Pulmonary embolism with thrombus in transit across a patent foramen ovale.

Thromboembolism-in-transit, specifically impending paradoxical embolism (IPDE), is a rare and life-threatening condition with limited reported cases. We present a case of a 51-year-old male with obstructive sleep apnea, initially diagnosed with deep vein thrombosis and pulmonary embolism. Further evaluation revealed a saddle pulmonary embolus extending into the right atrium, straddling a patent foramen ovale (PFO), confirmed by transesophageal echocardiogram. Despite a critical left anterior descending coronary artery stenosis, surgical thrombectomy, PFO closure, and coronary artery bypass grafting were successfully performed. Thromboembolism-in-transit poses diagnostic challenges, and there is a lack of consensus on the optimal treatment strategy. Surgical interventions, including embolectomy and PFO closure, have shown promise, while thrombolytic therapy remains controversial. This case underscores the importance of tailored management in the absence of standardized guidelines, emphasizing the need for further research to establish evidence-based protocols for this uncommon but potentially fatal condition.

Safety and efficacy of L-Glutamine in reducing the frequency of acute complications among patients with sickle cell disease: A randomized controlled study.

To evaluate the safety and efficacy of L-glutamine in reducing vaso-occlusive crisis (VOC) and improving cerebral arterial blood flow in children with sickle cell disease (SCD). This is an interventional randomized controlled trial that recruited sixty SCD patients, aged 9.2 ± 3.7 years, who had at least two VOCs during the last 12 months and on a stable dose of hydroxyurea. They were randomly assigned in a 1:1 ratio to receive glutamine (0.3 gm/kg/dose/12h) orally for 24 weeks or the standard of care (SOC). All patients had VOCs in the last year > 3, those on glutamine had a higher number of VOCs and hospitalization for VOC in the last year. There was a decreasing trend in the number, severity, and hospitalization of VOC and a significantly lower cumulative number of VOCs and hospitalizations in the glutamine group than in SOC (p = 0.008, p < 0.001 respectively). Time-averaged mean maximum velocity for the glutamine group had a marginal increase in both middle cerebral arteries, all values remained normal within a normal range, and in both internal carotid arteries, values increased from abnormally low to normal ranges at week 24. Glutamine reduced the number of VOCs and severity and may have a potentially favorable impact on the cerebral arterial flow velocities.

Kv7 Channel Activators Flupirtine and ML213 Alleviate Neuropathic Pain Behavior in the Streptozotocin Rat Model of Diabetic Neuropathy.

Background & Objective: Chronic peripheral neuropathic pain (PNP) is a debilitating condition that is associated with many types of injury/diseases, including diabetes mellitus. Patients with longstanding diabetes develop diabetic PNP (DPNP), which is resilient to currently available drugs. The underlying molecular mechanisms of DPNP are still illusive, but Kv7 channels that have been implicated in the pathogenesis of various types of chronic pain are likely to be involved. Indeed, using the streptozotocin (STZ) rat model of DPNP, we have previously shown that Kv7 activation with their non-selective activator retigabine attenuated neuropathic pain behavior suggesting that these channels are implicated in DPNP pathogenesis. Here, we evaluated, in the same STZ model, whether the more potent and more selective Kv7 channel openers flupirtine and ML213 attenuate STZ-induced pain hypersensitivity. Methods: Male Sprague Dawley rats (250-300 g) were used. The STZ model involved a single injection of STZ (60 mg/kg, i.p.). Behavioral testing for mechanical and heat pain sensitivity was performed using a dynamic plantar aesthesiometer and Hargreaves analgesiometer, respectively. Results: STZ rats exhibited behavioral signs of mechanical and heat hypersensitivity as indicated by significant decreases in the mean paw withdrawal threshold (PWT) and mean paw withdrawal latency (PWL), respectively, at 35 days post-STZ treatment. Single injections of flupirtine (10 mg/kg, i.p.) and ML213 (5 mg/kg, i.p.) to STZ rats (35-days after STZ treatment) caused significant increases in the mean PWT, but not PWL, indicating attenuation of mechanical, but not heat hypersensitivity. Both flupirtine and ML213 were as effective as the positive control gabapentin (10/kg, i.p.), and their anti-allodynic effects were prevented by the Kv7 channel-specific blocker XE991 (3 mg/kg, i.p.). Conclusion: The findings suggest that Kv7 channels are involved in the mechanisms of mechanical but not heat hypersensitivity associated with DPNP, and that their activation may prove to be effective in alleviating DPNP symptoms.

