Psychological Medicine

Medical Council of India's New competency-based curriculum for medical graduates: A critical appraisal KS Jacob Indian Journal of Psychological Medicine 2019 41(3):203-209

The P value and statistical significance: Misunderstandings, explanations, challenges, and alternatives Chittaranjan Andrade Indian Journal of Psychological Medicine 2019 41(3):210-215 The calculation of a P value in research and especially the use of a threshold to declare the statistical significance of the P value have both been challenged in recent years. There are at least two important reasons for this challenge: research data contain much more meaning than is summarized in a P value and its statistical significance, and these two concepts are frequently misunderstood and consequently inappropriately interpreted. This article considers why 5% may be set as a reasonable cut-off for statistical significance, explains the correct interpretation of P < 0.05 and other values of P, examines arguments for and against the concept of statistical significance, and suggests other and better ways for analyzing data and for presenting, interpreting, and discussing the results.

Depression in children and adolescents: A review of Indian studies Sandeep Grover, V Venkatesh Raju, Akhilesh Sharma, Ruchita Shah Indian Journal of Psychological Medicine 2019 41(3):216-227 Background: Depression is a common mental disorder seen across all age groups, including children and adolescents. Depression is often associated with significant disability in children and adolescents. Aim: This review aims to evaluate the Indian research on depression in children and adolescents. Results: Available data suggest that the point prevalence of depression/affective disorders ranges from 1.2% to 21% in the clinic-based studies; 3%–68% in school-based studies and 0.1%–6.94% in community studies. There has been only one incidence study from India which estimated the incidence to be 1.6%. With respect to the risk factors for depression, studies have reported various education-related difficulties, relationship issues with parents or at home, family-related issues, economic difficulties, and other factors. A limited number of studies have evaluated the symptom profile, and the commonly reported symptoms include depressed mood, diminished interest in play activities, concentration difficulties, behavior problems in the form of anger and aggression, pessimism, decreased appetite, decreased sleep, anhedonia, and somatic symptoms. None of the studies from India has evaluated the efficacy/effectiveness of various antidepressants in children and adolescents with depression. Conclusion: There is a wide variation in the point prevalence reported across different studies, which is mainly due to methodological differences across studies. Limited data are available with respect to symptom profile and factors associated with depression in children and adolescents.

Children of parents with mental illness: The need for family focussed interventions in India Divya Ballal, Janardhana Navaneetham, Prabha S Chandra Indian Journal of Psychological Medicine 2019 41(3):228-234 Family interventions have been an integral part of mental healthcare in India for several decades. This paper highlights the need for an emerging change in the nature of family interventions in India—from generic interventions for heterogeneous caregiver groups to interventions addressing particular needs based on family stages and structures. It makes a case for recognizing the experiences and needs of one such group, that is, families affected by parental mental illness with children in their care and summarizes the current status of research on this topic in the Indian and global context. It presents implications for future research in India and discusses preliminary ideas for professionals working in adult mental health settings to address the needs of children and families affected by parental mental illness.

Interventions for childhood anxiety disorders – What works best from a child's perspective: A qualitative study Preeti Kandasamy, Satish Chandra Girimaji, Shekhar P Seshadri, Shoba Srinath, John Vijay Sagar Kommu Indian Journal of Psychological Medicine 2019 41(3):235-239 Background: Anxiety spectrum disorders are the most prevalent psychopathology among children and adolescents. Qualitative research in childhood anxiety disorders can provide valuable insights regarding interventions. The objectives of this study were to examine the child's perspectives on the subjective experience of concerns, the impact of the symptoms on socioacademic functioning, and the process of recovery with interventions. Methods: Children and adolescents aged 6–16 years, presenting with any subtype of anxiety spectrum disorder as per International Classification of Diseases and Related Health problems, 10th Revision (ICD-10) Diagnostic Criteria for Research, were included. Convenience sampling was used, and 30 children fulfilling inclusion and exclusion criteria were selected. An interview guide with simple questions to facilitate response was used, at the baseline and 12th week of follow-up, to generate a written narrative account of the experience of concerns, the impact of symptoms, and the treatment process. Children received treatment as usual, which included a workbook-based cognitive behavioral intervention. Results: Content analysis was done using 30 baseline and 20 follow-up narratives. Clustering of themes were done. Themes related to the recovery process reflected perceived improvement in academic performance and competence, apart from the improvement in symptoms. There were more themes in favor of cognitive interventions. Conclusion: Children's narratives highlight the importance of cognitive interventions for anxiety disorders.

Emotional and behavioral problems among left-behind children in Indonesia Raisatul Umami, Sherly S Turnip Indian Journal of Psychological Medicine 2019 41(3):240-245 Background: The number of migrant workers in Indonesia has been increasing over the years. Most of the migrant workers are females with children, creating a huge number of left-behind children (LBC). The issue of LBC has become important to discuss because LBC tends to experience more emotional and behavioral problems than non-LBC. The aim of this study was to assess and compare emotional and behavioral problems between LBC and non-LBC in Indonesia. This paper analyzes data from a project by the Community Mental Health Research Group from the Faculty of Psychology, Universitas Indonesia, held in 2015 − 2016. Materials and Methods: Participants were 629 adolescents: 359 LBC and 270 non-LBC. The data were acquired in a cross-sectional study conducted in rural Indonesia. Data on emotional and behavioral problems were assessed with Strength and Difficulties Questionnaire, while data related to risk factor variables were collected using multidimensional scale of perceived social support, the 6-item De Jong Gierveld Loneliness Scale, and Inventory of Parent and Peer Attachment. The data were analyzed with descriptive statistics and multiple regression analysis. Results: The prevalence of emotional and behavioral problems in LBC was 28.4% compared to 21% among non-LBC. Peer attachment, communication, social support, and loneliness were identified as factors that impact the emotional and behavioral problems among LBC. Conclusions: LBC has more emotional and behavioral problems than non-LBC. Comprehensive understanding of various protective and risk factors is needed to provide impactful interventions for LBC.

Neuro-Cognition in adolescents with dissociative disorder: A study from a Tertiary Care Center of North India Ayushi Dixit, Shweta Singh, Sujita K Kar, Amit Arya, Vivek Agarwal Indian Journal of Psychological Medicine 2019 41(3):246-251 Background: Dissociative disorder is a common neurotic disorder. Patients with dissociative disorder experience significant psychological distress and have deficits in various domains of neurocognitive functions. Objective: To assess the neurocognitive functioning of adolescents diagnosed with dissociative disorder and compare it with that of healthy controls. Materials and Methods: This is a cross-sectional observational study conducted on adolescents diagnosed with dissociative disorder, attending child and adolescent specialty clinic of a tertiary care hospital of North India from October 2016 to February 2017. Healthy control subjects were also recruited for comparison on study variables. Malin's Intelligence Scale for Indian children and standardized neuropsychological tools were administered for the assessment of intellectual functioning and neurocognitive functioning. Results: A total of 50 participants with dissociative disorder and 50 healthy controls completed the study. Participants of both the groups had an average level of intellectual functioning. Participants with dissociative disorder showed poorer performance on tasks of attention and executive functions. After the Bonferroni correction, deficits were detected in the domains of coding (P = 0.0012), maze (P = 0.0001), and mathematics (P = 0.0016). Conclusions: Adolescents with dissociative disorder have impaired neurocognitive functions in comparison to healthy controls.

