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Purpose of Review: Choanal atresia (CA) is a congenital nasal airway anomaly that, when present bilaterally, requires urgent surgical intervention. Surgical technique has evolved since its inception with most practices now favoring an endoscopic repair. Restenosis requiring revision surgery is a frequent complication, occurring in as many as 50% of cases. This review aims to highlight the most common surgical approaches, techniques used to prevent restenosis, and newer adjuncts to surgery that may improve outcomes., Recent Findings: Bioabsorbable, steroid-eluting stents were first developed for the adult chronic rhinosinusitis population but have been adapted for use in choanal atresia since 2017. The existing literature consists of multiple case series and one case-control study comparing these stents to traditional stents. To date, there have been no reports of restenosis or stent-related complications with these newer products., Summary: Choanal atresia remains a difficult surgical pathology for which sustainable surgical results can be challenging. There is reason for optimism in bioabsorbable, steroid-eluting stents as an adjunct to CA repair if future studies expound upon their safety and efficacy., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Behavioral factors increase the risk of contracting HIV. A comprehensive prevention services (CPS) intervention includes risk assessment and referral for those with confirmed risk. This project sought to assess the feasibility of an emergency department (ED)-based CPS program. A prospective cross-sectional assessment was conducted from October, 2021 through May, 2023, at a single ED in Birmingham, Alabama. Either of two screening methods were subjected to HIV negative adults: 1) manual chief complaint review or 2) objective electronic medical record (EMR) query. Manual and EMR screening methods considered sexually transmitted infections (STIs) or a positive urine drug test (to observe for commonly injectable drugs) within 12 months of current ED visit. Identified patients were approached in the ED (manual review) or via phone (EMR alert). Persons confirmed at risk for HIV following engagement questionnaire completion were made aware of their risk and offered referral to local CPS clinics. Primary outcome was CPS linkage. Descriptive analysis was performed. Of 184 patients approached, 147 agreed to engagement (79.9%), 117 in-person and 30 via phone; 125 (85.1%) were confirmed at risk for HIV; majority were white (66.4%), male (63.2%), between the ages of 30 and 49 (64.8%), uninsured (78.4%), and without a primary care provider (93.6%). Sexual behavior was identified as a recent (within six months) risk factor in 97 (77.6%) patients. Injection drug use was identified as a recent (within six months) risk factor in 71 (56.8%) patients. Fifty-four (43.2%) expressed interest in obtaining CPS follow-up. To-date, ten patients (18.5%) have connected with a CPS counsellor via phone and five (9.3%) have had a subsequent follow-up appointment to discuss CPS with a medical provider. Thirty at-risk patients (24.0%) received ED-initiated buprenorphine/naloxone. Targeted screening tools can aid in the identification of persons at risk for HIV in the ED; further, subsequent engagement and CPS implementation amongst this cohort is feasible. CPS clinic linkage may be challenging however, a CPS definition inclusive of ED-initiated medication for opioid use disorder, may offer opportunity for increased uptake., Competing Interests: The commercial funder does not alter our adherence to all PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Osman et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Dyslipidemia is a leading contributor to atherosclerotic cardiovascular disease (ASCVD). There has been a significant improvement in the treatment of dyslipidemia in the past 10 years with the development of new pharmacotherapies. The intent of this review is help enhance clinicians understanding of non-statin lipid lowering therapies in accordance with the 2022 American College of Cardiology Expert Consensus Clinical Decision Pathway on the Role of Non-statin Therapies for LDL-Cholesterol Lowering. We also present a single-center experience implementing a systematic inpatient protocol for lipid lowering therapy for secondary prevention of ASCVD., Competing Interests: OC reports consulting/speaking fees from Amgen and Penumbra The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Gier, Gilchrist, Fordham, Riordan, Milchan, Patel, Mojahedi, Choudhury, Kits, Cohen, Doughtery, Reilly, Kalogeropoulos, Rahman and Chen.)

In Low and Middle Income Countries (LMIC), one of the causes of maternal and child mortality is a lack of medical knowledge and consequently the inability to seek timely healthcare. Mobile health (mHealth) technology is gradually becoming a universal intervention platform across the globe due to ubiquity of mobile phones and network coverage. MANTRA is a novel mHealth intervention developed to tackle maternal and child health issues through a serious mobile game app in rural Nepal, which demonstrated a statistically significant knowledge improvement in rural women. This paper explores the perceptions and usability of the MANTRA app amongst rural women and Female Community Health Volunteers (FCHVs) in Nepal. Despite the challenges of a target user group with limited educational levels and low smartphone experience, all participants viewed the MANTRA app with approval and enthusiasm. They were willing to engage further with the mHealth intervention and to share their experience and knowledge with fellow community members. Participants also showed an increase in awareness of danger signs enabling them to make better informed health decisions in the future. FCHVs viewed the app as a validation tool providing and support for greater impact of their efforts in rural Nepal. Growing mobile ownership, network coverage and availability of smartphones along with acceptance of the prototype MANTRA app in rural communities suggest encouraging prospects for mHealth interventions to be incorporated in the national health infrastructure in Nepal and other LMICs., Competing Interests: GH was employed by the company Hearn Geoserve, Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kayastha, Mueller, Yadav, Kelman, Boscor, Saville, Arjyal, Baral, Fordham, Hearn and Kostkova.)

