the recent severe damage to the flame trenches, a new refractory material is sought to replace Fondu Fyre. In order to replace Fondu Fyre, a methodology to test and evaluate refractory products was developed. This paper outlines this methodology and discusses current testing requirements, as well as the laboratory testing that might be required. Furthermore, this report points out the necessity for subscale testing, the locations where this testing can be performed, and the parameters that will be necessary to qualify a product. The goal is to identify a more durable refractory material that has physical, chemical, and thermal properties suitable to withstand the harsh environment of the launch pads at KSC.

  8. Testing Requirements for Refractory Materials

    NASA Technical Reports Server (NTRS)

    Calle, Luz Marina; Hintze, Paul E.; Parlier, Christopher R.; Curran, Jerome P.; Kolody, Mark R.; Sampson, Jeffrey W.; Montgomery, Eliza M.

    2010-01-01

    Launch Pads 39A and 39B currently use refractory material (Fondu Fyre) in the flame trenches. This material was initially approved for the Saturn program. This material had a lifetime of 10 years according to the manufacturer, and it has been used for over 40 years. As a consequence, the Fondu Fyre at Launch Complex 39 requires repair subsequent to almost every launch. A review of the literature indicates that the gunned Fondu Fyre refractory product (WA-1G) was never tested prior to use. With the recent severe damage to the flame trenches, a new refractory material is sought to replace Fondu Fyre. In order to replace Fondu Fyre, a methodology to test and evaluate refractory products was developed. This paper outlines this methodology and discusses current testing requirements, as well as the laboratory testing that might be required. Furthermore, this report points out the necessity for subscale testing, the locations where this testing can be performed, and the parameters that will be necessary to qualify a product. The goal is to identify a more durable refractory material that has physical, chemical, and thermal properties suitable to withstand the harsh environment of the launch pads at KSC.

  9. Results of the ACSUS for pediatric AIDS patients: utilization of services, functional status, and social severity.

    PubMed Central

    Fahs, M C; Waite, D; Sesholtz, M; Muller, C; Hintz, E A; Maffeo, C; Arno, P; Bennett, C

    1994-01-01

    OBJECTIVE. This study describes demographic characteristics of pediatric AIDS patients, describes hospital and community-based service utilization patterns, and analyzes medical and social support service usage patterns with respect to patient demographic characteristics, clinical trial participation, functional/developmental status, and social environment. DATA SOURCES AND STUDY SETTING. Data reported in this study are from the AIDS Costs and Service Utilization Survey (ACSUS) and cover the six-month period beginning March 1991 (N = 135). Pediatric patients who sought care for HIV-related problems were sampled at seven different hospitals in five metropolitan regions of the United States. All of the participating hospitals had clinics specifically serving pediatric patients infected with HIV. The sample consists of HIV-positive patients who had had at least one HIV-related symptom or condition. STUDY DESIGN. A stratified probability sample design guided the sampling strategy, which included oversampling in two large hospitals from two of the five metropolitan areas. Survey data cover an 18-month time period of health care utilization, cost, and financing information from HIV-infected patients and their providers. Utilization measures are standardized to a six-month period. Per capita income, family structure, informal personal network, functional status, and clinical trial participation are tested for associations with patterns of utilization. In addition, a weighted ten-point social severity scale was developed to assess family/household stability. DATA COLLECTION. Data were collected through a screener instrument completed by the person accompanying the child to a hospital clinic visit (usually a a parent), and through two interviews conducted in person with the patients' primary caregivers. Data from the questionnaires were coded and assembled into computerized SAS analysis files by WESTAT. PRINCIPAL FINDINGS. Children in this sample are 62 percent African

  10. Socioeconomic status affects pulmonary hypertension disease severity at time of first evaluation

    PubMed Central

    Sahni, Sonu; Talwar, Ankoor; Kohn, Nina; Klinger, James R.

    2016-01-01

    Abstract A low socioeconomic status (SES) has been linked to disproportionate access to health care in many diseases, leading to worse disease severity at initial presentation. There is a paucity of these data in the pulmonary hypertension (PHTN) population. We studied the association of SES, as measured by zip code–based median annual household income, with World Health Organization functional class (WHO-FC) at time of first evaluation in PHTN patients. All patients evaluated at our center with a right heart catheterization revealing a mean pulmonary artery pressure of ≥25 mmHg within 12 months of initial evaluation were considered for the study. Demographics, WHO-FC, and zip codes were obtained from retrospective chart analysis. The 2010 US census was used to obtain zip code–based annual median income. The income groups were divided into quartiles. Patients were categorized by their WHO-FC and zip code–derived median income. Similar analyses were conducted for pulmonary arterial hypertension (PAH) patients. Survival was estimated with the Kaplan-Meier method. Data were analyzed in SAS, and P < 0.05 was considered significant. There were 228 PHTN patients (70 [30.7%] male, 158 [69.3%] female). As median income decreased, the FC at presentation increased, signifying higher disease severity (Spearman correlation: r = −0.161, P < 0.0515). This association between median income groups and WHO-FC at initial evaluation was significant (χ2 test: P < 0.0168). There were 116 PAH patients (32 [27.6%] male, 84 [72.4%] female). There was again a negative relationship between income and initial FC (Spearman correlation: r = −0.0307, P < 0.0007). A lower SES was associated with worse disease, as measured by WHO-FC. PMID:27252845

  11. Socioeconomic status affects pulmonary hypertension disease severity at time of first evaluation.

    PubMed

    Talwar, Arunabh; Sahni, Sonu; Talwar, Ankoor; Kohn, Nina; Klinger, James R

    2016-06-01

    A low socioeconomic status (SES) has been linked to disproportionate access to health care in many diseases, leading to worse disease severity at initial presentation. There is a paucity of these data in the pulmonary hypertension (PHTN) population. We studied the association of SES, as measured by zip code-based median annual household income, with World Health Organization functional class (WHO-FC) at time of first evaluation in PHTN patients. All patients evaluated at our center with a right heart catheterization revealing a mean pulmonary artery pressure of ≥25 mmHg within 12 months of initial evaluation were considered for the study. Demographics, WHO-FC, and zip codes were obtained from retrospective chart analysis. The 2010 US census was used to obtain zip code-based annual median income. The income groups were divided into quartiles. Patients were categorized by their WHO-FC and zip code-derived median income. Similar analyses were conducted for pulmonary arterial hypertension (PAH) patients. Survival was estimated with the Kaplan-Meier method. Data were analyzed in SAS, and P < 0.05 was considered significant. There were 228 PHTN patients (70 [30.7%] male, 158 [69.3%] female). As median income decreased, the FC at presentation increased, signifying higher disease severity (Spearman correlation: r = -0.161, P < 0.0515). This association between median income groups and WHO-FC at initial evaluation was significant (χ(2) test: P < 0.0168). There were 116 PAH patients (32 [27.6%] male, 84 [72.4%] female). There was again a negative relationship between income and initial FC (Spearman correlation: r = -0.0307, P < 0.0007). A lower SES was associated with worse disease, as measured by WHO-FC. PMID:27252845

  12. Use of the Progressive Aphasia Severity Scale (PASS) in monitoring speech and language status in PPA

    PubMed Central

    Sapolsky, Daisy; Domoto-Reilly, Kimiko; Dickerson, Bradford C.

    2014-01-01

    Background Primary progressive aphasia (PPA) is a devastating neurodegenerative syndrome involving the gradual development of aphasia, slowly impairing the patient’s ability to communicate. Pharmaceutical treatments do not currently exist and intervention often focuses on speech-language behavioral therapies, although further investigation is warranted to determine how best to harness functional benefits. Efforts to develop pharmaceutical and behavioral treatments have been hindered by a lack of standardized methods to monitor disease progression and treatment efficacy. Aims Here we describe our current approach to monitoring progression of PPA, including the development and applications of a novel clinical instrument for this purpose, the Progressive Aphasia Severity Scale (PASS). We also outline some of the issues related to initial evaluation and longitudinal monitoring of PPA. Methods & Procedures In our clinical and research practice we perform initial and follow-up assessments of PPA patients using a multi-faceted approach. In addition to standardized assessment measures, we use the PASS to rate presence and severity of symptoms across distinct domains of speech, language, and functional and pragmatic aspects of communication. Ratings are made using the clinician’s best judgment, integrating information from patient test performance in the office as well as a companion’s description of routine daily functioning. Outcomes & Results Monitoring symptom characteristics and severity with the PASS can assist in developing behavioral therapies, planning treatment goals, and counseling patients and families on clinical status and prognosis. The PASS also has potential to advance the implementation of PPA clinical trials. Conclusions PPA patients display heterogeneous language profiles that change over time given the progressive nature of the disease. The monitoring of symptom progression is therefore crucial to ensure that proposed treatments are appropriate at

  13. Management of chronic refractory cough.

    PubMed

    Gibson, Peter G; Vertigan, Anne E

    2015-01-01

    Chronic refractory cough (CRC) is defined as a cough that persists despite guideline based treatment. It is seen in 20-46% of patients presenting to specialist cough clinics and it has a substantial impact on quality of life and healthcare utilization. Several terms have been used to describe this condition, including the recently introduced term cough hypersensitivity syndrome. Key symptoms include a dry irritated cough localized around the laryngeal region. Symptoms are not restricted to cough and can include globus, dyspnea, and dysphonia. Chronic refractory cough has factors in common with laryngeal hypersensitivity syndromes and chronic pain syndromes, and these similarities help to shed light on the pathophysiology of the condition. Its pathophysiology is complex and includes cough reflex sensitivity, central sensitization, peripheral sensitization, and paradoxical vocal fold movement. Chronic refractory cough often occurs after a viral infection. The diagnosis is made once the main diseases that cause chronic cough have been excluded (or treated) and cough remains refractory to medical treatment. Several treatments have been developed over the past decade. These include speech pathology interventions using techniques adapted from the treatment of hyperfunctional voice disorders, as well as the use of centrally acting neuromodulators such as gabapentin and pregabalin. Potential new treatments in development also show promise. PMID:26666537

  14. Management of refractory hypoxemia

    PubMed Central

    Mehta, Chitra; Mehta, Yatin

    2016-01-01

    Mechanical ventilation remains the cornerstone in the management of severe acute respiratory failure. Acute respiratory distress syndrome (ARDS) is the most common cause of respiratory failure. It is associated with substantial mortality, and unmanageable refractory hypoxemia remains the most feared clinical possibility. If hypoxemia persists despite application of lung protective ventilation, additional therapies including inhaled vasodilators, prone positioning, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade (NMB), and extracorporeal membrane oxygenation may be needed. NMB and prone ventilation are modalities that have been clearly linked to reduced mortality in ARDS. Rescue therapies pose a clinical challenge requiring a precarious balance of risks and benefits, as well as, in-depth knowledge of therapeutic limitations. PMID:26750680

  15. Refractory inclusions in the Ornans C30 chondrite

    NASA Technical Reports Server (NTRS)

    Davis, A. M.

    1985-01-01

    Several types of metedorites contain unusual objects 10 micrometers to 2 centimeters across that are enriched in refractory elements such as calcium, aluminum and titanium. These objects, commonly known as refractory inclusions, are most abundant in the meteorites known as carbonaceous chondrites. The refractory inclusions that have been found in the Ornans metedorite, a member of a little-studied group of carbonaceous chondrites are described. Some refractory inclusions in Ornans resemble those found in other meteorites, while others are unlike any seen before. The unusual inclusions in Ornans contain minerals with extraordinary enrichments in highly refractory elements.

  16. Immune status in sepsis: the bug, the site of infection and the severity can make the difference

    PubMed Central

    2010-01-01

    Studying a large number of patients with sepsis, the Hellenic sepsis study group led by Evangello Giamarellos-Bourboulis emphasizes that the nature of the bacterial infection, its origin (community or nosocomial), its site, and its severity exert different pressures on the immune system. Their study illustrates the heterogeneity of patients with sepsis and points out that numerous key parameters of severe infection influence immune status. PMID:20584346

  17. The refractory painful arc syndrome.

    PubMed

    Watson, M

    1978-11-01

    Twenty-three patients with a severe refractory painful arc syndrome have been treated by excision of the outer end of the clavicle and division of the coracoacromial ligament through a deltoid-splitting approach. After a follow-up of more than six months all patients have been relieved of night pain. Six still have slight pain on movement, but the rest are symptom-free. PMID:711806

  18. Synthesis of refractory materials

    DOEpatents

    Holt, Joseph B.

    1984-01-01

    Refractory metal nitrides are synthesized during a combustion process utilizing a solid source of nitrogen. For this purpose, a metal azide is employed. The azide is combusted with a transition metal of the IIIB, IVB group, or a rare earth metal, and ignited to produce the refractory material.

  19. Synthesis of refractory materials

    DOEpatents

    Holt, J.B.

    Refractory metal nitrides are synthesized during a combustion process utilizing a solid source of nitrogen. For this purpose, a metal azide is employed. The azide is combusted with a transition metal of the IIIB, IVB group, or a rare earth metal, and ignited to produce the refractory material.

  20. Nitroso-Redox Status and Vascular Function in Marginal and Severe Ascorbate Deficiency

    PubMed Central

    Garcia-Saura, Maria-Francisca; Saijo, Fumito; Bryan, Nathan S.; Bauer, Selena; Rodriguez, Juan

    2012-01-01

    Abstract Marginal vitamin C (ascorbic acid) deficiency is a prevalent yet underappreciated risk factor for cardiovascular disease. Along with glutathione, ascorbate plays important roles in antioxidant defense and redox signaling. Production of nitric oxide (NO) and reactive oxygen species and their interaction, giving rise to nitroso and nitrosyl product formation, are key components of the redox regulation/signaling network. Numerous in vitro studies have demonstrated that these systems are interconnected via multiple chemical transformation reactions, but little is known about their dynamics and significance in vivo. Aims: We sought to investigate the time-course of changes in NO/redox status and vascular function during ascorbate depletion in rats unable to synthesize vitamin C. Results: We here show that both redox and protein nitros(yl)ation status in blood and vital organs vary dynamically during development of ascorbate deficiency. Prolonged marginal ascorbate deficiency is associated with cell/tissue-specific perturbations in ascorbate and glutathione redox and NO status. Scurvy develops earlier in marginally deficient compared to adequately supplemented animals, with blunted compensatory NO production and a dissociation of biochemistry from clinical symptomology in the former. Paradoxically, aortic endothelial reactivity is enhanced rather than impaired, irrespective of ascorbate status. Innovation/Conclusion: Enhanced NO production and protein nitros(yl)ation are integral responses to the redox stress of acute ascorbate deprivation. The elevated cardiovascular risk in marginal ascorbate deficiency is likely to be associated with perturbations of NO/redox-sensitive signaling nodes unrelated to the regulation of vascular tone. This new model may have merit for the future study of redox-sensitive events in marginal ascorbate deficiency. Antioxid. Redox Signal. 17, 937–950. PMID:22304648

  1. Development of improved refractories

    SciTech Connect

    Wereszczak, A.A.; Ferber, M.K.; Liu, K.C.; Moore, R.E.

    1997-04-01

    The goal of the proposed project is to provide expertise and facilities for the high temperature mechanical properties characterization of refractory materials which are of interest to the US DOE`s Office of Industrial Technologies Advanced Industrial Materials Project. Initially the project would establish dedicated refractory testing facilities which would be capable of generating representative engineering creep and high temperature modulus of elasticity (MOE) data to a temperature of 3300{degrees}F (1815{degrees}C) in ambient air. The generated engineering creep and MOE data would serve R&D requirements of refractories-manufacturers and its glass-manufacturer end-users and designers. The relevance of this effort to the refractory and glass-making industries would be ensured by coordinating the research activities through a membership with Alfred University`s Center for Glass Research (CGR) Satellite Center at the University of Missouri-Rolla (UMR), an NSF Center. Valid engineering creep and high temperature MOE data currently do not exist for almost all commercial refractories. Refractory end-users such as glass-manufacturers require such data for efficient and economical design of their various glass-melting furnace superstructures (e.g., furnace crowns). Refractories in glass production furnaces may be subjected to extreme temperatures as high as 3200{degrees}F (1760{degrees}C). With the simultaneous imposition of mechanical and thermal stresses, creep deformation of the refractory material will assuredly occur as a consequence. Designers must ensure that the structural integrity is maintained, so these high temperature deformations must be considered for successful glass furnace superstructure design. These criteria can only be satisfied with the utilization of representative engineering creep and high temperature MOE data for the refractory materials that are chosen for the design of the refractory superstructures.

  2. BALB/c Mice Infected with Antimony Treatment Refractory Isolate of Leishmania braziliensis Present Severe Lesions due to IL-4 Production

    PubMed Central

    Costa, Diego L.; Carregaro, Vanessa; Lima-Júnior, Djalma S.; Silva, Neide M.; Milanezi, Cristiane M.; Cardoso, Cristina R.; Giudice, Ângela; de Jesus, Amélia R.; Carvalho, Edgar M.; Almeida, Roque P.; Silva, João S.

    2011-01-01

    Background Leishmania braziliensis is the main causative agent of cutaneous leishmaniasis in Brazil. Protection against infection is related to development of Th1 responses, but the mechanisms that mediate susceptibility are still poorly understood. Murine models have been the most important tools in understanding the immunopathogenesis of L. major infection and have shown that Th2 responses favor parasite survival. In contrast, L. braziliensis–infected mice develop strong Th1 responses and easily resolve the infection, thus making the study of factors affecting susceptibility to this parasite difficult. Methodology/Principal Findings Here, we describe an experimental model for the evaluation of the mechanisms mediating susceptibility to L. braziliensis infection. BALB/c mice were inoculated with stationary phase promastigotes of L. braziliensis, isolates LTCP393(R) and LTCP15171(S), which are resistant and susceptible to antimony and nitric oxide (NO), respectively. Mice inoculated with LTCP393(R) presented larger lesions that healed more slowly and contained higher parasite loads than lesions caused by LTCP15171(S). Inflammatory infiltrates in the lesions and production of IFN-γ, TNF-α, IL-10 and TGF-β were similar in mice inoculated with either isolate, indicating that these factors did not contribute to the different disease manifestations observed. In contrast, IL-4 production was strongly increased in LTCP393(R)-inoculated animals and also arginase I (Arg I) expression. Moreover, anti-IL-4 monoclonal antibody (mAb) treatment resulted in decreased lesion thickness and parasite burden in animals inoculated with LTCP393(R), but not in those inoculated with LTCP15171(S). Conclusion/Significance We conclude that the ability of L. braziliensis isolates to induce Th2 responses affects the susceptibility to infection with these isolates and contributes to the increased virulence and severity of disease associated with them. Since these data reflect what happens

  3. Status of ANL out-of-pile investigations of severe accident phenomena for liquid metal reactors

    SciTech Connect

    Spencer, B.W.; Marchaterre, J.F.; Anderson, R.P.; Armstrong, D.R.; Baker, L.; Cho, D.H.; Gabor, J.D.; Pedersen, D.R.; Sienicki, J.J.; Stein, R.P.

    1986-01-01

    Research addressing LMFBR whole core accidents has been terminated, and there is now emphasis on quantifying reactivity feedbacks, and in particular enhancing negative feedback, so that advanced LMR designs will provide inherently safe operation. The status of recent HCDA-related laboratory research performed at ANL, up to the time that such activities were no longer needed to support CRBR licensing, is described. Included are descriptions of programs addressing sodium channel voiding, fuel sweepout, fuel dispersal and plugging, boiled-up pool, UO/sub 2//sodium FCI, and debris coolability. Descriptions of recent investigations involving the metal fuel/sodium system are also included.

  4. Severe subcutaneous emphysema and pneumomediastinum secondary to noninvasive ventilation support in status asthmaticus

    PubMed Central

    González García, Lara; Rey, Corsino; Medina, Alberto; Mayordomo-Colunga, Juan

    2016-01-01

    A 12-year-old male with status asthmaticus developed subcutaneous emphysema and pneumomediastinum. He was transferred to our unit, where he received noninvasive ventilation (NIV). This respiratory support technique is not an absolute contraindication in these cases. After 2 h on NIV, he worsened sharply and the subcutaneous emphysema got bigger suddenly. He needed invasive ventilation for 5 days. Final outcome was satisfactory. This case illustrates that it is mandatory to keep a high level of vigilance when using NIV in patients with air leaks.

  5. Severe subcutaneous emphysema and pneumomediastinum secondary to noninvasive ventilation support in status asthmaticus.

    PubMed

    González García, Lara; Rey, Corsino; Medina, Alberto; Mayordomo-Colunga, Juan

    2016-04-01

    A 12-year-old male with status asthmaticus developed subcutaneous emphysema and pneumomediastinum. He was transferred to our unit, where he received noninvasive ventilation (NIV). This respiratory support technique is not an absolute contraindication in these cases. After 2 h on NIV, he worsened sharply and the subcutaneous emphysema got bigger suddenly. He needed invasive ventilation for 5 days. Final outcome was satisfactory. This case illustrates that it is mandatory to keep a high level of vigilance when using NIV in patients with air leaks. PMID:27303140

  6. CFB refractory repair

    SciTech Connect

    Sur, C.; Nagar, A.; Singh, D.K.; Chakraborty, I.N.

    2006-01-15

    ACC Refractories has provided the refractories of 13 of the 20 circulating fluidized-bed combustion (CFBC) plants in India. If high levels of sulfur oxide gases are generated in India's coal, lignite or pet coke fuelled power plants they can wreak havoc on furnace liners. Calcium sulfate was the most common denominator in failed castable matrices analysed by ACC. To solve the problem, Accplast 80, a phosphate-bonded aluminous plastic has been used successfully. The article gives advice on installation of plastic refractories and on steps to prevent erosion. 10 figs., 1 tab., 4 photos.

