Turbostratic Carbon/Graphene Prepared via the Dry Ice in Flames Method and Its Purification Using Different Routes: A Comparative Study

Although the dry ice method used to synthesize turbostratic carbon/graphene is little known and used, it has significant advantages over others, such as the following: it is low cost, simple, and a large quantity of material can be obtained using some inorganic and highly available acids (which can be reused). Despite the above advantages, the main reason for its incipient development is the resulting presence of magnesium oxide in the final product. In the present work, three different treatments were tested to remove this remnant using some acid chemical leaching processes, including hydrochloric acid, aqua regia, and piranha solution. Based on the experimental evidence, it was determined that using aqua regia and combining the leaching process with mechanical milling was the most efficient way of removing such a remnant, the residue being only 0.9 wt.%. This value is low compared to that obtained with the other acid leaching solutions and purification processes (2.8–29.6 wt.%). A mandatory high-energy mechanical milling stage was necessary during this treatment to expose and dissolve the highly insoluble oxide without secondary chemical reactions on the turbostratic carbon. High-energy mechanical milling is an effective route to exfoliate graphite, which allows the magnesium oxide to be more susceptible to acid treatment. A yield of turbostratic carbon/graphene of 1 wt.% was obtained from the metallic Mg. The obtained surface area was 504.8 m²g⁻¹; this high value resulting from the intense exfoliation can potentiate the use of this material for a wide variety of applications.     

An Approach of Producing Ultra-High-Performance Concrete with High Elastic Modulus by Nano-Al2O3: A Preliminary Study

Ultra-high-performance concrete (UHPC) has promising applications in civil engineering. However, the elastic modulus of UHPC is relatively low compared with its compressive strength, which may result in insufficient stiffness in service. This work was carried out to explore the feasibility of producing UHPC with high elastic modulus by nano-Al₂O₃ (NA). Based on particle densely packing theory, the initial mixture of UHPC was designed via the modified Andreasen and Andersen model. An experimental investigation was conducted to systematically examine the effects of NA on different properties of UHPC, including its fluidity, mechanical properties, durability, and microstructure. It was found that: (1) Compared with UHPC without NA, the flexural strength, compressive strength, and elastic modulus of UHPC were improved by 7.38–16.87%, 4.08–20.58%, and 2.89–14.08%, respectively, because of the incorporation of NA; (2) the addition of NA had a prohibiting impact on the threshold pore diameter and porosity of UHPC, which suggested that NA could be conducive to its pore structure; (3) the incorporation of NA led to a decline of 2.9–11.76% in the dry shrinkage of UHPC, which suggested that incorporating NA in a proper amount could reduce the risk of cracking and alleviate the dry shrinkage of UHPC; (4) the optimal amount of NA in UHPC was 1.0%, considering the effects of NA on workability, mechanical properties, microstructure, and the durability of UHPC.     

The Burden of Illness Experienced by Young Children Associated with Asthma: A Population-Based Cohort Study

Using Ontario healthcare administrative databases, over 228,000 children aged 0 to 9 years were identified as having asthma between 1994 and 1998 and followed until they turned 10 years old or the end of the study. The prevalence of childhood asthma increased by 35% during the study period. These children had a higher healthcare utilization and cost over $100 more per child per year than the general population, and contributed to over one third of the total Ontario Health Insurance Plan expenditures. Findings of this study revealed an enormous burden of illness to children with asthma and the healthcare system.     

Rectal Hypersensitivity Reduced by Acupoint TENS in Patients with Diarrhea-Predominant Irritable Bowel Syndrome: A Pilot Study