Factors associated with treatment adherence in children with attention deficit hyperactivity disorder Parvin Safavi, Mehrdad Saberzadeh, Afsaneh Malekpour Tehrani Indian Journal of Psychological Medicine 2019 41(3):252-257 Background: Attention deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder in children. The aim of this study was to investigate factors related to treatment adherence in children with ADHD. Methods: This cross-sectional study was done in 118 children (aged 6–12 years) with ADHD who have been on medications for at least 6 months. The patients were selected based on the convenience sampling method from those who were referred to child psychiatry clinic. Medication Adherence Report Scale, Belief about Medicines Questionnaire specific version, and Children Symptom Inventory-4 were completed by parents and teachers. Findings: Medication adherence had significant negative correlation with inattention scores on teacher-report forms (r = -0.27, P= 0.003) and poor economic status (P = 0.03). There was a positive correlation between medication adherence and history of psychopharmacological treatment in the family (P = 0.01), and father's education level (P = 0.001). Treatment adherence had no significant correlation with age, gender, comorbid disorders, mother's education, family history of ADHD, medication side effects, or parental concerns and beliefs about the necessity of drug use. Conclusion: The factors found to have a correlation with adherence should be taken in to account by clinicians so that adherence can be improved in their patients.

Cognitive schemas among mental health professionals and other health professionals Saloni Dang, Pragya Sharma, Lokesh Singh Shekhawat Indian Journal of Psychological Medicine 2019 41(3):258-265 Objective: Research has demonstrated that dysfunctional cognitive schemas among mental health professionals (MHPs) may influence the ability to process clients' information in an unbiased manner, may be a substantial source of error in psychotherapeutic ratings, hinder accurate reporting of clients' cognitive schemas, and have a detrimental effect on therapeutic alliance. The present study compared cognitive schemas among MHPs and other health professionals (OHPs). Materials and Method: A sample of 128 professionals (64 MHPs and 64 OHPs) was chosen using a purposive sampling technique. The study used a cross-sectional observational research design. The Young Schema Questionnaire Short Form 3rd version was administered on the consenting participants. Results: OHPs had higher maladaptive schemas on the domains of abandonment and defectiveness. Overall, males had more maladaptive schemas in the domains of abandonment, mistrust, entitlement/superiority, admiration/recognition seeking, and emotional inhibition. Among MHPs, a weak positive correlation of years of experience with vulnerability to harm or illness was seen. Among other health professionals, a significant but weak positive correlation of age with admiration/recognition seeking was seen. Conclusion: This study highlights the presence of maladaptive schemas in health professionals and the need for incorporation of training modules to address these.

Adaptation and validation of parental behavioral scale for children with autism spectrum disorders to Kannada Karukayil Sivadas Gayathri, Shivani Tiwari Indian Journal of Psychological Medicine 2019 41(3):266-270 Background: Assessment of parenting behaviors in parents of children with autism is crucial in the assessment and treatment processes. Efficient tools and instruments with known psychometric properties are needed to assess parenting behaviors in parents of children with autism. Given the lack of such tools in the Indian context, there is a need to develop and/or adapt tools/scale to assess the parenting behaviors in regional languages. Aim of the Study: To adapt, translate and validate the Parental behavioral scale for Autism spectrum disorder (PBS-A) to Kannada. Materials and Methods: The original version of PBS-A was given to three healthcare professionals to examine the sociocultural suitability of items. The linguistic adaptation was performed through a forward-backward translation scheme. It was then administered on 50 parents of children with autism. Further, the psychometric properties of PBS-A Kannada version were examined, viz. acceptability, test-retest reliability and internal consistency. Results: Kannada version of PBS-A showed an excellent test-retest reliability (ICC = 0.993) and an overall high level of internal consistency (α = 0.93). The acceptability was found to be good among the Speech-language pathologists (SLP) ratings (k = 0.485). Conclusions: Kannada version of PBS-A is a valid and reliable scale that can be useful for assessing the parenting behavior.

ALEXANDROS SFAKIANAKIS ANAPAFSEOS 5 AGIOS NIKOLAOS CRETE 72100 GREECE +306932607174 +302841026182

Hazardous Materials

Enhanced diuron remediation by microorganism-immobilized silkworm excrement composites and their impact on soil microbial communities Publication date: 15 August 2019 Source: Journal of Hazardous Materials, Volume 376 Author(s): Jie Liu, Menrang Yang, Yutai Wang, Liwen Qu, Guohua Zhong Abstract In response to the potential threats stemming from the constantly increasing consumption of herbicides, bioremediation offers a beneficial technology for reducing the widespread herbicide contamination. In order to facilitate the in-situ degradation of diuron, Arthrobacter globiformis D47 is captured onto a biocompatible carrier to assemble the microorganism-immobilized silkworm excrement (MSE) composites. By characterization, bacterial cells are intensively entrapped in/onto the carriers, showing high survival and stable catalytic degradation of target pollutants. Meanwhile, MES composites display excellent adaptiveness and feasibility under different conditions, and the average half-life of diuron is shortened to 7.69 d in sugarcane field where diuron is regularly sprayed for weed management. Importantly, we assess that the use of MSE may generally boost the overall xenobiotic-degrading ability, likely due to the slight alternation of the diversity and composition of soil microbial communities. Taking together, the presented MSE provides an attractive in situ approach for the efficient diuron removal as well as for the more feasible utilization of various pollutant-degrading microorganisms. Graphical abstract

Study on the effects of oxygen-containing functional groups on Hg0 adsorption in simulated flue gas by XAFS and XPS analysis Publication date: 15 August 2019 Source: Journal of Hazardous Materials, Volume 376 Author(s): Jinjing Luo, Qiang Niu, Mingchang Jin, Yinan Cao, Lurong Ye, Rupeng Du Abstract The effect of physicochemical properties of activated carbon on adsorption of elemental mercury (Hg0) was investigated on a series of modified activated carbons. Heat treatment and benzoic acid impregnation were conducted to vary the oxygen functional groups on carbon surface. Hg0 adsorption experiments were run in a fixed-bed reactor at 140 °C. Surface characteristics of carbon samples were studied by N2 adsorption, Boehm titration, X-ray photoelectron spectroscopy (XPS) and X-ray absorption fine structure (XAFS), respectively. The predominant mechanism of Hg0 removal was the formation of chemical bonds between Hg and various functional groups. Both XPS and XAFS analysis revealed that mercury bound on carbon surface was mainly in oxidation state. Under N2 atmosphere, the absorbed Hg was found as Hg2+, and coordinated to O atom. With the existence of HCl in simulated flue gas, Hg0 was bonded on Cl sites and HgCl2 was assumed to be the dominated form.

Carbon dots sensitized 2D-2D heterojunction of BiVO4/Bi3TaO7 for visible light photocatalytic removal towards the broad-spectrum antibiotics Publication date: 15 August 2019 Source: Journal of Hazardous Materials, Volume 376 Author(s): Shukun Le, Wenjing Li, Yuanjiang Wang, Xue Jiang, Xiaoxue Yang, Xiaojing Wang Abstract Focused on the removal of the complicated residual antibiotic in aqueous environment, in this work, a novel carbon dots (C-dots) sensitized 2D-2D heterojunction of BiVO4/Bi3TaO7 were assembled through a simple hydrothermal process. The characteristic by TEM, SEM, and XPS confirmed C-dots evenly anchored on the surface of BiVO4/Bi3TaO7 heterojunction. The as-prepared C-dots/BiVO4/Bi3TaO7 showed superior performance for the degradation of the various antibiotics under visible light illumination. When the concentration of C-dots in the composite is 3 wt.%, the photodegraded rates are obtained to be 91.7%, 89.3%, 87.1%, for tetracycline (TC), amoxicillin (AMX) and ciprofloxacin (CIP), respectively, without significant deactivation during consecutive ten recycle experiments. Furthermore, by assessing the antibiotics mixture solution of TC, AMX and CIP, it is proposed that the prepared samples are potentially effective for the wastewater effluents. A probable mechanism was reasonably proposed. The improved photocatalytic activities could be attributed to the unique construction of the C-dots mediated heterojunction, which could expedite electron migration, improve light harvesting capacity and enhance charge separation efficiency. The present investigation may provide a new perspective to design C-dots mediated heterojunction which could be a potential visible-light-driven photocatalysts for the better practical applications in remediation of broad-spectrum antibiotic residues. Graphical abstract