  7. Mesenchymal stromal cells from pooled mononuclear cells of multiple bone marrow donors as rescue therapy in pediatric severe steroid-refractory graft-versus-host disease: a multicenter survey

    PubMed Central

    Kuçi, Zyrafete; Bönig, Halvard; Kreyenberg, Hermann; Bunos, Milica; Jauch, Anna; Janssen, Johannes W.G.; Škifić, Marijana; Michel, Kristina; Eising, Ben; Lucchini, Giovanna; Bakhtiar, Shahrzad; Greil, Johann; Lang, Peter; Basu, Oliver; von Luettichau, Irene; Schulz, Ansgar; Sykora, Karl-Walter; Jarisch, Andrea; Soerensen, Jan; Salzmann-Manrique, Emilia; Seifried, Erhard; Klingebiel, Thomas; Bader, Peter; Kuçi, Selim

    2016-01-01

    To circumvent donor-to-donor heterogeneity which may lead to inconsistent results after treatment of acute graft-versus-host disease with mesenchymal stromal cells generated from single donors we developed a novel approach by generating these cells from pooled bone marrow mononuclear cells of 8 healthy “3rd-party” donors. Generated cells were frozen in 209 vials and designated as mesenchymal stromal cell bank. These vials served as a source for generation of clinical grade mesenchymal stromal cell end-products, which exhibited typical mesenchymal stromal cell phenotype, trilineage differentiation potential and at later passages expressed replicative senescence-related markers (p21 and p16). Genetic analysis demonstrated their genomic stability (normal karyotype and a diploid pattern). Importantly, clinical end-products exerted a significantly higher allosuppressive potential than the mean allosuppressive potential of mesenchymal stromal cells generated from the same donors individually. Administration of 81 mesenchymal stromal cell end-products to 26 patients with severe steroid-resistant acute graft-versus-host disease in 7 stem cell transplant centers who were refractory to many lines of treatment, induced a 77% overall response at the primary end point (day 28). Remarkably, although the cohort of patients was highly challenging (96% grade III/IV and only 4% grade II graft-versus-host disease), after treatment with mesenchymal stromal cell end-products the overall survival rate at two years follow up was 71±11% for the entire patient cohort, compared to 51.4±9.0% in graft-versus-host disease clinical studies, in which mesenchymal stromal cells were derived from single donors. Mesenchymal stromal cell end-products may, therefore, provide a novel therapeutic tool for the effective treatment of severe acute graft-versus-host disease. PMID:27175026

  8. Mesenchymal stromal cells from pooled mononuclear cells of multiple bone marrow donors as rescue therapy in pediatric severe steroid-refractory graft-versus-host disease: a multicenter survey.

    PubMed

    Kuçi, Zyrafete; Bönig, Halvard; Kreyenberg, Hermann; Bunos, Milica; Jauch, Anna; Janssen, Johannes W G; Škifić, Marijana; Michel, Kristina; Eising, Ben; Lucchini, Giovanna; Bakhtiar, Shahrzad; Greil, Johann; Lang, Peter; Basu, Oliver; von Luettichau, Irene; Schulz, Ansgar; Sykora, Karl-Walter; Jarisch, Andrea; Soerensen, Jan; Salzmann-Manrique, Emilia; Seifried, Erhard; Klingebiel, Thomas; Bader, Peter; Kuçi, Selim

    2016-08-01

    To circumvent donor-to-donor heterogeneity which may lead to inconsistent results after treatment of acute graft-versus-host disease with mesenchymal stromal cells generated from single donors we developed a novel approach by generating these cells from pooled bone marrow mononuclear cells of 8 healthy "3(rd)-party" donors. Generated cells were frozen in 209 vials and designated as mesenchymal stromal cell bank. These vials served as a source for generation of clinical grade mesenchymal stromal cell end-products, which exhibited typical mesenchymal stromal cell phenotype, trilineage differentiation potential and at later passages expressed replicative senescence-related markers (p21 and p16). Genetic analysis demonstrated their genomic stability (normal karyotype and a diploid pattern). Importantly, clinical end-products exerted a significantly higher allosuppressive potential than the mean allosuppressive potential of mesenchymal stromal cells generated from the same donors individually. Administration of 81 mesenchymal stromal cell end-products to 26 patients with severe steroid-resistant acute graft-versus-host disease in 7 stem cell transplant centers who were refractory to many lines of treatment, induced a 77% overall response at the primary end point (day 28). Remarkably, although the cohort of patients was highly challenging (96% grade III/IV and only 4% grade II graft-versus-host disease), after treatment with mesenchymal stromal cell end-products the overall survival rate at two years follow up was 71±11% for the entire patient cohort, compared to 51.4±9.0% in graft-versus-host disease clinical studies, in which mesenchymal stromal cells were derived from single donors. Mesenchymal stromal cell end-products may, therefore, provide a novel therapeutic tool for the effective treatment of severe acute graft-versus-host disease. PMID:27175026

  9. Refractory delirium tremens: a case report and brief review.

    PubMed

    Mattoo, Surendra Kumar; Kate, Natasha; Verma, Anant Kumar

    2012-03-01

    Delirium tremens is a common presentation in tertiary care hospitals. Severe and/or refractory delirium tremens is not as common, is potentially lethal, and requires intensive management. Usually delirium tremens responds to management with standard doses of benzodiazepines. Limited literature is available, however, for the management of refractory delirium tremens. We describe a case of refractory delirium tremens in which the patient was successfully managed with a combination of high doses of lorazapam, midazolam, and phenytoin. PMID:22567606

  10. Understanding and treating refractory constipation.

    PubMed

    Bassotti, Gabrio; Blandizzi, Corrado

    2014-05-01

    Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful re-evaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments. PMID:24868488

  11. Precursors to potential severe core damage accidents. A status report, 1982--1983

    SciTech Connect

    Forester, J.A.; Mitchell, D.B.; Whitehead, D.W.

    1997-04-01

    This study is a continuation of earlier work that evaluated 1969-1981 and 1984-1994 events affecting commercial light-water reactors. One-hundred nine operational events that affected 51 reactors during 1982 and 1983 and that are considered to be precursors to potential severe core damage are described. All these events had conditional probabilities of subsequent severe core damage greater than or equal to 1.0 x 10{sup {minus}6}. These events were identified by first computer screening the 1982-83 licensee event reports from commercial light-water reactors to select events that could be precursors to core damage. Candidates underwent engineering evaluation that identified, analyzed, and documented the precursors. This report discusses the general rationale for the study, the selection and documentation of events as precursors, and the estimation of conditional probabilities of subsequent severe core damage for the events.

  12. Precursors to potential severe core damage applications, 1991. A status report, main report and Appendix A

    SciTech Connect

    Minarick, J.W.; Dolan, B.W.; Cletcher, J.W.; Copinger, D.A.

    1992-09-01

    Twenty-seven operational events with conditional probabilities of subsequent severe core damage of 1.0 x 10-6 or higher occurring at commercial light-water reactors during 1991 are considered to be precursors to potential severe core damage. These are described along with associated significance estimates, categorization, and subsequent analyses. This study is a continuation of earlier work, which evaluated 1969-1981 and 1984-1990 events. The report discusses (1) the general rationale for this study, (2) the selection and documentation of events as precursors, (3) the estimation and use of conditional probabilities of subsequent severe core damage to mnk precursor events, and (4) the plant models used in the analysis process.

  13. Refractory Thrombocytopenia and Neutropenia: a Diagnostic Challenge

    PubMed Central

    Gyan, Emmanuel; Dreyfus, François; Fenaux, Pierre

    2015-01-01

    The 2008 WHO classification identified refractory cytopenia with unilineage dysplasia (RCUD) as a composite entity encompassing refractory anemia, refractory thrombocytopenia (RT), and refractory neutropenia (RN), characterized by 10% or more dysplastic cells in the bone marrow respective lineage. The diagnosis of RT and RN is complicated by several factors. Diagnosing RT first requires exclusion of familial thrombocytopenia, chronic auto-immune thrombocytopenia, concomitant medications, viral infections, or hypersplenism. Diagnosis of RN should also be made after ruling out differential diagnoses such as ethnic or familial neutropenia, as well as acquired, drug-induced, infection-related or malignancy-related neutropenia. An accurate quantification of dysplasia should be performed in order to distinguish RT or RN from the provisional entity named idiopathic cytopenia of unknown significance (ICUS). Cytogenetic analysis, and possibly in the future somatic mutation analysis (of genes most frequently mutated in MDS), and flow cytometry analysis aberrant antigen expression on myeloid cells may help in this differential diagnosis. Importantly, we and others found that, while isolated neutropenia and thrombocytopenia are not rare in MDS, those patients can generally be classified (according to WHO 2008 classification) as refractory cytopenia with multilineage dysplasia or refractory anemia with excess blasts, while RT and RN (according to WHO 2008) are quite rare. These results suggest in particular that identification of RT and RN as distinct entities could be reconsidered in future WHO classification updates. PMID:25745545

  14. Treatment of Established Status Epilepticus.

    PubMed

    Falco-Walter, Jessica J; Bleck, Thomas

    2016-01-01

    Status epilepticus is the most severe form of epilepsy, with a high mortality rate and high health care costs. Status epilepticus is divided into four stages: early, established, refractory, and super-refractory. While initial treatment with benzodiazepines has become standard of care for early status epilepticus, treatment after benzodiazepine failure (established status epilepticus (ESE)) is incompletely studied. Effective treatment of ESE is critical as morbidity and mortality increases dramatically the longer convulsive status epilepticus persists. Phenytoin/fosphenytoin, valproic acid, levetiracetam, phenobarbital, and lacosamide are the most frequently prescribed antiseizure medications for treatment of ESE. To date there are no class 1 data to support pharmacologic recommendations of one agent over another. We review each of these medications, their pharmacology, the scientific evidence in support and against each in the available literature, adverse effects and safety profiles, dosing recommendations, and limitations of the available evidence. We also discuss future directions including the established status epilepticus treatment trial (ESETT). Substantial further research is urgently needed to identify these patients (particularly those with non-convulsive status epilepticus), elucidate the most efficacious antiseizure treatment with head-to-head randomized prospective trials, and determine whether this differs for convulsive vs. non-convulsive ESE. PMID:27120626

  15. Treatment of Established Status Epilepticus

    PubMed Central

    Falco-Walter, Jessica J.; Bleck, Thomas

    2016-01-01

    Status epilepticus is the most severe form of epilepsy, with a high mortality rate and high health care costs. Status epilepticus is divided into four stages: early, established, refractory, and super-refractory. While initial treatment with benzodiazepines has become standard of care for early status epilepticus, treatment after benzodiazepine failure (established status epilepticus (ESE)) is incompletely studied. Effective treatment of ESE is critical as morbidity and mortality increases dramatically the longer convulsive status epilepticus persists. Phenytoin/fosphenytoin, valproic acid, levetiracetam, phenobarbital, and lacosamide are the most frequently prescribed antiseizure medications for treatment of ESE. To date there are no class 1 data to support pharmacologic recommendations of one agent over another. We review each of these medications, their pharmacology, the scientific evidence in support and against each in the available literature, adverse effects and safety profiles, dosing recommendations, and limitations of the available evidence. We also discuss future directions including the established status epilepticus treatment trial (ESETT). Substantial further research is urgently needed to identify these patients (particularly those with non-convulsive status epilepticus), elucidate the most efficacious antiseizure treatment with head-to-head randomized prospective trials, and determine whether this differs for convulsive vs. non-convulsive ESE. PMID:27120626

  16. High-oleic ready-to-use therapeutic food maintains docosahexaenoic acid status in severe malnutrition

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Ready-to-use therapeutic food (RUTF) is the preferred treatment for uncomplicated severe acute malnutrition. It contains large amounts of linoleic acid and little a-linolenic acid, which may reduce the availability of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) to the recovering child...

  17. Sexuality Education Issues and Students Statused Severely Mentally Impaired Regardless of Additional Handicaps.

    ERIC Educational Resources Information Center

    Heler, Ann

    This monograph considers issues in the training of sexuality skills in students with severe mental retardation. An introduction stresses the importance of such skills for these students. A profile of 12 common characteristics of this population and a summary of human commonalities precede the body of the guide. Common manifestations of sexuality…

  18. Switching between Abstract Rules Reflects Disease Severity but Not Dopaminergic Status in Parkinson's Disease

    ERIC Educational Resources Information Center

    Kehagia, Angie A.; Cools, Roshan; Barker, Roger A.; Robbins, Trevor W.

    2009-01-01

    This study sought to disambiguate the impact of Parkinson's disease (PD) on cognitive control as indexed by task set switching, by addressing discrepancies in the literature pertaining to disease severity and paradigm heterogeneity. A task set is governed by a rule that determines how relevant stimuli (stimulus set) map onto specific responses…

  19. Epidemiologic Association Between FUT2 Secretor Status and Severe Rotavirus Gastroenteritis in Children in the United States

    PubMed Central

    Payne, Daniel C.; Currier, Rebecca L.; Staat, Mary A.; Sahni, Leila C.; Selvarangan, Rangaraj; Halasa, Natasha B.; Englund, Janet A.; Weinberg, Geoffrey A.; Boom, Julie A.; Szilagyi, Peter G.; Klein, Eileen J.; Chappell, James; Harrison, Christopher J.; Davidson, Barbara S.; Mijatovic-Rustempasic, Slavica; Moffatt, Mary D.; McNeal, Monica; Wikswo, Mary; Bowen, Michael D.; Morrow, Ardythe L.; Parashar, Umesh D.

    2016-01-01

    IMPORTANCE A genetic polymorphism affecting FUT2 secretor status in approximately one-quarter of humans of European descent affects the expression of histo-blood group antigens on the mucosal epithelia of human respiratory, genitourinary, and digestive tracts. These histo-blood group antigens serve as host receptor sites necessary for attachment and infection of some pathogens, including norovirus. OBJECTIVE We investigated whether an association exists between FUT2 secretor status and laboratory-confirmed rotavirus infections in US children. DESIGN, SETTING, AND PARTICIPANTS Multicenter case-control observational study involving active surveillance at 6 US pediatric medical institutions in the inpatient and emergency department clinical settings. We enrolled 1564 children younger than 5 years with acute gastroenteritis (diarrhea and/or vomiting) and 818 healthy controls frequency matched by age and month, from December 1, 2011, through March 31, 2013. MAIN OUTCOMES AND MEASURES Paired fecal-saliva specimens were tested for rotavirus and for secretor status. Comparisons were made between rotavirus test–positive cases and healthy controls stratified by ethnicity and vaccination status. Adjusted multivariable analyses assessed the preventive association of secretor status against severe rotavirus gastroenteritis. RESULTS One (0.5%) of 189 rotavirus test–positive cases was a nonsecretor, compared with 188 (23%) of 818 healthy control participants (P < .001). Healthy control participants of Hispanic ethnicity were significantly less likely to be nonsecretors (13%) compared with healthy children who were not of Hispanic ethnicity (25%) (P < .001). After controlling for vaccination and other factors, children with the nonsecretor FUT2 polymorphism appeared statistically protected (98% [95% CI, 84%–100%]) against severe rotavirus gastroenteritis. CONCLUSIONS AND RELEVANCE Severe rotavirus gastroenteritis was virtually absent among US children who had a genetic

  20. Nutritional and metabolic status of children with autism vs. neurotypical children, and the association with autism severity

    PubMed Central

    2011-01-01

    Background The relationship between relative metabolic disturbances and developmental disorders is an emerging research focus. This study compares the nutritional and metabolic status of children with autism with that of neurotypical children and investigates the possible association of autism severity with biomarkers. Method Participants were children ages 5-16 years in Arizona with Autistic Spectrum Disorder (n = 55) compared with non-sibling, neurotypical controls (n = 44) of similar age, gender and geographical distribution. Neither group had taken any vitamin/mineral supplements in the two months prior to sample collection. Autism severity was assessed using the Pervasive Development Disorder Behavior Inventory (PDD-BI), Autism Treatment Evaluation Checklist (ATEC), and Severity of Autism Scale (SAS). Study measurements included: vitamins, biomarkers of vitamin status, minerals, plasma amino acids, plasma glutathione, and biomarkers of oxidative stress, methylation, sulfation and energy production. Results Biomarkers of children with autism compared to those of controls using a t-test or Wilcoxon test found the following statistically significant differences (p < 0.001): Low levels of biotin, plasma glutathione, RBC SAM, plasma uridine, plasma ATP, RBC NADH, RBC NADPH, plasma sulfate (free and total), and plasma tryptophan; also high levels of oxidative stress markers and plasma glutamate. Levels of biomarkers for the neurotypical controls were in good agreement with accessed published reference ranges. In the Autism group, mean levels of vitamins, minerals, and most amino acids commonly measured in clinical care were within published reference ranges. A stepwise, multiple linear regression analysis demonstrated significant associations between several groups of biomarkers with all three autism severity scales, including vitamins (adjusted R2 of 0.25-0.57), minerals (adj. R2 of 0.22-0.38), and plasma amino acids (adj. R2 of 0.22-0.39). Conclusion The autism

  1. Refractory alloy technology for space nuclear power applications

    SciTech Connect

    Cooper, R.H. Jr.; Hoffman, E.E.

    1984-01-01

    Purpose of this symposium is twofold: (1) to review and document the status of refractory alloy technology for structural and fuel-cladding applications in space nuclear power systems, and (2) to identify and document the refractory alloy research and development needs for the SP-100 Program in both the short and the long term. In this symposium, an effort was made to recapture the space reactor refractory alloy technology that was cut off in midstream around 1973 when the national space nuclear reactor program began in the early 1960s, was terminated. The six technical areas covered in the program are compatibility, processing and production, welding and component fabrication, mechanical and physical properties, effects of irradiation, and machinability. The refractory alloys considered are niobium, molybdenum, tantalum, and tungsten. Thirteen of the 14 pages have been abstracted separately. The remaining paper summarizes key needs for further R and D on refractory alloys. (DLC)

  2. Iron refractory iron deficiency anemia

    PubMed Central

    De Falco, Luigia; Sanchez, Mayka; Silvestri, Laura; Kannengiesser, Caroline; Muckenthaler, Martina U.; Iolascon, Achille; Gouya, Laurent; Camaschella, Clara; Beaumont, Carole

    2013-01-01

    Iron refractory iron deficiency anemia is a hereditary recessive anemia due to a defect in the TMPRSS6 gene encoding Matriptase-2. This protein is a transmembrane serine protease that plays an essential role in down-regulating hepcidin, the key regulator of iron homeostasis. Hallmarks of this disease are microcytic hypochromic anemia, low transferrin saturation and normal/high serum hepcidin values. The anemia appears in the post-natal period, although in some cases it is only diagnosed in adulthood. The disease is refractory to oral iron treatment but shows a slow response to intravenous iron injections and partial correction of the anemia. To date, 40 different Matriptase-2 mutations have been reported, affecting all the functional domains of the large ectodomain of the protein. In vitro experiments on transfected cells suggest that Matriptase-2 cleaves Hemojuvelin, a major regulator of hepcidin expression and that this function is altered in this genetic form of anemia. In contrast to the low/undetectable hepcidin levels observed in acquired iron deficiency, in patients with Matriptase-2 deficiency, serum hepcidin is inappropriately high for the low iron status and accounts for the absent/delayed response to oral iron treatment. A challenge for the clinicians and pediatricians is the recognition of the disorder among iron deficiency and other microcytic anemias commonly found in pediatric patients. The current treatment of iron refractory iron deficiency anemia is based on parenteral iron administration; in the future, manipulation of the hepcidin pathway with the aim of suppressing it might become an alternative therapeutic approach. PMID:23729726

  3. Precursors to potential severe core damage accidents: 1994, a status report. Volume 22: Appendix I

    SciTech Connect

    Belles, R.J.; Cletcher, J.W.; Copinger, D.A.; Vanden Heuvel, L.N.; Dolan, B.W.; Minarick, J.W. |

    1995-12-01

    Nine operational events that affected eleven commercial light-water reactors (LWRs) during 1994 and that are considered to be precursors to potential severe core damage are described. All these events had conditional probabilities of subsequent severe core damage greater than or equal to 1.0 {times} 10{sup {minus}6}. These events were identified by computer-screening the 1994 licensee event reports from commercial LWRs to identify those that could be potential precursors. Candidate precursors were then selected and evaluated in a process similar to that used in previous assessments. Selected events underwent engineering evaluation that identified, analyzed, and documented the precursors. Other events designated by the Nuclear Regulatory Commission (NRC) also underwent a similar evaluation. Finally, documented precursors were submitted for review by licensees and NRC headquarters and regional offices to ensure that the plant design and its response to the precursor were correctly characterized. This study is a continuation of earlier work, which evaluated 1969--1981 and 1984--1993 events. The report discusses the general rationale for this study, the selection and documentation of events as precursors, and the estimation of conditional probabilities of subsequent severe core damage for events. This document is bound in two volumes: Vol. 21 contains the main report and Appendices A--H; Vol. 22 contains Appendix 1.

  4. Precursors to potential severe core damage accidents: 1995 A status report

    SciTech Connect

    Belles, R.J.; Cletcher, J.W.; Copinger, D.A.