Our aim was to compare rectal perception of patients with diarrhea-predominant irritable bowel syndrome (IBS-D), constipation-predominant irritable bowel syndrome (IBS-C), functional constipation (FC), and healthy controls and to evaluate the therapeutic effect of acupoint transcutaneous electric nerve stimulation (TENS). Age- and sex-matched patients (24 IBS-D, 20 IBS-C, and 30 FC) were selected, and 30 volunteers served as healthy controls. Rectal sensory thresholds were evaluated by rectal balloon distension. Short- and long-term acupoint TENS was given respectively. IBS-D patients had significantly lower rectal sensory thresholds of the first sensation of stool, urgency of defecation, and pain than IBS-C or FC patients or healthy controls (P < 0.05), but there were no differences in rectal sensory thresholds among IBS-C and FC patients and healthy controls. In each group, females had significantly lower rectal sensory thresholds than males (P < 0.05), but there was no difference between younger (< or = 50 years old) and older (> 50 years old) patients. Short-term acupoint TENS increased rectal sensory thresholds of IBS-D patients. After 2-month acupoint TENS treatment in IBS-D patients, rectal sensory thresholds were significantly increased, stool times and the intensity of abdominal pain were decreased, and psychological scores were relieved to normal. Lowered rectal perception threshold is a hallmark of IBS-D patients. Females have significantly lower rectal sensory thresholds than males. Acupoint TENS is effective to treat IBS-D.     

Failure to Intensify Antihypertensive Treatment by Primary Care Providers: A Cohort Study in Adults with Diabetes Mellitus and Hypertension

Background Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications. Objective To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes. Design Non-concurrent prospective cohort study. Patients A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999–2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg). Measurements and Main Results Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were “routine” odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36–3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11–3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31–0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38–0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41–1.03). Conclusions Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.     

Evaluation of Immediate Implantation and Provisionalization Combined with Guided Bone Regeneration by a Flap Approach in the Maxillary Esthetic Zone: A Retrospective Controlled Study

The aim of this research was too compare the thickness change of labial contour and bone tissues, as well as some biological complications of immediate implantation with and without immediate provisionalization for a single anterior maxilla presenting a vertical defect on labial bone with the need of guided bone regeneration (GBR) by a flap approach. A total of 40 single implants were placed in 40 patients into fresh extraction sockets of the anterior maxilla with a vertical defect on the labial bone (<4 mm). Simultaneously, GBR was conducted at the sites by a flap approach, and the implants were given immediate or delayed provisionalization. The thickness change of bone tissues during six-month evaluation and labial contour during three and six-month follow-up were measured. Complications such as implant and restoration survival rates, infection as well as wound exposure were also evaluated at six months postoperatively. After six months, the mean thickness losses in labial bone were 0.9040, 0.8050, 0.7165, 0.5285 and 0.5335 mm at five different sites in immediate provisionalization group, and 0.8780, 0.8605, 0.7560, 0.5900 and 0.6300 mm, respectively, in delayed provisionalization group, showing no significant difference between the groups at all measurement sites. Although the labial contour changes of the two groups were similar at most sites, the values at 1 and 2 mm above the implant neck remained significantly lower in the immediate provisionalization group at three and six months postoperatively. No complications occurred during the follow-up time. Based on the limitation of this study, the immediate implantation combined with GBR, flap operation and immediate provisionalization obtained acceptable outcomes for a single anterior maxilla with vertical defect on the labial bone, but more long-term research with a larger sample are urgently needed in the future.     

Early Detection of Left Ventricular Dysfunction in Diabetes Mellitus Patients with Normal Ejection Fraction,Stratified by BMI: A Preliminary Speckle Tracking Echocardiography Study

Background:

Diabetes mellitus (DM) represents by itself a major risk factor for cardiovascular events and the coexistence of obesity with consequent left ventricular volumetric overload could be responsible for further damages on left ventricular function. Aim of this study was to demonstrate the effect of body mass index (BMI) on left ventricular function in diabetes patients with no cardiovascular complications and with normal ejection fraction (EF).