Removal and simultaneous reduction of Cr(VI) by organo-Fe(III) composites produced during coprecipitation and coagulation processes Publication date: 15 August 2019 Source: Journal of Hazardous Materials, Volume 376 Author(s): Kai-Yue Chen, Yu-Min Tzou, Ya-Ting Chan, Jeng-Jzung Wu, Heng-Yi Teah, Yu-Ting Liu Abstract Composites formed during the coprecipitation and/or coagulation of ubiquitous dissolved organic matter (DOM) and Fe in natural and waste water systems might be potential scavengers for Cr(VI) in terms of sorption and reduction. Our objective here was to determine sorption and simultaneous reduction of Cr(VI) on organo-Fe(III) composites (OFC) in relation coprecipitated pH and C/(C + Fe) ratios. Results showed the greatest Cr sorption of 51.8 mg g−1 on the OFC sample that was precipitated at pH 3 and contained the C/(C + Fe) molar ratio of 0.71. Wherein the Cr(VI) removal subsequent to the coprecipitation was dominated by the sorption on Fe hydroxides. Although amounts of total sorbed Cr decreased with increasing C/(C + Fe) molar ratio, the reverse trend on Cr(VI) reducibility compensated the Cr(VI) removal capability of OFC samples. With C/(C + Fe) molar ratios ≥ 0.89, the increasing amounts of coprecipitated organic matter that homogeneously distributed with Fe domains on OFC surfaces could trigger a significantly pronounced Cr reduction. Collectively, our results suggested an alternative method for Cr(VI) remediation by manipulating C/Fe ratios in suspensions. After the sorption of most Cr(VI) on Fe hydroxides, increasing C/Fe ratio in systems could further improve the Cr(VI) removal efficiency by the reduction of remaining Cr(VI) to Cr(III). Graphical abstract

Use of a floating adsorbent to remove dyes from water: A novel efficient surface separation method Publication date: 5 August 2019 Source: Journal of Hazardous Materials, Volume 375 Author(s): Yanyan An, Huaili Zheng, Xinyu Zheng, Qiang Sun, Yuhao Zhou Abstract In this study, our group grafted 2-acrylamido-2-methylpropane sulfonic acid (AMPS) onto the surface of hollow glass microspheres (HGM) and successfully prepared AMPS grafted floating adsorbent (AFA). The prepared AFA carries a large amount of negative charges, and the adsorptions of cationic dyes are achieved under the action of strong electrostatic interaction. Furthermore, due to the unique shell structure of AFA, it has a stable self-floating ability, which may change the traditional separation method to make the adsorbent easier to enrich and separate from water surface. Characterizations of AFA by scanning electron microscope, energy dispersive spectrometry, X-ray photoelectron spectroscopy. Fourier transform infrared spectra, Brunauer-Emmett-Teller surface areas, thermogravimetric analysis, and X-ray diffractometer shows the successful grafting of AMPS. Adsorption experiments confirmed that the adsorption capacities of AFA for methylene blue, malachite green, basic fuchsin and crystal violet under optimum conditions were 436.8 mg g−1, 637.6 mg g−1, 457.8 mg g−1, and 399.4 mg g−1, respectively. At the same time, AFA has excellent recyclability, and its adsorption capacity can be maintained after 6 cycles of reuse. Graphical abstract

Use 3-D tomography to reveal structural modification of bentonite-enriched clay by nonionic surfactants: Application of organo-clay composites to detoxify aflatoxin B1 in chickens Publication date: 5 August 2019 Source: Journal of Hazardous Materials, Volume 375 Author(s): Yu-Min Tzou, Ya-Ting Chan, Shuen-Ei Chen, Chun-Chieh Wang, Po-Neng Chiang, Heng Yi Teah, Jui-Ting Hung, Jeng-Jzung Wu, Yu-Ting Liu Abstract Although nonionic surfactants are relatively eco-friendly compared with cationic and anionic surfactants, few studies have investigated their application in modified clay. Herein we prepared organo-clay composites (OCCs) by mixing bentonite-enriched clay (BEC) with nonionic surfactants (Brij 30 and Igepal CO-890) and determined if these modifications would enable chickens to detoxify aflatoxin B1 (AFB1). For the first time, in situ three-dimensional (3-D) microstructures of modified BEC was characterized in suspension using transmission X-ray microscopy. Although X-ray diffraction patterns indicated the expansion in the spacing between planes of atoms (basal spacing) of surfactant-modified BEC, 3-D images indicated shrinkage in its microscale porous framework with increasing surfactant additions from 1 to 30 wt%. Such declining trends in porous dimensions caused by the dehydration in interlayer galleries of clays positively correlated with sorption amounts of AFB1 on OCCs. After chickens had consumed amended feeds for 11 weeks, AFB1 concentrations in liver, kidney, and plasma were significantly lower than in the control treatment. Thus, we suggest using BEC with 1 wt% surfactant addition, an amendment to chicken feeds, to detoxify AFB1. Modifying BEC with nonionic surfactants show the promise in mitigating AFB1 accumulation in chickens, which should improve food safety and reduce environmental contamination. Graphical abstract

Co-transport of Pb(II) and oxygen-content-controllable graphene oxide from electron-beam-irradiated graphite in saturated porous media Publication date: 5 August 2019 Source: Journal of Hazardous Materials, Volume 375 Author(s): Yanji Jiang, Xianqiang Yin, Duo Guan, Tao Jing, Huimin Sun, Nong Wang, Jing Bai Abstract It is essential to investigate the role of the surface oxygen content of graphene oxide (GO) in transport processes. In this study, GO was prepared using flake graphite with different radiation doses. The effects of the flow rate and ionic strength (IS) on the migration and co-transport of GO and Pb(II) ions were investigated via laboratory packed-column experiments. The experimental results showed that the mobility of GO in saturated porous media decreased with increasing flow rate. Further, the mobility of GO with a radiation dose of 18 kGy was lower than that of GOs with other radiation doses for an IS below 0.01 M. Regarding the co-transport of irradiated GO and Pb(II) in porous media, the greater the radiation dose, the stronger was the ability of GO to promote Pb(II) transport. The surface oxygen content promoted the ability of GO to remove Pb(II). However, radiation doses exceeding a certain range inhibited the release of Pb(II). The transport of GO in saturated porous media was successfully simulated with the advection–dispersion–reaction (ADR) equation. This study is expected to provide a new perspective on the potential risks of GO due to surface changes during its transport in the environment. Graphical abstract

Development of a model (SWNano) to assess the fate and transport of TiO2 engineered nanoparticles in sewer networks Publication date: 5 August 2019 Source: Journal of Hazardous Materials, Volume 375 Author(s): Ki-Eun Kim, Yu Sik Hwang, Min-Hee Jang, Jee Hey Song, Hee Seok Kim, Dong Soo Lee Abstract A new model, SWNano (Sewer-Water Nano), has been developed in the present study that quantitatively simulates the spatio-temporal changes in the concentrations of TiO2 ENPs of dispersed and aggregated forms in the sewage water and sediment of a sewer network. As a brief example of SWNano applications, a small section of the entire sewer network of Seoul, Korea, was chosen to study where the sewage water was experimentally characterized. The predictions of SWNano present important findings that i) heteroaggregation is the most significant process following the advective transport among the fate and transport processes in the sewer pipes, ii) the heteroaggregation of TiO2 ENPs with SPMs in the sewage water can substantially (a few % to more than 50%) reduce the freely dispersed TiO2 ENPs depending on the magnitude of attachment efficiency, and iii) accurate determination of attachment efficiency is of critical importance in predicting the quantity of individual forms of ENPs exiting the sewer system. The predictions strongly suggest that the fate and transport of TiO2ENPs in the sewer networks be taken into account to improve the assessment of exposure to TiO2 ENPs in the aquatic ecosystems, which warrants further development and use of models like SWNano. Graphical abstract

