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Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.
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Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.
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Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.
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The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).Copyright © 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.
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Aim: To study the characterization of the CT Brain in COVID 19. Material(s) and Method(s): Patients of COVID 19 who had neurological signs either before they were admitted or while they were in the hospital had a CT brain plain once during their time in the hospital. CT Brain plain presentations were shown to correspond with CNS symptoms, progression throughout the patients' hospital stays, and outcomes. Several tests, such as RT-PCR for COVID 19, CT Brain plain, complete blood count, liver function tests, renal function tests with electrolytes, and others were performed. Result(s): In the current investigation, there were a total of 50 patients, 46 (92%) of whom were male, while just 4 (8%), on the other hand, were female. The patients' ages ranged anywhere from 35 to 82 years old, with a mean of 65.85+/-8.69 years. NLR was 14.98+/-2.69 (range 1.31-47.5), mean LDH 992.17+/-25.69 (range 221-5125), and Hs-CRP was 171.22+/-22.69 (range 2.9-321.5). Mean haemoglobin of the patients was 11.12+/-1.85 (range 4-15 g/dl), total leukocyte count was 16580.63+/-5896.45, mean platelet count was 2.11+/-1.02 / lacs (0. 27 patients, or 54%, were discovered to have had an ischemic stroke, whereas 5 patients, or 10%, were found to have had a hemorrhagic stroke. The CT brain results were found to be abnormal in 30 individuals (or 60%), whereas in 20 patients (or 40%), they were determined to be normal. 11 (22%) of the patients required the assistance of a ventilator, 6 (12%), of the patients used a BiPAP, 2 (4%), of the patients used a Hudson mask, and 10 (20%) of the patients had NRM. Conclusion(s): In conclusion, we were surprised to find that the proportion of patients with severe COVID-19 infection who had abnormal brain CT scans was rather significant. Ischemic stroke was the most common kind of stroke that occurred in conjunction with aberrant CT results. We believe that the connection between aberrant brain CT and the fate of patients warrants further validation in a wider patient population.Copyright ©2022Int. J. Life Sci. Biotechnol. Pharma. Res.
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The RUTIROX clinical trial aims to determine clinical predictors of respiratory failure using high-flow nasal cannula (HFNC) for acute respiratory failure (ARF) P/F ratio<200 due to COVID-19 pneumonia. Study protocol includes a change to NIV after HFNC failure, prior to endotracheal intubation (ETI). Local ethics committee approval NCT05094661. Method(s): Interventional randomized study in PICU during Mar-Nov 21. In supine position HFNC was started at 60l/min Fio2 0.9, ABG and analysis were controled. If respiratory failure (defined as RR>30 or Sat<92% or P/F<80) occurred, participants were randomized to CPAP/BPAP. At day 28 ETI and death were evaluated. Statistical analysis SPSS. Chi-square tests, U-Mann Whitney and ROC analysis. Result(s): n=128 63% Men. Mean age 62. Mean P/F 164. 49% required NIV (28 CPAP/35 BIPAP). 21.9% required ETI. Mortality 9.3%. Advanced age, diabetes, neoplasia, low P/F ratio, low pO2 and high initial LDH value, were significantly more frequent in HFNC failure group (p-value <0.05). Area Under the ROC curve (AUC) of initial LDH is 0,65 (level of 300 U/L) and LDH at 48h 0,67. AUC of P/F is 0,69 for survival. No differences were found between NIV groups. Conclusion(s): Older age, higher degree of ARF and high LDH value are factors associated with HFNC failure. Despite presenting high intragroup failure frequency values, ETI rate and mortality rate were lower than those reported in other series. (Figure Presented).