Materials and Methods:

We evaluated 71 stable asymptomatic diabetes patients in optimal medical treatment and 24 healthy controls (C) (45% females; mean age: 58.4 +/− 9.4 years; BMI: 23.5 +/− 1.5). We stratified diabetes patients into two groups according to BMI: BMI <30 kg/m² (A: 44 patients; 47% females; mean age: 60.9 +/− 6.6 years; BMI: 25.7 +/− 1.9; Diabetes duration: 9.1 +/− 9.5 years); BMI >30 kg/m² (B: 27 patients; 37% females; mean age: 56.2 +/− 7.8 years; BMI: 33.0 +/− 2.1; Diabetes duration: 8.5 +/− 5.2 years). The following parameters were evaluated by conventional two dimensional (2D) echocardiography (GE VIVID 7) and tissue Doppler imaging (TDI): left ventricular dimensions (LVIDd; PWTd; IVSd), Left Ventricular Volumes (EDV, ESV), EF (by biplane Simpson’s method), Left Ventricular Mass (by ASE formula), peak mitral annular velocity at septal and lateral levels (Sm and Sl). Global longitudinal strain (GLS) was obtained off line by Speckle tracking imaging method using Echopac 10 software.

Results:

Groups A, B were comparable for diabetes duration and glycated hemoglobin level, history of hypertension, and lipid profile. The EF was similar in the three groups, (A: 64 +/− 6%; B: 63 +/− 4%; C: 61 +/−5%; P= NS). LVMass^2.7 indexed for height was significantly higher in A and B in comparison with C (A: 45.2 +/− 8.1 g/m^2.7; B: 46.1 +/− 9.6 g/m^2.7; C: 39.5 +/− 4.9 g/m^2.7; P < 0.05). The stroke volume index (SVi) was significantly lower in B vs A (B: 35.3 +/− 5.7 ml/m²; A: 39.3 +/7.1 ml/m²; P = 0.033). GLS was significantly lower in group B respect A and C (C: 20.9 +/− 1.3%; A: -20.3+/−2.6%; B: -19 +/− 2; P < 0.05; P < 0.01).

Conclusions:

In uncomplicated asymptomatic DM patients, the presence of first degree obesity plays an incremental role in adversely affecting left ventricular function and remodeling. The conventional echocardiographic methods such as the EF and the TDI are not so sensitive to identify the early LV dysfunction such as the evaluation of GLS by Speckle Tracking echocardiography. The longitudinal subendocardial fibers dysfunction in diabetes/obese patients could be derived by the complex interaction between metabolic (diabetes) and hemodynamic/endocrine abnormalities.     

Influence of Oral Antidiabetic Drugs on Hyperglycemic Response to Foods in Persons with Type 2 Diabetes Mellitus as Assessed by Continuous Glucose Monitoring System: A Pilot Study

Background

The purpose of this prospective open-label trial was (1) to assess the influence of oral antidiabetic drugs (OAD) on the glycemic index (GI), glucose response curves (GRCs), daily mean plasma glucose (MPG) and (2) to compare the GI of foods in persons with OAD-treated type 2 diabetes mellitus (T2DM) with the respective GI in healthy persons (HP).

Methods

Tested foods containing 50 g of carbohydrates were eaten for breakfast and dinner after 10 and 4 h of fasting, respectively. Glycemic index, GRC, and MPG were obtained using the CGMS^®System Gold™ (CGMS). In T2DM patients [n = 16; age (mean ± standard error) 56.0 ± 2.25 years], foods were tested four times: tests 1, 2, and 3 were performed within one week in which placebo was introduced on day 2, and test 4 was carried out five weeks after reintroduction of OAD. Glycemic indexes, GRC, and MPG from tests 1, 2, 3, and 4 were compared. In a control group of 20 HP (age 24.4 ± 0.71 years), the mean GIs were calculated as the mean from 20 subject-related GIs.

Results

In T2DM patients, subject-related assessment of GIs, GRC, and MPG distinguished persons with and without OAD effect. Nevertheless, the group-related GIs and the MPG on days 2, 8, and 39 showed no significant difference. There was no significant difference between the GIs in OAD-treated T2DM patients (test 4) versus HP (except in apple baby food). Glucose response curves were significantly larger in T2DM patients (test 4) versus HP.

Conclusions

Determination of GRC and subject-related GI using the CGMS appears to be a potential means for the evaluation of efficacy of OAD treatment. Further studies are underway.     