    1997-04-01

    Ten operational events that affected 10 commercial light-water reactors during 1995 and that are considered to be precursors to potential severe core damage are described. All these events had conditional probabilities of subsequent severe core damage greater than or equal to 1.0 x 10{sup {minus}6}. These events were identified by first computer-screening the 1995 licensee event reports from commercial light-water reactors to identify those events that could potentially be precursors. Candidate precursors were selected and evaluated in a process similar to that used in previous assessments. Selected events underwent engineering evaluation that identified, analyzed, and documented the precursors. Other events designated by the Nuclear Regulatory Commission (NRC) also underwent a similar evaluation. Finally, documented precursors were submitted for review by licensees and NRC headquarters and regional offices to ensure the plant design and its response to the precursor were correctly characterized. This study is a continuation of earlier work, which evaluated 1969-1981 and 1984-1994 events. The report discusses the general rationale for this study, the selection and documentation of events as precursors, and the estimation of conditional probabilities of subsequent severe core damage for the events.

  5. Precursors to potential severe core damage accidents: 1997 -- A status report. Volume 26

    SciTech Connect

    Belles, R.J.; Cletcher, J.W.; Copinger, D.A.; Muhlheim, M.D.; Dolan, B.W.; Minarick, J.W.

    1998-11-01

    This report describes the five operational events in 1997 that affected five commercial light-water reactors (LWRs) and that are considered to be precursors to potential severe core damage accidents. All these events had conditional probabilities of subsequent severe core damage greater than or equal to 1.0 {times} 10{sup {minus}6}. These events were identified by first computer-screening the 1997 licensee event reports from commercial LWRs to identify those events that could be precursors. Candidate precursors were selected and evaluated in a process similar to that used in previous assessments. Selected events underwent engineering evaluation that identified, analyzed, and documented the precursors. Other events designated by the Nuclear Regulatory Commission (NRC) also underwent a similar evaluation. Finally, documented precursors were submitted for review by licensees and NRC headquarters to ensure that the plant design and its response to the precursor were correctly characterized. This study is a continuation of earlier work, which evaluated 1969--1996 events. The report discusses the general rationale for this study, the selection and documentation of events as precursors, and the estimation of conditional probabilities of subsequent severe core damage for the events.

  6. Development and Application of Refractory Materials for Molten Aluminum Applications

    SciTech Connect

    Hemrick, James Gordon; Headrick, William; Peters, Klaus-Markus

    2008-01-01

    Two new refractory materials have been developed for use in molten aluminum contact applications which exhibit improved corrosion and wear resistance, along with improved thermal management through reduced heat losses. The development of these materials was based on understanding of the corrosion and wear mechanisms associated with currently used aluminum contact refractories through physical, chemical, and mechanical characterization and analysis performed by Oak Ridge National Laboratory (ORNL) and the University of Missouri, Rolla (UMR) along with their industrial partners, under the ITP Materials project "Multifunctional Metallic and Refractory Materials for Energy Efficient Handling of Molten Metals". Spent castable refractories obtained from a natural gas fired reverberatory aluminum alloy melting furnace were analyzed leading to identification of several refractory degradation mechanisms and strategies to produce improved materials. The newly developed materials have been validated through both R&D industrial trials and independent commercial trials by the refractory manufacturers.

  7. The severity, extent and recurrence of necrotizing periodontal disease in relation to HIV status and CD4+ T cell count.

    PubMed

    Phiri, Reality; Feller, Liviu; Blignaut, Elaine

    2010-10-01

    South Africa ranks among the three countries with the highest prevalence of HIV infection in sub-Saharan Africa, with an estimated 29.5% of women attending antenatal clinics being infected. Necrotizing periodontal disease is a well recognized HIV-associated oral condition. The objective of this investigation was to determine a possible correlation between the extent, severity and treatment outcome of necrotizing periodontal disease in relation to a person's HIV status and CD4+ T cell count. Data from 105 consecutive patients presenting with necrotizing periodontal disease at an academic oral health centre in South Africa were analysed. All patients were provided with an opportunity to undergo voluntary counseling and testing for HIV infection, were treated for necrotizing periodontal disease and followed over a period of nine months. The mean age of the cohort was 28 years old (range 12 - 52). Of 98 (93.3%) patients unaware of their HIV serostatus at the initial visit, 59 (56.2%) consented to testing. In total 45 (42.9%) were HIV-seropositive with a mean CD4+ T cell count of 222.7 cells/microl and 14 (13.3%) were HIV-seronegative, with a significantly higher mean CD4+ T cell count of 830 cells/microl (Fisher's exact test, p < 0.001), while the status of 46 (43.8%) remained unknown. In 101 (96.2%) patients, > or = 5 tooth sites were affected, and in 27 (26%) > or = 4 mm of gingival tissue were affected. This study, which included HIV-seropositive, HIV-seronegative and persons of unknown HIV status, revealed no statistical evidence that HIV infection was associated with the extent, severity or relapse of necrotizing periodontal disease. No statistically significant association could be demonstrated between the extent, severity and recurrence of necrotizing periodontal disease and a CD4+ T cell count < or = 200 cells/microl among HIV-seropositive patients. PMID:21128527

  8. KCC2 activity is critical in limiting the onset and severity of status epilepticus.

    PubMed

    Silayeva, Liliya; Deeb, Tarek Z; Hines, Rochelle M; Kelley, Matt R; Munoz, Michaelanne B; Lee, Henry H C; Brandon, Nicholas J; Dunlop, John; Maguire, Jaime; Davies, Paul A; Moss, Stephen J

    2015-03-17

    The K(+)/Cl(-) cotransporter (KCC2) allows adult neurons to maintain low intracellular Cl(-) levels, which are a prerequisite for efficient synaptic inhibition upon activation of γ-aminobutyric acid receptors. Deficits in KCC2 activity are implicated in epileptogenesis, but how increased neuronal activity leads to transporter inactivation is ill defined. In vitro, the activity of KCC2 is potentiated via phosphorylation of serine 940 (S940). Here we have examined the role this putative regulatory process plays in determining KCC2 activity during status epilepticus (SE) using knockin mice in which S940 is mutated to an alanine (S940A). In wild-type mice, SE induced by kainate resulted in dephosphorylation of S940 and KCC2 internalization. S940A homozygotes were viable and exhibited comparable basal levels of KCC2 expression and activity relative to WT mice. However, exposure of S940A mice to kainate induced lethality within 30 min of kainate injection and subsequent entrance into SE. We assessed the effect of the S940A mutation in cultured hippocampal neurons to explore the mechanisms underlying this phenotype. Under basal conditions, the mutation had no effect on neuronal Cl(-) extrusion. However, a selective deficit in KCC2 activity was seen in S940A neurons upon transient exposure to glutamate. Significantly, whereas the effects of glutamate on KCC2 function could be ameliorated in WT neurons with agents that enhance S940 phosphorylation, this positive modulation was lost in S940A neurons. Collectively our results suggest that phosphorylation of S940 plays a critical role in potentiating KCC2 activity to limit the development of SE. PMID:25733865

  9. KCC2 activity is critical in limiting the onset and severity of status epilepticus

    PubMed Central

    Silayeva, Liliya; Deeb, Tarek Z.; Hines, Rochelle M.; Kelley, Matt R.; Munoz, Michaelanne B.; Lee, Henry H. C.; Brandon, Nicholas J.; Dunlop, John; Maguire, Jaime; Davies, Paul A.; Moss, Stephen J.

    2015-01-01

    The K+/Cl– cotransporter (KCC2) allows adult neurons to maintain low intracellular Cl– levels, which are a prerequisite for efficient synaptic inhibition upon activation of γ-aminobutyric acid receptors. Deficits in KCC2 activity are implicated in epileptogenesis, but how increased neuronal activity leads to transporter inactivation is ill defined. In vitro, the activity of KCC2 is potentiated via phosphorylation of serine 940 (S940). Here we have examined the role this putative regulatory process plays in determining KCC2 activity during status epilepticus (SE) using knockin mice in which S940 is mutated to an alanine (S940A). In wild-type mice, SE induced by kainate resulted in dephosphorylation of S940 and KCC2 internalization. S940A homozygotes were viable and exhibited comparable basal levels of KCC2 expression and activity relative to WT mice. However, exposure of S940A mice to kainate induced lethality within 30 min of kainate injection and subsequent entrance into SE. We assessed the effect of the S940A mutation in cultured hippocampal neurons to explore the mechanisms underlying this phenotype. Under basal conditions, the mutation had no effect on neuronal Cl– extrusion. However, a selective deficit in KCC2 activity was seen in S940A neurons upon transient exposure to glutamate. Significantly, whereas the effects of glutamate on KCC2 function could be ameliorated in WT neurons with agents that enhance S940 phosphorylation, this positive modulation was lost in S940A neurons. Collectively our results suggest that phosphorylation of S940 plays a critical role in potentiating KCC2 activity to limit the development of SE. PMID:25733865

  10. Severity of household food insecurity is sensitive to change in household income and employment status among low-income families.

    PubMed

    Loopstra, Rachel; Tarasuk, Valerie

    2013-08-01

    Cross-sectional studies have established a relationship between poverty and food insecurity, but little is known about the acute changes within households that lead to changes in food insecurity. This study examined how changes in income, employment status, and receipt of welfare related to change in severity of food insecurity during 1 y among low-income families. In 2005-2007, 501 families living in market and subsidized rental housing were recruited through door-to-door sampling in high-poverty neighborhoods in Toronto. One year later, families were re-interviewed. The final longitudinal analytic sample included 331 families. Within-household change in income, employment, and welfare receipt were examined in relation to change in severity of food insecurity. Severity was denoted by the aggregate raw score on the Household Food Security Survey Module (HFSSM). Analyses were stratified by housing subsidy status owing to differences in characteristics between households. Food insecurity was a persistent problem among families; 68% were food insecure at both interviews. Severity was dynamic, however, as 73.4% answered more or fewer questions affirmatively on the HFFSM between baseline and follow-up. Among market-rent families, a $2000 gain in income during the year and gain of full-time employment were associated with a 0.29 and 1.33 decrease in raw score, respectively (P < 0.01). This study suggests that improvements in income and employment are related to improvements in families' experiences of food insecurity, highlighting the potential for income- and employment-based policy interventions to affect the severity of household food insecurity for low-income families. PMID:23761648

  11. Interventional Treatment of Abdominal Compartment Syndrome during Severe Acute Pancreatitis: Current Status and Historical Perspective

    PubMed Central

    Radenkovic, Dejan V.; Johnson, Colin D.; Milic, Natasa; Gregoric, Pavle; Ivancevic, Nenad; Bezmarevic, Mihailo; Bilanovic, Dragoljub; Cijan, Vladimir; Antic, Andrija; Bajec, Djordje

    2016-01-01

    Abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) is a marker of severe disease. It occurs as combination of inflammation of retroperitoneum, visceral edema, ascites, acute peripancreatic fluid collections, paralytic ileus, and aggressive fluid resuscitation. The frequency of ACS in SAP may be rising due to more aggressive fluid resuscitation, a trend towards conservative treatment, and attempts to use a minimally invasive approach. There remains uncertainty about the most appropriate surgical technique for the treatment of ACS in SAP. Some unresolved questions remain including medical treatment, indications, timing, and interventional techniques. This review will focus on interventional treatment of this serious condition. First line therapy is conservative treatment aiming to decrease IAP and to restore organ dysfunction. If nonoperative measures are not effective, early abdominal decompression is mandatory. Midline laparostomy seems to be method of choice. Since it carries significant morbidity we need randomized studies to establish firm advantages over other described techniques. After ACS resolves efforts should be made to achieve early primary fascia closure. Additional data are necessary to resolve uncertainties regarding ideal timing and indication for operative treatment. PMID:26839539

  12. Interventional Treatment of Abdominal Compartment Syndrome during Severe Acute Pancreatitis: Current Status and Historical Perspective.

    PubMed

    Radenkovic, Dejan V; Johnson, Colin D; Milic, Natasa; Gregoric, Pavle; Ivancevic, Nenad; Bezmarevic, Mihailo; Bilanovic, Dragoljub; Cijan, Vladimir; Antic, Andrija; Bajec, Djordje

    2016-01-01

    Abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) is a marker of severe disease. It occurs as combination of inflammation of retroperitoneum, visceral edema, ascites, acute peripancreatic fluid collections, paralytic ileus, and aggressive fluid resuscitation. The frequency of ACS in SAP may be rising due to more aggressive fluid resuscitation, a trend towards conservative treatment, and attempts to use a minimally invasive approach. There remains uncertainty about the most appropriate surgical technique for the treatment of ACS in SAP. Some unresolved questions remain including medical treatment, indications, timing, and interventional techniques. This review will focus on interventional treatment of this serious condition. First line therapy is conservative treatment aiming to decrease IAP and to restore organ dysfunction. If nonoperative measures are not effective, early abdominal decompression is mandatory. Midline laparostomy seems to be method of choice. Since it carries significant morbidity we need randomized studies to establish firm advantages over other described techniques. After ACS resolves efforts should be made to achieve early primary fascia closure. Additional data are necessary to resolve uncertainties regarding ideal timing and indication for operative treatment. PMID:26839539

  13. History and Current Status of Newborn Screening for Severe Combined Immunodeficiency

    PubMed Central

    Kwan, Antonia; Puck, Jennifer M.

    2015-01-01

    The development of a T cell receptor excision circle (TREC) assay utilizing dried blood spots in universal newborn screening has allowed the early detection of T cell lymphopenia in newborns. Diagnosis of severe combined immunodeficiency (SCID) in affected infants in the neonatal period while asymptomatic permits early treatment and restoration of a functional immune system. SCID was the first immunodeficiency disease to be added to the Recommended Uniform Screening Panel of Core Conditions in the United States in 2010, and is now implemented in 26 states in the U.S. This review covers the development of newborn screening for SCID, the biology of the TREC test, its current implementation in the U.S., new findings for SCID in the newborn screening era, and future directions. PMID:25937517

  14. Association between iron status, iron deficiency anaemia, and severe early childhood caries: a case–control study

    PubMed Central

    2013-01-01

    Background Severe tooth decay is known to affect the health and well-being of young children. However, little is known about the influence of Severe Early Childhood Caries (S-ECC) on childhood nutritional status. The purpose of this study was to contrast ferritin and haemoglobin levels between preschoolers with S-ECC and caries-free controls. Methods Children were recruited as part of a larger case–control study examining differences in nutritional status between those with and without S-ECC. Preschoolers with S-ECC were recruited on the day of their dental surgery, while caries-free controls were recruited from the community. Parents completed a questionnaire and the child underwent venipuncture. The study was approved by the University’s Health Research Ethics Board. Statistics included descriptive, bivariate and logistic regression analyses. A p value ≤ .05 was significant. A total of 266 children were recruited; 144 with S-ECC and 122 caries-free. Results The mean age was 40.8 ± 14.1 months. The mean ferritin concentration for all children was 29.6 ± 17.9 μg/L while the mean haemoglobin level was 115.1 ± 10.1 g/L. Children with S-ECC were significantly more likely to have low ferritin (p=.033) and low haemoglobin levels (p>.001). Logistic regression analyses revealed that children with S-ECC were nearly twice as likely to have low ferritin levels and were over six times more likely to have iron deficiency anaemia than caries-free controls. Conclusions Children with S-ECC appear to be at significantly greater odds of having low ferritin status compared with caries-free children and also appear to have significantly lower haemoglobin levels than the caries-free control group. Children with S-ECC also appear to be at significantly greater odds for iron deficiency anaemia than cavity-free children. PMID:23388209

  15. High oleic ready-to-use therapeutic food maintains docosahexaenoic acid status in severe malnutrition: a randomized, blinded trial

    PubMed Central

    Hsieh, Ji-Cheng; Liu, Lei; Zeilani, Mamane; Ickes, Scott; Trehan, Indi; Maleta, Ken; Craig, Christina; Thakwalakwa, Chrissie; Singh, Lauren; Brenna, J. Thomas; Manary, Mark J.

    2015-01-01

    Objective Ready-to-use therapeutic food (RUTF) is the preferred treatment for uncomplicated severe acute malnutrition. RUTF contains large amounts of linoleic acid and very little α-linolenic acid, which may reduce the availability of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) to the recovering child. A novel high oleic RUTF (HO-RUTF) was developed with less linoleic acid to determine its effect on DHA and EPA status. Methods We conducted a prospective, randomized, double-blinded, clinical effectiveness trial treating rural Malawian children with severe acute malnutrition. Children were treated with either HO-RUTF or standard RUTF. Plasma phospholipid (PL) fatty acid status was measured upon enrollment and after 4 weeks and compared between the two intervention groups. Results Among the 141 children enrolled, 48/71 receiving HO-RUTF and 50/70 receiving RUTF recovered. Plasma PL samples were analyzed from 43 children consuming HO-RUTF and 35 children consuming RUTF. The change in DHA content during the first 4 weeks was +4% and −25% in the HO-RUTF and RUTF groups, respectively (P = 0.04). For EPA, the change in content was 63% and −24% in the HO-RUTF and RUTF groups (P < 0.001). For arachidonic acid, the change in content was −3% and 13% in the HO-RUTF and RUTF groups (P < 0.009). Conclusions The changes in DHA and EPA seen in the children treated with HO-RUTF warrant further investigation as they suggest HO-RUTF support improved PUFA status, necessary for neural development and recovery. PMID:25633498

  16. Treatment refractory schizophrenia: how should we proceed?

    PubMed

    Sharif, Z A

    1998-01-01

    A substantial portion of schizophrenic patients demonstrate suboptimal response to conventional antipsychotics. These agents are primarily effective in the treatment of psychotic symptoms; their efficacy in other domains of psychopathology such as negative symptoms, chronic aggressive behavior, and cognitive deficits, is limited or non-existent. In this group of refractory patients, the novel atypical antipsychotic clozapine has demonstrated robust efficacy, with response rates approaching 60% after twelve weeks of treatment. Efficacy of clozapine extends to symptom domains other than psychosis, including negative symptoms, mood stabilization, aggressive behavior and compulsive water drinking. Several novel agents, each of which shares some, but not all, of the preclinical and clinical characteristics that make clozapine so unique, have been introduced in the last 4 years. These agents demonstrate a broader spectrum of efficacy and an improved side effect profile in non-refractory patients. Initial data on their efficacy in refractory patients suggests that olanzapine does not achieve overall superior efficacy in this patient population compared to conventional agents although there is some evidence of relatively greater efficacy in negative symptoms and aggressivity. Several studies suggest that the efficacy of risperidone is superior to that of conventional agents in refractory patients. Preliminary conclusions are not possible for quetiapine because of a paucity of data in the literature. The literature supports a risperidone trial prior to a clozapine trial in a treatment algorithm for refractory patients because of its more favorable risk/benefit profile. PMID:9793107

  17. Efficacy of ketamine in refractory convulsive status epilepticus in children: a protocol for a sequential design, multicentre, randomised, controlled, open-label, non-profit trial (KETASER01)

    PubMed Central

    Rosati, Anna; Ilvento, Lucrezia; L'Erario, Manuela; De Masi, Salvatore; Biggeri, Annibale; Fabbro, Giancarlo; Bianchi, Roberto; Stoppa, Francesca; Fusco, Lucia; Pulitanò, Silvia; Battaglia, Domenica; Pettenazzo, Andrea; Sartori, Stefano; Biban, Paolo; Fontana, Elena; Cesaroni, Elisabetta; Mora, Donatella; Costa, Paola; Meleleo, Rosanna; Vittorini, Roberta; Conio, Alessandra; Wolfler, Andrea; Mastrangelo, Massimo; Mondardini, Maria Cristina; Franzoni, Emilio; McGreevy, Kathleen S; Di Simone, Lorena; Pugi, Alessandra; Mirabile, Lorenzo; Vigevano, Federico; Guerrini, Renzo

    2016-01-01

    Introduction Status epilepticus (SE) is a life-threatening neurological emergency. SE lasting longer than 120 min and not responding to first-line and second-line antiepileptic drugs is defined as ‘refractory’ (RCSE) and requires intensive care unit treatment. There is currently neither evidence nor consensus to guide either the optimal choice of therapy or treatment goals for RCSE, which is generally treated with coma induction using conventional anaesthetics (high dose midazolam, thiopental and/or propofol). Increasing evidence indicates that ketamine (KE), a strong N-methyl-d-aspartate glutamate receptor antagonist, may be effective in treating RCSE. We hypothesised that intravenous KE is more efficacious and safer than conventional anaesthetics in treating RCSE. Methods and analysis A multicentre, randomised, controlled, open-label, non-profit, sequentially designed study will be conducted to assess the efficacy of KE compared with conventional anaesthetics in the treatment of RCSE in children. 10 Italian centres/hospitals are involved in enrolling 57 patients aged 1 month to 18 years with RCSE. Primary outcome is the resolution of SE up to 24 hours after withdrawal of therapy and is updated for each patient treated according to the sequential method. Ethics and dissemination The study received ethical approval from the Tuscan Paediatric Ethics Committee (12/2015). The results of this study will be published in peer-reviewed journals and presented at international conferences. Trial registration number NCT02431663; Pre-results. PMID:27311915

  18. Comprehensive Creep and Thermophysical Performance of Refractory Materials

    SciTech Connect

    Ferber, M.K.; Wereszczak, A.; Hemrick, J.A.