Conventional spectrometers are limited by trade-offs set by size, cost, signal-to-noise ratio (SNR), and spectral resolution. Here, we demonstrate a deep learning-based spectral reconstruction framework using a compact and low-cost on-chip sensing scheme that is not constrained by many of the design trade-offs inherent to grating-based spectroscopy. The system employs a plasmonic spectral encoder chip containing 252 different tiles of nanohole arrays fabricated using a scalable and low-cost imprint lithography method, where each tile has a specific geometry and thus a specific optical transmission spectrum. The illumination spectrum of interest directly impinges upon the plasmonic encoder, and a CMOS image sensor captures the transmitted light without any lenses, gratings, or other optical components in between, making the entire hardware highly compact, lightweight, and field-portable. A trained neural network then reconstructs the unknown spectrum using the transmitted intensity information from the spectral encoder in a feed-forward and noniterative manner. Benefiting from the parallelization of neural networks, the average inference time per spectrum is ∼28 μs, which is much faster compared to other computational spectroscopy approaches. When blindly tested on 14 648 unseen spectra with varying complexity, our deep-learning based system identified 96.86% of the spectral peaks with an average peak localization error, bandwidth error, and height error of 0.19 nm, 0.18 nm, and 7.60%, respectively. This system is also highly tolerant to fabrication defects that may arise during the imprint lithography process, which further makes it ideal for applications that demand cost-effective, field-portable, and sensitive high-resolution spectroscopy tools.

Serious games, conveying educational knowledge rather than merely entertainment, are a rapidly expanding research domain for cutting-edge educational technology. Digital interventions like serious games are great opportunities to overcome challenges in low-and-middle-income countries that limit access to health information, such as social barriers like low-literacy and gender. MANTRA: Increasing maternal and child health resilience before, during and after disasters using mobile technology in Nepal takes on these challenges with a novel digital health intervention; a serious mobile game aimed at vulnerable low-literacy female audiences in rural Nepal. The serious game teaches 28 learning objectives of danger signs in geohazards, maternal, and neonatal health to improve knowledge and self-assessment of common conditions and risks to inform healthcare-seeking behavior. Evaluations consisted of recruiting 35 end users to participate in a pre-test assessment, playing the game, post-test assessment, and focus groups to elicit qualitative feedback. Assessments analyzed knowledge gain in two ways; by learning objective with McNemar tests for each learning objective, and by participant scores with paired t -tests of overall scores and by module. Results of assessments of knowledge gain by learning objective (McNemar tests) indicate participants had sufficient prior knowledge to correctly interpret and respond to 26% of pictograms (coded AA), which is a desirable result although without the possibility of improvement through the intervention. The geohazard module had greatest impact as 16% of responses showed knowledge gain (coded BA). The two most successful learning objectives showing statistically significant positive change were evidence of rockfalls and small cracks in the ground ( p = < 0.05). Assessment of knowledge gain by participant scores (paired t -tests) showed the 35 participants averaged a 7.7 point improvement ( p < 0.001) in the assessment (28 learning objectives). Average change in knowledge of subdivided module scores (each module normalized to 100 points for comparison) was greatest in the geohazard module (9.5 points, p < 0.001), then maternal health (7.4 points, p = 0.0067), and neonatal health (6.0 points, p = 0.013). This evaluation demonstrated that carefully designed digital health interventions with pictograms co-authored by experts and users can teach complex health and geohazard situations. Significant knowledge gain was demonstrated for several learning objectives while those with non-significant or negative change will be re-designed to effectively convey information., Competing Interests: GH was employed by the company Hearn Geoserve, Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Mueller, Soriano, Boscor, Saville, Arjyal, Baral, Fordham, Hearn, Kayastha and Kostkova.)

Background: Mobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal., Methods: The serious game was developed through a co-creation process between London and Kathmandu based researchers by email and video-calling, and face-to-face with local stakeholders in Nepal. The process identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot serious game to the local cultural context. Evaluations and feedback from end users took place in rural villages and suburban Kathmandu in Province Three. Field evaluation sessions used mixed methods. Researchers observed game play and held focus group discussions to elicit qualitative feedback and understand engagement, motivation, and usability, and conducted a paired pre- and post-game knowledge assessment., Results: The MANTRA serious game is contextualized to rural Nepal. The game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geohazards, through picture matching with immediate audio and visual feedback. User feedback from focus groups demonstrated high engagement, motivation, and usability of the game., Conclusions: This MANTRA study is a unique mHealth intervention of a serious game to teach core health and geohazards messages to low-literacy audiences in rural Nepal. Although the mobile game is tailored for this specific context, the developmental process and insights could be transferable to the development of other games-based interventions and contextualized for any part of the world. Successfully targeting this low-literacy and illiterate audience makes the MANTRA development process the first of its kind and a novel research endeavor with potential for widespread impact and adoption following further game development., Trial Registration: This project was approved by the University College London Ethics Committee in London, United Kingdom [10547/001], and the Nepal Health Research Council in Kathmandu, Nepal [Reg. No. 105/2017]. All participants provided informed written consent.

Purpose of Review: To identify strategies for communicating with youth and children pre- and post-disaster in the context of a broader survey of child participation in disaster risk reduction as well as methods for communication with children., Recent Findings: Youth and children are capable of peer and community education and activism concerning disaster issues and such participation benefits the young actors. Family and sibling support are important in easing the impact of trauma on children. Contemporary forms of psychological first aid appear to do no harm and in line with current evidence. Generally, more evidence from evaluations is necessary to guide the development of communication strategies. Children are growing up in increasingly urban environments with less contact with nature and greater reliance on techno-social systems. Thus, young people may misunderstand natural hazards. Schools and conscious parenting can play important roles in building understanding and psychological resilience.

Background: Training programs are expected to provide clinical outcomes data to residents. Few systems have the necessary infrastructure. We evaluated initial adoption and use of the Quality In-Training Initiative (QITI) platform linking National Surgical Quality Improvement Program (NSQIP) data to trainees., Study Design: Proportions of Accreditation Council for Graduate Medical Education general surgery residency programs with differing levels of NSQIP and QITI affiliation were calculated and program characteristics were compared. All NSQIP sites that captured QITI custom field data from July 2013 to June 2016 were included in case analysis. Differences in case collection were compared between participating (P) sites that actively participated in QITI and nonparticipating (NP) sites that did not. Resident participation by procedure type was examined., Results: Of 268 accredited general surgery residency programs, 92% (n = 248) is affiliated with a NSQIP hospital and 61% of all clinical months is spent at NSQIP sites. For 42% of all programs (n = 114), the primary teaching hospital is affiliated with the QITI. In all, 74 P sites and 89 NP sites captured a total of 417,816 cases. The median number of cases captured per site was statistically higher for P sites (3063) compared with NP sites (2307, p < 0.001). A total of 68.3% of all cases captured had resident participation indicated by postgraduate year (n = 285,469). The most common procedures with resident participation were laparoscopic appendectomy (n = 17,082, 6.0%) and laparoscopic cholecystectomy (n = 15,502, 5.4%). Percentage coverage rates ranged from 17.3% to 91.8%., Conclusion: Most general surgery rotations are at NSQIP sites. Identifying resident participation in captured NSQIP cases is feasible on a large scale. Captured cases reflect national case-mix. The platform has the potential to collect data on institutional and program-level variation in resident operative experience that may be used to improve training., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