Presentation,Management, and In-Hospital Outcomes of Patients with Acute Heart Failure in South India by Sex: A Secondary Analysis of a Prospective,Interrupted Time Series Study

Background:Sex differences in presentation, management, and outcomes of heart failure (HF) have been observed, but it is uncertain whether these differences exist in South India.Objective:We describe sex differences in presentation, management, and in-hospital outcomes in patients hospitalized with HF in South India and explore sex-based differences in the effect of the quality improvement intervention in a secondary analysis of a prospective, interrupted time series study.Methods:The Heart Failure Quality Improvement in Kerala (HF QUIK) study evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized with HF in eight hospitals in Kerala using an interrupted time series design from February 2018 to August 2018. The primary outcome was guideline-directed medical therapy (GDMT) at hospital discharge for patients with HF with reduced ejection fraction (HFrEF). We performed sex-stratified analyses using mixed effect logistic regression models.Results:Among 1,400 patients, 536 (38.3%) were female. Female patients were older (69.6 vs. 65 years, p < 0.001), were less likely to have an ischemic etiology of HF (control period: 78.2% vs. 87.5%; intervention period: 83.6% vs. 91.5%; p < 0.05 for both) and were less likely to undergo coronary angiography or percutaneous coronary intervention. The quality improvement intervention had similar effects on the odds of GDMT at discharge in females with HFrEF (adjusted OR 1.79, 95% CI 0.92, 3.47) and males with HFrEF (adjusted OR 1.68, 95% CI 1.07, 2.64, p_interaction = 0.69).Conclusions:We observed sex-specific differences in presentation and procedural management of patients with HF but no differences in the effect of the quality improvement intervention on discharge GDMT rates. Both male and female patients with HFrEF remained undertreated in the study intervention period, demonstrating the need for implementation strategies to close the HFrEF treatment gap in South India.     

Tumor Hypoxia Detected by Positron Emission Tomography with <Superscript>60</Superscript>Cu-ATSM as a Predictor of Response and Survival in Patients Undergoing Neoadjuvant Chemoradiotherapy for Rectal Carcinoma: A Pilot Study

PURPOSE  The response of rectal cancers to neoadjuvant chemoradiotherapy is variable. Tumor hypoxia reduces the effectiveness of both radiation therapy and chemotherapy and is a well-known risk factor for tumor radioresistence. We hypothesized that imaging with the novel hypoxia-detecting agent, ⁶⁰Cu-diacetyl-bis (N⁴-methylthiosemicarbazone) (⁶⁰Cu-ATSM), previously validated in cervical and lung cancers, would predict the response of rectal cancers to neoadjuvant chemoradiotherapy and prognosis. METHODS  Patients with locally invasive (T2–4) primary or node-positive rectal cancer located <12 cm from the anal verge were recruited for this pilot study. Pretreatment tumor size and stage were determined by endorectal ultrasonography, CT, and magnetic resonance imaging. Eleven patients also underwent clinical positron emission tomography with ¹⁸F-fluorodeoxyglucose at the discretion of the treating clinician. The primary tumor was imaged by positron emission tomography with ⁶⁰Cu-ATSM, and accumulation of the tracer was measured semiquantitatively by determining the tumor-to-muscle activity ratio. Neoadjuvant chemoradiotherapy was then administered (within 2 weeks of ⁶⁰Cu-ATSM-positron emission tomography) and consisted of 45 Gy given in 25 fractions to the pelvis with continuous intravenous infusion of 5-fluorouracil (225 mg/m²/day). Proctectomy was performed six to eight weeks after neoadjuvant chemoradiotherapy and the tumor submitted to pathology for size measurement and staging. Tumor-to-muscle activity ratios were compared with tumor ¹⁸F-fluorodeoxyglucose uptake, tumor response to neoadjuvant chemoradiotherapy, and with patient survival. RESULTS  Nineteen patients were enrolled in the study, two of whom were excluded from final analysis (1 death during neoadjuvant chemoradiotherapy and 1 tumor perforation during neoadjuvant chemoradiotherapy requiring emergent surgery). Of the 17 remaining patients, 14 had a reduction in tumor size and 13 were downstaged. The median tumor-to-muscle activity ratio of 2.6 discriminated those with worse prognosis from those with better prognosis. Both overall and progression-free survivals were worse with hypoxic tumors (tumor-to-muscle activity ratio >2.6) than with nonhypoxic tumors (tumor-to-muscle activity ratio ≤2.6; both P < 0.05). In addition, 2 of the 3 tumors with no change in size had tumor-to-muscle activity ratios >2.6 (positive predictive value 66 percent), whereas 6 of 14 with decreased size had tumor-to-muscle activity ratios >2.6 (negative predictive value 57 percent). Three of the 4 tumors not downstaged had tumor-to-muscle activity ratios >2.6 (positive predictive value 75 percent), whereas 5 of 13 downstaged tumors had tumor-to-muscle activity ratios >2.6 (negative predictive value 62 percent). The mean tumor-to-muscle activity ratio for downstaged tumors (2.2) was significantly lower than that of nondownstaged tumors (3.3) (P = 0.03). The difference in mean tumor-to-muscle activity ratio between downsized (2.3) and nondownsized (2.9) tumors did not reach statistical significance (P = 0.36). Tumor ¹⁸F-fluorodeoxyglucose uptake (n = 11) did not correlate with ⁶⁰Cu-ATSM uptake (r = 0.4; P = 0.9) and there was no significant difference in mean tumor ¹⁸F-fluorodeoxyglucose uptake between patients with hypoxic tumors and those with normoxic tumors (P = 0.3). CONCLUSIONS  The results of this small pilot study suggest that ⁶⁰Cu-ATSM-PET may be predictive of survival and, possibly, tumor response to neoadjuvant chemoradiotherapy in patients with rectal cancer. A larger Phase II study is warranted to validate these results. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. Supported by an American Cancer Society Institutional Research Grant (ACS-IRG #58–010–46).     