    2006-06-29

    Furnace designers and refractory engineers recognize that optimized furnace superstructure design and refractory selection are needed as glass production furnaces are continually striving toward greater output and efficiencies. Harsher operating conditions test refractories to the limit, while changing production technology (such as the conversion to oxy-fuel from traditional air-fuel firing) can alter the way the materials perform [1-3]. Refractories for both oxy- and air-fuel fired furnace superstructures (see Fig. 1) are subjected to high temperatures that may cause them to creep excessively or subside during service if the refractory material is not creep resistant, or if it is subjected to high stress, or both. Furnace designers can ensure that superstructure structural integrity is maintained if the creep behavior of the refractory material is well understood and well represented by appropriate engineering creep models. Several issues limit the abilities of furnace designers to (1) choose the optimum refractory for their applications, (2) optimize the engineering design, or (3) predict the service mechanical integrity of their furnace superstructures. Published engineering creep data are essentially nonexistent for almost all commercially available refractories used for glass furnace superstructures. The limited data that do exist are supplied by the various refractory suppliers. Unfortunately, the suppliers generally have different ways of conducting their mechanical testing, and they interpret and report their data differently. This inconsistency makes it hard for furnace designers to draw fair comparisons between competing grades of candidate refractories. Furthermore, the refractory suppliers' data are often not available in a form that can be readily used for furnace design or for the prediction and design of long-term structural integrity of furnace superstructures. As a consequence, the U.S. Department of Energy (DOE) Industrial Technology Program (ITP

  19. [Treatment of refractory ascites].

    PubMed

    Martínez, Javier; Albillos, Agustín

    2014-07-01

    Ascites is a common complication of hepatic cirrhosis and portal hypertension. Patients present systemic and splanchnic circulation disorders, which cause central hypovolemia and arterial hypotension, with the subsequent activation of vasoconstrictor systems and increased renal reabsorption of sodium and water. Approximately 5%-10% of patients present refractory ascites. Refractory ascites is considered when it is not controllable with standard dietary (sodium restriction) and diuretic (furosemide up to 160 mg a day and spironolactone up to 400mg a day) treatment or when patients present adverse effects due to diuretics that impede their administration at optimum dosages. The current therapeutic options for these patients are repeated evacuative paracentesis and the percutaneous intrahepatic portosystemic shunt. Despite these treatments, refractory ascites has a poor prognosis; patients should therefore be assessed for liver transplantation. PMID:25087715

  20. SINTERED REFRACTORY MASS

    DOEpatents

    Williams, A.E.

    1955-09-01

    A method is given for joining sintered masses of refractory compounds. It consists in maintaining the masses in contact with each other by application of a moderate pressure, while they are at sintering temperature. The sintered masses are subjected to am applied pressure of about 1/2 to 1 ton per square inch of the surface in contact for about 10 minutes, and the temperature employed may be fropn about 1400 deg C to 2000 deg C. Refractory oxides to which the invention may be applied are beryllia, alumina, thoria, and magnesia.

  1. Intraarticular corticosteroids in refractory childhood Lyme arthritis.

    PubMed

    Nimmrich, S; Becker, I; Horneff, G

    2014-07-01

    Lyme arthritis caused by infection with Borrelia burgdorferi is a common late manifestation of Lyme borreliosis. Current treatment recommendations include at least one oral or intravenous antibiotic course, followed by antirheumatic therapy in case of refractory arthritis. We reviewed the course of 31 children with Lyme arthritis who had received antibiotic treatment and assessed outcome and requirement of antirheumatic therapy. Of a total of 31 patients, 23 (74%) showed complete resolution of arthritis after one or two courses of antibiotics, whereas in 8 patients (28%), steroid injections had been performed due to relapsing or remaining symptoms. All of these 8 patients showed immediate resolution of symptoms after intraarticular steroid injections. Four of them (50%) remained asymptomatic so far with a follow-up period between five up to 40 months. In two cases, multiple intraarticular corticosteroid injections were required; three patients received additional or consecutive treatment with systemic antirheumatic treatment. Patients with antibiotic refractory arthritis showed a higher rate of positivity of the IgG p58 and OspC immunoblot bands (p = 0.05) at presentation. Antibodies against OspA, an indicator of later stage infection, occurred more frequently in the refractory group without reaching significant level. No clinical marker as indicator for severe or prolonged course of Lyme arthritis was identifiable. A quarter of childhood Lyme arthritis patients were refractory to antibiotics and required antirheumatic treatment. Intraarticular steroid injections in childhood Lyme arthritis refractory to antibiotics can lead to marked clinical improvement. PMID:24390634

  2. Identification of platelet refractoriness in oncohematologic patients

    PubMed Central

    Ferreira, Aline Aparecida; Zulli, Roberto; Soares, Sheila; de Castro, Vagner; Moraes-Souza, Helio

    2011-01-01

    OBJECTIVES: To identify the occurrence and the causes of platelet refractoriness in oncohematologic patients. INTRODUCTION: Platelet refractoriness (unsatisfactory post-transfusion platelet increment) is a severe problem that impairs the treatment of oncohematologic patients and is not routinely investigated in most Brazilian services. METHODS: Forty-four episodes of platelet concentrate transfusion were evaluated in 16 patients according to the following parameters: corrected count increment, clinical conditions and detection of anti-platelet antibodies by the platelet immunofluorescence test (PIFT) and panel reactive antibodies against human leukocyte antigen class I (PRA-HLA). RESULTS: Of the 16 patients evaluated (median age: 53 years), nine (56%) were women, seven of them with a history of pregnancy. An unsatisfactory increment was observed in 43% of the transfusion events, being more frequent in transfusions of random platelet concentrates (54%). Platelet refractoriness was confirmed in three patients (19%), who presented immunologic and non-immunologic causes. Alloantibodies were identified in eight patients (50%) by the PIFT and in three (19%) by the PRA-HLA. Among alloimmunized patients, nine (64%) had a history of transfusion, and three as a result of pregnancy (43%). Of the former, two were refractory (29%). No significant differences were observed, probably as a result of the small sample size. CONCLUSION: The high rate of unsatisfactory platelet increment, refractoriness and alloimmunization observed support the need to set up protocols for the investigation of this complication in all chronically transfused patients, a fundamental requirement for the guarantee of adequate management. PMID:21437433

  3. Refractory of Furnaces to Reduce Environmental Impact

    NASA Astrophysics Data System (ADS)

    Hanzawa, Shigeru

    2011-10-01

    The energy load of furnaces used in the manufacturing process of ceramics is quite large. Most of the environmental impact of ceramics manufacturing is due to the CO2 produced from this high energy load. To improve this situation, R&D has focused on furnace systems and techniques of control in order to reduce energy load. Since furnaces are comprised of refractory, consideration of their mechanical and thermal characteristics is important. Herein are described several refractory types which were chosen through comparison of the characteristics which contribute to heat capacity reduction, heat insulating reinforcement and high emissivity, thereby improving thermal radiation heat transfer efficiency to the ceramic articles. One selected refractory material which will reduce the environmental impact of a furnace, chosen considering low heat capacity and high emissivity characteristics, is SiC. In this study, thermal radiation heat transfer efficiency improvement and its effect on ceramic articles in the furnace and oxidation behaviour were investigated at 1700K. A high density SiC refractory, built into the furnace at construction, has relatively high oxidation durability and has the ability to reduce environmental impact-CO2 by 10 percent by decreasing the furnace's energy load. However, new oxidation prevention techniques for SiC will be necessary for long-term use in industrial furnaces, because passive to active oxidation transition behaviour of commercial SiC refractory is coming to close ideal.

  4. Dynamic Testing of Gasifier Refractory

    SciTech Connect

    Michael D. Mann; Wayne S. Seames; Devdutt Shukla; Xi Hong; John P. Hurley

    2005-12-01

    The University of North Dakota (UND) Chemical Engineering Department in conjunction with the UND Energy & Environmental Research Center (EERC) have initiated a program to examine the combined chemical (reaction and phase change) and physical (erosion) effects experienced by refractory materials under slagging coal gasification conditions. The goal of this work is to devise a mechanism of refractory loss under these conditions. The controlled-atmospheric dynamic corrodent application furnace (CADCAF) was utilized to simulate refractory/slag interactions under dynamic conditions that more realistically simulate the environment in a slagging coal gasifier than any of the static tests used previously by refractory manufacturers and researchers. High-alumina and high-chromia refractory bricks were tested using slags obtained from two solid fuel gasifiers. Testing was performed at 1475 C in a reducing atmosphere (2% H{sub 2} in N{sub 2}) The CADCAF tests show that high-chrome refractories have greater corrosion resistance than high-aluminum refractories; coal slag readily diffuses into the refractory through its grain boundaries; the refractory grains are more stable than the matrix in the tests, and the grains are the first line of defense against corrosion; calcium and alkali in the slag are more corrosive than iron; and silicon and calcium penetrate the deepest into the refractory. The results obtained from this study are preliminary and should be combined with result from other research programs. In particular, the refractory corrosion results from this study should be compared with refractories removed from commercial gasifiers.

  5. Refractory ceramic fibers

    Integrated Risk Information System (IRIS)

    Refractory ceramic fibers ; CASRN Not found Human health assessment information on a chemical substance is included in the IRIS database only after a comprehensive review of toxicity data , as outlined in the IRIS assessment development process . Sections I ( Health Hazard Assessments for Noncarcino

  6. Low Health System Performance, Indigenous Status and Antivenom Underdosage Correlate with Spider Envenoming Severity in the Remote Brazilian Amazon

    PubMed Central

    Sampaio, Vanderson Souza; Gomes, André Alexandre; Silva, Iran Mendonça; Sachett, Jacqueline; Ferreira, Luiz Carlos Lima; Oliveira, Sâmella; Sabidò, Meritxell; Chalkidis, Hipócrates; Barbosa Guerra, Maria Graças Vale; Salinas, Jorge Luis; Wen, Fan Hui; Lacerda, Marcus Vinícius Guimarães; Monteiro, Wuelton Marcelo

    2016-01-01

    Background A better knowledge of the burden and risk factors associated with severity due to spider bites would lead to improved management with a reduction of sequelae usually seen for this neglected health problem, and would ensure proper use of antivenoms in remote localities in the Brazilian Amazon. The aim of this study was to analyze the profile of spider bites reported in the state of Amazonas in the Western Brazilian Amazon, and to investigate potential risk factors associated with severity of envenomation. Methodology/Principal Findings We used a case-control study in order to identify factors associated with spider bite severity in the Western Brazilian Amazon from 2007 to 2014. Patients evolving to any severity criteria were considered cases and those with non-severe bites were included in the control group. All variables were retrieved from the official Brazilian reporting systems. Socioeconomical and environmental components were also included in a multivariable analysis in order to identify ecological determinants of incidence and severity. A total of 1,181 spider bites were recorded, resulting in an incidence of 4 cases per 100,000 person/year. Most of the spider bites occurred in males (65.8%). Bites mostly occurred in rural areas (59.5%). The most affected age group was between 16 and 45 years old (50.9%). A proportion of 39.7% of the bites were related to work activities. Antivenom was prescribed to 39% of the patients. Envenomings recorded from urban areas [Odds ratio (OR) = 0.40 (95%CI = 0.30–0.71; p<0.001)] and living in a municipality with a mean health system performance index (MHSPI >median [OR = 0.64 (95%CI = 0.39–0.75; p<0.001)] were independently associated with decreased risk of severity. Work related accidents [OR = 2.09 (95%CI = 1.49–2.94; p<0.001)], Indigenous status [OR = 2.15 (95%CI = 1.19–3.86; p = 0.011)] and living in a municipality located >300 km away from the state capital Manaus [OR = 1.90 (95%CI = 1.28–2.40; p<0

  7. The role of anti-infectives in the treatment of refractory asthma.

    PubMed

    Maselli, Diego Jose; Adams, Sandra; Peters, Jay

    2011-12-01

    Refractory asthma not only has a significant effect on quality of life, but also imposes an economic burden on society. Increasing evidence suggests that there is a pathophysiologic interaction between infection and allergic disease in patients with severe or refractory asthma. Therapeutic trials of macrolides and azoles are being utilized in some patients with refractory asthma who fail to respond to standard therapy. In this article we review the definition of refractory asthma and the potential pathophysiologic interactions between infection and allergic disease. Emerging data suggest that microorganisms and their byproducts may be a therapeutic target in the therapy of patients with severe or refractory asthma. PMID:21459926

  8. Refractory Glass Seals for SOFC

    SciTech Connect

    Chou, Y. S.; Stevenson, Jeffry W.

    2011-07-01

    One of the critical challenges facing planar solid oxide fuel cell (SOFC) technology is the need for reliable sealing technology. Seals must exhibit long-term stability and mechanical integrity in the high temperature SOFC environment during normal and transient operation. Several different approaches for sealing SOFC stacks are under development, including glass or glass-ceramic seals, metallic brazes, and compressive seals. Among glass seals, rigid glass-ceramics, self-healing glass, and composite glass approaches have been investigated under the SECA Core Technology Program. The U.S. Department of Energy's Pacific Northwest National Laboratory (PNNL) has developed the refractory glass approach in light of the fact that higher sealing temperatures (e.g., 930-1000 degrees C) may enhance the ultimate in-service bulk strength and electrical conductivity of contact materials, as well as the bonding strength between contact materials and adjacent SOFC components, such as interconnect coatings and electrodes. This report summarizes the thermal, chemical, mechanical, and electrical properties of the refractory sealing glass.

  9. PENETRATION OF COAL SLAGS INTO HIGH-CHROMIA REFRACTORIES

    SciTech Connect

    Longanbach, Sara C.; Matyas, Josef; Sundaram, S. K.

    2009-10-05

    Slagging coal gasifiers are used for the production of electricity and synthetic gases, as well as chemicals. High temperatures in the reaction chamber, typically between 1250ºC and 1600ºC, high pressure, generally greater than 400 psi, and corrosive slag place severe demands on the refractory materials. Slag produced during the combustion of coal flows over the refractory surface and penetrates the porous material. Slag penetration is typically followed by spalling of a brick that significantly decreases the service life of gasifier refractories. Laboratory tests were conducted to determine the penetration depth of slags into high-chromia refractories as a function of time and temperature for various refractory-slag combinations.

  10. Use of nocturnal melatonin concentration and urinary 6-sulfatoxymelatonin excretion to evaluate melatonin status in children with severe sepsis.

    PubMed

    Bagci, Soyhan; Yildizdas, Dincer; Horoz, Ozden Ozgür; Reinsberg, Jochen; Bartmann, Peter; Mueller, Andreas

    2011-01-01

    The aim of this study was to evaluate whether nocturnal melatonin concentration (NMC) and urinary 6-sulphatoxymelatonin (aMT6s) excretion can predict melatonin status in patients with severe sepsis in the pediatric intensive care unit (PICU). Blood samples for the determination of NMC were obtained from each patient at 3 a.m. Urine samples for the determination of aMT6s excretion were obtained from each patient at 12 h intervals. We obtained 89 blood and 178 urine samples from 23 septic patients, and 52 blood and 104 urine samples from 13 non-septic patients. The NMC of septic patients in a state of septic shock was significantly higher than that of septic patients not in septic shock (p = 0.017) and those of non-septic patients (p = 0.019). In contrast, there was no significant difference for nocturnal (NaMT6s) and total aMT6s (TaMT6s) excretion between septic patients with and without septic shock and non-septic patients (p > 0.05). The NMC was significantly higher in septic patients in shock with and without hepatic dysfunction (HD) than in non-septic patients (p = 0.004 and p = 0.024, respectively). NaMT6s and TaMT6s excretion was significantly lower in septic patients with HD than in septic patient without HD (p = 0.040 and p = 0.029, for NaMT6s and TaMT6s, respectively). Our results showed that an elevated NMC may not reflect an increased MT production in septic patients in septic shock. It seems that, to evaluate the melatonin status of septic PICU patients, it is necessary to collect both serum and urine samples. PMID:22308859

  11. Vitamin D status and its associations with disease activity and severity in African Americans with recent onset rheumatoid arthritis

    PubMed Central

    Craig, Steven M.; Yu, Fang; Curtis, Jeffrey R.; Alarcón, Graciela S.; Conn, Doyt L.; Jonas, Beth; Callahan, Leigh F.; Smith, Edwin A.; Moreland, Larry W.; Bridges, S. Louis; Mikuls, Ted R.

    2011-01-01

    Objective To examine the prevalence of vitamin D insufficiency and the associations of vitamin D concentration with disease status in African Americans with rheumatoid arthritis (RA). Methods Study participants (n = 266) were enrolled in the Consortium for the Longitudinal Evaluation of African Americans with Early RA (CLEAR) Registry. 25(OH)-D was measured on baseline plasma and associations of 25(OH)-D with disease status (baseline and at 3 years disease duration) were examined using univariate and multivariate regression. Results The prevalence of 25(OH)-D insufficiency (≤ 37.5 nmol/L or 15 ng/ml) was 50%, with the highest prevalence in winter. In unadjusted analyses, vitamin D concentrations were inversely associated with baseline pain (p = 0.04), swollen joints (p = 0.04), and Disease Activity Score (DAS-28, p = 0.05) but not with measures at 3 years disease duration. There were no multivariate associations of 25(OH)-D with any disease measures at baseline or at 3 years with the exception of a positive borderline association with rheumatoid factor positivity at enrollment (p = 0.05). Conclusions Vitamin D insufficiency is common in African Americans with recent-onset RA. Unadjusted associations of circulating vitamin D with baseline pain, swollen joints, and DAS-28 were explained by differences in season, age, and gender and were not significant in multivariate analyses. In contrast to reports of Northern Europeans with early inflammatory arthritis, there are not strong associations of 25(OH)-D concentration with symptoms or disease severity in African Americans with RA. PMID:20032100

  12. Controlled, cross-sectional MRI evaluation of joint status in severe haemophilia A patients treated with prophylaxis vs. on demand

    PubMed Central

    Oldenburg, J; Zimmermann, R; Katsarou, O; Theodossiades, G; Zanon, E; Niemann, B; Kellermann, E; Lundin, B

    2015-01-01

    In patients with haemophilia A, factor VIII (FVIII) prophylaxis reduces bleeding frequency and joint damage compared with on-demand therapy. To assess the effect of prophylaxis initiation age, magnetic resonance imaging (MRI) was used to evaluate bone and cartilage damage in patients with severe haemophilia A. In this cross-sectional, multinational investigation, patients aged 12–35 years were assigned to 1 of 5 groups: primary prophylaxis started at age <2 years (group 1); secondary prophylaxis started at age 2 to <6 years (group 2), 6 to <12 years (group 3), or 12−18 years (group 4); or on-demand treatment (group 5). Joint status at ankles and knees was assessed using Compatible Additive MRI scoring (maximum and mean ankle; maximum and mean of all 4 joints) and Gilbert scores in the per-protocol population (n = 118). All prophylaxis groups had better MRI joint scores than the on-demand group. MRI scores generally increased with current patient age and later start of prophylaxis. Ankles were the most affected joints. In group 1 patients currently aged 27−35 years, the median of maximum ankle scores was 0.0; corresponding values in groups 4 and 5 were 17.0 and 18.0, respectively [medians of mean index joint scores: 0.0 (group 1), 8.1 (group 2) and 13.8 (group 4)]. Gilbert scores revealed outcomes less pronounced than MRI scores. MRI scores identified pathologic joint status with high sensitivity. Prophylaxis groups had lower annualized joint bleeds and MRI scores vs. the on-demand group. Primary prophylaxis demonstrated protective effects against joint deterioration compared with secondary prophylaxis. PMID:25470205

  13. Controlled, cross-sectional MRI evaluation of joint status in severe haemophilia A patients treated with prophylaxis vs. on demand.