The relationship between hydrogen sulfide (H 2 S), microRNAs (miRs), matrix metalloproteinases (MMPs) and poly-ADP-ribose-polymerase-1 (PARP-1) in diabetic kidney remodeling remains mostly obscured. We aimed at investigating whether alteration of miR-194-dependent MMPs and PARP-1 causes renal fibrosis in diabetes kidney, and whether H 2 S ameliorates fibrosis. Wild type, diabetic Akita mice as well as mouse glomerular endothelial cells (MGECs) were used as experimental models, and GYY4137 as H 2 S donor. In diabetic mice, plasma H 2 S levels were decreased while ROS and expression of its modulator (ROMO1) were increased. In addition, alteration of MMPs-9, -13 and -14 expression, PARP-1, HIF1α, and increased collagen biosynthesis as well as collagen cross-linking protein, P4HA1 and PLOD2 were observed along with diminished vascular density in diabetic kidney. These changes were ameliorated by GYY4137. Further, downregulated miRNA-194 was normalized by GYY4137 in diabetic kidney. Similar results were obtained in in vitro condition. Interestingly, miR-194 mimic also diminished ROS production, and normalized ROMO1, MMPs-9, -13 and -14, and PARP-1 along with collagen biosynthesis and cross-linking protein in HG condition. We conclude that decrease H 2 S diminishes miR-194, induces collagen deposition and realignment leading to fibrosis and renovascular constriction in diabetes. GYY4137 mitigates renal fibrosis in diabetes through miR-194-dependent pathway.

CASE DESCRIPTION 3 ferrets (Mustela putorius furo), aged 1 to 2 years, were referred for evaluation of a 4-day to 2-week history of gastrointestinal signs, including anorexia, regurgitation, and vomiting. CLINICAL FINDINGS All 3 ferrets had clinical signs suggestive of dysphagia or esophagitis on initial examination. Esophagoscopy, barium-contrast esophagography, or both revealed foreign bodies with mucosal inflammation in 1 patient and an esophageal foreign body with stricture in 2 patients. One of the latter ferrets had a recent history of gastrotomy to remove a foreign body. TREATMENT AND OUTCOME 1 ferret was treated with endoscopic retrieval of the foreign bodies. Esophageal stricture was treated in 2 ferrets by means of endoscopic balloon dilation accompanied by placement of an esophageal stent in 1 ferret. After resolution of clinical signs and completion of all prescribed treatments, 2 of 3 ferrets successfully transitioned to a regular hard kibble diet; 1 ferret remained on a soft diet for 2 years. All owners were satisfied with the outcome of treatment. CLINICAL RELEVANCE Ferrets are prone to foreign body ingestion. Results of this small series of cases suggested that minimally invasive techniques may be useful for the management of esophageal disease in this species.

Extramedullary hematopoiesis occurs in children with hemoglobinopathy and chronic anemia. The liver and spleen are often affected first, but other foci can develop to support erythrocyte demand. We report a case of a nine-year-old with beta thalassemia and temporal bone extramedullary hematopoiesis causing ossicular fixation and bilateral conductive hearing loss. There is only one case in the literature describing this phenomenon in pediatric patients, and this is the first case report of bilateral hearing loss from this physiologic phenomenon. Otolaryngologists should consider this etiology in patients with chronic anemia and conductive hearing loss in the absence of otitis media., (Published by Elsevier B.V.)

Peritonsillar infections are one of the most common deep neck space infections, particularly in adolescents. Inaccurate diagnosis can lead to delay in management and potentially life-threatening complications. Contrast-enhanced computed tomography (CT) scan of the neck traditionally has been used to diagnose suspected peritonsillar abscess. With growing concern over radiation exposure, there has been increasing utilization of ultrasound (US) using intraoral and transcutaneous approaches. We chose the transcutaneous US technique due to its ease of performance in children. The purpose of this article is twofold: a) to describe our technique of performing transcutaneous US of the tonsil showing sonographic appearance of normal tonsil, highlighting pertinent anatomy and unique considerations for this modality in children, and b) to illustrate the sonographic findings in the spectrum of pediatric peritonsillar infections, which includes uncomplicated tonsillitis, peritonsillar cellulitis, small intratonsillar abscess and frank peritonsillar abscess. Parapharyngeal abscess can sometimes be detected.