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Introduction: The occurrence of pneumomediastinum (PNMMD) or pneumothorax (PNMTX) was evaluated in patients with severe SARS-CoV-2 pneumonia. Method(s): This is a prospective observational descriptive study that was carried out on patients admitted to the IRCU of a COVID-19 monographic hospital in Madrid from 14/01/2021 to 27/09/2021. All of them had a diagnosis of severe SARS-CoV-2 pneumonia and required NIRS (HFNC, CPAP, BPAP). The incidences of PNMMD and PNMTX, total and according to NIRS, and their impact on the probability of IMV and death were studied. Result(s): (tables 1 and 2) 4.3% (56/1306) developed PNMMD or PNMTX, 3.8% (50) PNMMD, 1.6% (21) PNMTX, and 1.1% (15) PNMMD+PNMTX. 16.1% of patients with PNMMD or PNMTX had HFNC alone (vs 41.7% without PNMMD or PNMTX;p<0.001) and 83.9% CPAP (vs 57.5%;p<0.001). There was a probability of needing IMV of 64.3% among patients with PNMMD or PNMTX (vs 21.0%;p<0.001), and a mortality of 33.9% (vs 10.5%;p<0.001). Conclusion(s): In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia who required NIRS, incidences of 3.8% for PNMMD and 1.6% for PNMTX were observed. LDH was a risk factor for developing PNMMD or PNMTX (median 438 vs 395;p=0.013), and PNMMD (median 438 vs 395;p=0.014). The majority of patients with PNMMD or PNMTX had CPAP as the NIRS device, much more frequently than patients without PNMTX or PNMMD. However, the pressures used in CPAP were even lower in patients with PNMMD or PNMTX (median 8 vs 10;p=0.031). The probabilities of IMV and mortality among patients with PNMMD or PNMTX were 64.3% and 33.9%, respectively, higher than in patients without PNMMD or PNMTX, 21.0% and 10.5%.
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A painful lesson got from pandemic COVID-19 is that preventive healthcare service is of utmost importance to governments since it can make massive savings on healthcare expenditure and promote the welfare of the society. Recognizing the importance of preventive healthcare, this research aims to present a methodology for designing a network of preventive healthcare facilities in order to prevent diseases early. The problem is formulated as a bilevel non-linear integer programming model. The upper level is a facility location and capacity planning problem under a limited budget, while the lower level is a user choice problem that determines the allocation of clients to facilities. A genetic algorithm (GA) is developed to solve the upper level problem and a method of successive averages (MSA) is adopted to solve the lower level problem. The model and algorithm is applied to analyze an illustrative case in the Sioux Falls transport network and a number of interesting results and managerial insights are provided. It shows that solutions to medium-scale instances can be obtained in a reasonable time and the marginal benefit of investment is decreasing. © 2023, Journal of Industrial and Management Optimization. All Rights Reserved.
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The COVID-19 pandemic forced upon the world, severe social distancing restrictions, which led to prolonged confinement across populations. The latter directly impacted actors along the supply chain in a variety of industrial sectors (for instance, raw material suppliers, manufacturers, distributors, and customers, among others). Some actors involved had to cease participation altogether due to closures. As a result, the supply chain requires restructuring and its reactivation requires careful consideration. In addition to the pandemic, poor air quality has brought about an environmental crisis in recent years. Primary polluters include greenhouse gas (GHG) emissions caused by manufacturers and distributors. Therefore, this research studies the problem of restructuring a particular multicommodity and hierarchized supply chain. Specifically for companies dealing with situations derived from a reduction in manufacturing capacity and service level in light of the pandemic. In this case, a company (leader) is faced with selecting customers that it will service in pursuit of maximizing profit, all while looking to minimize GHG emissions. The consolidated demand is nearshored once the leader company decides on the customers to be supplied. That is, an order is placed on a company with a lower hierarchy (follower). The follower, in turn, aims to minimize its own manufacturing costs without exceeding the pollution limits imposed by the government. However, its manufacturing plan inevitably pollutes and incurs different costs. In addition, the follower's decisions impact both leader's objective functions. We propose a bi-objective bi-level programming model to study this situation. To solve the problem in reasonable computational time, a heuristic algorithm that takes into account existing asynchrony between leader and follower companies is proposed to approximate the Pareto front. Computational experimentation reveals that the proposed algorithm provides good trade-off solutions, which can reduce GHG emissions by 67% on average without significantly affecting company revenue. Moreover, the algorithm is able to provide solutions for instances of up to 1000 nodes in a competitive computational timeframe. In addition, we discuss the advantages of computing GHG emissions proposed herein. Finally, useful managerial insights are discussed by performing a sensitivity analysis regarding the distribution company's minimum acceptable level of profit. © 2023 Elsevier Ltd