    PubMed

    Oldenburg, J; Zimmermann, R; Katsarou, O; Theodossiades, G; Zanon, E; Niemann, B; Kellermann, E; Lundin, B

    2015-03-01

    In patients with haemophilia A, factor VIII (FVIII) prophylaxis reduces bleeding frequency and joint damage compared with on-demand therapy. To assess the effect of prophylaxis initiation age, magnetic resonance imaging (MRI) was used to evaluate bone and cartilage damage in patients with severe haemophilia A. In this cross-sectional, multinational investigation, patients aged 12-35 years were assigned to 1 of 5 groups: primary prophylaxis started at age <2 years (group 1); secondary prophylaxis started at age 2 to <6 years (group 2), 6 to <12 years (group 3), or 12-18 years (group 4); or on-demand treatment (group 5). Joint status at ankles and knees was assessed using Compatible Additive MRI scoring (maximum and mean ankle; maximum and mean of all 4 joints) and Gilbert scores in the per-protocol population (n = 118). All prophylaxis groups had better MRI joint scores than the on-demand group. MRI scores generally increased with current patient age and later start of prophylaxis. Ankles were the most affected joints. In group 1 patients currently aged 27-35 years, the median of maximum ankle scores was 0.0; corresponding values in groups 4 and 5 were 17.0 and 18.0, respectively [medians of mean index joint scores: 0.0 (group 1), 8.1 (group 2) and 13.8 (group 4)]. Gilbert scores revealed outcomes less pronounced than MRI scores. MRI scores identified pathologic joint status with high sensitivity. Prophylaxis groups had lower annualized joint bleeds and MRI scores vs. the on-demand group. Primary prophylaxis demonstrated protective effects against joint deterioration compared with secondary prophylaxis. PMID:25470205

  14. Cladribine and cytarabine in refractory multisystem Langerhans cell histiocytosis: results of an international phase 2 study

    PubMed Central

    Bernard, Frederic; van Noesel, Max; Barkaoui, Mohamed; Bardet, Odile; Mura, Rosella; Arico, Maurizio; Piguet, Christophe; Gandemer, Virginie; Armari Alla, Corinne; Clausen, Niels; Jeziorski, Eric; Lambilliote, Anne; Weitzman, Sheila; Henter, Jan Inge; Van Den Bos, Cor

    2015-01-01

    An international phase 2 study combining cladribine and cytarabine (Ara-C) was initiated for patients with refractory, risk-organ–positive Langerhans cell histiocytosis (LCH) in 2005. The protocol, comprising at least two 5-day courses of Ara-C (1 g/m2 per day) plus cladribine (9 mg/m2 per day) followed by maintenance therapy, was administered to 27 patients (median age at diagnosis, 0.7 years; median follow-up, 5.3 years). At inclusion, all patients were refractory after at least 1 course of vinblastine (VBL) plus corticosteroid, all had liver and spleen involvement, and 25 patients had hematologic cytopenia. After 2 courses, disease status was nonactive (n = 2), better (n = 23), or stable (n = 2), with an overall response rate of 92%. Median disease activity scores decreased from 12 at the start of therapy to 3 after 2 courses (P < .0001). During maintenance therapy, 4 patients experienced reactivation in risk organs. There were 4 deaths; 2 were related to therapy toxicity and 2 were related to reactivation. All patients experienced severe toxicity, with World Health Organization grade 4 hematologic toxicity and 6 documented severe infections. The overall 5-year survival rate was 85% (95% confidence interval, 65.2%-94.2%). Thus, the combination of cladribine/Ara-C is effective therapy for refractory multisystem LCH but is associated with high toxicity. PMID:26194764

  15. Self-Organizing Maps with Refractory Periods

    NASA Astrophysics Data System (ADS)

    Neme, Antonio; Mireles, Victor

    2008-11-01

    Self-organizing map (SOM) has been studied as a model of map formation in the brain cortex. However, the original model present several oversimplifications. For example, neurons in the cortex present a refractory period in which they are not able to be activated, restriction that should be included in the SOM if a better model is to be achieved. Although several modifications have been studied in order to include this biological restriction to the SOM, they do not reflect biological plausibility. Here, we present a modification in the SOM that allows neurons to enter a refractory period (SOM-RP) if they are the best matching unit (BMU) or if they belong to its neighborhood. This refractory period is the same for all affected neurons, which contrasts with previous models. By including this biological restriction, SOM dynamics resembles in more detail the behavior shown by the cortex, such as non-radial activity patterns and long distance influence, besides the refractory period. As a side effect, two error measures are lower in maps formed by SOM-RP than in those formed by SOM.

  16. Self-Organizing Maps with Refractory Periods

    SciTech Connect

    Neme, Antonio; Mireles, Victor

    2008-11-06

    Self-organizing map (SOM) has been studied as a model of map formation in the brain cortex. However, the original model present several oversimplifications. For example, neurons in the cortex present a refractory period in which they are not able to be activated, restriction that should be included in the SOM if a better model is to be achieved. Although several modifications have been studied in order to include this biological restriction to the SOM, they do not reflect biological plausibility. Here, we present a modification in the SOM that allows neurons to enter a refractory period (SOM-RP) if they are the best matching unit (BMU) or if they belong to its neighborhood. This refractory period is the same for all affected neurons, which contrasts with previous models. By including this biological restriction, SOM dynamics resembles in more detail the behavior shown by the cortex, such as non-radial activity patterns and long distance influence, besides the refractory period. As a side effect, two error measures are lower in maps formed by SOM-RP than in those formed by SOM.

  17. Catalytic, hollow, refractory spheres

    NASA Technical Reports Server (NTRS)

    Wang, Taylor G. (Inventor); Elleman, Daniel D. (Inventor); Lee, Mark C. (Inventor); Kendall, Jr., James M. (Inventor)

    1987-01-01

    Improved, heterogeneous, refractory catalysts are in the form of gas-impervious, hollow, thin-walled spheres (10) suitable formed of a shell (12) of refractory such as alumina having a cavity (14) containing a gas at a pressure greater than atmospheric pressure. The wall material may be itself catalytic or a catalytically active material coated onto the sphere as a layer (16), suitably platinum or iron, which may be further coated with a layer (18) of activator or promoter. The density of the spheres (30) can be uniformly controlled to a preselected value within .+-.10 percent of the density of the fluid reactant such that the spheres either remain suspended or slowly fall or rise through the liquid reactant.

  18. High temperature barrier coatings for refractory metals

    NASA Technical Reports Server (NTRS)

    Malone, G. A.; Walech, T.

    1995-01-01

    Improvements in high temperature oxidation resistant metal coating technology will allow NASA and commercial entities to develop competitive civil space transport and communication systems. The success of investigations completed in this program will have a positive impact on broadening the technology base for high temperature materials. The work reported herein describes processes and procedures for successfully depositing coherent oxidation barrier coatings on refractory metals to prevent degradation under very severe operating environments. Application of the new technology developed is now being utilized in numerous Phase 3 applications through several prominent aerospace firms. Major achievements have included: (1) development of means to deposit thick platinum and rhodium coatings with lower stress and fewer microcracks than could be previously achieved; (2) development of processes to deposit thick adherent coatings of platinum group metals on refractory substrates that remain bonded through high temperature excursions and without need for intermediate coatings (bonding processes unique to specific refractory metals and alloys have been defined; (3) demonstration that useful alloys of refractory and platinum coatings can be made through thermal diffusion means; (4) demonstration that selected barrier coatings on refractory substrates can withstand severe oxidizing environments in the range of 1260 deg and 1760 deg C for long time periods essential to the life requirements of the hardware; and (5) successful application of the processes and procedures to prototype hardware. The results of these studies have been instrumental in improved thermal oxidation barrier coatings for the NASP propulsion system. Other Phase 3 applications currently being exploited include small uncooled thrusters for spacecraft and microsatellite maneuvering systems.

  19. Refractory plasmonics (Conference Presentation)

    NASA Astrophysics Data System (ADS)

    Guler, Urcan; Boltasseva, Alexandra; Shalaev, Vladimir M.

    2016-04-01

    The use of plasmonic effects over a broad range of electromagnetic spectrum has been a challenge over the first few decades of research due to limited number of available materials. Recently, the efforts in the area has been concentrated on identifying and examining new material classes as the building blocks for optical technologies over a broader electromagnetic spectrum. Transition metal nitrides attract attention as plasmonic materials in the visible and infrared spectral regions with optical properties resembling gold. As refractory materials, nitrides can withstand heat induced physical phenomena as well as aggressive chemical environment. Adjustable dielectric permittivity of plasmonic nitrides allow fine tuning of optical properties for selected applications. In addition to favorable optical, physical and chemical properties; transition metal nitrides provide CMOS- and bio-compatibility. In this talk, novel designs and concepts based on refractory plasmonic materials for infrared applications will be presented. Additionally, light confinement at the nanoscale with refractory plasmonic antennas, spectral engineering of absorption and emission with metamaterials, and the use of colloidal solutions for a variety of applications will be discussed.

  20. Modelling of High-Chromia Refractory Spalling in Slagging Coal Gasifiers

    SciTech Connect

    Williford, Rick E.; Johnson, Kenneth I.; Sundaram, S. K.

    2008-10-31

    The economic viability of converting coal into clean burning liquid fuels in slagging coal gasifiers is compromised by the limited service lifetime of hot-face refractories. One of the most severe refractory degradation mechanisms is spalling, which can occur by either volume expansion phenomena (compressive stresses) or by volume shrinkage phenomena (tensile stresses). A volume shrinkage model is benchmarked to high-chromia refractory material properties and performance under gasifier operating conditions. The model is found to be appropriate for first order estimates of gasifier refractory lifetime when the apparent diffusivity of volatized Cr in the refractory includes the effects of slag-filled pores and cracks.

  1. Refractories Keep Silicon Crystals Pure

    NASA Technical Reports Server (NTRS)

    Schmid, F.; Khattak, C. P.

    1982-01-01

    Formation of carbon monoxide gas is prevented by a linear of refractory material free of elemental carbon. For pressures above about 4 torr, silicon carbide can be used as refractory liner. The problem of carbide contamination can arise in crystal growth of any material that forms a carbide more stable than carbon monoxide. Prevention in such cases is possible by using noncarbon refractories in place of graphite.

  2. [The refractory glaucomas].

    PubMed

    Valtot, F

    2003-10-01

    Refractory types of glaucoma continue to present a therapeutic challenge to ophthalmologists. Approaches toward the management of these difficult glaucomas are addressed in this paper. The first part devotes special attention to understand the cause(s) of the failure of previous filtering surgery(ies). The next part emphasizes filtration surgery with intraoperative application of antimetabolites: 5-fluorouracil or mitomycin C and the surgical and pharmacological management of failing filtration. In case of failure of multiple filtering surgery with application of antimetabolites, surgeons have to consider cyclodestructive procedures (transscleral diode laser or endoscopic cyclophotocoagulation) to reduce aqueous production, or fistulizing procedures with tube implants or other drainage devices (valves). PMID:14646834

  3. Synthesis of refractory materials

    DOEpatents

    Holt, J.B.

    1983-08-16

    Refractory metal nitrides are synthesized during a self-propagating combustion process utilizing a solid source of nitrogen. For this purpose, a metal azide is employed, preferably NaN/sub 3/. The azide is combusted with Mg or Ca, and a metal oxide is selected from Groups III-A, IV-A, III-B, IV-B, or a rare earth metal oxide. The mixture of azide, Ca or Mg and metal oxide is heated to the mixture's ignition temperature. At that temperature the mixture is ignited and undergoes self-sustaining combustion until the starter materials are exhausted, producing the metal nitride.

  4. Synthesis of refractory materials

    DOEpatents

    Holt, Joseph B.

    1984-01-01

    Refractory metal nitrides are synthesized during a self-propagating combustion process utilizing a solid source of nitrogren. For this purpose, a metal azide is employed, preferably NaN.sub.3. The azide is combusted with Mg or Ca, and a metal oxide is selected from Groups III-A, IV-A, III-B, IV-B, or a rare earth metal oxide. The mixture of azide, Ca or Mg and metal oxide is heated to the mixture's ignition temperature. At that temperature the mixture is ignited and undergoes self-sustaining combustion until the starter materials are exhausted, producing the metal nitride.

  5. Refractory intraoperative hypotension with elevated serum tryptase

    PubMed Central

    Larson, Kelly J.; Divekar, Rohit D.; Butterfield, Joseph H.; Schwartz, Lawrence B.; Weingarten, Toby N.

    2015-01-01

    Severe intraoperative hypotension has been reported in patients on angiotensin-converting enzyme inhibitors and angiotensin II receptor subtype 1 antagonists. We describe a patient on lisinopril who developed refractory intraoperative hypotension associated with increased serum tryptase level suggesting mast cell activation (allergic reaction). However, allergology workup ruled out an allergic etiology as well as mastocytosis, and hypotension recalcitrant to treatment was attributed to uninterrupted lisinopril therapy. Elevated serum tryptase was attributed to our patient's chronic renal insufficiency. PMID:25653920

  6. The geochemical behavior of refractory noble metals and lithophile trace elements in refractory inclusions in carbonaceous chondrites

    NASA Astrophysics Data System (ADS)

    Fegley, B.; Kornacki, A. S.

    1984-05-01

    Recent models of Ca, Al-rich (CAI) inclusion petrogenesis, and the recent availability of thermodynamic data have led to the reexamination of the geochemical behavior of the refractory noble metals (RNM) and several lithophile refractory trace elements in CAI's in the context of distillation models. Here, pertinent chemical and mineralogical properties of the various classes of refractory inclusions are reviewed, and calculations of the stability of LRTE-RNM alloys and several LRTE oxides under nebular conditions are presented. The calculations, observations and experimental results are applied to a new model of the origin of refractory metal nuggets, and a specific mechanism is identified for producing Group II chemical patterns in a cold star nebula by fractionating interstellar dust at low temperature on the basis of physical differences between different populations of pre-solar grains.

  7. The geochemical behavior of refractory noble metals and lithophile trace elements in refractory inclusions in carbonaceous chondrites

    NASA Technical Reports Server (NTRS)

    Fegley, B., Jr.; Kornacki, A. S.

    1984-01-01

    Recent models of Ca, Al-rich (CAI) inclusion petrogenesis, and the recent availability of thermodynamic data have led to the reexamination of the geochemical behavior of the refractory noble metals (RNM) and several lithophile refractory trace elements in CAI's in the context of distillation models. Here, pertinent chemical and mineralogical properties of the various classes of refractory inclusions are reviewed, and calculations of the stability of LRTE-RNM alloys and several LRTE oxides under nebular conditions are presented. The calculations, observations and experimental results are applied to a new model of the origin of refractory metal nuggets, and a specific mechanism is identified for producing Group II chemical patterns in a cold star nebula by fractionating interstellar dust at low temperature on the basis of physical differences between different populations of pre-solar grains.

  8. REFRACTORY COATING FOR GRAPHITE MOLDS

    DOEpatents

    Stoddard, S.D.

    1958-06-24

    Refractory coating for graphite molds used in the casting of uranium is described. The coating is an alumino-silicate refractory composition which may be used as a mold surface in solid form or as a coating applied to the graphite mold. The composition consists of a mixture of ball clay, kaolin, alumina cement, alumina, water, sodium silicate, and sodium carbonate.

  9. Endorsement of Interpersonal Strategies for Dealing with Hypothetical Everyday Arthritis Problems as a Function of Marital Status, Gender, and Problem Severity

    ERIC Educational Resources Information Center

    Strough, Jonell; McFall, Joseph P.; Schuller, Kelly L.

    2010-01-01

    We used hypothetical vignettes to examine whether older adults' endorsement of interpersonal strategies for dealing with health-related (arthritis) everyday problems varied as a function of marital status, gender, and the severity of the problem. Adults 60 years and older (N= 127, M= 71.40 years, SD = 7.21) rated interpersonal (i.e., discuss with…

  10. Uterine Artery Embolisation for Management of Refractory Postpartal Haemmorhage

    PubMed Central

    Urundady, Vishalakshi; Shetty, Vrinda

    2012-01-01

    Management of Postpartal Haemorrhage (PPH) refractory to medical management continues to be a formidable condition, further compounded by unstable haemodynamic condition and associated coagulopathy, usually associated with this condition. Though surgical exploration is the usual therapeutic option for such patients, selective pelvic arterial embolisation is gaining the popularity in view of its safety and efficacy profile. Uterine preservation further adds to its advantages. We present our experience of managing 5 such patients with Uterine Artery Embolisation (UAE). The current status of UAE as therapeutic modality for management of refractory PPH is discussed. PMID:23373044

  11. Refractory experience in circulating fluidized bed combustors, Task 7

    SciTech Connect

    Vincent, R.Q.

    1989-11-01

    This report describes the results of an investigation into the status of the design and selection of refractory materials for coal-fueled circulating fluidized-bed combustors. The survey concentrated on operating units in the United States manufactured by six different boiler vendors: Babcock and Wilcox, Combustion Engineering, Foster Wheeler, Keeler Dorr-Oliver, Pyropower, and Riley Stoker. Information was obtained from the boiler vendors, refractory suppliers and installers, and the owners/operators of over forty units. This work is in support of DOE's Clean Coal Technology program, which includes circulating fluidized-bed technology as one of the selected concepts being evaluated.

  12. Refractory gastroesophageal reflux disease

    PubMed Central

    Subramanian, Charumathi Raghu; Triadafilopoulos, George

    2015-01-01

    Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents into the esophagus causes troublesome symptoms, esophageal injury, and/or complications. Use of proton pump inhibitors (PPI) remains the standard therapy for GERD and is effective in most patients. Those whose symptoms are refractory to PPIs should be evaluated further and other treatment options should be considered, according to individual patient characteristics. Response to PPIs could be total (no symptoms), partial (residual breakthrough symptoms), or absent (no change in symptoms). Patients experiencing complete response do not usually need further management. Patients with partial response can be treated surgically or by using emerging endoscopic therapies. Patients who exhibit no response to PPI need further evaluation to rule out other causes. PMID:25274499

  13. Do You Hear Voices? Problems in Assessment of Mental Status in Deaf Persons with Severe Language Deprivation

    ERIC Educational Resources Information Center

    Glickman, Neil

    2007-01-01

    When mental health clinicians perform mental status examinations, they examine the language patterns of patients because abnormal language patterns, sometimes referred to as language dysfluency, may indicate a thought disorder. Performing such examinations with deaf patients is a far more complex task, especially with traditionally underserved…

  14. Pharmacological approaches of refractory angina.

    PubMed

    Giannopoulos, Andreas A; Giannoglou, George D; Chatzizisis, Yiannis S

    2016-07-01

    Refractory angina refers to a group of patients with stable coronary atherosclerotic disease and angina symptoms, unresponsive to traditional medical management, while considered to be suboptimal candidates for revascularization procedures. Up to 15% of angina patients are considered to have refractory angina and, taking into account the aging population and the improvements in the treatment of stable coronary artery disease, the incidence of this entity is expected to increase. This review describes traditional and novel pharmacotherapies for symptoms relief and for long-term management of refractory angina. Mechanisms of action and relevant clinical trials are discussed and current recommendations from major European and US cardiovascular societies are reported. PMID:27013345

  15. Mechanisms and management of refractory coeliac disease.

    PubMed

    van Gils, Tom; Nijeboer, Petula; van Wanrooij, Roy L; Bouma, Gerd; Mulder, Chris J J

    2015-10-01

    A small subset of patients with coeliac disease become refractory to a gluten-free diet with persistent malabsorption and intestinal villous atrophy. The most common cause of this condition is inadvertent gluten exposure, but concomitant diseases leading to villous atrophy should also be considered and excluded. After exclusion of these conditions, patients are referred to as having refractory coeliac disease, of which two categories are recognized based on the absence (type I) or presence (type II) of a clonal expansion of premalignant intraepithelial lymphocyte population with a high potential for transformation into an overt enteropathy-associated T-cell lymphoma. Type I disease usually has a benign course that can be controlled by mild immunosuppressive treatment, but type II can be more severe with cladribine with or without autologous stem cell transplantation effective as treatment. Patients who fail to respond to cladribine therapy, however, still have a high risk of malignant transformation. Insights into the immunophenotype of these cells and the recognition that type II disease is a low-grade, no-mass lymphoma opens avenues for new treatment strategies, including chemotherapeutic and immunomodulating strategies. This Review will provide an overview of refractory coeliac disease, discussing mechanisms, diagnosis and management. PMID:26347156

  16. Evolving ideas about the male refractory period.

    PubMed

    Turley, Kenneth R; Rowland, David L

    2013-08-01

    The male refractory period (MRP) continues to be a topic of discussion and debate within the field of sexual medicine. To date explanations rely on central descending (efferent) influences involving specific neurotransmitter systems. Herein we explore the issue of the male refractory period, identifying problems with current explanations, specifying the parameters of an adequate model, and suggesting possible mechanisms mediating this phenomenon. We review the literature regarding existing explanations for the MRP and look to other systems of physiological regulation that might provide a model for the conceptualization of the MRP. Our approach differs from traditional explanations in that it emphasizes the possible roles of various peripheral, rather than central, feedback (afferent) systems that affect peripheral autonomic functioning and response. Yet our approach is consistent with other peripheral regulatory feedback systems controlling autonomic response related to such processes as heart rate, respiration, and gut motility. Although direct empirical research supporting our approach is lacking, sufficient evidence exists to support the idea that such processes are not only possible but likely with respect to the male refractory period. We suggest several lines of research that might provide empirical support for this approach. PMID:23470051

  17. Review of the status of validation of the computer codes used in the severe accident source term reassessment study (BMI-2104). [PWR; BWR

    SciTech Connect

    Kress, T. S.

    1985-04-01

    The determination of severe accident source terms must, by necessity it seems, rely heavily on the use of complex computer codes. Source term acceptability, therefore, rests on the assessed validity of such codes. Consequently, one element of NRC's recent efforts to reassess LWR severe accident source terms is to provide a review of the status of validation of the computer codes used in the reassessment. The results of this review is the subject of this document. The separate review documents compiled in this report were used as a resource along with the results of the BMI-2104 study by BCL and the QUEST study by SNL to arrive at a more-or-less independent appraisal of the status of source term modeling at this time.

  18. Impact of Chronic Condition Status and Severity on the Time to First Dental Visit for Newly Medicaid-Enrolled Children in Iowa

    PubMed Central

    Chi, Donald L; Momany, Elizabeth T; Neff, John; Jones, Michael P; Warren, John J; Slayton, Rebecca L; Weber-Gasparoni, Karin; Damiano, Peter C

    2011-01-01

    Objective To assess the extent to which chronic condition (CC) status and severity affected how soon children had a dental visit after enrolling in Medicaid. Data Source Enrollment and claims data (2003–2008) for newly Medicaid-enrolled children ages 3–14 in Iowa. Study Design 3M Clinical Risk Grouping methods were used to identify CC status (no/yes) and CC severity (less severe/more severe). Survival analysis was used to identify the factors associated with earlier first dental visits after initially enrolling in Medicaid. Principal Findings Children with a CC were 17 percent more likely to have earlier first dental visits after enrolling in Medicaid (p<.0001). There was no significant difference by CC severity. Children who lived in a dental health professional shortage area and those who did not utilize primary medical care had significantly later first Medicaid dental visits, whereas these factors failed to reach statistical significance for children with a CC. Conclusion While newly Medicaid-enrolled children with a CC were significantly more likely to have earlier first dental visits, we failed to detect a relationship between CC severity and the time to first Medicaid dental visit. The determinants of first Medicaid dental visits were heterogeneous across subgroups of newly Medicaid-enrolled children. Future studies should identify the sociobehavioral factors associated with CCs that are potential barriers to earlier first Medicaid dental visits for newly Medicaid-enrolled children. PMID:20849559

  19. Refractory hypoglycaemia in a dog infected with Trypanosoma congolense

    PubMed Central

    Deschamps, Jack-Yves; Desquesnes, Marc; Dorso, Laetitia; Ravel, Sophie; Bossard, Géraldine; Charbonneau, Morgane; Garand, Annabelle; Roux, Françoise A.