Industrial textile effluent treatment and antibacterial effectiveness of Zea mays L. Dry husk mediated bio-synthesized copper oxide nanoparticles Publication date: 5 August 2019 Source: Journal of Hazardous Materials, Volume 375 Author(s): Assumpta Chinwe Nwanya, Lovasoa Christine Razanamahandry, A.K.H. Bashir, Chinwe O. Ikpo, Stephen C. Nwanya, Subelia Botha, S.K.O. Ntwampe, Fabian I. Ezema, Emmanuel I. Iwuoha, Malik Maaza Abstract Zea mays L. dry husk extract was used to bio synthesize copper oxide nanoparticles. Red coloured cubic Cu2O nanoparticles were obtained for the first time via this simple, eco- friendly, green synthesis route. The Cu2O nanoparticles were thermally oxidized to pure monoclinic CuO nanoparticles at 600 °C. The phases of the copper oxides were confirmed from the x-ray diffraction (XRD) studies. The nanoparticle sizes as obtained from high resolution transmission electron microscope (HRTEM) analysis range from 10 to 26 nm, 36–73 nm and 30−90 nm for the unannealed Cu2O, 300 °C and 600 °C annealed CuO respectively. The values of the bandgap energies obtained from diffuse reflectance of the nanoparticles are 2.0, 1.30 and 1.42 eV respectively for the unannealed, 300 °C, and 600 °C annealed copper oxide nanoparticles. The 600 °C annealed copper oxide nanoparticles showed 91% and 90% degradation ability for methylene blue dye (BM) and textile effluent (TE) respectively under visible light irradiation. While CuO_300 is more effective to inhibit the growth of Escherichia coli 518,133 and Staphylococcus aureus 9144, Cu2O is better for Pseudomonas aeruginosa and Bacillus licheniformis. The results confirm the photo-catalytic and anti-microbial effectiveness of the copper oxide nanoparticles.

Valorization of glycerol/ethanol-rich wastewater to bioflocculants: recovery, properties, and performance Publication date: 5 August 2019 Source: Journal of Hazardous Materials, Volume 375 Author(s): Victor Ajao, Siti Millah, Maria Cristina Gagliano, Harry Bruning, Huub Rijnaarts, Hardy Temmink Abstract Microbial extracellular polymeric substances (EPS) were produced in two membrane bioreactors, each separately treating fresh and saline synthetic wastewater (consisting of glycerol and ethanol), with the purpose of applying them as sustainable bioflocculants. The reactors were operated under nitrogen-rich (COD/N ratios of 5 and 20) and limited (COD/N ratios of 60 and 100) conditions. Under both conditions, high COD removal efficiencies of 87–96% were achieved. However, nitrogen limitation enhanced EPS production, particularly the polysaccharide fraction. The maximum EPS recovery (g EPS−COD/g CODinfluent) from the fresh wastewater was 54% and 36% recovery was obtained from the saline (30 g NaCl/L) wastewater. The biopolymers had molecular weights up to 2.1 MDa and anionic charge densities of 2.3–4.7 meq/g at pH 7. Using kaolin clay suspensions, high flocculation efficiencies of 85–92% turbidity removal were achieved at EPS dosages below 0.5 mg/g clay. Interestingly, EPS produced under saline conditions proved to be better flocculants in a saline environment than the corresponding freshwater EPS in the same environment. The results demonstrate the potential of glycerol/ethanol-rich wastewater, namely biodiesel/ethanol industrial wastewater, as suitable substrates to produce EPS as effective bioflocculants. Graphical abstract

ALEXANDROS SFAKIANAKIS ANAPAFSEOS 5 AGIOS NIKOLAOS CRETE 72100 GREECE +306932607174 +302841026182

critical care

Early Enteral Nutrition in Patients Undergoing Sustained Neuromuscular Blockade: A Propensity-Matched Analysis Using a Nationwide Inpatient Database Objectives: Whether enteral nutrition should be postponed in patients undergoing sustained treatment with neuromuscular blocking agents remains unclear. We evaluated the association between enteral nutrition initiated within 2 days of sustained neuromuscular blocking agent treatment and in-hospital mortality. Design: Retrospective administrative database study from July 2010 to March 2016. Setting: More than 1,200 acute care hospitals covering approximately 90% of all tertiary-care emergency hospitals in Japan. Patients: Mechanically ventilated patients, who had undergone sustained treatment with neuromuscular blocking agents in an ICU, were retrospectively reviewed. We defined patients who received sustained treatment with neuromuscular blocking agents as those who received either rocuronium at greater than or equal to 250 mg/d or vecuronium at greater than or equal to 50 mg/d for at least 2 consecutive days. Interventions: Enteral nutrition started within 2 days from the initiation of neuromuscular blocking agents (defined as early enteral nutrition). Measurements and Main Results: We identified 2,340 eligible patients during the 69-month study period. Of these, 378 patients (16%) had received early enteral nutrition. One-to-three propensity score matching created 374–1,122 pairs. The in-hospital mortality rate was significantly lower in the early than late enteral nutrition group (risk difference, –6.3%; 95% CI, –11.7% to –0.9%). There was no significant difference in the rate of hospital pneumonia between the two groups (risk difference, 2.8%; 95% CI, –2.7% to 8.3%). Length of hospital stay among survivors was significantly shorter in the early compared with the late enteral nutrition group (risk difference, –11.4 d; 95% CI, –19.1 to –3.7 d). There was no significant difference between the two groups in length of ICU stay or length of mechanical ventilation among survivors. Conclusions: According to this retrospective database study, early enteral nutrition may be associated with lower in-hospital mortality with no increase in-hospital pneumonia in patients undergoing sustained treatment with neuromuscular blocking agents. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). Supported, in part, by grants from the Ministry of Health, Labour and Welfare of Japan (H30-Policy-Designated-004 and H29-ICT-Genral-004) and the Ministry of Education, Culture, Sports, Science and Technology of Japan (17H04141). Dr. Ohbe received support for article research from the Ministry of Health, Labour and Welfare of Japan and the Ministry of Education, Culture, Sports, Science and Technology of Japan. Dr. Yasunaga's institution received funding from the Ministry of Health, Labour and Welfare, Japan and the Ministry of Education, Culture, Sports, Science and Technology, Japan. The remaining authors have disclosed that they do not have any potential conflicts of interest. This work was performed at The University of Tokyo. For information regarding this article, E-mail: hohbey@gmail.com Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Trends and Outcomes in Sepsis Hospitalizations With and Without Atrial Fibrillation: A Nationwide Inpatient Analysis Objectives: Atrial fibrillation is frequently seen in sepsis-related hospitalizations. However, large-scale contemporary data from the United States comparing outcomes among sepsis-related hospitalizations with versus without atrial fibrillation are limited. The aim of our study was to assess the frequency of atrial fibrillation and its impact on outcomes of sepsis-related hospitalizations. Design: Retrospective cohort study. Setting: The National Inpatient Sample databases (2010–2014). Patients: Primary discharge diagnosis of sepsis with and without atrial fibrillation were identified using prior validated International Classification of Diseases, 9th Edition, Clinical Modification codes. Interventions: None. Measurements and Main Results: Overall, 5,808,166 hospitalizations with the primary diagnosis of sepsis, of which 19.4% (1,126,433) were associated with atrial fibrillation. The sepsis-atrial fibrillation cohort consisted of older (median [interquartile range] age of 79 yr [70–86 yr] vs 67 yr [53–79 yr]; p < 0.001) white (80.9% vs 68.8%; p < 0.001) male (51.1% vs 47.5%; p < 0.001) patients with an extended length of stay (median [interquartile range] 6 d [4–11 d] vs 5 d [3–9 d]; p < 0.001) and higher hospitalization charges (median [interquartile range] $44,765 [$23,234–$88,657] vs $35,737 [$18,767–$72,220]; p < 0.001) as compared with the nonatrial fibrillation cohort. The all-cause mortality rate in the sepsis-atrial fibrillation cohort was significantly higher (18.4% and 11.9%; p = 0.001) as compared with those without atrial fibrillation. Although all-cause mortality (20.4% vs 16.6%) and length of stay (median [interquartile range] 7 d [4–11 d] vs 6 d [4–10 d]) decreased between 2010 and 2014, hospitalization charges increased (median [interquartile range] $41,783 [$21,430–$84,465] vs $46,251 [$24,157–$89,995]) in the sepsis-atrial fibrillation cohort. The greatest predictors of mortality in the atrial fibrillation-sepsis cohort were African American race, female gender, advanced age, and the presence of medical comorbidities. Conclusions: The presence of atrial fibrillation among sepsis-related hospitalizations is a marker of poor prognosis and increased mortality. Although we observed rising trends in sepsis and sepsis-atrial fibrillation–related hospitalizations during the study period, the rate and odds of mortality progressively decreased. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: rsachdeva@msm.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Argon Inhalation for 24 Hours After Onset of Permanent Focal Cerebral Ischemia in Rats Provides Neuroprotection and Improves Neurologic Outcome Objectives: We tested the hypothesis that prolonged inhalation of 70% argon for 24 hours after in vivo permanent or temporary stroke provides neuroprotection and improves neurologic outcome and overall recovery after 7 days. Design: Controlled, randomized, double-blinded laboratory study. Setting: Animal research laboratories. Subjects: Adult Wistar male rats (n = 110). Interventions: Rats were subjected to permanent or temporary focal cerebral ischemia via middle cerebral artery occlusion, followed by inhalation of 70% argon or nitrogen in 30% oxygen for 24 hours. On postoperative day 7, a 48-point neuroscore and histologic lesion size were assessed. Measurements and Main Results: After argon inhalation for 24 hours immediately following "severe permanent ischemia" induction, neurologic outcome (neuroscore, p = 0.034), overall recovery (body weight, p = 0.02), and infarct volume (total infarct volume, p = 0.0001; cortical infarct volume, p = 0.0003; subcortical infarct volume, p = 0.0001) were significantly improved. When 24-hour argon treatment was delayed for 2 hours after permanent stroke induction or until after postischemic reperfusion treatment, neurologic outcomes remained significantly improved (neuroscore, p = 0.043 and p = 0.014, respectively), as was overall recovery (body weight, p = 0.015), compared with nitrogen treatment. However, infarct volume and 7-day mortality were not significantly reduced when argon treatment was delayed. Conclusions: Neurologic outcome (neuroscore), overall recovery (body weight), and infarct volumes were significantly improved after 24-hour inhalation of 70% argon administered immediately after severe permanent stroke induction. Neurologic outcome and overall recovery were also significantly improved even when argon treatment was delayed for 2 hours or until after reperfusion. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http;/journals.lww.com/ccmjournal). Supported, in part, by a DREAM Award from the Department of Anesthesiology at Duke University Medical Center. Dr. Sheng's institution received funding from the National Institutes of Health (NIH). Drs. Sheng and Turner received support for article research from the NIH. Dr. Yang received support for article research from departmental funds. Dr. Hoffmann received support for article research from the Department of Duke Anesthesiology DREAM award, and he disclosed off-label product use of noble gas argon. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: ulrike.hoffmann@duke.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