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Background Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an extremely rare disorder. Case A 20-year-old, 36-week pregnant female (G1P0) presented with acute shortness of breath, sharp chest pain and fever. She was COVID-19 positive and required BiPAP. Echocardiogram showed 40% EF, dilated LV with global hypokinesis and moderate mitral regurgitation (MR). She was hypotensive and on oxygen despite diuresis, emergent cesarean and COVID-19 treatment. Left heart catheterization showed anomalous takeoff of the left main coronary artery (LCA) from the dilated pulmonary artery (PA) with coronary steal (Figure 1). She had ALCAPA repair with LIMA to LAD bypass grafting. Decision-making Differential diagnoses included peripartum cardiomyopathy, Covid-myocarditis, pulmonary embolism, and spontaneous coronary artery dissection. LHC was performed only when symptoms failed to improve and troponin kept rising. ALCAPA has two major clinical subtypes - Infantile type and adult type. Adult type presents as dyspnea, chest pain, reduced exercise ability, and sudden cardiac death. Despite having good RCA to LCA collaterals, adult patients can still have ongoing ischemia of the LV myocardium, causing ischemic MR, malignant ventricular dysrhythmias. Diagnosis was delayed due to pregnancy and COVID-19 infection. Conclusion ALCAPA is a lethal coronary disorder. Elevated troponin and dilated cardiomyopathy with acute MR should raise suspicion of ALCAPA in young adults. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Designing efficient vaccination programs that consider the needs of the population is very relevant to prevent reoccurrence of the COVID-19 pandemic. The government needs to provide vaccination points to give out vaccine doses to the population. In this paper, the authors analyze the location of vaccination points whilst addressing the inhabitants' preferences. Two objectives that prevent crowding of inhabitants are considered. The government aims for the minimum distance between located vaccination points is maximized, and for the number of inhabitants that attend the different vaccination points to be equitable. One of the key aspects of this problem is the assumption that inhabitants freely choose the located vaccination point to go. That decision affects the objectives of the government, since crowding at vaccination points may appear due to the inhabitants' decisions. This problem is modeled as a bi-objective, bi-level program, in which the upper level is associated to the government and the lower level to the inhabitants. To approximate the Pareto front of this problem, a cross-entropy metaheuristic is proposed. The algorithm incorporates criteria to handle two objective functions in a simultaneous manner, and optimally solve the lower-level problem for each government decision. The proposed algorithm is tested over an adapted set of benchmark instances and pertinent analysis of the results is included. An important managerial insight is that locating far vaccination points does not lead us to a more equitable allocation of inhabitants. © 2023 by the authors.
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Background: Non-invasive ventilation (NIV) has been tried in COVID-19 ARDS (CARDS), and its role is being increasingly recognised. If proven, it could be a game-changer in resource limited settings. We report our experience with administration of respiratory support using a tabletop NIV device in a respiratory intermediate care unit (RIMCU). Methodology: We retrospectively studied a cohort of hospitalised COVID-19 patients, who received protocolised management with positive airway pressure using a tabletop NIV device in the RIMCU as a step-up rescue therapy for deterioration despite low flow oxygen support. Treatment was commenced with continuous positive airway pressure (CPAP) mode up to a pressure of 10 cm H2O and if required inspiratory pressures were added with the bilevel positive airway pressure (BPAP) mode. Success was defined as weaning from NIV and stepping down to the ward. Failure was defined as escalation to the intensive care unit (ICU) or need for intubation or death. Result(s): In all, 246 patients were treated in the RIMCU during the study period. Of these, 168 received respiratory support via tabletop NIV device as a step-up rescue therapy. Their mean age was 54 years, and 83% were males. Diabetes Mellitus (78%) and hypertension (44%) were the commonest comorbidities. Treatment was successful with tabletop NIV in 77%;of this, 41% was on CPAP alone and 36% after receiving increased inspiratory pressures on BPAP mode. Conclusion(s): Respiratory support using a tabletop NIV device is an effective, and economical treatment for CARDS. Further studies are required to assess the appropriate time of initiation for maximal benefit and judicious resource utilisation.
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The need for a study of project portfolio optimization in pharmaceutical R&D has become all the more urgent with the outbreak of COVID-19. This study examines a new model for optimizing R&D project portfolios under a decentralized decision-making structure in a pharmaceutical holding company. Specifically, two levels of decision makers hierarchically decide on budget allocation and project portfolio selection-scheduling to maximize their profit, and we formulate the problem as a bi-level multi-follower mixed-integer optimization model. At the upper level, the investment company has complete knowledge of the subsidiaries' response, acts first, and decides on the best budget allocation. At the lower level, each subsidiary responds to the allocated budget and decides on its portfolio scheduling. Since the lower level represents several mixed-integer programming problems, solving the resulting bi-level model is challenging. Therefore, we propose an efficient hybrid solution approach based on parametric optimization and convert the bi-level model into a single-level mixed-integer model. To validate it, we solve a case and discuss the optimal strategy of each actor. The experimental results show that the planned project portfolio for each subsidiary of the holding company is drastically affected by the allocated budget and its decisions. Supplementary Information: The online version contains supplementary material available at 10.1007/s10479-022-05052-0.