Importance: The use of 3-dimensional (3D) endoscopy has been described in the pediatric airway and has been shown to improve visualization of complex airway anatomy. Laryngomalacia is one of the most common airway disorders evaluated in pediatric otolaryngology offices. Whether 3D visualization is superior to standard endoscopy as a means for assessment and surgical management of complex airway anatomy is unclear., Objective: To describe a pilot case series using 3D endoscopy to facilitate supraglottoplasty and to assess surgical outcomes., Design, Setting, and Participants: A prospective case series was conducted of 11 children undergoing supraglottoplasty from July 1, 2010, to June 31, 2014, at a tertiary care pediatric hospital. Infants and children with symptomatic laryngomalacia were eligible for the study. Follow-up was completed on December 31, 2014, and data were assessed from February 1 to 15, 2015., Interventions: Supraglottoplasty performed using 3D endoscopy., Main Outcomes and Measures: The outcome data collected included length of hospital stay and frequency of complications (ie, aspiration, granuloma formation, supraglottic narrowing, revision surgery, tracheostomy, and gastrostomy)., Results: Eleven children were treated for laryngomalacia with supraglottoplasty (6 boys and 5 girls; mean [SD] age, 29 [85] months). Four of these children (36%) also had grade I subglottic stenosis. The 3D endoscope was judged by all participating senior surgeons to improve visualization of the supraglottic anatomy and to permit more precise tissue removal. No complications occurred after the surgery. Hospital stay was found to be an unreliable indicator owing to multiple comorbidities in many children. Worsening of aspiration occurred in 1 child (9%) who subsequently required gastrostomy tube placement. This child demonstrated progressive neurologic impairment and had severe hypotonia and developmental delay. Another child with subglottic stenosis and subglottic cysts required a tracheostomy owing to severe rhinovirus tracheitis. The remaining 9 children (82%) had good outcomes, with a mean follow-up of 14.7 (range, 12-24) months., Conclusions and Relevance: The anatomy of the supraglottis in laryngomalacia is better visualized using 3D techniques. Use of 3D endoscopy may allow for more precise tissue removal. The outcomes and complication rates are similar to those of standard 2D techniques. This study provides a platform to begin comparative analysis between 3D and standard 2D techniques.

Objectives/hypothesis: Pediatric peritonsillar abscess (PTA) is a common infection, particularly in the adolescent population. Physical examination alone is not always sufficient to diagnose this pathology, and thus, computed tomography is often utilized as a diagnostic adjunct. With growing concern over radiation exposure in the pediatric population, we conducted a prospective study to investigate the use of ultrasonography in the detection of pediatric PTA., Study Design: Prospective single arm cohort study., Methods: Pediatric patients examined in consultation for concern for PTA were prospectively enrolled in the study. Patients were managed based on clinical symptoms and presentation. Transcervical ultrasonography of the peritonsillar region was performed on all patients. Clinical outcomes were reviewed retrospectively and compared to ultrasound findings., Results: Forty-three patients (age range, 2-20 years) were enrolled in the study. The sensitivity and specificity of transcervical ultrasound when compared to clinical outcomes were 100% and 76.5%, respectively. The positive and negative predictive values were 52.9% and 100%, respectively. Fisher exact test showed a statistically significant association (P < .01) between negative ultrasonography and successful medical management, and multivariate regression analysis showed a strong correlation between ultrasound findings and presence/absence of purulence during surgical intervention (P = .01)., Conclusions: Transcervical ultrasonography is a useful tool in diagnosing pediatric PTA. This imaging modality not only avoids undue radiation exposure, but it also proves to be an excellent tool at identifying patients who will not need surgical intervention. To our knowledge, this is the first study to explore this technique for the diagnosis of pediatric PTA., Level of Evidence: 2b., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

ABSTRACT In this article, insights into the lived experience of homeless women arising from a PhD study on the specialist role of the SCPHN in homelessness are presented. A key narrative text of a rough sleeping pregnant woman is included. The reflexive narrative study, used an eclectic, philosophical framework which included reflective practice/guidance, narrative inquiry, and storytelling methodologies. Story texts uniquely illuminated complex knowledge about homelessness and homeless health care. Homeless women were found to be a heterogeneous group which included former health professionals. The women's stories were often shocking; they were frequently contextualised against a background of service exclusion, including GP services, learning disability services, mental health services, housing services and social services. The role of the specialist nurse (SCPHN) in engagement with homeless people is illuminated. A therapeutic model of 'Effective Engagement with Homeless People and Homeless Families' is presented to guide health professionals in holistic care. The author invites the reader to dialogue within their teams on how homeless people are included or excluded from SCPHN services. In this way, the term 'audiencing' rather than transferability of findings is used in a continuing dialogue with the reader to improve the health and wellbeing of homeless women.

Reflective practice was used as a process of self-inquiry and transformation in a PhD study of my specialist role in single and family homelessness. New to homelessness when I embarked on the study, there was little to guide my nursing practice and, notably, there was insufficient research evidence to demonstrate the effectiveness of specialist practice with homeless people. Through my reflexive narrative study, that research gap was addressed. The aim of the narrative was to inform the reader of the reflexive journey and my transformation as a specialist practitioner in homeless health care, and to invite readers to reflect on their own perceptions of homelessness along with the health needs of homeless people. Study findings illuminated the key ethical role that mainstream health professionals, including specialist community public health nurses (SCPHNs), have towards effective engagement to reduce suffering and prevent homeless people and families falling through the net of care. As my research progressed I metaphorically understood the specialist practitioner role as a clinical and strategic 'net-weaver' in a net of care between homeless people, multi-agency partnerships, community and acute health services, and in education.

Objectives/hypothesis: To retrospectively analyze the postoperative management and care needs of patients undergoing spontaneous ventilation supraglottoplasty (SVS)., Study Design: Retrospective chart review., Methods: Charts of children undergoing (SVS) for severe laryngomalacia from 2007 to 2011 at a single institution were reviewed. Intraoperative and postoperative management data were collected to review the airway management, postoperative care needs, and potential complications associated with this surgery., Results: A total of 65 patients were included in the study. Only three patients (4.5%) required more than an overnight stay in the hospital, and no patients left the operating room intubated. One patient required temporary intensive care unit observation, and the majority (78.1%) demonstrated adequate oral intake within 4 hours of surgery. Comorbidities did not portend a longer hospital stay or slower return to oral intake., Conclusions: SVS with cold-steel instruments is a safe and effective surgical intervention with low complication rates. This study suggests that postoperative intubation or intensive care unit monitoring may not be necessary when using these techniques., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Reactive oxygen species (ROS) can potentiate cellular injury and inflammation. This study aimed to (1) assess the presence of reactive oxygen species in the sinus tissue of patients with chronic rhinosinusitis (CRS) and (2) assess the impact of secondhand smoke (SHS) exposure on reactive oxygen species (ROS) production., Study Design: Retrospective cohort study., Setting: Academic medical center., Subjects and Methods: Sinus tissue samples from patients undergoing sinus surgery were analyzed using diaminobenzidine (DAB) staining to assess for ROS. Stained specimens were photographed at random by a blinded photographer and then quantified by 3 blinded graders. The patient's SHS exposure was determined by hair nicotine levels., Results: were compared between non-smoke exposed cohorts and those exposed to secondhand smoke and by diagnosis., Results: Sixty-nine adults undergoing sinus surgery were included in the study. For the non-SHS-exposed cohorts, chronic rhinosinusitis with nasal polyps (CRSwNP) had the highest number of DAB+ cells/high-powered field (hpf) followed by chronic rhinosinusitis without nasal polyps (CRSsNP) and controls. When comparing the control patients to their SHS-exposed counterparts, SHS exposure yielded statistically significantly higher levels of DAB-positive cells/hpf. SHS exposure did not affect DAB staining in CRSsNP or CRSwNP patients., Conclusion: ROS are differentially expressed in various subtypes of CRS. SHS exposure increases ROS in sinus tissue of control patients, but the clinical significance of this is unclear.