Infectious Mononucleosis Revealed by Non-steroidal Anti-inflammatory Drug: A First Clinical Report.

Infectious mononucleosis (IM), primarily caused by the Epstein-Barr virus (EBV), is a common viral illness among adolescents and young adults. IM typically presents with symptoms such as fever, lymphadenopathy, and pharyngitis. We present a case of a 32-year-old woman who developed a maculopapular rash following ibuprofen administration, revealing an underlying undiagnosed IM. Laboratory investigations confirmed EBV infection. This represents the first documented case linking non-steroidal anti-inflammatory drugs (NSAIDs) to IM presentation. Awareness of this association is crucial for timely diagnosis and management, especially when evaluating patients with unexplained skin reactions to medications.

Stacked hybridization to enhance the performance of artificial neural networks (ANN) for prediction of water quality index in the Bagh river basin, India.

Water quality assessment is paramount for environmental monitoring and resource management, particularly in regions experiencing rapid urbanization and industrialization. This study introduces Artificial Neural Networks (ANN) and its hybrid machine learning models, namely ANN-RF (Random Forest), ANN-SVM (Support Vector Machine), ANN-RSS (Random Subspace), ANN-M5P (M5 Pruned), and ANN-AR (Additive Regression) for water quality assessment in the rapidly urbanizing and industrializing Bagh River Basin, India. The Relief algorithm was employed to select the most influential water quality input parameters, including Nitrate (NO3-), Magnesium (Mg2+), Sulphate (SO42-), Calcium (Ca2+), and Potassium (K+). The comparative analysis of developed ANN and its hybrid models was carried out using statistical indicators (i.e., Nash-Sutcliffe Efficiency (NSE), Pearson Correlation Coefficient (PCC), Coefficient of Determination (R2), Mean Absolute Error (MAE), Root Mean Square Error (RMSE), Relative Root Square Error (RRSE), Relative Absolute Error (RAE), and Mean Bias Error (MBE)) and graphical representations (i.e., Taylor diagram). Results indicate that the integration of support vector machine (SVM) with ANN significantly improves performance, yielding impressive statistical indicators: NSE (0.879), R2 (0.904), MAE (22.349), and MBE (12.548). The methodology outlined in this study can serve as a template for enhancing the predictive capabilities of ANN models in various other environmental and ecological applications, contributing to sustainable development and safeguarding natural resources.

Asthma prevalence among United States population insights from NHANES data analysis.

Asthma is a prevalent respiratory condition that poses a substantial burden on public health in the United States. Understanding its prevalence and associated risk factors is vital for informed policymaking and public health interventions. This study aims to examine asthma prevalence and identify major risk factors in the U.S. POPULATION: Our study utilized NHANES data between 1999 and 2020 to investigate asthma prevalence and associated risk factors within the U.S. POPULATION: We analyzed a dataset of 64,222 participants, excluding those under 20 years old. We performed binary regression analysis to examine the relationship of demographic and health related covariates with the prevalence of asthma. The study found that asthma affected 8.7% of the U.S. POPULATION: Gender emerged as a significant factor, with 36.0% of asthma patients being male and 64.0% female (p < 0.001). Individuals aged 60 and older having the highest asthma prevalence at 34.0%. Non-Hispanic whites had the highest prevalence at 46.4%, followed by non-hispanic blacks at 26.0%. In contrast, Mexican Americans and other hispanic individuals had lower rates, at 9.6% and 9.0%, respectively. Females were 1.76 times more likely to have asthma than males (p < 0.001). Obese individuals had a 1.74 times higher likelihood of current asthma compared to underweight individuals (p < 0.001). Notably, both Non-Hispanic Whites and Non-Hispanic Blacks showed higher odds of current asthma compared to Mexican Americans (with adjusted odds ratios of 2.084 and 2.096, respectively, p < 0.001). The research findings indicate that asthma is prevalent in 8.7% of the U.S. POPULATION: Our study highlights that individuals who are female, have low income, are obese, and smoke have the highest likelihood of being affected by asthma. Therefore, public health policies should prioritize addressing these risk factors in their preventive strategies.

