Iatrogenic Tracheal Rupture Related to Prehospital Emergency Intubation in Adults: A 15-Year Single Center Experience

Objective: Iatrogenic tracheal rupture is an unusual and severe complication that can be caused by tracheal intubation. The frequency, management, and outcome of iatrogenic tracheal rupture due to prehospital emergency intubation in adults by emergency response physicians has not yet been sufficiently explored. Methods: Adult patients with iatrogenic tracheal ruptures due to prehospital emergency intubation admitted to an academic referral center over a 15-year period (2004-2018) with consideration of individual risk factors were analyzed. Results: Thirteen patients (eight female) with a mean age of 67 years met the inclusion criteria and were analyzed. Of these, eight tracheal ruptures (62%) were caused during the airway management of cardiopulmonary resuscitation (CPR). Stylet use and difficult laryngoscopy requiring multiple attempts were documented in eight cases (62%) and four cases (30%), respectively. Seven patients (54%) underwent surgery, while six patients (46%) were treated conservatively. The overall 30-day mortality was 46%; five patients died due to their underlying emergencies and one patient died of tracheal rupture. Three survivors (23%) recovered with severe neurological sequelae and four (30%) were discharged in good neurological condition. Survivors had significantly smaller mean rupture sizes (2.7cm versus 6.3cm; P <.001) and less cutaneous emphysema (n = 2 versus n = 6; P = .021) than nonsurvivors. Conclusions: Iatrogenic tracheal rupture due to prehospital emergency intubation is a rare complication. Published risk factors are not consistently present and may not be applicable to identify patients at high risk, especially not in rescue situations. Treatment options depend on individual patient condition, whereas outcome largely depends on the underlying disease and rupture extension.

Controlling the Mitigating Impacts of Communication Delay on Load Frequency Control with an Adaptive Method

Load Frequency Control is one of the most essential frequency management technologies in modern power systems (LFC). When employing LFC over a vast region, communication latency is unavoidable. A delay might not only affect system performance but also cause system instability. An alternate design strategy for constructing delay compensators for LFC in one or more control areas utilising an AFPI controller and ANFIS is proposed in this paper. For one-area LFC, a sufficient and required condition for designing a delay compensator is described. It is demonstrated that for multi-area LFC with Area Control Errors (ACEs), each control area can have its own delay controller designed as if it were a one-area system if the index of coupling among the areas is less than the small gain theorem's threshold value. The effectiveness of the proposed technique is validated by simulation experiments on LFCs with communication delays in one and multiple interconnected areas with and without time variable delays.

BESS Assisted Frequency Management for Black Start Process of Microgrid

This paper proposes a method for restoring the nominal frequency and improving the system recovery time using battery energy storage system (BESS) for an islanded microgrid (MG) which is operated by a black start unit (BSU). The frequency stability is controlled by varying the apparent power (MVA) rating of the BESS after simultaneously connecting with the BSU during the post fault scenarios. Simulations are performed on the IEEE Std. 399-1997 test MG using DIgSILENT PowerFactory. Results show that the nominal frequency of the system can be retained by connecting the BESS during the transient period and increasing the MVA rating up to a maximum value. Simulation results also show that with a higher distributed connection of the BESS units over the system, the frequency recovery time can be reduced.

A 30-Month Complete Urinary Obstruction Resulting from Trapped and Incarcerated Uterus: A Case Report

Uterine incarceration is rare, but it can cause serious complications, in which the uterus is trapped in the pelvic cavity behind the sacral promontory. Fibroid uterus can cause urinary frequency and retention, which can result from compression of the urinary bladder with an enlarged fibroid uterus and the compression of the bladder neck or urethra, respectively. To our knowledge, there is no report on prolonged complete urinary obstruction because of an incarcerated uterus in nonpregnant women to date. A 51-year-old woman was referred for uterine myomas. She could not void for 30 months after she received an intradetrusor injection of botulinum toxin for urinary frequency management at the urology department of another hospital. She underwent clean intermittent catheterization for 30 months. She was referred to the gynecologic department for the evaluation of uterine myoma found on using abdominopelvic computed tomography. On physical examination, the uterine cervix was extremely displaced in the upward direction and was not exposed on speculum examination. Sonography and magnetic resonance imaging revealed that the urethra and the bladder neck were compressed by an extremely retroflexed fibroid uterus. Manual reduction of the incarcerated uterus failed; hence, we performed robot-assisted laparoscopic total hysterectomy with left salpingo-oophorectomy. She immediately urinated immediately after the operation and had normal urination at 1- and 48-month follow-up visits. Uterine incarceration by a fibroid uterus can cause complete urinary obstruction, as in this case. Uterine incarceration should be considered in women with urinary frequency or retention to avoid prolonged, serious complications.

Frequency, management, and resource use of adverse events (AEs) in nonmetastatic castrate-resistant prostate cancer (nmCRPC) patients receiving apalutamide or enzalutamide: A real-world study.

217 Background: Second generation androgen receptor inhibitors (SGARIs), apalutamide (APA) and enzalutamide (ENZ) and darolutamide, are approved in the United States (US) for the treatment of nmCRPC. The objectives of this study were to describe the frequency of AEs and actions taken to manage AEs among nmCRPC patients treated with APA or ENZ and their downstream resource implications. Methods: This is a further descriptive analysis of a retrospective chart review study conducted in 43 US nmCRPC-treating sites. In our sample, the 43 physicians identified 699 nmCRPC patients initiating treatment with APA (N = 368) or ENZ (N = 333) with 2 patients receiving both, between February 1, 2018 and December 31, 2018 and AEs were collected as reported in regular clinical practice. A representative subset of patients, experiencing at least 1 AE for either APA (N = 125) or ENZ (N = 125), were selected randomly from the initial cohort, and their detailed chart data were extracted to understand the actions taken to manage AEs. Results: Of the initial cohort of nmCRPC patients, 72.0% and 78.7% of men receiving APA (N = 368) and ENZ (N = 333) experienced ≥1 AE, respectively. The three most common AEs reported were fatigue/asthenia (APA, 30.2%; ENZ, 38.7%), hot flush (APA, 14.1%; ENZ, 13.5%), and arthralgia (APA, 14.4%; ENZ, 12.9%). Cognitive and mental changes were observed in 5.4% (APA) and 7.8% (ENZA) men. The subset analysis of randomly selected patients experiencing ≥1 AE (APA, 125; ENZ, 125) were mostly Caucasian (APA, 72.8%; ENZ, 71.2%), ECOG score 0-1 (APA, 84%; ENZ, 88%), median prostate specific antigen (PSA) value 13 ng/ml and 11 ng/ml (APA, ENZ; respectively). Actions to address AEs included treatment of AE, SGARI discontinuation, dose reduction and hospitalization (Table). Specifically, treatment discontinuation due to AE was observed in 8.0% (APA) and 12.8 (%) of men. AEs were often not resolved (APA, 43.6%; ENZ, 39.4%), and the median duration of days to resolve AEs were 60.0 for APA and 56.0 for ENZ. Conclusions: This real-world study highlights the clinical and resource use burden of AEs among nmCRPC patients treated with APA and ENZ. The results demonstrate the importance of safety and tolerability as key considerations in shared clinician-patient decision-making regarding SGARI therapy in nmCRPC. [Table: see text]