At-Risk Drinking Is Independently Associated With Acute Kidney Injury in Critically Ill Patients Objectives: Unhealthy use of alcohol and acute kidney injury are major public health problems, but little is known about the impact of excessive alcohol consumption on kidney function in critically ill patients. We aimed to determine whether at-risk drinking is independently associated with acute kidney injury in the ICU and at ICU discharge. Design: Prospective observational cohort study. Setting: A 21-bed polyvalent ICU in a university hospital. Patients: A total of 1,107 adult patients admitted over a 30-month period who had an ICU stay of greater than or equal to 3 days and in whom alcohol consumption could be assessed. Interventions: None. Measurements and Main Results: We assessed Kidney Disease Improving Global Outcomes stages 2–3 acute kidney injury in 320 at-risk drinkers (29%) and 787 non–at-risk drinkers (71%) at admission to the ICU, within 4 days after admission and at ICU discharge. The proportion of patients with stages 2–3 acute kidney injury at admission to the ICU (42.5% vs 18%; p < 0.0001) was significantly higher in at-risk drinkers than in non–at-risk drinkers. Within 4 days and after adjustment on susceptible and predisposing factors for acute kidney injury was performed, at-risk drinking was significantly associated with acute kidney injury for the entire population (odds ratio, 2.15; 1.60–2.89; p < 0.0001) in the subgroup of 832 patients without stages 2–3 acute kidney injury at admission to the ICU (odds ratio, 1.44; 1.02–2.02; p = 0.04) and in the subgroup of 971 patients without known chronic kidney disease (odds ratio, 1.92; 1.41–2.61; p < 0.0001). Among survivors, 22% of at-risk drinkers and 9% of non–at-risk drinkers were discharged with stages 2–3 acute kidney injury (p < 0.001). Conclusions: Our results suggest that chronic and current alcohol misuse in critically ill patients is associated with kidney dysfunction. The systematic and accurate identification of patients with alcohol misuse may allow for the prevention of acute kidney injury. Dr. Gacouin had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Gacouin and Tadié drafted the work. All authors contributed to the conception and design of the work, data acquisition, and analysis. All authors contributed to the interpretation of data for the work. All authors revised it critically for important intellectual content. All authors gave final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: arnaud.gacouin@chu-rennes.fr Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Cardiac Arrest Prior to Venoarterial Extracorporeal Membrane Oxygenation: Risk Factors for Mortality Objectives: Mortality after cardiac arrest remains high despite initiation of venoarterial extracorporeal membrane oxygenation. We aimed to identify pre-venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality in patients with witnessed cardiac arrest and with greater than or equal to 1 minute of cardiopulmonary resuscitation before venoarterial extracorporeal membrane oxygenation. The association between preimplant variables and all-cause mortality at 90 days was analyzed with multivariable logistic regression. Design: Retrospective observational cohort study. Setting: Tertiary medical center. Patients: Seventy-two consecutive patients with cardiac arrest prior to venoarterial extracorporeal membrane oxygenation cannulation. Interventions: None. Measurements and Main Results: Median age was 56 years (interquartile range, 43–56 yr), 75% (n = 54) were men. Out-of-hospital cardiac arrest occurred in 12% (n = 9) of the patients. Initial cardiac rhythm was nonshockable in 57% (n = 41) and shockable in 43% (n = 31) of patients. Median cardiopulmonary resuscitation duration was 21 minutes (interquartile range, 10–73 min; range, 1–197 min]. No return of spontaneous circulation was present in 64% (n = 46) and postarrest cardiogenic shock in 36% (n = 26) of the patients at venoarterial extracorporeal membrane oxygenation cannulation. Median duration of venoarterial extracorporeal membrane oxygenation was 5 days (interquartile range, 2–12 d). The 90-day overall mortality and in-hospital mortality were 57% (n = 41), 53% (n = 38) died during venoarterial extracorporeal membrane oxygenation, and 43% (n = 31) were successfully weaned. All survivors had Cerebral Performance Category score 1–2 at discharge to home. Multivariable logistic regression analysis identified initial nonshockable cardiac arrest rhythm (odds ratio, 12.2; 95% CI, 2.83–52.7; p = 0.001), arterial lactate (odds ratio per unit, 1.15; 95% CI, 1.01–1.31; p = 0.041), and ischemic heart disease (7.39; 95% CI, 1.57–34.7; p = 0.011) as independent risk factors of 90-day mortality, whereas low-flow duration, return of spontaneous circulation, and age were not. Conclusions: In 72 patients with cardiac arrest before venoarterial extracorporeal membrane oxygenation initiation, nonshockable rhythm, arterial lactate, and ischemic heart disease were identified as independent pre-venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality. The novelty of this study is that the metabolic state, expressed as level of lactate just before venoarterial extracorporeal membrane oxygenation initiation seems more predictive of outcome than cardiopulmonary resuscitation duration or absence of return of spontaneous circulation. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. This work was performed at the Karolinska University Hospital, SE-17176 Stockholm, Sweden. For information regarding this article, E-mail: thomas.fux@sll.se Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Effect of Increasing Blood Pressure With Noradrenaline on the Microcirculation of Patients With Septic Shock and Previous Arterial Hypertension Objectives: To assess whether an increase in mean arterial pressure in patients with septic shock and previous systemic arterial hypertension changes microcirculatory and systemic hemodynamic variables compared with patients without arterial hypertension (control). Design: Prospective, nonblinded, interventional study. Setting: Three ICUs in two teaching hospitals. Patients: After informed consent, we included patients older than 18 years with septic shock for at least 6 hours, sedated, and under mechanical ventilation. We paired patients with and without arterial hypertension by age. Interventions: After obtaining systemic and microcirculation baseline hemodynamic variables (time 0), we increased noradrenaline dose to elevate mean arterial pressure up to 85–90 mm Hg before collecting a new set of measurements (time 1). Measurements and Main Results: We included 40 patients (20 in each group). There was no significant difference in age between the groups. After the rise in mean arterial pressure, there was a significant increase in cardiac index and a slight but significant reduction in lactate in both groups. We observed a significant improvement in the proportion of perfused vessels (control: 57.2 ± 14% to 66 ± 14.8%; arterial hypertension: 61.4 ± 12.3% to 70.8 ± 7.1%; groups: p = 0.29; T0 and T1: p < 0.001; group and time interaction: p = 0.85); perfused vessels density (control: 15.6 ± 4 mm/mm2 to 18.6 ± 4.5 mm/mm2; arterial hypertension: 16.4 ± 3.5 mm/mm2 to 19.1 ± 3 mm/mm2; groups: p = 0.51; T0 and T1: p < 0.001; group and time interaction: p = 0.70), and microcirculatory flow index (control: 2.1 ± 0.6 to 2.4 ± 0.6; arterial hypertension: 2.1 ± 0.5 to 2.6 ± 0.2; groups: p = 0.71; T0 and T1: p = 0.002; group and time interaction: p = 0.45) in both groups. Conclusions: Increasing mean arterial pressure with noradrenaline in septic shock patients improves density and flow in small vessels of sublingual microcirculation. However, this improvement occurs both in patients with previous arterial hypertension and in those without arterial hypertension. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). Supported, in part, by grant from Fundação de Pesquisa do Estado de São Paulo—Grant 2012/19051-1. Drs. Fiorese Coimbra's, de Freitas's, Bafi's, Pinheiro's, Nunes's, and Machado's institution received funding from Fundação de Amparo à Pesquisa do Estado de São Paulo—FAPESP, a government grant agency from State of São Paulo. Dr. de Azevedo disclosed that he does not have any potential conflicts of interest. Trial registration: ClinicalTrials.gov NCT02519699. For information regarding this article, E-mail:karla.tuanny@hotmail.com Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting Objectives: Assess interventions' impact on preventing IV infusion identification and disconnection mix-ups. Design: Experimental study with repeated measures design. Setting: High fidelity simulated adult ICU. Subjects: Forty critical care nurses. Interventions: Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system. Measurements and Main Results: Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) (p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions (p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions (p < 0.001). Conclusions: The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. This work was performed at a Toronto hospital. This study was funded by Health Quality Ontario and the Association for the Advancement of Medical Instrumentation Foundation. Mr. Fan and Dr. Trbovich have received presentation honoraria from Becton Dickinson (BD), and Dr. Trbovich is the principal applicant on a grant (ROR2017-04260JH - North York General Hospital [NYGH]) from BD paid to NYGH (unrelated to this study). Ms. Koczmara's and Dr. Trbovich's institutions received funding from Health Quality Ontario (agency of the Ontario Ministry of Health and Long-term Care). Dr. Trbovich's institution received funding from Association for the Advancement of Medical Instrumentation Foundation. Dr. Trbovich's institution received funding from Becton Dickinson Canada (paid the travel costs for team members to present the research findings to their Alaris infusion product team). Ms. Pinkney, Mr. Fan, Ms. Koczmara, and Dr. Trbovich disclosed work for hire, and they disclosed off-label product use of Nurse Buddy II (Verafied Medical Innovations LLC, American Canyon, CA), and prototype Light Linking System (developed by research team solely for this research study; not for sale and no commercialization plans). Mr. Fan and Dr. Trbovich disclosed working on a project aimed at adapting pre-existing e-learning modules regarding elastomeric infusors for Baxter Canada. Ms. Koczmara received funding from a consulting honorarium paid to Institute for Safe Medication Practices Canada to attend and participate in Hospira Infusion Systems 1-day Conference "Canadian Infusion Pump Safety Collaborative Forum." Address requests for reprints to: Sonia J. Pinkney, MHSc, PEng, Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada. E-mail: Sonia.pinkney@uhn.ca Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