A practical guide to the management of immune thrombocytopenia co-existing with acute coronary syndrome.

Introduction: Immune thrombocytopenia (ITP) management with co-existing acute coronary syndrome (ACS) remains challenging as it requires a clinically relevant balance between the risk and outcomes of thrombosis and the risk of bleeding. However, the literature evaluating the treatment approaches in this high-risk population is scarce. Methods and Results: In this review, we aimed to summarize the available literature on the safety of ITP first- and second-line therapies to provide a practical guide on the management of ITP co-existing with ACS. We recommend holding antithrombotic therapy, including antiplatelet agents and anticoagulation, in severe thrombocytopenia with a platelet count < 30 × 109/L and using a single antiplatelet agent when the platelet count falls between 30 and 50 × 109/L. We provide a stepwise approach according to platelet count and response to initial therapy, starting with corticosteroids, with or without intravenous immunoglobulin (IVIG) with a dose limit of 35 g, followed by thrombopoietin receptor agonists (TPO-RAs) to a target platelet count of 200 × 109/L and then rituximab. Conclusion: Our review may serve as a practical guide for clinicians in the management of ITP co-existing with ACS.

Forensic investigation of carcass decomposition and dipteran fly composition over the summer and winter: a comparative analysis of indoor versus outdoor at a multi-story building.

This study aimed to explore the rate of decomposition of rabbit carcasses and the succession pattern of the associated dipteran flies outdoor, indoor, and on the roof of a 4-story building during the summer and winter. A total of 6,069 flies were recorded, with 30.91% reported as 2 waves outdoor and on the roof in the summer and 69.09% as 4 waves outdoor in the winter. The roof showed the most flies in the summer but the least in the winter, whereas the outdoor showed the most in the winter but the least in the summer. The ground and first floors showed the most indoor flies, while the second and third floors showed the least in both seasons. Indoor carcasses decomposed slower than those outdoor, and those on the second and third floors decomposed slower than those on the ground and first floors. Ten fly species from 8 families were identified in the winter, compared to 6 from 5 families in the summer. The most abundant species was Musca domestica Linnaeus (Muscidae) on the roof in the summer, while it was Chrysomya albiceps (Wiedemannn) (Calliphoridae) outdoor in the winter. The rare species (singletons) were Musca sp. (Muscidae) and Megaselia scalaris (Loew) (Phoridae) on the first floor in both seasons, Scaptomyza pallida (Zetterstedt) (Drosophilidae) on the ground floor in the summer, and Atherigona orientalis Schiner (Muscidae) outdoor in the winter. These data highlight the variance in carcass decomposition and fly composition across outdoor, indoor, and the roof of human dwellings, which could be of forensic importance.

Forensic analysis of mosquito blood meal digestion process and the impact of heroin opiate: determination of the post-feeding interval as a PMI estimation.

Females of some mosquito species are anthropophilic, as they feed on human blood to support egg production and, hence, are forensically valuable if found at a crime scene. The present study investigated the blood meal digestion process in Culex pipiens L. both with and without heroin and proposed a method for estimating the post-feeding interval (PFI). Mosquitoes were fed on a control mouse, a heroin-injected mouse, or in vitro heroin-treated mouse blood. The blood meal digestion was then investigated at different hours post-feeding. Data showed that the blood meal size ingested by control mosquitoes was 0.681 ±â€…0.04 mg/mosquito and was completely digested within 45 h post-feeding. An estimation of the PFI was proposed in terms of the rate of hemoglobin (Hb) digestion. The blood meal size of the mosquitoes fed on the in vitro heroin-treated blood and the heroin-injected mouse was 0.96 ±â€…0.06 and 0.79 ±â€…0.01 mg/mosquito and was completely digested within 50 and 55 h post-feeding, respectively. The digestion of Hb started similarly in all experimental mosquitoes until 10 h post-feeding, after which it significantly decreased in heroin-treated blood meals compared with the control ones. This may suggest that heroin impacted the digestion process, as it took an extra 5-10 h to complete. These findings could be valuable in the forensic context since an estimation of PFI is proposed as a potential estimation of the postmortem interval (PMI). However, care should be taken as heroin in the host blood has significantly impacted the overall digestion process and, hence, may bias the PFI/PMI estimation.