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Bi-level programming is an efficient tool to tackle decentralized decision-making processes in supply chains with upper level (i.e., leader) and lower level (i.e., follower). The leader makes the first decision while the follower makes the second decision. In this research, a bi-level programming formulation for the problem of location-inventory-routing in a two-echelon supply chain, including a number of central warehouses in the first echelon and retailers in the second echelon with perishable products under uncertain demand, is proposed. The total operational costs at both levels are minimized considering capacity constraints. Due to the uncertain nature of the problem, a scenario-based programming is utilized. The economic condition or unforeseen events such as COVID-19 or Russia-Ukraine war can be good examples for uncertainty sources in today's world. The model determines the optimal locations of warehouses, the routes between warehouses and retailers, number of received shipments and the amount of inventory held at each retailer. A revised solution method is designed by using multi-choice goal programming for solving the problem. The given revised method attempts to minimize the deviations of each decision maker's solution from its ideal value assuming that the upper level is satisfied higher than the lower level. Base on some numerical analysis, the proposed solution technique is more sensitive to the upper bounds of the goals rather than the lower bounds. © 2022 Elsevier B.V.
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Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd
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To mitigate the spread of novel coronavirus, how to optimise COVID-19 medical waste location-transport strategies remains an open but urgent issue. In this paper, a novel digital twin-driven conceptual framework is proposed to improve the strategic decision on the location of temporary disposal centres and, subsequently, the operational decision on the transport of COVID-19 medical waste in the presence of hierarchical relationships amongst stakeholders, circular economy, uncertainty in infection probability, and service level. The circular economy aspect is measured by the reduction of infection risks and costs, as well as limiting exhaust emissions. The polyhedral uncertainty set is introduced to characterise stochastic infection probability. Digital twin technology is further used to estimate the upper and lower bound of the uncertainty set. Such a problem is formulated as a digital twin-driven robust bi-level mixed-integer programming model to minimise total infection risks on the upper level and total costs on the lower level. A hybrid solution strategy is designed to combine dual theory, Karush-Kuhn-Tucker (KKT) conditions, and a branch-and-bound approach. Finally, a real case study from Maharashtra in India is presented to evaluate the proposed model. Results demonstrate that the solution strategy performs well for such a complex problem because the CPU time required to conduct all experiments is less than one hour. Under a given uncertainty level of 36 and perturbation ratio of 20%, a regional transport strategy is preferred from generation points to transfer points, while a cross-regional one is usually implemented from transfer points to disposal centres. It is of significance to determine the bound of available temporary disposal centres. Using digital technology (e.g., digital twin) to accurately estimate the amount of COVID-19 medical waste is beneficial for controlling the pandemic. Reducing infection risks relative to cost is the prioritised goal in cleaning up COVID-19 medical waste within a relatively long period.
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The COVID-19 pandemic has taught global businesses that a pandemic can put business dynamics in unforeseeable turbulence. The disruptions created by the pandemic in the apparel industry exposed the vulnerabilities of apparel supply chains (SCs). To recover the supply chain impacts (SCIs) during an unprecedented event such as the COVID-19 pandemic, apparel SCs need a robust framework that can identify, measure, and mitigate the severity of SCIs by assessing effective mitigation strategies. This study identifies 12 critical SCIs in apparel SCs during a pandemic and 17 mitigation strategies. To assess SCIs and mitigation strategies, a modified grey-based bi-level analytical network process (ANP) is proposed to deal with the complex relationship between the SCIs and mitigation strategies. A real-life case study is conducted from an apparel supply chain for validation purposes. The findings suggest that policymakers in apparel SCs should prioritize implementing government policies and financial aid to deal with increased material and operational costs, the sudden surge in the unemployment rate, cancellation of orders and delayed payment, and increased transportation costs during a pandemic. This study also contributes to the literature by providing a robust decision-making framework for practitioners to deal with the complexity of SCs during future pandemics.
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Finding the infected regions in medical image modalities is a crucial and challenging task. In this paper, a new image segmentation method is introduced to detect the COVID-19 infection in CT images. In this method, a bi-level-thresholding based image segmentation is proposed using Henry gas solubility optimization. This method used Kapur entropy as a fitness function. Efficiency of the developed segmentation method has been validated on publicly available CT images of COVID-19 patients in terms of PSNR (Pick Signal-to-Noise Ratio), MSE (Mean Square Error), SSIM (Structural Similarity Index Measure) and FSIM (Feature Similarity Index Measure). Moreover, the proposed HGSO-based segmentation method has been compared with SCA, SSA, GWO, CPSOGSA, and MFO-based image segmentation methods to show its efficacy. © 2022 IEEE.