The Effectiveness of α2Agonists As Sedatives in Pediatric Critical Care: A Propensity Score-Matched Cohort Study Objectives: There is limited evidence supporting the widespread use of α2 agonists (clonidine and dexmedetomidine) in pediatric critical care sedation. This study sought to test the association between the use of α2 agonists and enhanced sedation. Design: A retrospective observational cohort study was conducted. Noninferiority of time adequately sedated (COMFORT Behavior Score 11–16) while mechanically ventilated was assessed. Secondarily, dosing of opioids and benzodiazepines was examined. Setting: Two tertiary PICUs. Patients: Children were classified into an exposed group, who received an α2 agonist as part of their sedation regimen, and an unexposed group. Groups were matched using propensity score analysis. Interventions: None. Measurements and Main Results: One-thousand eighty-five patients were included. The exposed group were adequately sedated 74% (95% CI, 72–75%) of the study time compared with the unexposed group at 70% (95% CI, 67–72%) giving a ratio of 1.06 (95% CI, 1.02–1.10) and a noninferior time adequately sedated. A decrease in time oversedated was observed with 8.1% (95% CI, 4.3–11.9%) less time classified as oversedated in the exposed group. Reduction in morphine use of 0.25 μg/kg/hr (95% CI, –0.68 to 1.18 μg/kg/hr) was not statistically significant. Midazolam use did not decrease and was statistically higher. Conclusions: Use of α2 agonists was associated with similar time adequately sedated as a matched unexposed group although no reduction in morphine or benzodiazepine coadministration was observed. There was a shift toward lighter sedation with α2 agonist use. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). This project received funding from the Children's Fund for Health at Children's University Hospital, Temple Street, Dublin, Ireland. The authors disclosed that they have no potential conflicts of interest. This work was carried out at the Royal College of Surgeons in Ireland. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For information regarding this article, E-mail: johnhayden@rcsi.ie Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Low-Dose Versus Therapeutic Anticoagulation in Patients on Extracorporeal Membrane Oxygenation: A Pilot Randomized Trial Objectives: To determine whether randomization of patients undergoing extracorporeal membrane oxygenation to either therapeutic or a low-dose anticoagulation protocol results in a difference in activated partial thromboplastin time and anti-Xa. Design: Randomized, controlled, unblinded study. Setting: Two ICUs of two university hospitals. Patients: Patients admitted to the ICU, who required extracorporeal membrane oxygenation (venovenous or venoarterial) and who did not have a preexisting indication for therapeutic anticoagulation. Interventions: Therapeutic anticoagulation with heparin (target activated partial thromboplastin time between 50 and 70 s) or lower dose heparin (up to 12,000 U/24 hr aiming for activated partial thromboplastin time < 45 s). Measurements and Main Results: Thirty-two patients were randomized into two study groups that were not significantly different in demographics and extracorporeal membrane oxygenation characteristics. There was a significant difference in the daily geometric mean heparin dose (11,742 U [95% CI, 8,601–16,031 U] vs 20,710 U [95% CI, 15,343–27,954 U]; p = 0.004), daily geometric mean activated partial thromboplastin time (48.1 s [95% CI, 43.5–53.2 s] vs 55.5 s [95% CI, 50.4–61.2 s]; p = 0.04), and daily geometric mean anti-Xa (0.11 international units/mL [95% CI, 0.07–0.18] vs 0.27 [95% CI, 0.17–0.42]; p = 0.01). We found similar results when considering only venovenous extracorporeal membrane oxygenation episodes; however, no difference in daily geometric mean activated partial thromboplastin time between groups when considering only venoarterial extracorporeal membrane oxygenation episodes. Conclusions: Allocating patients on extracorporeal membrane oxygenation to two different anticoagulation protocols led to a significant difference in mean daily activated partial thromboplastin time and anti-Xa levels between groups. When considering subgroups analyses, these results were consistent in patients on venovenous extracorporeal membrane oxygenation. Our results support the feasibility of a larger trial in patients undergoing venovenous extracorporeal membrane oxygenation to compare different anticoagulation protocols; however, this study does not provide evidence on the optimal anticoagulation protocol for patients undergoing extracorporeal membrane oxygenation. The complete list of board members for the International ECMO Network (ECMONet) is: Laurent Brochard, Daniel Brodie, Alain Combes, Eddy Fan, Niall Ferguson, John Fraser, Carol Hodgson, Alain Mercat, Thomas Mueller, Vin Pellegrino, Antonio Pesenti, Marco Ranieri, Art Slutsky, Danny McAuley, and Michael Quintel. Drs. Aubron and McQuilten have contributed equally to this work and are co-first authors. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). This study was funded by an Australian and New Zealand College of Anaesthestists Project Grant (2015/007). This work was also supported by the Australian National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Patient Blood Management in Critical Illness and Trauma (APP1040971). Dr. McQuilten is supported by a NHMRC Early Career Fellowship (APP1111485). Dr. McQuilten disclosed that she is employed by Monash University Transfusion Research Unit that has received financial support from Alexion, Amgen, Bayer, Celgene, CSL Behring, Janssen-Cilag, Takeda, Novartis, Australian Red Cross Blood Service, New Zealand Blood Service, Department of Health Victoria (Australia), and Myeloma Foundation of Australia. None of these funding sources had any involvement the design or conduct of this study. Drs. Board's and McIlroy's institutions received funding from Australia and New Zealand College of Anaesthetists. Dr. Board disclosed off-label product use of heparin low-dose protocol. Dr. Buhr's institution received funding from Alfred Health and the Intensive Care Foundation (research grant). Dr. Hodgson disclosed that she is employed by Monash University and she holds a Heart Foundation of Australia Future Leader Fellowship. Dr. Pellegrino received accommodation support for European ECMONet meetings where the work was presented during development. Dr. Tran received funding from Novartis, Shire, and Pfizer. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: cecile.aubron@chu-brest.fr; cecile.aubron@monash.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Fresh Red Cells for Transfusion in Critically Ill Adults: An Economic Evaluation of the Standard Issue Transfusion versus Fresher Red-Cell Use in Intensive Care (TRANSFUSE) Clinical Trial Objectives: Trials comparing the effects of transfusing RBC units of different storage durations have considered mortality or morbidity as outcomes. We perform the first economic evaluation alongside a full age of blood clinical trial with a large population assessing the impact of RBC storage duration on quality-of-life and costs in critically ill adults. Design: Quality-of-life was measured at 6 months post randomization using the EuroQol 5-dimension 3-level instrument. The economic evaluation considers quality-adjusted life year and cost implications from randomization to 6 months. A generalized linear model was used to estimate incremental costs (2016 U.S. dollars) and quality-adjusted life years, respectively while adjusting for baseline characteristics. Setting: Fifty-nine ICUs in five countries. Patients: Adults with an anticipated ICU stay of at least 24 hours when the decision had been made to transfuse at least one RBC unit. Interventions: Patients were randomized to receive either the freshest or oldest available compatible RBC units (standard practice) in the hospital transfusion service. Measurements and Main Results: EuroQol 5-dimension 3-level utility scores were similar at 6 months—0.65 in the short-term and 0.63 in the long-term storage group (difference, 0.02; 95% CI, –0.00 to 0.04; p = 0.10). There were no significant differences in resource use between the two groups apart from 3.0 fewer hospital readmission days (95% CI, –5.3 to –0.8; p = 0.01) during follow-up in the short-term storage group. There were no significant differences in adjusted total costs or quality-adjusted life years between the short- and long-term storage groups (incremental costs, –$2,358; 95% CI, –$5,586 to $711) and incremental quality-adjusted life years: 0.003 quality-adjusted life years (95% CI, –0.003 to 0.008). Conclusions: Without considering the additional supply cost of implementing a freshest available RBC strategy for critical care patients, there is no evidence to suggest that the policy improves quality-of-life or reduces other costs compared with standard transfusion practice. This work was performed at the Centre for Health Economics, Monash Business School, Monash University, Caulfield, VIC, Australia. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccmjournal). The full list of board members of the Standard Issue Transfusion versus Fresher Red-Cell Use in Intensive Care (TRANSFUSE) Investigators is provided in the Supplementary Appendix (Supplemental Digital Content 1,http://links.lww.com/CCM/E540). The TRANSFUSE trial was supported, in part, by grants from the Australian National Health and Medical Research Council (APP102064 and APP1040971), the Health Research Council of New Zealand (12/575), and the Irish Health Research Board (HRA-DI-2015–589 and CTN-2014-012) and by funding from the Australian Red Cross Blood Service. Ms. Higgins's and Ms. Murray's institutions received funding from Australian National Health and Medical Research Council (NHMRC) and Australian Red Cross Blood Service. Drs. Cooper's and Gantner's institutions received funding from NHMRC, Health Research Council of New Zealand, and Irish Health Research Board, and they received other support from Australian Red Cross Blood Service. Dr. Cooper received funding from Eustralis Pharmaceuticals (consulting) and National Blood Authority, Australia. Dr. French's institution received funding from NHMRC. Dr. Irving's institution received funding from the Australian Government (via the National Blood Authority). Dr. McQuilten's institution received funding from Abbvie, Celgene, Janssen-Cilag, CSL Biotherapies, and Gilead Sciences (for research undertaken by the Transfusion Research Unit). The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Zoe K. McQuilten, PhD, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia. E-mail: zoe.mcquilten@monash.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00306932607174,00302841026182,alsfakia@gmail.com