Percutaneous coronary intervention can be safely performed with left ventricular thrombus without increasing stroke risk: A 5-year retrospective review using real-world data.

INTRODUCTION: Left ventricular thrombus (LVT) increases the risk of ischemic stroke. However, it remains uncertain if the percutaneous coronary intervention (PCI) in the confirmed LVT setting further augments the stroke risk. Therefore, in this study, we evaluated the risk of stroke among patients with LVT undergoing CAG +/- PCI. METHODS: This retrospective observational cohort study included all the patients encountered with LVT from 1st of April 2015, to 31st of March 2020. The study population was divided into two groups: Longobardo et al. (2018) [1] patients with LVT who underwent CAG +/- PCI; Solheim et al. (2010) [2] patients with LVT who did not undergo CAG +/- PCI. The primary outcome evaluated was stroke during the index admission, and the secondary outcomes included in-hospital mortality, all-cause mortality, and stroke at 12 months post-discharge. Logistic regression was used to determine the risk of stroke associated with PCI among patients with LVT, and a p-value<0.05 indicated statistical significance. RESULTS: Of the 210 patients included, 119 underwent CAG +/- PCI, while 91 patients did not undergo CAG +/- PCI. Most of the patients were Asian (67%), male (96%), with a mean age of 56 years. Ischemic cardiomyopathy was the primary etiology of LVT in both groups (96% in the CAG +/- PCI group and 80% in non CAG +/- PCI group). During the index admission, stroke among patients with LVT did not differ between the CAG +/- PCI and non CAG +/- PCI groups (5% versus 3.3%; odds ratio (OR) 1.6, 95% confidence interval (CI) 0.34-6.4, p = 0.539; adjusted OR 0.9, 95% CI 0.09-10.6, p = 0.968). Similarly, in-hospital mortality, all-cause mortality, and stroke at 12 months did not differ between the study groups. CONCLUSION: Performing CAG +/- PCI among patients with LVT was not associated with an increased risk of stroke during admission or within 12 months in comparison to patients who did not undergo CAG +/- PCI, which may reassure cardiologists to perform CAG +/- PCI among patients with LVT safely.

A preliminary investigation of rabbit carcass decomposition and attracted ants (Hymenoptera: Formicidae) on the seaward coastal beach of Al-Jubail City, Saudi Arabia.

The current study was carried out in the seaward coastal beach environment of Al-Jubail City, Saudi Arabia, to analyze the rabbit carcass decomposition process, the succession pattern of associated ants, and their potential utility in forensic investigation. Experiments were conducted over a 4-season course (from autumn 2018 to summer 2019). A total of 9 species belonging to the 2 subfamilies, Myrmicinae and Formicinae, were recorded. The myrmicine species were Crematogaster aegyptiaca Mayr, 1862; Messor ebeninus Santschi, 1927; Messor foreli Santschi, 1923; and Monomorium abeillei Andre, 1881. The formicine species were Camponotus xerxes Forel, 1904; Cataglyphis albicans (Roger, 1859); Cataglyphis hologerseniCollingwood & Agosti, 1996; Cataglyphis viaticoides (André, 1881); and Nylanderia jaegerskioeldi (Mayr, 1904). M. abeillei was the only species recorded in all 4 seasons, while M. abeillei and C. albicans were the dominant species in summer and C. aegyptiaca and C. albicans in spring. Diversity was lowest in the autumn, with only 4 species recorded. The COI gene sequences of 5 species have been successfully deposited in the GenBank database for the first time. In total, 4 carcass decomposition stages were observed, with the longest duration in winter (13 days), the shortest in summer (11 days), and in between for both autumn and spring. Most ant species were present during both decay and dry stages, while M. abeillei, C. aegyptiaca, M. ebeninus, and C. albicans were observed in all decomposition stages. These data may indicate that ants on this coastal beach showed seasonal and geographical succession patterns that could be taken into consideration in forensic investigations.