Objective: To determine whether the human papillomavirus (HPV) status of head and neck squamous cell carcinomas (HNSCCs) can be reliably predicted based on sociodemographic and disease characteristics alone. DESIGN A retrospective medical chart review of clinical and pathologic features., Setting: Tertiary academic medical center., Patients: We studied patients treated for HNSCC who were tested for markers of HPV or had tissue available for testing between 2006 and 2010., Main Outcome Measures: Four otolaryngology-head and neck surgery trainees were given the database of patient clinical and pathologic features and asked to predict the HPV status for each patient. The trainees' responses were scored for accuracy, positive and negative predictive value, and interrater agreement. Multiple linear regression analyses were performed to determine predictors of HPV positivity., Results: A total of 174 patients meeting inclusion criteria were identified, 95 of whom were determined to have HPV-positive tumor tissue. Residents were able to accurately predict HPV status in 110 to 125 patients (63%-72%), with positive predictive values of 76% to 84% and negative predictive values of 61% to 69%. The only variables significantly related to HPV status were male sex (P = .01) and oropharyngeal subsite (P = .02). Only 4 patients had a "typical" HPV-positive profile., Conclusions: Knowledge of cancer stage, primary site, basaloid features, tumor differentiation, and presence of cystic neck disease and patient age, race, and smoking status did not allow accurate predictions of HPV status in many patients. Clinical testing of tumor tissue remains essential for a diagnosis of HPV-positive disease.

Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma. The clinical course of EPN can be severe and life-threatening if not recognized and treated promptly. Most of the information has been from case reports, a few large series have also been reported. Using an evidence-based approach, this review describes the pathogenesis, classification, complications, and management of EPN. Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The cause for mortality in EPN is primarily due to septic complications. Up to 95% of the cases with EPN have underlying uncontrolled diabetes mellitus. The risk of developing EPN secondary to a urinary tract obstruction is about 25-40%. There are three classifications of EPN based on radiological findings. Acute renal failure, microscopic or macroscopic haematuria, severe proteinuria are other positive findings in EPN. Escherichia coli is the most common causative pathogen with the organism isolated on urine or pus cultures in nearly 70% of the reported cases. A plain radiograph shows an abnormal gas shadow in the renal bed raising the suspicion whereas an ultrasound scan or computed tomography (CT) will confirm the presence of intra-renal gas thus supporting the diagnosis of EPN. Gas may extend beyond the site of inflammation to the sub capsular, perinephric and pararenal spaces. In some cases, gas was found to be extending into the scrotal sac and spermatic cord. Subsequent case studies have shown patients being successfully treated with PCD when used in addition to medical management, with significant reduction in the morality rates. PCD should be performed on patients who have localized areas of gas and functioning renal tissue is present. The treatment strategies include MM alone, PCD plus MM, MM plus emergency nephrectomy, and PCD plus MM plus emergency nephrectomy. In small proportion of patients managed with MM and PCD, subsequent nephrectomy will be required and in these patients the reported mortality is 6.6% Nephrectomy in patients with EPN can be simple, radical or laparoscopic., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Ferrets have increased in popularity as pets, and a growing number are seen in companion animal practice. Domestic ferrets are commonly used as animal models for research of human oral conditions. The present study evaluated the prevalence of oral pathology in rescued ferrets which - to the authors' knowledge - has not yet been described in the scientific literature. Conscious oral examination was performed on 63 ferrets, of which 49 underwent general anesthesia for further examination. The most common clinical findings included malocclusion of mandibular second incisor teeth (95.2%); extrusion of canine teeth (93.7%); and abrasion and attrition of teeth (76.2%). Tooth fractures were exclusively associated with canine teeth and found in 31.7% of ferrets. Pulp exposure was confirmed in 60.0% of fractured teeth. The normal gingival sulcus depth measured < 0.5-mm in 87.8% of anesthetized ferrets. Clinical evidence of periodontal disease was present in 65.3% of anesthetized ferrets (gingivitis or probing depths > 0.5-mm), however advanced periodontal disease (i.e. periodontal pockets > 2-mm or stage 3 furcation exposure) was not found upon clinical examination. There was no evidence of tooth resorption, dental caries, stomatitis, or oral tumors in the examined group of ferrets.

Background: Despite national and international policies to develop social capital in disaster-affected communities, empiric evidence on the association between social capital and disaster mental health is limited and ambiguous., Objective: The study explores the relationship between social capital and disaster mental health outcomes (PTSD, anxiety, and depression) in combination with individual factors (appraisal, coping behavior, and social support)., Design: This is a community-based cross-sectional study in a flood-affected town in northern England. The study is part of the MICRODIS multi-country research project that examines the impact of natural disasters. It included 232 flood-affected respondents., Results: The findings showed that a considerable part of the association between cognitive and structural social capital and mental health is exerted through individual appraisal processes (i.e. property loss, primary and secondary appraisal), social support, and coping behavior. These individual factors were contingent on social capital. After the inclusion of individual characteristics, cognitive social capital was negatively related to lower mental health problems and structural social capital was positively associated to experiencing anxiety but not to PTSD or depression. Depression and anxiety showed a different pattern of association with both components of social capital., Conclusions: Individual oriented stress reducing interventions that use appraisal processes, social support, and coping as starting points could be more effective by taking into account the subjective experience of the social context in terms of trust and feelings of mutual support and reciprocity in a community. Findings indicate that affected people may especially benefit from a combination of individual stress reducing interventions and psychosocial interventions that foster cognitive social capital.