    2016-01-01

    A 20 kg German shepherd dog was presented to a French veterinary teaching hospital for seizures and hyperthermia. The dog had returned 1 month previously from a six-month stay in Senegal and sub-Saharan Africa. Biochemistry and haematology showed severe hypoglycaemia (0.12 g/L), anaemia and thrombocytopenia. Despite administration of large amounts of glucose (30 mL of 30% glucose IV and 10 mL of 70% sucrose by gavage tube hourly), 26 consecutive blood glucose measurements were below 0.25 g/L (except one). Routine cytological examination of blood smears revealed numerous free extracytoplasmic protozoa consistent with Trypanosoma congolense. PCR confirmed a Trypanosoma congolense forest-type infection. Treatment consisted of six injections of pentamidine at 48-hour intervals. Trypanosomes had disappeared from the blood smears four days following the first injection. Clinical improvement was correlated with the normalization of laboratory values. The infection relapsed twice and the dog was treated again; clinical signs and parasites disappeared and the dog was considered cured; however, 6 years after this incident, serological examination by ELISA T. congolense was positive. The status of this dog (infected or non-infected) remains unclear. Hypoglycaemia was the most notable clinical feature in this case. It was spectacular in its severity and in its refractory nature; glucose administration seemed only to feed the trypanosomes, indicating that treatment of hypoglycaemia may in fact have been detrimental. PMID:26795063

  20. A rapid appraisal of the nutritional status of Irian Jaya refugees and Papua New Guineans undergoing severe food shortage in the North Fly region.

    PubMed

    Ulijaszek, S J; Welsby, S M

    1985-06-01

    A survey of nutritional status of recent border crossers from Irian Jaya undergoing severe food shortages was carried out. The two camps visited were those considered to have the most serious problems at the height of the crisis. Komopkin Camp had the highest levels of malnutrition in all age groups and in all categories, including 52% of children aged 1 to 5 years with signs of kwashiorkor. No kwashiorkor, however, was found in the other camp. Papua New Guinea villagers living alongside the refugees in Komopkin were also suffering from malnutrition, though of lesser severity and shorter duration. PMID:3866430

  1. Abemaciclib in Children With DIPG or Recurrent/Refractory Solid Tumors

    ClinicalTrials.gov

    2016-04-12

    Diffuse Intrinsic Pontine Glioma; Brain Tumor, Recurrent; Solid Tumor, Recurrent; Neuroblastoma, Recurrent, Refractory; Ewing Sarcoma, Recurrent, Refractory; Rhabdomyosarcoma, Recurrent, Refractory; Osteosarcoma, Recurrent, Refractory; Rhabdoid Tumor, Recurrent, Refractory

  2. Refractory ulcerative colitis and iatrogenic colorectal Kaposi's sarcoma.

    PubMed

    Girelli, C M; Serio, G; Rocca, E; Rocca, F

    2009-02-01

    Colorectal Kaposi's sarcoma, a human herpes virus-8 associated mesenchymal tumour, is exceedingly rare in human immunodeficiency virus-negative subjects and almost always reported in association with severe, refractory, inflammatory bowel disease. In this paper we report a case--the second from Italy--of a colorectal Kaposi's sarcoma in a human immunodeficiency virus-negative, heterosexual man with severe refractory ulcerative colitis. Kaposi's sarcoma developed after starting glucocorticosteroid therapy, supporting the theory that colorectal Kaposi's sarcoma associated with ulcerative colitis is iatrogenic. PMID:18054849

  3. Restoring Functional Status: A Long-Term Case Report of Severe Lung and Ventilatory Muscle Pump Dysfunction Involving Recurrent Bacterial Pneumonias

    PubMed Central

    Sobush, Dennis C.; Laatsch, Linda; Lipchik, Randolph J.

    2012-01-01

    Background and Purpose Prolonged mechanical ventilation contributes to immobility and deconditioning making efforts to safely discontinue ventilator support desirable. This case report documents how implementing physical therapy treatment interventions, based on the Guide to Physical Therapist Practice, can help to restore a person's functional status even after multiple years of mechanical ventilation dependency. Case Description A patient (female; aged 63 years) with severe restrictive and obstructive ventilatory impairment has survived 34 recurrent pneumonias involving 6 bacterial pathogens while being mechanically ventilated at home. A 3-year study was approved and informed consent obtained for a home exercise program of resistive extremity and inspiratory muscle training along with exercise reconditioning. Tolerable distances walked, maximal inspiratory and expiratory pressures, hours spent on versus off mechanical ventilation, activities performed within and around her home, and community excursions taken were charted. Outcomes Daily time tolerated off the ventilator improved from less than one to 12 hours, distance walked in 6 minutes increased 33%, and maximal inspiratory and expiratory pressures improved 62% and 9.6% respectively. These improvements made out-of-home social excursions possible. Discussion and Conclusions This patient's functional status improved following multiple physical therapy interventions dictated by the evaluation of initial physical therapy examination findings according to the Guide to Physical Therapist Practice. Long term mechanical ventilator dependency in the home environment did not exclude this patient from achieving clinically significant gains in functional status even when having severe restrictive and obstructive ventilator impairment. PMID:22833704

  4. Advances in the treatment of relapsed/refractory acute lymphoblastic leukemia: a case study compendium.

    PubMed

    Roboz, Gail J; Jabbour, Elias J; Faderl, Stefan; Douer, Dan

    2014-12-01

    Acute lymphoblastic leukemia (ALL) is a heterogeneous hematologic malignancy characterized by proliferation of immature lymphoid cells throughout the bone marrow and peripheral blood. Most cases are diagnosed before the age of 20 years. Adults have a worse prognosis than children. Approximately half of adult ALL patients relapse after their initial treatment. There is no standard treatment for ALL; strategies vary according to the patient’s age, comorbidities, and Philadelphia chromosome status. Regimens used in pediatric patients are being adapted for use in adults. Frontline management can include hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with cycles of high-dose methotrexate and cytarabine (hyper-CVAD) and the Berlin-Frankfurt-Münster regimen. Relapsed/refractory patients have several options, including a regimen consisting of fludarabine, high-dose cytarabine, and granulocyte colony–stimulating factor (FLAG); tyrosine kinase inhibitors; and chemotherapy. The US Food and Drug Administration recently approved 3 therapies for these patients: clofarabine, nelarabine, and vincristine sulfate liposome injection, a modified formulation of vincristine that allows the drug to be administered at a higher dosage. Several novel strategies are currently under investigation, including the monoclonal antibody blinatumomab, a bispecific T-cell engager that targets the B-cell–specific antigen CD19 and activates T cells to exert cytotoxic activity against the target B cell. This clinical roundtable monograph features case studies that illustrate important points in the management of adult patients with relapsed/refractory ALL. PMID:25768269

  5. Platinum group metals base refractory superalloys

    SciTech Connect

    Yamabe-Mitarai, Y.; Koizumi, Y.; Murakami, H.; Harada, H.; Maruko, T.

    1997-12-31

    Ir- and Rh-base refractory superalloys wit h an fcc and L1{sub 2} two phase structure similar to Ni-base superalloys, yet with considerably higher melting temperatures have been proposed. Fcc and L1{sub 2} two phases were observed in these alloys by transmission electron microscopy and X-ray powder diffractometry. The compression tests of these alloys showed that the strengths of several alloys were about 200 MPa at 1,800 C and these alloys have potential to become ultra-high temperature materials for use in power engineering field.

  6. Refractory leg ulcers associated with Klinefelter syndrome.

    PubMed

    Yabuno, Yuto; Tosa, Mamiko; Iwakiri, Itaru; Nomoto, Shunichi; Kaneko, Mayuko; Kuwahara, Kousuke; Hyakusoku, Hiko; Murakami, Masahiro

    2015-01-01

    We present a man with refractory leg ulcers, bilateral varicosis of the lower extremities, and Buerger disease. Autoimmune work-up was negative. However, chromosome analysis showed Klinefelter syndrome (48 XXY). Ulcerative lesions of the lower extremities are a complication of Klinefelter syndrome. To date, the pathogenesis of ulcers in Klinefelter syndrome has not been clarified, but several factors, such as abnormalities of fibrinolysis and prothrombotic states, might be involved. Our present case emphasizes the importance of considering Klinefelter syndrome in the differential diagnosis of a male patient with nonhealing ulcers of the lower extremities. PMID:25797879

  7. Acute phase proteins increase with sarcoptic mange status and severity in Iberian ibex (Capra pyrenaica, Schinz 1838).

    PubMed

    Ráez-Bravo, Arián; Granados, José Enrique; Cerón, José Joaquín; Cano-Manuel, Francisco Javier; Fandos, Paulino; Pérez, Jesús María; Espinosa, José; Soriguer, Ramón Casimiro; López-Olvera, Jorge Ramón

    2015-11-01

    Sarcoptic mange is a contagious skin disease caused by Sarcoptes scabiei, affecting both domestic and wild mammals, including the Iberian ibex (Capra pyrenaica), a medium-sized mountain ungulate almost endemic to the Iberian Peninsula. Acute phase proteins (APPs) could be an indicator of sarcoptic mange disease and severity in Iberian ibex. Serum samples from 131 healthy and sarcoptic mange-affected Iberian ibexes were collected from 2005 to 2012 in Sierra Nevada Natural Space in southern Spain. Serum alpha-1-acid glycoprotein (AGP), serum amyloid A (SAA) and haptoglobin (Hp) concentrations were quantified, and statistically significant differences according to sarcoptic mange disease and severity were assessed. Both AGP and SAA were significantly higher in the sarcoptic mange-affected ibexes than in the healthy ones as well as in the severely affected ibexes as compared to those with less than 50 % of the body surface affected. For the first time, changes in APP are reported in relation to sarcoptic mange in Iberian ibex. It is also reported for the first time that the intensity of APP increase depends on the severity of sarcoptic mange, which could be related with the pathological secondary amyloidosis, leading to organ dysfunction in severely mange-affected animals. Species and population differences in the increase of APP in response to sarcoptic mange could indicate individual and population differences in the immune capability of each population to deal with mange, population prevalence and mortality being the last indicators of such sensitivity. PMID:26227139

  8. Dynamic Testing of Gasifier Refractory

    SciTech Connect

    Michael D. Mann; Devdutt Shukla; Xi Hong; John P. Hurley

    2004-09-27

    The University of North Dakota (UND) Chemical Engineering Department in conjunction with the UND Energy & Environmental Research Center (EERC) have initiated a program to thoroughly examine the combined chemical (reaction and phase change) and physical (erosion) effects experienced by a variety of refractory materials during both normal operation and thermal cycling under slagging coal gasification conditions. The goal of this work is to devise a mechanism of refractory loss under these conditions. The controlled-atmospheric dynamic corrodent application furnace (CADCAF) is being utilized to simulate refractory/slag interactions under dynamic conditions that more realistically simulate the environment in a slagging coal gasifier than any of the static tests used previously by refractory manufacturers and researchers. Shakedown testing of the CADCAF has been completed. Samples of slag and refractory from the Tampa Electric Polk Power Station have been obtained for testing in the CADCAF. The slag has been dried and sieved to the size needed for our flowing slag corrosion tests. Screening tests are in currently in progress. Detailed analysis of corrosion rates from the first tests is in progress.

  9. Dynamic Testing of Gasifier Refractory

    SciTech Connect

    Michael D. Mann; Devdutt Shukla; John P. Hurley

    2003-09-27

    The University of North Dakota (UND) Chemical Engineering Department in conjunction with the UND Energy & Environmental Research Center (EERC) have initiated a program to thoroughly examine the combined chemical (reaction and phase change) and physical (erosion) effects experienced by a variety of refractory materials during both normal operation and thermal cycling under slagging coal gasification conditions. The goal of this work is to devise a mechanism of refractory loss under these conditions. The controlled-atmospheric dynamic corrodent application furnace (CADCAF) is being utilized to simulate refractory/slag interactions under dynamic conditions that more realistically simulate the environment in a slagging coal gasifier than any of the static tests used previously by refractory manufacturers and researchers. Shakedown testing of the CADCAF is in progress. Samples of slag and refractory from the Tampa Electric Polk Power Station have been obtained for testing in the CADCAF. The slag has been dried and sieved to the size needed for our flowing slag corrosion tests. Testing is expected to begin in October.

  10. Refractory failure in slagging gasifiers

    SciTech Connect

    Bennett, James P.; Kwong, Kyei-Sing

    2004-08-01

    Slagging gasifiers are used to produce chemicals and/or electricity from feedstocks such as coal and/or petroleum coke. A gasifier environment includes pressures from 400 to 1000 psi, temperatures from 1250-1550 C, are cyclic, reducing gases of CO and H2, and molten ash that interacts with the refractory liner materials. The high Cr2O3 refractory liners of gasifiers fail within 3 to 24 months due to slag attack at elevated temperatures. Gasifier users seek materials with increased reliability and service life. The causes of refractory failure and efforts to increase refractory service life are discussed. Mechanisms involving corrosion and slag infiltration/spalling are the main causes of refractory wear. The reduction of slag penetration can reduce hot face lining wear. The performance of high Cr2O3-Al2O3 materials with phosphate additions were evaluated. Phosphate additions were found to have comparable wear and physical properties to materials with no additions, and to have good slag penetration resistance. Field trials in a gasifier are needed to clarify the potential of the materials.

  11. An overview of recycling refractory materials

    SciTech Connect

    Bennett, James P.; Kwong, Kyei-Sing

    2004-09-01

    Refractory materials must be disposed of or recycled when removed from service. Off-specification or reject material has been reused by the refractory industry for a number of years, with small percentages of these materials added as a part of refractory formulations. Historically, limed reuse of spent refractory materials in other applications has occurred. Environmental legislation, stewardship programs, and other forces encouraged some businesses to recycle spent refractories. Reuse of spent refractory material varies considerably among different industries and with the location of the industrial user. Efforts to recycle, the driving forces for recycling, and issues and steps to be taken into account initiating a recycling program will be discussed.

  12. Precursors to potential severe core damage accidents: 1992, A status report. Volume 17, Main report and Appendix A

    SciTech Connect

    Cox, D.F.; Cletcher, J.W.; Copinger, D.A.; Cross-Dial, A.E.; Morris, R.H.; Vanden Heuvel, L.N.; Dolan, B.W.; Jansen, J.M.; Minarick, J.W.; Lau, W.; Salyer, W.D.

    1993-12-01

    Twenty-seven operational events with conditional probabilities of subsequent severe core damage of 1.0 {times} 10E-06 or higher occurring at commercial light-water reactors during 1992 are considered to be precursors to potential core damage. These are described along with associated significance estimates, categorization, and subsequent analyses. The report discusses (1) the general rationale for this study, (2) the selection and documentation of events as precursors, (3) the estimation and use of conditional probabilities of subsequent severe core damage to rank precursor events, and (4) the plant models used in the analysis process.

  13. Modification of the association between smoking status and severity of coronary stenosis by vitamin D in patients suspected of coronary heart disease.

    PubMed

    Li, Kuibao; Yang, Xiyan; Wang, Lefeng; Chen, Mulei; Zhao, Wenshu; Xu, Li; Yang, Xinchun

    2016-09-01

    Given both smoking and vitamin D are associated with coronary heart disease (CHD) via inflammation and smoking may interfere with the local antiinflammatory effects of vitamin D. We hypothesized that the relationship between smoking and severity of CHD may be modified by vitamin D.A cross-sectional study was conducted. 25-OH vitamin D values were determined in 348 consecutive patients (mean age 62.4 ± 10.5 years; 56.3% male) undergoing coronary angiography at the Heart Center of Chaoyang Hospital affiliated to Capital Medical University between the period of September 2014 and May 2015. We categorized the patients into 2 groups based on 25-OH vitamin D levels, that is, severe hypovitaminosis D (25-OH vitamin D < 10 ng/mL) and higher vitamin D (25-OH vitamin D > =  10 ng/mL). Multivariable logistic regression models were used to estimate odds ratios (ORs) of severe coronary stenosis or higher Gensini score across three smoking status, that is, never smokers, former smokers, and current smokers in severe hypovitaminosis D and higher vitamin D groups, respectively.Of these patients, we identified 212 (60.9%) cases of severe CHD and 161 (46.3%) cases of severe hypovitaminosis D. Multivariable logistic regression model showed the ORs of severe CHD were 1.94 (95% confidence interval [CI]: 0.47, 7.98) for former smokers and 2.62 (95% CI: 0.83, 8.24) for current smokers, compared with never smokers in group with severe hypovitaminosis D (P-trend = 0.005). In contrast, smoking was not found to be significantly associated with severe CHD in group with higher 25-OH vitamin D (P-trend = 0.115). We found a significant interaction between smoking status and vitamin D on presence of severe CHD (P-interaction = 0.015). In terms of Gensini score as a dependent variable, similar results were identified.Our finding indicated the association between smoking and severity of CHD appeared to be substantially stronger among patients with severe hypovitaminosis D as

  14. Effect of breed, intake, and carcass composition on the status of several macro and trace minerals of adult beef cattle.

    PubMed

    Littledike, E T; Wittum, T E; Jenkins, T G

    1995-07-01

    The objective was to determine the association between breed, intake, and carcass composition and the status of liver Cu, Zn, and Fe, and serum Cu, Zn, Ca, and Mg of 118 mature cows representing nine breeds of cattle. Breeds used were Angus, Braunvieh, Charolais, Gelbvieh, Hereford, Limousin, Red Poll, Pinzgauer, and Simmental. The cows were fed one of four levels of DMI: 58, 76, 93, and 111 g of DMI.wt-75.d-1. A ground alfalfa, corn, and corn silage diet was fed for up to 5 yr. There was no relationship between liver and serum concentrations of Cu, a negative correlation (P < .05) existed between liver and serum concentrations of Zn and a positive correlation (P < .01) existed between liver concentrations of Cu and Zn. Concentrations of serum Ca were positively correlated (Cu and Zn, P < .01; Mg, P < .05) with serum concentrations of Cu, Zn, and Mg, but negatively correlated (P < .01) with liver Fe. Liver Cu was higher (P < .05) for the Limousin breed than all others, except Angus. Liver Zn concentrations were higher (P < .05) for Limousin than for Pinzgauer, but no other breed differences were observed. Liver Cu concentration was not affected by daily intake, but liver Zn concentration increased (P < .05) with increased daily intake. Liver Fe concentration decreased (P < .01) in a curvilinear manner with increased daily intake. No breed differences in serum concentrations of Cu or Zn were observed.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:7592099

  15. Chronic granulomatous disease presenting as refractory pneumonia in late adulthood.

    PubMed

    Sarwar, Ghulam; de Malmanche, Theo; Rassam, Loui; Grainge, Christopher; Williams, Andrew; Arnold, David

    2015-06-01

    We present a case of refractory pneumonia in an adult patient with underlying chronic granulomatous disease (CGD). Her lobectomy tissue grew B urkholderia cepacia and histopathology revealed diffuse severe pneumonic consolidation with suppurative/necrotizing granulomata. An initial attempt to find an underlying immune deficiency was unsuccessful. Following recurrent invasive infections, repeat immunological assessment revealed reduced neutrophil function, demonstrating skewed carrier status (lyonization) for X-linked CGD (only 3% normal cells). A pathogenic mutation in the CYBB gene was found on sequencing. CYBB gene encodes the gp91phox, a catalytic subunit of nicotinamide adenine dinucleotide phosphate-oxidase that produces reactive oxygen species in phagocytes. Lyonization increases with age, explaining the delayed clinical CGD. CGD is a rare neutrophil disorder that usually presents in early life with recurrent infections due to bacteria and fungi primarily involving lungs and skin. It is secondary to a defective NADPH oxidase system needed to kill intracellular organisms and activate the formation of neutrophil extracellular traps. PMID:26090111

  16. The impact of nutritional status and appetite on the hospital length of stay and postoperative complications in elderly patients with severe aortic stenosis before aortic valve replacement

    PubMed Central

    Jagielak, Dariusz; Wernio, Edyta; Bramlage, Peter; Gruchała-Niedoszytko, Marta; Rogowski, Jan; Małgorzewicz, Sylwia

    2016-01-01

    Introduction Severe aortic stenosis (AS) is associated with the reduction of physical activity and muscle mass and may be associated with decreased appetite. Aim To assess the nutritional status and the impact of nutritional status and appetite on the hospital length of stay and postoperative complications in elderly patients with severe AS before aortic valve replacement. Material and methods Ninety-nine patients (55 male, 44 female; 74.3 ±5.2 years old) with severe AS and an indication for aortic valve replacement (AVR) were included. The nutritional status was assessed by different questionnaires (7-point Subjective Global Assessment Score – 7-SGA, full-Mini Nutritional Assessment – full-MNA) and anthropometric measurements (body mass index (BMI) kg/m2). Body composition was estimated using multi-frequency bioelectrical impedance analysis. Appetite was assessed by the Simplified Nutrition Assessment Questionnaire (SNAQ). Results The average BMI of patients was 28.8 ±5.8 kg/m2. Results of the 7-SGA and f-MNA questionnaires revealed that 39 patients (39.4%) were at risk of malnutrition. The mean SNAQ score was 15.8 ±1.8. The average length of hospital stay was 10 ±5.8 days. There was a positive correlation of LOS with age (r = 0.26, p = 0.03) and a negative correlation with fat mass (kg) (r = –0.28, p = 0.04) and BMI (r = –0.22, p = 0.03). Postoperative complications were observed in 37 patients (37.4%). Patients who developed complications were older and had poorer nutritional status according to the results of the 7-SGA. Conclusions Despite many patients undergoing AVR being overweight and obese, a considerable proportion displayed clinical signs of malnutrition. The results suggest that an assessment of nutritional status and appetite in this group of patients should be conducted regularly and that the 7-SGA scale could represent a reliable tool to assess malnutrition. PMID:27516781

  17. Directed light fabrication of refractory metals and alloys

    SciTech Connect

    Fonseca, J.C.; Lewis, G.K.; Dickerson, P.G.; Nemec, R.B.