Clinical and structural remission rates increased annually and radiographic progression was continuously inhibited during a 3-year administration of tocilizumab in patients with rheumatoid arthritis: A multi-center,prospective cohort study by the Michinoku Tocilizumab Study Group

Objective: To evaluate the clinical and structural efficacy of tocilizumab (TCZ) during its long-term administration in patients with rheumatoid arthritis (RA).

Methods: In total, 693 patients with RA who started TCZ therapy were followed for 3 years. Clinical efficacy was evaluated by DAS28-ESR and Boolean remission rates in 544 patients. Joint damage was assessed by calculating the modified total Sharp score (mTSS) in 50 patients.

Results: When the reason for discontinuation was limited to inadequate response or adverse events, the 1-, 2-, and 3-year continuation rates were 84.0%, 76.8%, and 72.2%, respectively. The mean DAS28-ESR was initially 5.1 and decreased to 2.5 at 6 months and to 2.2 at 36 months. The Boolean remission rate was initially 0.9% and increased to 21.7% at 6 months and to 32.2% at 36 months. The structural remission rates (ΔmTSS/year?≤?0.5) were 68.8%, 78.6%, and 88.9% within the first, second, and third years, respectively. The structural remission rate at 3 years (ΔmTSS?≤?1.5) was 66.0%, and earlier achievement of swollen joint count (SJC) of 1 or less resulted in better outcomes.

Conclusions: TCZ was highly efficacious, and bone destruction was strongly prevented. SJC was an easy-to-use indicator of joint destruction.     

Identification of Left Ventricular “Rigid Body Rotation” by Three‐Dimensional Speckle‐Tracking Echocardiography in a Patient with Noncompaction of the Left Ventricle: A Case from the MAGYAR‐Path Study

Noncompaction of the left ventricular myocardium (LVNC) is a new clinical entity firstly described by Engberding and Bender in 1984. LVNC is characterized by the presence of numerous prominent trabeculations and deep intertrabecular recesses within the left ventricle. Recently, it has been demonstrated by two‐dimensional (2D) speckle‐tracking echocardiography (STE), that left ventricular (LV) basal and LV apical rotations are in the same direction resulting in the near absence of LV twist in LVNC patients, which was called as “LV solid/rigid body rotation.” Three‐dimensional (3D)‐STE has just been introduced, and found to be an accurate method for the evaluation of LV rotation mechanics. The aim of this report was to confirm LV “rigid body rotation” in an LVNC patient by 3D‐STE.