An adult, presumed intact female Umbrella Cockatoo (Cacatua alba), presented with acute hemorrhage from an intraocular mass that perforated through the right cornea. Computed tomography scanning revealed a large soft tissue mass in the right orbit, invading and displacing the globe laterally, and destroying the scleral ossicles. There was no evidence of bony changes of the orbit or extension of the mass into the optic nerve or brain. Exenteration and mass removal were performed, and osteosarcoma was diagnosed via histopathology. Radiotherapy was delivered with an orthovoltage unit to a total dose of 68 Gray delivered in 17 fractions over 6 weeks. The bird recovered well from treatment, but died 2 months after the last radiation session with neurological signs. Necropsy was not performed. To our knowledge, this is the first case of an intraocular osteosarcoma reported in a bird, and the first case of attempted treatment of osteosarcoma in a bird by a combination of surgery and radiation therapy.

The establishment of reference intervals for hematologic and blood chemistry values in a given species is essential for subsequent diagnosis of disease at rehabilitation facilities and in captive breeding programs. In this study, blood samples were obtained from nestlings (18 males and 22 females) of a natural-vegetation breeding population of Montagu's harrier (Circus pygargus) in eastern Spain in order to establish reference intervals for blood values. This is the first study documenting hematologic and biochemical reference intervals for free-living Montagu's harriers. The studied population may reflect typical blood values for the species, since it is a free-living population that seems not to be constrained by food availability, as it is the population of Montagu's harriers with the highest productivity within Europe. Differences related to sex, year, clutch size, brood size, and number of fledglings were analyzed. Packed cell volume and hemoglobin were significantly lower from nests with five chicks compared to values from nests with fewer chicks, indicating that the cost of rearing more than four chicks in this species may be excessive. Total protein, calcium (Ca), and phosphorus (P) were significantly lower in the year with lowest mean rainfall, which correlates with the worst breeding success rate since the population has been monitored. No gender differences were found; this is likely a result of the prepubertal age of the animals sampled.

A series of simple tests have been used to measure the performance of flat-bed film scanners suitable for digitisation of electron micrographs. Two of the film scanners evaluated are commercially available and one has been constructed in the laboratory paying special attention to the needs of the electron microscopist. The tests may be useful for others.

By learning lessons from weed science we have adopted three approaches to make plants more effective in phytoremediation: (1) The application of functional genomics to identify key components involved in the detoxification of, or tolerance to, xenobiotics for use in subsequent genetic engineering/breeding programmes. (2) The rational metabolic engineering of plants through the use of forced evolution of protective enzymes, or alternatively transgenesis of detoxification pathways. (3) The use of chemical treatments which protect plants from herbicide injury. In this paper we examine the regulation of the xenome by herbicide safeners, which are chemicals widely used in crop protection due to their ability to enhance herbicide selectivity in cereals. We demonstrate that these chemicals act to enhance two major groups of phase 2 detoxification enzymes, notably the glutathione transferases and glucosyltransferases, in both cereals and the model plant Arabidopsis thaliana, with the safeners acting in a chemical- and species-specific manner. Our results demonstrate that by choosing the right combination of safener and plant it should be possible to enhance the tolerance of diverse plants to a wide range of xenobiotics including pollutants.

Intra-abdominal (as opposed to extremity or limb and limb-girdle) soft tissue sarcomas (STS) are rare and account for less than 1% of all diagnosed neoplasms. These tumours are usually associated with a poor prognosis and are often locally invasive and metastatic at the time of presentation. Retroperitoneal sarcomas with synchronous or metachronous different histological types are rare and intra-duodenal sarcomas extremely unusual. A case of a giant retroperitoneal STS weighing approximately 15 kg consisting of two histologically different types is presented. Intra-duodenal involvement with sarcoma was found intra-operatively. We discuss the management of this condition in the context of an illustrative case in our recent experience.

Objective: To document long-term survival in patients with renal cell carcinoma (RCC) in whom the primary tumour was left in situ and treatment limited to palliative and symptomatic measures., Patients and Methods: All patients with a diagnosis of RCC from January 1994 to January 1999 and in whom the primary tumour was left in situ were identified from hospital records (nine women and 16 men, mean age 69 years). The tumour stage was T1-T4., Results: The mean survival overall was 19.3 months; patients with locally advanced disease, i.e. stage >or= T3a, had a mean survival of 16.9 months., Conclusions: There is renewed interest in the management of advanced RCC, with data supporting cytoreductive nephrectomy with systemic biological therapy. These results confirm that such patients with or without metastatic disease can survive for a considerable period with no aggressive surgical or systemic measures, and such intervention may offer no significant advantage in outcome and survival over supportive treatment alone.

Gonococcal urethritis in a heterosexual male complicated by periurethral abscess and its treatment with antibiotics and surgical drainage is presented.