    1999-05-30

    This report covers deposition of refractory pure metals and alloys using the Directed Light Fabrication (DLF) process and represents progress in depositing these materials through September 1998. In extending the DLF process technology to refractory metals for producing fully dense, structurally sound deposits, several problems have become evident. (1) Control of porosity in DLF-deposited refractory metal is difficult because of gases, apparently present in commercially purchased refractory metal powder starting materials. (2) The radiant heat from the molten pool during deposition melts the DLF powder feed nozzle. (3) The high reflectivity of molten refractory metals, at the Nd-YAG laser wavelength (1.06{micro}m), produces damaging back reflections to the optical train and fiber optic delivery system that can terminate DLF processing. (4) The current limits on the maximum available laser power to prevent back reflection damage limit the parameter range available for densification of refractory metals. The work to date concentrated on niobium, W-25Re, and spherodized tungsten. Niobium samples, made from hydride-dehydride powder, had minimal gas porosity and the deposition parameters were optimized; however, test plates were not made at this time. W-25Re samples, containing sodium and potassium from a precipitation process, were made and porosity was a problem for all samples although minimized with some process parameters. Deposits made from potassium reduced tungsten that was plasma spherodized were made with minimized porosity. Results of this work indicate that further gas analysis of starting powders and de-gassing of starting powders and/or gas removal during deposition of refractory metals is required.

  18. Directed Light Fabrication of Refractory Metals and Alloys

    SciTech Connect

    Fonseca, J.C.; Lewis, G.K.; Dickerson, P.G.; Nemec, R.B.

    1999-05-14

    This report covers work performed under Order No. FA0000020 AN Contract DE-AC12-76SN00052 for deposition of refractory pure metals and alloys using the Directed Light Fabrication (DLF) process and represents the progress in depositing these materials through September 1998. In extending the DLF process technology to refractory metals for producing fully dense, structurally sound deposits, several problems have become evident. 1. Control of porosity in DLF-deposited refractory metal is difficult because of gases, apparently present in commercially purchased refractory metal powder starting materials. 2. The radiant heat from the molten pool during deposition melts the DLF powder feed nozzle. 3. The high reflectivity of molten refractory metals, at the Nd-YAG laser wavelength (1.06{micro}m), produces damaging back reflections to the optical train and fiber optic delivery system that can terminate DLF processing. 4. The current limits on the maximum available laser power to prevent back reflection damage limit the parameter range available for densification of refractory metals. The work to date concentrated on niobium, W-25Re, and spherodized tungsten. Niobium samples, made from hydride-dehydride powder, had minimal gas porosity and the deposition parameters were optimized; however, test plates were not made at this time. W-25Re samples, containing sodium and potassium from a precipitation process, were made and porosity was a problem for all samples although minimized with some process parameters. Deposits made from potassium reduced tungsten that was plasma spherodized were made with minimized porosity. Results of this work indicate that further gas analysis of starting powders and de-gassing of starting powders and/or gas removal during deposition of refractory metals is required.

  19. A girl with tuberous sclerosis complex presenting with severe epilepsy and electrical status epilepticus during sleep, and with high-functioning autism and mutism.

    PubMed

    Pacheva, Iliyana; Panov, Georgi; Gillberg, Christopher; Neville, Brian

    2014-06-01

    Most patients with tuberous sclerosis complex (TSC) suffer from epilepsy, and many have cognitive and behavioral problems like severe intellectual disability, autism, and hyperactivity. Only rare patients with TSC and autism have a normal intelligence quotient. We report a 13-year-old girl with definite TSC who had early-onset severe epilepsy, autistic behavior, and moderate developmental delay. By school age, however, she had normal intelligence; her intelligence quotient was at least 70 based on a Stanford-Binet test that she refused to complete. She showed good reading, writing, and language comprehension skills, and the special abilities of hyperlexia, hypermnesia, and hypercalculia. However, she did not speak. Criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and her Childhood Autism Rating Scale score of 36 indicated mild to moderate autism. She had severe electroencephalographic abnormalities: hypsarrhythmia, multifocal or generalized epileptiform discharges, and electrical status epilepticus during sleep, with a continuous left temporal focus. Magnetic resonance imaging showed many cortical tubers in all brain lobes, and subependymal nodules. We discuss possible explanations for her lack of speech. Considered as speech apraxia, her mutism could be either a symptom of her TSC or a component of her autism. Another possibility is that long-lasting electrical status epilepticus during sleep led to her autistic behavior and language arrest. Still another possibility is that a disinhibited mammalian target of rapamycin (mTOR) pathway was at the root of all of her neuropsychiatric symptoms. PMID:24968009

  20. Refractory Wear Mechanisms in the Nonferrous Metal Industry: Testing and Modeling Results

    NASA Astrophysics Data System (ADS)

    Gregurek, D.; Ressler, A.; Reiter, V.; Franzkowiak, A.; Spanring, A.; Prietl, T.

    2013-11-01

    Nonferrous pyrometallurgical processes today operate at a high intensity requiring the best standards for the furnace refractory systems. From one plant to another, there is a range of process conditions such as temperature, slag chemistry, and feed types, and each of these parameters can influence refractory life. It is generally understood that process changes at plants can impact refractory life. The ability to test and understand refractory responses to a wide range of furnace operating conditions is therefore important. The RHI Technology Centre in Leoben, Austria is well equipped with laboratory and pilot plant facilities to evaluate refractory suitability over the range of conditions encountered in modern nonferrous pyrometallurgical systems. This article describes refractory testing at the RHI Technology Centre of the impact of two metallurgical slags on a number of different RHI test bricks. The slags were a fayalite slag and a calcium ferrite slag supplied by two smelter plants. High-temperature corrosion tests were carried out in a 250-mm-diameter induction furnace and a 165-mm-diameter short rotary kiln; each unit was lined with a number of refractory bricks and tested against attack by the particular slag. After testing, the refractory bricks were subjected to several laboratory tests to determine the extent of corrosion. Optimal refractory choices for the customers' plants were developed based on the test results.

  1. Anti wetting additives for aluminosilicate refractories in molten aluminum contact applications

    NASA Astrophysics Data System (ADS)

    Shukla, Devdutt Pramod

    Aluminosilicate based refractories are widely used in furnace installations for melting aluminum because they are inexpensive, readily available and generally exhibit the properties desired from a refractory material. However, they face severe corrosion and degradation issues due to the extremely reducing nature of molten aluminum alloys. Isothermal static cup testing is widely used as a tool to evaluate the performance of refractories against penetration by molten aluminum alloys. Various testing methods were reviewed and an upgraded static cup test was recommended. Commercially available aluminosilicate refractories were tested using this method and their results were studied in order to understand the corrosion process. Barium sulfate, which is widely used as an anti-wetting additive to improve refractory performance by limiting physical contact between molten metal and the refractory, has proved ineffective at temperatures above 1000°C. A literature review suggested that barium sulfate formed barium celsian at high temperatures and that the celsian was responsible for the non-wetting effect. Wetting angle measurements of molten AL 5083 on synthetic celsian discs revealed that barium celsian and strontium celsian were both not wetted by molten aluminum. Static cup tests were performed on aluminosilicate refractories containing barium carbonate and strontium carbonate. These additives led to the in-situ formation of celsian phases within the refractory matrix that led to improved corrosion resistance at 1300°C. Phase analysis revealed that celsian formation suppressed the formation of mullite within refractories, thereby reducing penetration.

  2. Precursors to potential severe core damage accidents: 1994, a status report. Volume 21: Main report and appendices A--H

    SciTech Connect

    Belles, R.J.; Cletcher, J.W.; Copinger, D.A.; Vanden Heuvel, L.N.; Dolan, B.W.; Minarick, J.W. |

    1995-12-01

    Nine operational events that affected eleven commercial light-water reactors (LWRs) during 1994 and that are considered to be precursors to potential severe core damage are described. All these events had conditional probabilities of subsequent severe core damage greater than or equal to 1.0 {times} 10{sup {minus}6}. These events were identified by computer-screening the 1994 licensee event reports from commercial LWRs to identify those that could be potential precursors. Candidate precursors were then selected and evaluated in a process similar to that used in previous assessments. Selected events underwent engineering evaluation that identified, analyzed, and documented the precursors. Other events designated by the Nuclear Regulatory Commission (NRC) also underwent a similar evaluation. Finally, documented precursors were submitted for review by licensees and NRC headquarters and regional offices to ensure that the plant design and its response to the precursor were correctly characterized. This study is a continuation of earlier work, which evaluated 1969--1981 and 1984--1993 events. The report discusses the general rationale for this study, the selection and documentation of events as precursors, and the estimation of conditional probabilities of subsequent severe core damage for events. This document is bound in two volumes: Vol. 21 contains the main report and Appendices A--H; Vol. 22 contains Appendix 1.

  3. Treatment-refractory Tourette Syndrome.

    PubMed

    Kious, Brent M; Jimenez-Shahed, Joohi; Shprecher, David R

    2016-10-01

    Tourette Syndrome (TS) is a complex neurodevelopmental condition marked by tics and frequently associated with psychiatric comorbidities. While most cases are mild and improve with age, some are treatment-refractory. Here, we review strategies for the management of this population. We begin by examining the diagnosis of TS and routine management strategies. We then consider emerging treatments for refractory cases, including deep brain stimulation (DBS), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and novel pharmacological approaches such as new vesicular monoamine transporter type 2 inhibitors, cannabinoids, and anti-glutamatergic drugs. PMID:26875502

  4. Incidence of Severe Malaria Syndromes and Status of Immune Responses among Khat Chewer Malaria Patients in Ethiopia

    PubMed Central

    Ketema, Tsige

    2015-01-01

    Although more emphasis has been given to the genetic and environmental factors that determine host vulnerability to malaria, other factors that might have a crucial role in burdening the disease have not been evaluated yet. Therefore, this study was designed to assess the effect of khat chewing on the incidence of severe malaria syndromes and immune responses during malaria infection in an area where the two problems co-exist. Clinical, physical, demographic, hematological, biochemical and immunological data were collected from Plasmodium falciparum mono-infected malaria patients (age ≥ 10 years) seeking medication in Halaba Kulito and Jimma Health Centers. In addition, incidences of severe malaria symptoms were assessed. The data were analyzed using SPSS (version 20) software. Prevalence of current khat chewer malaria patients was 57.38% (95%CI =53-61.56%). Malaria symptoms such as hyperpyrexia, prostration and hyperparasitemia were significantly lower (P<0.05) among khat chewer malaria patients. However, relative risk to jaundice and renal failure were significantly higher (P<0.05) in khat chewers than in non-khat chewer malaria patients. Longer duration of khat use was positively associated with incidence of anemia. IgM and IgG antibody titers were significantly higher (P<0.05) among khat chewer malaria patients than among malaria positive non-chewers. Although levels of IgG subclasses in malaria patients did not show significant differences (P>0.05), IgG3 antibody was significantly higher (P<0.001) among khat chewer malaria patients. Moreover, IgM, IgG, IgG1and IgG3 antibodies had significant negative association (P<0.001) with parasite burden and clinical manifestations of severe malaria symptoms, but not with severe anemia and hypoglycemia. Additionally, a significant increment (P<0.05) in CD4+ T-lymphocyte population was observed among khat users. Khat might be an important risk factor for incidence of some severe malaria complications. Nevertheless, it

  5. Incidence of Severe Malaria Syndromes and Status of Immune Responses among Khat Chewer Malaria Patients in Ethiopia.

    PubMed

    Ketema, Tsige; Bacha, Ketema; Alemayehu, Esayas; Ambelu, Argaw

    2015-01-01

    Although more emphasis has been given to the genetic and environmental factors that determine host vulnerability to malaria, other factors that might have a crucial role in burdening the disease have not been evaluated yet. Therefore, this study was designed to assess the effect of khat chewing on the incidence of severe malaria syndromes and immune responses during malaria infection in an area where the two problems co-exist. Clinical, physical, demographic, hematological, biochemical and immunological data were collected from Plasmodium falciparum mono-infected malaria patients (age ≥ 10 years) seeking medication in Halaba Kulito and Jimma Health Centers. In addition, incidences of severe malaria symptoms were assessed. The data were analyzed using SPSS (version 20) software. Prevalence of current khat chewer malaria patients was 57.38% (95%CI =53-61.56%). Malaria symptoms such as hyperpyrexia, prostration and hyperparasitemia were significantly lower (P<0.05) among khat chewer malaria patients. However, relative risk to jaundice and renal failure were significantly higher (P<0.05) in khat chewers than in non-khat chewer malaria patients. Longer duration of khat use was positively associated with incidence of anemia. IgM and IgG antibody titers were significantly higher (P<0.05) among khat chewer malaria patients than among malaria positive non-chewers. Although levels of IgG subclasses in malaria patients did not show significant differences (P>0.05), IgG3 antibody was significantly higher (P<0.001) among khat chewer malaria patients. Moreover, IgM, IgG, IgG1and IgG3 antibodies had significant negative association (P<0.001) with parasite burden and clinical manifestations of severe malaria symptoms, but not with severe anemia and hypoglycemia. Additionally, a significant increment (P<0.05) in CD4+ T-lymphocyte population was observed among khat users. Khat might be an important risk factor for incidence of some severe malaria complications. Nevertheless, it

  6. Factors Associated with the Disposition of Severely Injured Patients Presenting to Non-Trauma Center Emergency Departments: Disparities by Insurance Status

    PubMed Central

    Delgado, M. Kit; Yokell, Michael A.; Staudenmayer, Kristan L.; Spain, David A.; Hernandez-Boussard, Tina; Wang, N. Ewen

    2014-01-01

    Importance Trauma is the leading cause of potential years of life lost before age 65 in the U.S. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially presenting to non-trauma centers. Objective Determine patient and hospital level factors associated with the decision to admit rather than transfer severely injured patients who present to non-trauma center emergency departments (EDs). We hypothesized that insured patients would be more likely to be admitted than transferred compared to patients without insurance. Design, Setting, and Participants Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (injury severity score [ISS] > 15) seen at non-trauma centers in patients aged 18–64. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs. transfer by insurance status while adjusting for age, sex, injury severity, injury mechanism, weekend admission, month, urban-rural status and median income of home zip code, ED volume and teaching status, and U.S. region Main Outcome Measures Inpatient admission vs. transfer to another acute care facility. Results There were 4,513 observations from 636 non-trauma centers for analysis, representing a nationally weighted population of 19,312 non-trauma center ED encounters for major trauma in 2009. In 2009 54.5% were admitted at the non-trauma center. Compared to the uninsured, the adjusted absolute risk of admission vs. transfer was 14.2% higher (95% CI: 9.2, 19.4) for patients with Medicaid and 11.1 % higher (95% CI: 6.9, 15.4) for patients with private insurance. Other factors associated with admission vs. transfer included severe abdominal injuries (risk difference 15.8%,95% CI: 9.3, 22.3) urban teaching hospital vs. non-teaching hospital ((26.2%,15.2, 37.2), and ED volume (3.4% higher

  7. Two cases of refractory Wegener's granulomatosis successfully treated with rituximab.

    PubMed

    Tamura, Naoto; Matsudaira, Ran; Hirashima, Mika; Ikeda, Makoto; Tajima, Michiko; Nawata, Masuyuki; Morimoto, Shinji; Kaneda, Kazuhiko; Kobayashi, Shigeto; Hashimoto, Hiroshi; Takasaki, Yoshinari

    2007-01-01

    Conventional therapy for Wegener's granulomatosis, steroid and cyclophosphamide, fails to control disease activity in some refractory patients and has treatment-related toxicity. B cell depletion therapy using rituximab, a chimeric anti-CD20 monoclonal antibody, has been shown to be effective for certain autoimmune diseases including antineutrophil cytoplasmic antibody (ANCA) -associated systemic vasculitis. We report two refractory cases of Wegener's granulomatosis: one with bronchial and pulmonary involvement and retroorbital granuloma, the other with retroorbital granuloma and hypertrophic pachymeningitis causing severe headache. Rituximab was effective in both cases, with diminished granuloma and reduced ANCA titers, allowing steroids to be tapered. No adverse effects were detected. PMID:17409608

  8. Commercial off-the-Shelf (COTS) Refractory Material Evaluation

    NASA Technical Reports Server (NTRS)

    Calle, Luz Marina; Kolody, Mark R.; Curran, Jerome P.; Back, Teddy; Hintze, Paul E.; Parlier, Christopher R.; Sampson, Jeffrey W.; Perusich, Stephen; Bucherl, Cori

    2009-01-01

    Fondu Fyre (FF) is currently the only refractory material qualified for use in the flame trench at KSC's Shuttle Launch Pads 39A and 39B. However, the material is not used as it was qualified and has undergone increasingly frequent and severe degradation due to the launch blasts. This degradation is costly as well as dangerous for launch infrastructure, crew and vehicle. FF is applied at the pad via the gunnite process, where wetted refractory material is sprayed onto a steel grid mounted on a support structure. The water content in this process can be manually adjusted by operators, causing distinct visual and physical discrepancies among repair areas. Since the application process is unlikely to change for new refractory materials, it is important to understand the effects of water content on commercial off-the-shelf (COTS) refractory materials. The purpose of this study was to evaluate the performance of the FF with respect to various water contents as well as heat treatments, to simulate aging and exposure to the blast. Initial results indicated that different water contents and heat treatments result in distinct differences in crushing strength, apparent porosity and bulk density. However, water content became an insignificant factor in both crush strength and porosity when FF was cured to at least 1500 deg. Additionally, inspection of the material's surface microstructure by scanning electron microscopy indicated distinguishable characteristics for different heat treatment levels. Results from this study will help guide future studies on the development and identification of new refractory materials.

  9. Engineering Antimicrobials that are Refractory to Resistance Development.

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Multi-drug resistant pathogens are a serious problem in modern health care and there is a need for novel antimicrobials that are refractory to resistance development. Several US government agencies (FDA, CDC and NIH) recommend avoiding the use of broad range antimicrobials, a practice that is known...

  10. IMPROVED FURNACE EFFICIENCY THROUGH THE USE OF REFRACTORY MATERIALS

    SciTech Connect

    Hemrick, James Gordon; Rodrigues-Schroer, Angela; Colavito,; Smith, Jeffrey D

    2011-01-01

    This paper describes efforts performed at Oak Ridge National Laboratory (ORNL), in collaboration with industrial refractory manufacturers, refractory users, and academic institutions, to improve energy efficiency of U.S. industry through increased furnace efficiency brought about by the employment of novel refractory systems and techniques. Work in furnace applications related to aluminum, gasification, and lime are discussed. The energy savings strategies discussed are achieved through reduction of chemical reactions, elimination of mechanical degradation caused by the service environment, reduction of temperature limitations of materials, and elimination of costly installation and repair needs. Key results of several case studies resulting from a US Department of Energy (DOE) funded research program are discussed with emphasis on applicability of these results to high temperature furnace applications.

  11. Compressive Creep Performance and High Temperature Dimensional Stability of Conventional Silica Refractories

    SciTech Connect

    Karakus, M.; Kirkland, T.P.; Liu, K.C.; Moore, R.E.; Pint, B.A.; Wereszczak, A.A.

    1999-03-01

    Furnace designers and refractory engineers recognize that optimized furnace superstructure design and refractory selection are needed as glass production furnaces are continually striving toward greater output and efficiencies. Harsher operating conditions test refractories to the limit, while changing production technology (such as the conversion to oxy-fuel from traditional air-fuel firing) can alter the way the materials perform. Refractories for both oxy- and air-fuel fired furnace superstructures are subjected to high temperatures during service that may cause them to excessively creep or subside if the refractory material is not creep resistant, or if it is subjected to high stress, or both. Furnace designers can ensure that superstructure structural integrity is maintained if the creep behavior of the refractory material is well understood and well represented by appropriate engineering creep models. Several issues limit the abilities of furnace designers to (1) choose the optimum refractory for their applications, (2) optimize the engineering design, or (3) predict the service mechanical integrity of their furnace superstructures. Published engineering creep data are essentially non-existent for almost all commercially available refractories used for glass furnace superstructures. The limited data that do exist are supplied by the various refractory suppliers. Unfortunately, these suppliers generally have different ways of conducting their mechanical testing and they also interpret and report their data differently; this makes it hard for furnace designers to draw fair comparisons between competing grades of candidate refractories. Furthermore, the refractory supplier's data are often not available in a form that can be readily used for furnace design and for the prediction and design of long-term structural integrity of furnace superstructures. With the aim of providing such comparable data, the US DOE's Office of Industrial Technology and its Advanced

  12. Gambling behaviors and attitudes in adolescent high-school students: Relationships with problem-gambling severity and smoking status

    PubMed Central

    Weinberger, Andrea H.; Franco, Christine A.; Hoff, Rani A.; Pilver, Corey E.; Steinberg, Marvin A.; Rugle, Loreen; Wampler, Jeremy; Cavallo, Dana A.; Krishnan-Sarin, Suchitra; Potenza, Marc N.