Appropriateness and clinical outcomes of short sustained low-efficiency dialysis: A national experience.

Sustained low-efficiency dialysis (SLED) is usually performed over 6-12 h among hemodynamically unstable patients. Conduction of 4-h SLED may spare time and manpower during hospitalization. Therefore, we conducted a retrospective observational study to explore the appropriateness and clinical outcomes of 4-h SLED among critically ill patients admitted to our center from 1/06/2016 to 1/06/2020. Renal parameters including blood urea nitrogen, serum creatinine, sodium, phosphorus, potassium, and bicarbonate were determined on the day of dialysis before SLED and within 24 h after SLED, and clinical outcomes including, acute kidney injury (AKI) recovery, in-hospital mortality, 30-day mortality, 180-day mortality, and re-admission with AKI, were evaluated. Of the 304 patients included, 69.4% were male. The majority of patients were from the Middle East (65.8%), followed by 28.6% from Asia. Four-hour SLED resulted in a significant improvement in the renal parameters. Recovery from AKI was observed in 25.4%, in-hospital mortality rate was 48.7%, while the 30- and 180-day mortality outcomes were 3.2 and 9.6%, respectively, and re-admission with AKI was observed in 16.9%. Our findings suggest that 4-h SLED significantly improved renal parameters and was associated with favorable clinical outcomes in terms of survival and AKI recovery, suggesting possible utilization of SLED shorter than 6 h in the acute settings to preserve time and manpower for procedures.

Experimental Investigation of Using Manganese Monoxide as a Hydrogen Sulfide Scavenger for Aqueous Drilling Fluids.

One of the most serious safety and health concerns during drilling oil and gas wells is the potential release of hydrogen sulfide (H2S) to the surface, exposing workers to high risks. Serious corrosion-related damage to handling equipment is also inevitable in the presence of H2S. Various H2S scavengers have been utilized, but each has its pros and cons; hence, research is continuing to develop an optimum and feasible scavenger. Since manganese monoxide (MnO) is a reactive metal oxide with high oxidation and absorption capabilities, it may have the potential to effectively scavenge H2S during drilling operations when included in drilling mud formulations. Consequently, the key aim of this work is to investigate the H2S scavenging performance of the aqueous drilling fluid containing MnO. This work studied the impact of MnO addition on the drilling mud's alkalinity, rheological behavior, filtration performance, and corrosion tendency. The experiments were also conducted for mud without a scavenger and a fluid containing the SourScav commercial scavenger, which serves as a benchmarking reference. The findings demonstrated that MnO performed exceptionally well for H2S scavenging where it boosted the aqueous mud's scavenging capacity from 84.3 to 426.2 mg of H2S/L of mud, showing more than 400% improvement relative to the base mud. Additionally, this scavenging performance is about 2.1 times higher than that of the commercial scavenger. As opposed to SourScav, MnO maintained the mud's pH at a safe level above 10. The addition of either MnO or SourScav did not weaken the mud rheology and provided practically satisfactory rheological parameters. Both SourScav and MnO marginally increased the formed filter-cake thickness from 2.9 to 3.9 mm with a slight increment in the filtrated volume but still within the acceptable limits. The corrosion test indicated the noncorrosive characteristics (i.e., the corrosion rate was nearly zero) of MnO and the commercial scavenger. This study illustrates the promising utilization of MnO as a cost-effective H2S scavenger, enhancing the efficiency and safety of drilling operations.

Applications of Different Classification Machine Learning Techniques to Predict Formation Tops and Lithology While Drilling.