Aim: Ten percent of soft tissue sarcomas (STS) arise in the retroperitoneal tissues. The prognosis for patients with retroperitoneal sarcoma is poor with a 5-year survival rate between 12% and 70%. Stage at presentation, high histological grade, unresectable primary tumour and incomplete resection are associated with a less favourable outcome., Methods: Complete follow-up data were available on 22 patients who underwent surgery for retroperitoneal STS in our institution between 1990 and 2000. Patient, tumour and treatment variables were analysed including use of adjuvant therapy and survival status., Results: Eighteen patients underwent surgery for primary disease, four patients were treated for recurrent disease or metastases. Ten patients presented with pain, seven with an abdominal mass, other presentation included weight loss and haematuria. Thirteen patients presented with tumours larger than 10 cm. The tumours were seven liposarcomas, six leiomyosarcomas, three malignant fibrous histiocytomas, two rhabdomyosarcomas, two malignant schwannomas and two undifferentiated sarcomas. Six primary tumours were completely excised, five patients received radiotherapy and five received chemotherapy. Local recurrence rate was 45% and recurrence-free interval for 10 patients with recurrence was 11 months. Five patients received radiotherapy and five received chemotherapy. The median survival for patients with primary tumours was 36 months, and 5-year survival was 44%. Adjuvant therapy was not associated with higher survival rates., Conclusion: This study re-emphasizes the poor outcome of patients with retroperitoneal STS. Adjuvant radiotherapy and chemotherapy do not appear to be any proven benefit and the single most important prognostic factor is aggressive successful en bloc resection of the primary tumour. Our resection rate and 5-year survival rates are comparable with previous reported UK series although lower than large reports from North American centres. This might partly be explained by difficulty in data collection in a retrospective analysis, but may reflect inadequate subspecialization in UK centres., (Copyright Harcourt Publishers Limited.)

Many woody species can be propagated from leafy cuttings. However, following rooting, cuttings of Corylus maxima Mill. cv. Purpurea do not always survive the transition from a highly supportive rooting environment (e.g., fog) to a more natural environment where evaporative demand is higher. We found that it is not the supply of water to leaves, but stomatal dysfunction that leads to severe water deficits in the rooted cuttings. Two hours after well-rooted cuttings were transferred from the rooting environment, we were able to relate visible signs of leaf water deficit to high stomatal conductance (g(s)) and low relative water content (R). Small expanding leaves (L3) had unusually high g(s) and lower R than fully expanded leaves (L1). Although high cuticular conductances (g(c)) were occasionally observed in L3, SEM confirmed that increased total leaf conductance (g) was mainly a result of abnormally wide stomatal opening. We measured changes in the ability of stomata to control water loss during rooting by determining stomatal responsiveness to leaf water deficit in detached L1 and L3 harvested from cuttings during the first 75 days after severance from stock plants. Reduced stomatal responsiveness was observed within 7 days of severance, prior to adventitious root formation, and was more pronounced in L3 than in L1. A period of acclimatization after rooting (no leaf wetting, but a vapor pressure deficit of 0.20 kPa) reduced g(s) by 50% in L3 but not in L1, and partially restored stomatal responsiveness in L1 but not in L3. After rooting, the original leaves on the cutting retained substantial capacity for photosynthesis (e.g., in L1, 8 micromol m(-2) s(-1) at a photosynthetic photon flux density of 400 micromol m(-2) s(-1)). The implications of the results for post-rooting acclimatization procedures are discussed.

Heat shock proteins (hsps) occupy a central role in the regulation of intracellular homeostasis, and differential expression of individual hsps occurs in a broad range of neoplastic processes. This study was performed to test the hypothesis that the particular patterns by which individual hsps become specifically modulated in human prostate cancers are correlated with behavioral phenotype and hence may be of value in determining the most appropriate clinical management of individual patients. Monoclonal antibodies specific for each hsp protein were used to assess expression of hsp27, hsp60, and hsp70 in formalin-fixed, paraffin wax-embedded, archival tissue specimens of early prostatic adenocarcinomas (pT1-2N0M0) removed at radical prostatectomy (n = 25) and in advanced cancers (n = 95) identified at transurethral resection of prostate (TURP). These findings were compared with similar data from control prostates (n = 10) removed at primary cystectomy for urinary bladder neoplasia not involving the prostate and also at TURP for benign prostatic hyperplasia (n = 50). Western blotting of whole cell lysates derived from established human prostatic epithelial cell lines PNT2, LNCaP, DU145, and PC3 was compared with expression of hsps by the primary human tissues. This study found that early in situ neoplastic transformation of normal prostatic epithelium was consistently associated with loss of hsp27 expression and that the level of hsp27 expression by individual prostate cancers was correlated with their Gleason grade. In advanced cancers, hsp27 expression was invariably associated with poor clinical outcome (P = 0.0001). Data from cell lines supported the primary tissue findings, with elevated hsp27 expression only in aggressive malignant cell lines and androgen-insensitive cell lines. Expression of hsp60 was significantly increased in both early and advanced prostate cancer when compared with nonneoplastic prostatic epithelium (P < 0.0001), as well as in malignant prostate cancer cell lines. Expression of hsp70 was unaltered in early prostate cancers when compared with nonneoplastic prostatic epithelium but showed a diminished expression in morphologically advanced cancers (P = 0.0029). No consistent correlation was found between levels of hsp60 or hsp70 expression and phenotypic behavior of individual primary prostatic cancers. Thus, patterns of hsp expression have been confirmed to be specifically and consistently modulated in both early and advanced human prostate cancers. Whereas absence of hsp27 is a reliable objective marker of early prostatic neoplasia, reexpression of this protein by an individual invasive prostatic carcinoma invariably heralds poor clinical prognosis. Because this protein has been shown to alter the balance between proliferation and apoptosis, understanding the mechanism(s) by which individual hsps regulate intracellular homeostasis may assist in explaining some key processes that occur during evolution of human prostate cancers. We suggest that hsp27 expression provides novel diagnostic and prognostic information on individual patient survival which, if obtained at the time of primary diagnosis, would assist in determining tumor-specific management strategies. Development of techniques to therapeutically modulate hsp27 expression raises the possibility of novel targeted approaches to regulate this homeostatic mechanism, thus allowing better control over tumor cell proliferation and hence patient survival.

The author discussed various advanced roles for the perioperative RN; commitment and passion for the OR professional; the need for education, education, education; and how to plan your career.