    2015-01-01

    Background and Aims Smoking is associated with more severe/extensive gambling in adults. The purpose of this study was to examine relationships between smoking and gambling in adolescents. Methods Analyses utilized survey data from 1,591 Connecticut high-school students. Adolescents were classified by gambling (Low-Risk Gambling [LRG], At Risk/Problem Gambling [ARPG]) and smoking (current smoker, non-smoker). The main effects of smoking and the smoking-by-gambling interactions were examined for gambling behaviors (e.g., type, location), and gambling attitudes. Data were analyzed using chi-square and logistic regression; the latter controlled for gender, race/ethnicity, grade, and family structure. Results For APRG adolescents, smoking was associated with greater online, school, and casino gambling; gambling due to anxiety and pressure; greater time spent gambling; early gambling onset; perceived parental approval of gambling; and decreased importance of measures to prevent teen gambling. For LRG adolescents, smoking was associated with non-strategic gambling (e.g., lottery gambling); school gambling; gambling in response to anxiety; gambling for financial reasons; greater time spent gambling; and decreased importance of measures to prevent teen gambling. Stronger relationships were found between smoking and casino gambling, gambling due to pressure, earlier onset of gambling, and parental perceptions of gambling for ARPG versus LRG adolescents. Discussion Smoking is associated with more extensive gambling for both low- and high-risk adolescent gamblers. Conclusion Smoking may be a marker of more severe gambling behaviors in adolescents and important to consider in gambling prevention and intervention efforts with youth. PMID:25959617

  13. Severe Acute Malnutrition in Childhood: Hormonal and Metabolic Status at Presentation, Response to Treatment, and Predictors of Mortality

    PubMed Central

    Bartz, Sarah; Mody, Aaloke; Hornik, Christoph; Bain, James; Muehlbauer, Michael; Kiyimba, Tonny; Kiboneka, Elizabeth; Stevens, Robert; Bartlett, John; St Peter, John V.; Newgard, Christopher B.

    2014-01-01

    Objective: Malnutrition is a major cause of childhood morbidity and mortality. To identify and target those at highest risk, there is a critical need to characterize biomarkers that predict complications prior to and during treatment. Methods: We used targeted and nontargeted metabolomic analysis to characterize changes in a broad array of hormones, cytokines, growth factors, and metabolites during treatment of severe childhood malnutrition. Children aged 6 months to 5 years were studied at presentation to Mulago Hospital and during inpatient therapy with milk-based formulas and outpatient supplementation with ready-to-use food. We assessed the relationship between baseline hormone and metabolite levels and subsequent mortality. Results: Seventy-seven patients were enrolled in the study; a subset was followed up from inpatient treatment to the outpatient clinic. Inpatient and outpatient therapies increased weight/height z scores and induced striking changes in the levels of fatty acids, amino acids, acylcarnitines, inflammatory cytokines, and various hormones including leptin, insulin, GH, ghrelin, cortisol, IGF-I, glucagon-like peptide-1, and peptide YY. A total of 12.2% of the patients died during hospitalization; the major biochemical factor predicting mortality was a low level of leptin (P = .0002), a marker of adipose tissue reserve and a critical modulator of immune function. Conclusions: We have used metabolomic analysis to provide a comprehensive hormonal and metabolic profile of severely malnourished children at presentation and during nutritional rehabilitation. Our findings suggest that fatty acid metabolism plays a central role in the adaptation to acute malnutrition and that low levels of the adipose tissue hormone leptin associate with, and may predict, mortality prior to and during treatment. PMID:24606092

  14. Continuous Production Of Refractory Microballoons

    NASA Technical Reports Server (NTRS)

    Schilling, Christopher H.; Lee, Mark C.; Wang, Taylor G.

    1988-01-01

    Continuous process has economic and quality advantages over batch processes. Expected to produce high-quality microballoons at relatively low cost. Continuous hollow-jet process produces microballoons of refractory metal. Microballoon products made by continuous process includes inertial-confinement fusion targets, thermal insulators, lightweight composites, impact absorbers, and containers for hazardous materials.

  15. Refractory lining for electrochemical cell

    DOEpatents

    Blander, Milton; Cook, Glenn M.

    1987-01-01

    Apparatus for processing a metallic fluid containing iron oxide, container for a molten metal including an electrically conductive refractory disposed for contact with the molten metal which contains iron oxide, an electrolyte in the form of a basic slag on top of the molten metal, an electrode in the container in contcat with the slag electrically separated from the refractory, and means for establishing a voltage across the refractory and the electrode to reduce iron oxide to iron at the surface of the refractory in contact with the iron oxide containing fluid. A process is disclosed for refining an iron product containing not more than about 10% by weight oxygen and not more than about 10% by weight sulfur, comprising providing an electrolyte of a slag containing one or more of calcium oxide, magnesium oxide, silica or alumina, providing a cathode of the iron product in contact with the electrolyte, providing an anode in contact with the electrolyte electrically separated from the cathode, and operating an electrochemical cell formed by the anode, the cathode and the electrolyte to separate oxygen or sulfur present in the iron product therefrom.

  16. Precursors to potential severe core damage accidents, 1986: A status report: Main report and Appendixes A,B, and C

    SciTech Connect

    Minarick, J W; Harris, J D; Austin, P N; Cletcher, J W; Hagen, E W

    1988-05-01

    The Accident Sequence Precursor Program reviews licensee event reports of operational events that have occurred at LWRs to identify and categorize precursors to potential severe core-damage accidents. Accident sequences considered in the study are those associated with inadequate core cooling. Accident sequence precursors are events that are important elements in such sequences. Such precursors could be infrequent initiating events or equipment failures that, when coupled with one or more postulated events, could result in a plant condition with inadequate core cooling. Originally proposed in the Risk Assessment Review Group Report (Lewis Committee report) in 1978, the study - subsequently named the Accident Sequence Precursor Program - was initiated at the Nuclear Operations Analysis Center in 1979. Earlier reports by the program involved assessment of events that occurred in 1969-1981 and 1984-1985. The present report involves the assessment of events that occurred during 1986. A nuclear plant has safety systems for mitigating the consequences of accidents or off-normal initiating events that may occur during the course of plant operation. These systems are built to high-quality standards and are redundant; nonetheless, they have a nonzero probability of failing or being in a failed state when required to operate. This report uses LERs and other plant data, estimated system unavailabilities, the expected average frequency of initiating events (LOFWs, LOOPs, LOCAs), and event details to evaluate the potential impact of the following two situations.

  17. New developments in gasifier refractories

    SciTech Connect

    Dogan, Cynthia P.; Kwong, Kyei-Sing; Bennet, James P.; Chinn, Richard E.; Dahlin, Cheryl L.

    2002-01-01

    For Integrated Gasification Combined Cycle (IGCC) systems, operational reliability depends in part upon the ability of the materials of construction to tolerate harsh, high-temperature environments for extended periods of time. The harshest conditions within an IGCC system occur inside the gasifier itself, where for slagging systems the environment includes elevated temperature and pressure, as well as the presence of corrosive slags and gases. Attempts to enhance gasifier performance by operating at higher temperatures, with higher throughputs, and/or with variable feedstocks, put additional stress on the materials exposed to the operating environment, often resulting in a corresponding decrease in their useful service life. Current generation refractory materials commonly used at the hot face of commercial slagging systems will typically last from four to 18 months, depending on the operating conditions of the specific gasifier. However, as gasification technology matures, the need for new and improved materials will increase as the time between required maintenance shutdowns, and hence the economics and reliability of operation, are defined more and more by the service life of the materials from which the system is built. To address this need for materials development, the U.S. Department of Energy's Office of Fossil Energy and the Albany Research Center are exploring ways to extend the service life of the refractory liner that contains the gasification reaction in slagging gasifiers. In this paper, we examine how refractory materials fail in the gasifier environment, and introduce a new refractory designed specifically to resist such failures. Based on laboratory exposure tests, this new refractory is predicted to significantly enhance gasifier reliability and availability through increased service life.

  18. Bulk Vitrification Castable Refractory Block Protection Study

    SciTech Connect

    Hrma, Pavel R.; Bagaasen, Larry M.; Beck, Andrew E.; Brouns, Thomas M.; Caldwell, Dustin D.; Elliott, Michael L.; Matyas, Josef; Minister, Kevin BC; Schweiger, Michael J.; Strachan, Denis M.; Tinsley, Bronnie P.; Hollenberg, Glenn W.

    2005-05-01

    penetration of molten salt. Out of several refractory tile candidates, only greystone and fused-cast alumina-zirconia-silica (AZS) refractory remained intact and well bonded to the CRB after firing to 1000 C. The deformation of the refractory-tile composite was avoided by prefiring the greystone tile to 800 C. Condensed vapors did not penetrate the tiles, but Re salts condensed on their surface. Refractory corrosion tests indicated that a 0.25-inch-thick greystone tile would not corrode during a BV melt. Tiles can reduce both vapor penetration and molten salt penetration, but vapor deposition above the melt line will occur even on tiles. The Tc/Re transport scenario was outlined as follows. At temperatures below 700 C, molten ionic salt (MIS) that includes all the Tc/Re penetrates, by capillarity, from the feed into the CRB open porosity. At approximately 750 C, the MIS decomposes through the loss of NOx, leaving mainly sulfate and chloride salts. The Na2O formed in the decomposition of the nitrates reacts with insoluble grains in the feed and with the aluminosilicates in the CRB to form more viscous liquids that reduce further liquid penetration into the CRB. At 800 to 1000 C, a continuous glass phase traps the remains of the MIS in the form of inclusions in the bulk glass melt. At 1000 to 1200 C, the salt inclusions in the glass slowly dissolve but also rise to the surface. The Tc/Re salts also evaporate from the free surface of the glass melt that is rapidly renewed by convective currents. The vapors condense on cooler surfaces in the upper portion of the CRB, the box lid, and the off-gas system.

  19. Destruction of Refractory Carbon in Protoplanetary Disks

    NASA Astrophysics Data System (ADS)

    Anderson, Dana; Bergin, Edwin A.; Blake, Geoffrey A.; Ciesla, Fred; Visser, Ruud; Lee, Jeong-Eun

    2016-01-01

    Rocky bodies in the inner solar system contain significantly less carbon than the dust of interstellar origin that seeded their formation. Even primitive meteorites exhibit carbon deficiencies, suggesting at least one process active prior to the formation of planetesimals. Selective erosion of carbonaceous materials by free oxygen atoms present in the photoactive surface layers of the protoplanetary disk provides one such mechanism for destroying refractory carbon while leaving silicate materials intact. We model this process with a large chemical network in a disk surrounding a T-Tauri star. We find that given sufficient turbulence to loft small grains into the oxidative surface regions of the disk, carbon grains are rapidly converted into CO. These oxidative regions can deplete carbon present in polycyclic aromatic hydrocarbons and small grains (˜0.02-20 μm) by at least two orders of magnitude, enough to explain the deficiencies in meteorites compared to interstellar dust, and extend out to ˜15-20 AU from the central star at the disk surface in our static model. When turbulence is considered, the effects may reach the midplane causing depletion out to ˜1 AU. However, the amount of the total carbon reservoir at these radii that is affected by this mechanism depends on several unconstrained parameters concerning the nature of the disk and refractory carbon sources.

  20. Dynamic Abnormal Grain Growth in Refractory Metals

    NASA Astrophysics Data System (ADS)

    Noell, Philip J.; Taleff, Eric M.

    2015-11-01

    High-temperature plastic deformation of the body-centered cubic (BCC) refractory metals Mo and Ta can initiate and propagate abnormal grains at significantly lower temperatures and faster rates than is possible by static annealing alone. This discovery reveals a new and potentially important aspect of abnormal grain growth (AGG) phenomena. The process of AGG during plastic deformation at elevated temperatures, termed dynamic abnormal grain growth (DAGG), was observed at homologous temperatures between 0.52 and 0.72 in both Mo and Ta sheet materials; these temperatures are much lower than those for previous observations of AGG in these materials during static annealing. DAGG was used to repeatedly grow single crystals several centimeters in length. Investigations to date have produced a basic understanding of the conditions that lead to DAGG and how DAGG is affected by microstructure in BCC refractory metals. The current state of understanding for DAGG is reviewed in this paper. Attention is given to the roles of temperature, plastic strain, boundary mobility and preexisting microstructure. DAGG is considered for its potential useful applications in solid-state crystal growth and its possibly detrimental role in creating undesired abnormal grains during thermomechanical processing.

  1. Relapsing and refractory ulcerative colitis in children.

    PubMed

    Turner, Dan

    2014-01-01

    Approximately half of the children with ulcerative colitis (UC) have refractory, relapsing or steroid-dependent disease. UC in children is more extensive than in adults, presents more often with severe attacks and carries a more aggressive disease course. Therefore, although a step-up approach is usually recommended in UC, aggressive therapy will often be indicated in children since steroid dependency should never be tolerated. It is vital to ensure that in every resistant case, the symptoms are truly related to the inflammatory disease activity and not to other conditions such as poor adherence to treatment, infections, adverse reactions to drugs, irritable bowel syndrome, lactose intolerance, celiac disease and bacterial overgrowth. The clinician should be ready to escalate therapy in a timely manner but only after ensuring optimization of current treatments. Optimization may include, among others, appropriate dosage, utilization of assays that determine thiopurine, calcineurin inhibitors and anti-tumor necrosis factor levels, introduction of combination therapy when indicated (enemas and immunomodulators) and a long enough time for treatment to become effective. Colectomy is always a valid option and should be discussed before major treatment escalations. Experimental therapies can be considered when all else fails and the family prefers to avoid colectomy. The management of refractory and relapsing disease is particularly challenging in children, and this review summarizes the available evidence to guide treatment decisions in this setup. PMID:24969290

  2. Refractory Materials for Flame Deflector Protection

    NASA Technical Reports Server (NTRS)

    Calle, Luz M.; Hintze, Paul E.; Parlier, Christopher R.; Sampson, Jeffrey W.; Curran, Jerome P.; Kolody, Mark R.; Peruisich, Stephen A.

    2010-01-01

    Fondu Fyre (FF) is currently the only refractory material qualified for use in the flame trench at KSC's Shuttle Launch Pads 39A and 3913. However, the material is not used as it was qualified and has undergone increasingly frequent and severe degradation due to the launch blasts. This degradation is costly as well as dangerous for launch infrastructure, crew and vehicle. The launch environment at KSC is unique. The refractory material is subject to the normal seacoast environment, is completely saturated with water before launch, and is subjected to vibrations and aggressive heat/blast conditions during launch. This report presents results comparing two alternate materials, Ultra-Tek FS gun mix and Kruzite GR Plus, with Fondu Fyre. The materials were subjected to bulk density, porosity, compression strength, modulus of rupture and thermal shock tests. In addition, test specimens were exposed to conditions meant to simulate the launch environment at KSC to help better understand how the materials will perform once installed.

  3. In Situ Analysis of Refractory Metal Nugget Crystallography Providing Clues to Early Solar System Events

    NASA Astrophysics Data System (ADS)

    Daly, L.; Bland, P. A.; Forman, L. V.; Trimby, P. W.; Moody, S.; Yang, L.; Liu, H. W.; Ringer, S. P.; Saunders, M.

    2015-07-01

    In situ analysis of refractory metal nuggets has revealed several textural features that have not previously been reported, such as twinning and crystallographic relationships with associated minerals; as well as the discovery of a new mineral phase.

  4. Failure Mechanisms in High Chrome Oxide Gasifier Refractories

    NASA Astrophysics Data System (ADS)

    Bennett, James P.; Kwong, Kyei-Sing

    2011-04-01

    Gasification is a high-temperature, high-pressure chemical process used to convert a carbon feedstock into CO and H2 (syngas) for use in power generation and the production of chemicals. It is also a leading candidate as a source of hydrogen in a hydrogen economy and is one of several technologies expected to see increased use in advanced fossil fuel power systems in the future. Gasification is being evaluated because of its high efficiency, its ability to capture CO2 for sequestration or reuse in other applications, and its potential for carbon feedstock fuel flexibility. At the heart of the gasification process is a gasifier, a high pressure chemical reaction vessel used to contain the interactions between carbon and water in a shortage of oxygen, producing syngas. The gasifier is lined with high chrome oxide materials to protect the containment vessel. Gasifiers are complex systems, and failure of the refractories used to line them was identified by industry as a limitation to their reliability and availability and to their increased use. NETL researchers have examined spent high-Cr2O3 (over 90 pct Cr2O3) refractories from numerous gasifiers to determine in-service failure mechanisms. This analysis revealed that premature failure of the high chrome oxide refractories was related to ash in the carbon feedstock, which liquefies during gasification and interacts with the refractories, leading to wear by chemical dissolution or spalling (structural and chemical). A discussion of this postmortem wear of spent refractory materials and of thermodynamic modeling used to explain microstructural changes leading to wear are explained in this article. This information will serve the basis to develop improved performance refractory materials.

  5. Evaluating the Relationship between Slabbing of Cr2O3/MgO Refractories Used in Steelmaking and Spalling of High Chrome Oxide Refractories Used in Gasification

    SciTech Connect

    Bennett, J.P.; Thomas, H.; Kwong, K.-S.

    2006-10-01

    Because of its excellent corrosion resistance and high temperature properties, chrome oxide refractories have been used in a number of severe service environments, including steelmaking and gasification. Refractory failure of Cr2O3/MgO or MgO/Cr2O3 refractories in steelmaking can involve a phenomena called slabbing, peeling, or chemical spalling. A similar failure mechanism exists in the high chrome oxide materials used in gasification. Gasifiers contain the reaction between a carbon feedstock, water, and oxygen under reducing conditions; producing H2 and CO used in chemicals or as fuel for power plants. A slagging gasifier typically operates between 1250- 1575°C, and with pressures between 300-1000 psi. Gasification refractory failure is by chemical dissolution and/or by spalling. Spalling is caused by slag penetration of the porous refractory surface and by expansion differences between the penetrated/non-penetrated areas, and is exacerbated by thermal cycling. Similarities between slabbing of steelmaking refractories and spalling of gasification refractories will be discussed.

  6. Refractory neural nets and vision

    NASA Astrophysics Data System (ADS)

    Fall, Thomas C.

    2014-02-01

    Biological understandings have served as the basis for new computational approaches. A prime example is artificial neural nets which are based on the biological understanding of the trainability of neural synapses. In this paper, we will investigate features of the biological vision system to see if they can also be exploited. These features are 1) the neuron's refractory period - the period of time after the neuron fires before it can fire again and 2) the ocular microtremor which moves the retinal neural array relative to the image. The short term memory due to the refractory period allows the before and after movement views to be compared. This paper will discuss the investigation of the implications of these two features.

  7. REFRACTORY DIE FOR EXTRUDING URANIUM

    DOEpatents

    Creutz, E.C.

    1959-08-11

    A die is presented for the extrusion of metals, said die being formed of a refractory complex oxide having the composition M/sub n/O/sub m/R/sub x/O/sub y/ where M is magnesium, zinc, manganese, or iron, R is aluminum, chromic chromium, ferric iron, or manganic manganese, and m, n, x, and y are whole numbers. Specific examples are spinel, magnesium aluminate, magnetite, magnesioferrite, chromite, and franklinite.

  8. Refractory materials from lunar resources

    NASA Technical Reports Server (NTRS)

    Fabes, B. D.; Poisl, W. H.

    1991-01-01

    Refractories - materials which are able to withstand extremely high temperatures - are sure to be an important part of any processing facility or human outpost which is built on Mars. Containers for processing lunar oxygen will need high temperature components. Fabrication of structural material from lunar resources need both containment vessels to hold high temperature melts and molds in which to form the final shapes. Certainly, it would be desirable to fabricate such vessels and molds on the Moon, rather than carrying them up from the Earth. At first glance, this might appear to be a trivial task, since the Moon's surface consists of a variety of refractory compositions. To turn the regolith into a useful fire brick or mold, however, will require water or other binders and additives which are likely to be in extremely short supply on the Moon. The steps needed to make fire bricks and molds for lunar-derived structural materials are examined, pointing out the critical steps and resources which will be needed. While these processes and applications may seem somewhat mundane, it is emphasized that it is precisely these rudimentary processes which must be mastered before discussing making aerobrakes, and other fancier refractories from lunar resources.

  9. Management of Status Epilepticus in Children

    PubMed Central

    Smith, Douglas M.; McGinnis, Emily L.; Walleigh, Diana J.; Abend, Nicholas S.

    2016-01-01

    Status epilepticus is a common pediatric neurological emergency. Management includes prompt administration of appropriately selected anti-seizure medications, identification and treatment of seizure precipitant(s), as well as identification and management of associated systemic complications. This review discusses the definitions, classification, epidemiology and management of status epilepticus and refractory status epilepticus in children. PMID:27089373

  10. Management of Status Epilepticus in Children.

    PubMed

    Smith, Douglas M; McGinnis, Emily L; Walleigh, Diana J; Abend, Nicholas S

    2016-01-01

    Status epilepticus is a common pediatric neurological emergency. Management includes prompt administration of appropriately selected anti-seizure medications, identification and treatment of seizure precipitant(s), as well as identification and management of associated systemic complications. This review discusses the definitions, classification, epidemiology and management of status epilepticus and refractory status epilepticus in children. PMID:27089373