cataract

Comparative analysis of outcomes after wavefront-guided and wavefront-optimized laser in-situ keratomileusis in high myopic eyes Ahmed Ghoneim, Tamer Wasfy, Sayed Abass, Hazem Elbedewy, Mohammed Khater, Mounir A Khalifa, Amr F Sharaf, Mohammed H Nasef, Heba M Shafik, Ahmed F Elmaria The Egyptian Journal of Cataract and Refractive Surgery 2018 24(1):1-7 Purpose The aim was to evaluate and compare the clinical outcomes after laser in-situ keratomileusis (LASIK) in high myopia using wavefront-guided (WFG) and wavefront-optimized (WFO) ablation profiles provided by two different excimer laser platforms. Patients and methods Prospective, consecutive, comparative, and masked clinical trial including 41 high myopic eyes treated with WFG LASIK using the Advanced CustomVue system (WFG group) and 40 eyes treated with a WFO profile using the Allegretto EX-500 platform (WFO group). Visual, refractive, contrast sensitivity (CVS-1000), and aberrometric outcomes were evaluated in both groups of eyes during a 6-month follow-up. Results The efficacy index was significantly better in the WFG group compared with the WFO (1.01±0.11 vs. 0.96±0.12, P=0.038). The safety index was also significantly better in the WFG group (1.03±0.12 vs. 0.94±0.11, P=0.011). All eyes achieved postoperatively an uncorrected distance visual acuity of 20/25 or better in the WFG group, whereas 87.5% of eyes achieved this uncorrected distance visual acuity in the WFO group. More eyes gained one line of corrected distance visual acuity in the WFG group (36.5 vs. 15.0%, P=0.015). Significantly lower postoperative manifest refraction spherical equivalent (P=0.045) and cylinder (P=0.005) were found in the WFG group. Manifest refraction spherical equivalent was within ±1.00 D in 90.3% and 80% of eyes in WFG and WFO groups, respectively (P=0.001). Contrast sensitivity decreased significantly only in the WFO group (P≤0.0397). More significant increase in high-order aberrations was found in the WFO group (P≤0.005). Conclusion WFG LASIK provides better efficacy, safety, predictability, and preservation of visual quality in high myopic eyes than WFO LASIK.

Histological comparison between the anterior capsule integrity in femtosecond laser-assisted capsulotomy and traditional continuous curvilinear capsulotomy in cataract surgeries Omar Attar, Alaa Al-Zawawi, Ibrahim Allam, Noha Zahran, Ihab Othman The Egyptian Journal of Cataract and Refractive Surgery 2018 24(1):8-17 Purpose To compare the histological edge structures of anterior lens capsule specimens obtained from laser-assisted cataract surgery capsulotomies using two different laser platforms (LenSx post-soft-fit and Victus II) with that of traditional continuous curvilinear capsulorhexis (CCC) using scanning electron microscopy (SEM). Setting I-Care Center, Alex Eye Center, Faculty of Medicine, Alexandria University, Alexandria, Egypt. Design Prospective comparative series. Patients and methods Anterior capsule specimens following CCC (n=15) or femtosecond laser-assisted capsulotomy using two platforms (LenSx, n=15 and Victus, n=15) were studied by SEM. Irregularity of the capsule edge was quantified using two parameters (angular second moment and contrast) using ImageJ software. The clinical features and laser parameters were correlated with angular second moment and contrast. SEM images were analyzed for the coefficient of variation (CoV) of pixilation along the capsule edge and homogeneity using gray-level co-occurrence matrix analysis. Subjective analysis for cut-surface irregularities and assessment for complications and anomalies, such as tags and misdirected laser shots, were also made. Results The femtosecond laser-assisted capsulotomy edge surfaces created by both laser platforms showed marked irregularity compared with the smoother edge of the CCC. The angular second moment and contrast measures for both lasers differed significantly from those obtained for CCC (P<0.001). There was little between-laser difference in angular second moment and contrast measures. The mean CoV values from the regression analysis showed the manual edge (16.47%) was smoother than the edges created with LenSx post-soft-fit (20.88%) and Victus II (23.04%) platforms. In the manual group, there is dishomogeneous thickness along the capsulorhexis edge, while in the femtosecond laser samples; the cuts are more homogeneous in thickness throughout the whole capsulorhexis edge. Tags occurred with a mean of 4. Misdirected pulses were seen with Victus II (5/15) cases. Conclusion Laser capsulotomies are approaching the smoothness of manual capsulorhexis. The LenSx post-soft-fit platform shows less anomalies and smaller difference for the CoV and homogeneity metrics compared with the Victus II platform. In the manual group, there is dishomogeneous thickness along the capsulorhexis edge, while in the femtosecond laser samples the cuts are more homogeneous regarding thickness throughout the whole capsulorhexis edge.

Evaluation of intrastromal corneal rings (two segments vs. keraring 355) in central keratoconus using femtosecond laser Abdelkhalek El-Saadany, Asmaa Ibrahim, Sherif Esaa The Egyptian Journal of Cataract and Refractive Surgery 2018 24(1):18-22 Purpose The aim was to compare visual acuity, refraction of intrastromal segment 355, and two, 160° symmetrical segments in central keratoconus. Setting Al-Fath Eye Hospital, Zagazig, Egypt. Design Prospective case series. Patients and methods Surgeries were performed using a femtosecond laser for tunnel creation for the 355° near-total ring (group 1) and the 160° two-segment device (group 2). The preoperative and 6-month postoperative uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) distance visual acuities were acquired. Results The study included 40 eyes. No statistically significant differences were found in the preoperative parameters between groups (P>0.05). The postoperative UCVA and CDVA were statistically better than the preoperative parameters in all study groups (P<0.001). A statistically significant increase in the median UCVA and BCVA occurred in group 2 compared with group 1 (P<0.01). Conclusions All devices were effective in improving UCVA and BCVA. The UCVA results in the two separated 160° segment better than the 355 segment. Patients with high spherical than cylindrical power had better vision and satisfaction with the 355 segment, while the two separated segments had better vision in high cylindrical patients than spherical power patients.

Visual and topographic outcomes of accelerated corneal cross-linking in keratoconus: 1-year follow-up Sherif H Emerah, Hazem Helmy The Egyptian Journal of Cataract and Refractive Surgery 2018 24(1):23-27 Purpose The aim of this study was to evaluate the visual and topographic outcomes of accelerated corneal collagen cross-linking (ACXL) in mild and moderate progressive keratoconus. Patients and methods This retrospective study evaluated the visual and topographic outcomes of 54 eyes of 36 patients of progressive keratoconus who had ACXL (9 mW/cm; 10 min). Data were collected 12 months after corneal collagen cross-linking. Results Uncorrected distance visual acuity was improved from 0.84±0.49 logMAR preoperatively to 0.79±0.3 logMAR postoperatively which is not statistically significant (P=0.1). Corrected distance visual acuity was not significantly changed. The mean preoperative corrected distance visual acuity was 0.25±0.18 and 0.23±0.2 logMAR preoperatively and postoperatively, respectively (P=0.4). Manifest spherical equivalent was not significantly changed, from −4.1±2.77 D preoperatively to −4.02±2.4 D postoperatively, which was not statistically significant (P=0.4). There were no significant changes of steep K, flat K, average K, and Kmax compared with preoperative measurements at 12 months. Conclusion ACXL (9 mW/cm; 10 min) is effective in stabilizing the keratoconus at 1-year follow-up.

The effect of strabismus on the quality of life in adult strabismus patients in Egypt Ahmed M Osman, Nihal A. El shkankiri, Amr ElKamshoushy, Mohamed M Elashry The Egyptian Journal of Cataract and Refractive Surgery 2018 24(1):28-33 Purpose The study aims at identifying the main concerns affecting quality of life (QOL) in adult strabismus patients in Egypt. Patients and methods Seventy adults with strabismus, 20 with diplopia and 50 without the disease were recruited. Individual interviews, using 11 open-ended questions, were audiotaped, transcribed, and transcripts reviewed. Phrases regarding how strabismus affected everyday life were grouped into topic areas and the frequency of each topic analyzed for patients with and without diplopia. Results With self-esteem, interpersonal relationships, and social anxiety was not surprising based on previous studies of the psychosocial effects of strabismus in adults. Nevertheless, some concerns identified in this study were more unexpected, for example appearance in photos, education, marriage, and no treatment for squint. Other concerns in this study were unexpected as most of the patients did not express these problems, for example, in-depth perception, driving, and sports. Conclusion Multiple individual interviews have shown many topics which negatively affect the QOL in strabismic adults. The frequency and type of concerns confirm the importance of health-related QOL assessment as an important aspect of strabismus management. Cultural difference resulted in a different pattern of patient responses and health-related QOL concerns.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00306932607174,00302841026182,alsfakia@gmail.com