Accurate prediction of formation tops and lithology plays a critical role in optimizing drilling processes, cost reduction, and risk mitigation in hydrocarbon operations. Although several techniques like well logging, core sampling, cuttings analysis, seismic surveys, and mud logging are available for identifying formation tops, they have limitations such as high costs, lower accuracy, manpower-intensive processes, and time or depth lags that impede real-time estimation. Consequently, this study aims to leverage machine learning models based on easily accessible drilling parameters to predict formation tops and lithologies, overcoming the limitations associated with traditional methods. Data from two wells (A and B) in the Middle East, encompassing drilling mechanical parameters such as rate of penetration (ROP), drill string rotation (DSR), pumping rate (Q), standpipe pressure (SPP), weight on bit (WOB), and torque, were collected for real-field analysis. Machine learning models including Gaussian naive Bayes (GNB), logistic regression (LR), and linear discriminant analysis (LDA) were trained and tested on the data set from well A, while the data set from well B was utilized for model validation as unseen data. The formations of wells A and B consist of four lithologies, namely, sandstone, anhydrite, carbonate/shale, and carbonates, necessitating the development of multiclass classification models. The drilling parameters, specifically the WOB and ROP, exhibited a strong influence on lithology identification. Among the models, GNB demonstrated exceptional performance in predicting formation lithology from the drilling parameters, achieving accuracy and nearly perfect precision, recall, and F1 score for the different classes. LDA and LR models accurately predicted sandstone and carbonate lithologies, although some misclassifications occurred in approximately 5% of points for anhydrite and around 20% in carbonate/shale formations. During validation, the models demonstrated accuracies of around 0.96, 0.95, and 0.92 for the GNB, LR, and LDA, respectively. The study highlights the efficacy of the developed machine learning models in accurately predicting the formation lithology and tops in real time. This is achieved by utilizing readily available drilling parameters, making the approach highly accurate and cost effective by leveraging existing real-time drilling data.

Severe mitral stenosis masquerading as cardiogenic shock successfully managed with extracorporeal membrane oxygenation and percutaneous mitral commissurotomy: a case report.

Background: Rheumatic fever is still a major cause of mitral valve (MV) stenosis in the developing world. Few patients with critical rheumatic MV stenosis can present with acute cardiogenic shock (CS) that requires urgent treatment with circulatory support and definitive valvular repair or replacement. Case summary: A 37-year-old gentleman was admitted with heart failure, CS Society for Cardiovascular Angiography and Interventions D, and atrial fibrillation with a rapid ventricular response. He had no prior medical history. He had multiple organ failures and required intubation, two DC shocks of 200 joules without haemodynamic improvement, continuous renal replacement therapy, and medical and mechanical circulatory support using extracorporeal membrane oxygenation (ECMO). His echocardiography showed severe rheumatic mitral stenosis (mitral valve area 2D of 0.7 cm2, mean diastolic gradient of 17 mmHg, Wilkins score 7). His Society of Thoracic Surgery score and EuroScore were 50.1% and 12.1%, respectively. Thus, a percutaneous transcatheter mitral commissurotomy (PTMC) was decided as the definitive treatment in a multidisciplinary team meeting. Following the procedure, the patient's circulatory support was gradually weaned off, and he was successfully extubated with a marked improvement in his renal functions. The patient achieved a complete recovery without any long-term sequelae. Discussion: Cardiogenic shock related to severe rheumatic MV stenosis requires multidisciplinary team management with prompt diagnosis, initiation of the most appropriate mechanical support device (e.g. ECMO or tandem heart), and relief of the MV obstruction. Percutaneous transcatheter mitral commissurotomy can be the preferred option in this setting if the valve is pliable.

Concurrent coronary artery disease and immune thrombocytopenia: a systematic review.