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INTRODUCTION: Intensivists have faced difficult decisions about when to intubate patients during the Covid 19 pandemic. Initial studies had suggested that early intubation may be beneficial, as patients would avoid self induced lung injury, whereas later studies indicated that delaying intubation could be advantageous in some patients by avoiding the inherent risks of mechanical ventilation. This study aims to assess if NIPPV and HiFlow NC are safe methods of oxygenation in patients with Covid 19 ARDS and can prevent intubation. METHOD(S): A retrospective chart review of 693 patients was conducted. These patients tested positive for Covid 19 during hospitalization AND required supplemental oxygen via either HiFlow or NIPPV (including CPAP and BiPAP). Demographic and clinical characteristics were compared between intubated and nonintubated patients. Associations between days on NIPPV/HiFlow and hospital outcomes were assessed by univariable linear regression for continuous outcomes and by univariable logistic regression for dichotomous outcomes. Subgroup analysis was conducted on patients who were intubated, those who were in the ICU, and those who died. All analyses were conducted using R v. 4.0.3. RESULT(S): Among all patients, each additional day on NIPPV/HiFlow was associated with a 0.14 day decrease in overall hospital length of stay and reduced odds of intubation. Furthermore, each additional day on NIPPV/HiFlow was NOT associated with increased odds of complications such as VTE, PE, cerebral thrombosis, pneumothorax, GI bleeding or ICU admission. This held true in the subgroups as well. We also found that when compared against nonintubated patients, intubated patients had a significantly shorter median length of time on NIPPV/HiFlow (5 days vs 7) and a longer total median hospital length of stay (23 days vs 11), along with a significantly higher rate of VTE (15% vs 4.9%), pneumothorax (8.1% vs 1.5%), cerebral thrombosis (4.5% vs 1.5%), and PE (4.5% vs 1.1%). CONCLUSION(S): Our results suggest that NIPPV/ HiFlow does not worsen patient outcomes in patients with Covid 19 and may save some patients from intubation. Nonetheless, intubation should not be withheld in patients who decompensate on NIPPV/HiFlow as these patients have more Covid related complications and require additional support.
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INTRODUCTION: Achromobacter denitrificans bacteremia is a rare condition and generally affects adults with multiple comorbidities and is usually a hospital acquired infection. We report a case of hospital acquired Achromobacter denitrificans bacteremia in a young female without any comorbidities, who presented to the hospital with severe viral pneumonia. DESCRIPTION: A 33-year-old female was presented to the ER with increasing difficulty in breathing. On examination, she had labored breathing. Her oxygen saturation was 80% at room air. With oxygen support via face mask, her saturation increased to 83% with 15 L/min. Then non-invasive ventilation via BiPAP it improved to 90% and she was admitted to the medical ICU. Meanwhile, as per history from the husband, she had a cough and coryza for the past one week and was taking over the counter medications. Lab investigations at the time of admission reported WBC count as 7500/ cumm. She was tested negative for COVID-19. HR CT-scan showed bilateral ground glass opacities with bilateral patchy consolidations. For worsening hypoxia, she was intubated and placed on ventilator support (FiO2:60%). Her blood and urine culture reports were negative. The Liver function tests showed elevated SGOT/SGPT, suggesting acute hypoxic liver injury. Supportive care with IV steroids, and broad-spectrum antibiotics Pipercillin and Tazobactam was provided. In the second week, the patient's WBC started rising and peaked at 40,000/cumm on Day-10. Her condition worsened further despite being on 100% FiO2. The tracheal sample grew a colony of Acinetobacter Baumannii, while her blood cultures reported positive for A. Denitrificans sensitive to Pipercillin and Tazobactum. Chest X-Ray suggested features of acute respiratory distress syndrome with no signs of a cavitary lesion or abscess. Ultrasound abdomen and Echocardiography ruled out other sources of infection. Despite ventilatory support and medications, the patient deteriorated, and passed away after cardiorespiratory arrest. DISCUSSION: Achromobacter denitrificans cause opportunistic nosocomial infections, which has been recovered from ventilators, humidifiers, "sterile" saline, and IV fluids. A. denitrificans is associated with pneumonia, peritonitis, bacteremia, endocarditis, empyema, renal abscess, and pancreatic pseudocysts.