Introduction: Coronary artery disease (CAD) management in the setting of immune thrombocytopenia (ITP) remains very challenging to clinicians as a reasonable balance between bleeding and thrombosis risks needs to be achieved, and the evidence guiding such management is scarce. Methods: We conducted a systematic review following the PRISMA guidelines to summarize the available literature on the management and outcomes of CAD coexisting with ITP. We searched PubMed and Embase for studies published in English exploring CAD and ITP management until 05 October 2022. Two independent reviewers screened and assessed the articles for inclusion. Patients' characteristics, CAD treatment modalities, ITP treatment, and complications were reported. Results: We identified 32 CAD cases, among which 18 cases were revascularized with percutaneous coronary intervention (PCI), 12 cases underwent coronary artery bypass graft surgery (CABG), and two cases were managed conservatively. More than 50% were men, with a mean age of 61 ± 13 years and a mean baseline platelet count of 52 ± 59 × 109/L. Irrespective of the revascularization modality, most patients were treated with either corticosteroids alone, intravenous immunoglobulins (IVIG) alone, or in combination. Among those who underwent PCI, two patients had bleeding events, and one patient died. Similarly, among those with CABG, one patient developed bleeding, and one patient died. Conclusion: We found that revascularization with either PCI or CABG with the concurrent use of corticosteroids and/or IVIG for ITP was feasible, with an existing non-negligible risk of bleeding and mortality.

The utility of testing erythropoietin level in polycythemia diagnosis.

OBJECTIVES: Polycythemia vera (PV) is classically thought to be associated with low erythropoietin (EPO) levels. Here, we present a review of the utility of using EPO levels in diagnosing polycythemia. METHODS: We conducted a systematic literature review of the Medline data through Pubmed and Google Scholar. We included the articles which described confirmed PV associated with elevated EPO level. Our search strategy included the following terms in Pubmed (((polycythemia vera[MeSH Terms]) OR (jak2 protein tyrosine kinase[MeSH Terms])) OR (Myeloproliferative Disorders[MeSH Terms])) AND (Erythropoietin[MeSH Terms]), and 'polycythemia vera with erythropoietin' in Google Scholar. RESULTS: Our research yielded four cases of PV with elevated EPO levels. The most common symptom was a headache. Thrombotic phenomena happened in a single case in the form of Budd-Chiari syndrome. The mean Hb level was 20.2 gm/dl, and the EPO level was 213 mlU/mL. DISCUSSION: Although PV is usually associated with low EPO levels, high levels do not exclude this diagnosis. Workup should include testing for JAK2 mutation and bone marrow biopsy in the presence of suggestive signs and symptoms. Novel biomarkers are also being proposed to aid in the diagnosis. CONCLUSION: Although elevated EPO levels suggest secondary causes of polycythemia, cases where elevated EPO levels were associated with an underlying PV are reported in the literature, and we have summarized a review of them. Workup for polycythemia should include JAK2 mutation testing if signs and symptoms suggest PV even if EPO is elevated.

Evaluation of Using Fly Ash as a Weighing Material for Oil-Based Drilling Fluid.

Innovation and sustainability are essential in the fast-changing oil and gas business. Fly ash, a byproduct of coal combustion in power plants and factories, has become a valuable resource in many industries, changing the concept of waste materials. Fly ash is essential to sustainable development and environmental care due to its unique qualities and multiple applications. In the drilling industry, a well-designed drilling fluid is essential and this requires the use of various additives that serve specific functions to achieve a successful borehole. This study investigates the use of fly ash as a weighing material in oil-based mud, with the intent to develop an economically acceptable drilling fluid system using industrial waste. The study compared fly ash to three commonly used weighing materials in the drilling industry: calcium carbonate (CaCO3), barite (BaSO4), and ilmenite (FeTiO3). Drilling fluids were prepared using these weighing materials at various weights, and their properties (density, electrical stability, rheological features, and filtration properties) were measured using API-recommended methods. The rheology and filtration tests were conducted at elevated temperatures (350 °F). The results indicate that fly ash has the potential to be a useful weighing material in drilling operations. It can increase the fluid density up to 10 ppg without affecting the rheological properties at 350 °F. Additionally, the electrical stability of the drilling fluid was enhanced compared to the other used weighing materials. The addition of fly ash also improved rheological characteristics such as plastic viscosity, yield point, and gel strength without affecting HPHT filtration properties. The carrying capacity was improved by 53 and 86% over calcium carbonate and barite, respectively. Overall, the findings suggest that fly ash can be a viable alternative to other weighing materials in the recommended density range.

Spontaneous coronary artery dissection: an overview.

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.