Acclimation to elevated CO 2 was investigated in Parmelia caperata originating from the vicinity of a natural CO 2 spring, where the average daytime CO 2 concentration was 729 ± 39 μmol mol -1 dry air. Thalli showed no evidence of a down-regulation in photosynthetic capacity following long-term exposure to CO 2 enrichment in the field; carboxylation efficiency, total Ribulose bisphosphate carboxylase/oxygenase (Rubisco) content, apparent quantum yield of CO 2 assimilation, and the light-saturated rate of CO 2 assimilation (measured under ambient and saturating CO 2 concentrations) were similar in thalli from the naturally CO 2 enriched site and an adjacent control site where the average long-term CO 2 concentration was about 355 μmol mol -1 . Thalli from both CO 2 environments exhibited low CO 2 compensation points and early saturation of CO 2 uptake kinetics in response to increasing external CO 2 concentrations, suggesting the presence of an active carbon-concentrating mechanism. Consistent with the lack of significant effects on photosynthetic metabolism, no changes were found in the nitrogen content of thalli following prolonged exposure to elevated CO 2 . Detailed intrathalline analysis revealed a decreased investment of nitrogen in Rubisco in the pyrenoid of algae located in the elongation zone of thalli originating from elevated CO 2 , an effect associated with a reduction in the percentage of the cell volume occupied by lipid bodies and starch grains. Although these differences did not affect the photosynthetic capacity of thalli, there was evidence of enhanced limitations to CO 2 assimilation in lichens originating from the CO 2 -enriched site. The light-saturated rate of CO 2 assimilation measured at the average growth CO 2 concentration was found to be significantly lower in thalli originating from a CO 2 -enriched atmosphere compared with that of thalli originating and measured at ambient CO 2 . At lower photosynthetic photon flux densities, the light compensation point of net CO 2 assimilation was significantly higher in thalli originating from elevated CO 2 , and this effect was associated with higher usnic acid content.

Gender awareness and sensitivity in disaster research and management remains uncommon and tends to focus on the developing rather than the developed world. This paper uses a feminist oral geography to present some findings about women's experiences in two floods in Scotland. It is conceptualised around public and private (masculinised and feminised) space, problematising the private domain and presenting it, in the feminist research tradition, as a legitimate object of research. It shows the ordinary and everyday to be more opaque and complex than usually imagined and makes recommendations for their recognition and incorporation into disaster management. While there is a specific focus on the private domain of the home, this is not intended to reinforce gender stereotypes but simply to recognise the reality of many of the women interviewed. It concludes that disaster research generally has yet to advance much beyond the earliest stages of feminist studies which merely sought to make women visible in society.

The aim of this study was to characterise growth and photosynthetic capacity in plants adapted to long-term contrasting atmospheric CO 2 concentrations (C a ). Seeds of Agrostis canina L. ssp. monteluccii were collected from a natural CO 2 transect in central-western Italy and plants grown in controlled environment chambers at both ambient and elevated CO 2 (350 and 700 μmol mol -1 ) in nutrient-rich soil. Seasonal mean C a at the source of the plant material ranged from 610 to 451 μmol CO 2 mol -1 , derived from C 4 leaf stable carbon isotope discrimination (δ 13 C). Under chamber conditions, CO 2 enrichment stimulated the growth of all populations. However, plants originating from elevated C a exhibited higher initial relative growth rates (RGRs) irrespective of chamber CO 2 concentrations and a positive relationship was found between RGR and C a at the seed source. Seed weight was positively correlated with C a , but differences in seed weight were found to explain no more than 34% of the variation in RGRs at elevated CO 2 . Longer-term experiments (over 98 days) on two populations originating from the extremes of the transect (451 and 610 μmol CO 2 mol -1 ) indicated that differences in growth between populations were maintained when plants were grown at both 350 and 700 μmol CO 2 mol -1 . Analysis of leaf material revealed an increase in the cell wall fraction (CWF) in plants grown at elevated CO 2 , with plants originating from high C a exhibiting constitutively lower levels but a variable response in terms of the degree of lignification. In vivo gas exchange measurements revealed no significant differences in light and CO 2 saturated rates of photosynthesis and carboxylation efficiency between populations or with CO 2 treatment. Moreover, SDS-PAGE/ LISA quantification of leaf ribulose bisphosphate carboxylase/oxygenase (Rubisco) showed no difference in Rubisco content between populations or CO 2 treatments. These findings suggest that long-term adaptation to growth at elevated CO 2 may be associated with a potential for increased growth, but this does not appear to be linked with differences in the intrinsic capacity for photosynthesis.

Objective: To determine the effectiveness of prostatectomy in reducing symptom severity and bother and in improving disease-specific and general quality of life., Patients and Methods: A prospective, cohort study was performed in National Health Service and private hospitals in the Northern, Wessex, Mersey, and South-West Thames Health Regions which comprised 5276 men undergoing prostatectomy recruited by 101 of the 106 (96%) surgeons (specialist and non-specialist) performing prostatectomy during a 6-month period. Patients were assessed using the American Urological Association (AUA) Symptom Index Score, the AUA symptom bother score, disease-specific and generic quality-of-life scores, the occurrence of adverse events (urinary incontinence, erectile impotence and retrograde ejaculation) and three global (general) questions on the results of their treatment. The outcome was assessed 3 months after surgery., Results: Prostatectomy was effective in reducing both symptoms (initial mean score 20.1 reduced to 7.4, P < 0.001) and symptom bother (initial mean score 14.4 reduced to 4.3, P < 0.001). Not all men experienced a good reduction in symptoms; 121 (3.9%) were worse, 301 (9.6%) were the same, and 721 (23%) experienced only slight improvement. The type of operation, grade of principal operator and use of pre-operative investigations were not associated with the extent of symptomatic improvement. Changes in symptom severity were highly correlated with changes in bothersomeness++ and disease-specific quality of life but not with generic quality of life. A third of men who were continent before surgery reported some incontinence 3 months later, although only 6% found it a problem. Two-thirds of men experienced retrograde ejaculation and 31% experienced some erectile impotence following surgery., Conclusions: Prostatectomy is effective in reducing symptoms in most men. Men who experience a substantial reduction in symptoms were more likely to report a favourable outcome. The study confirmed that approximately one-third of men reported an unfavourable result 3 months after their operation.

Objective--To determine the feasibility of performing multicentre process and outcome audits of common interventions taking prostatic procedures as an example. Design--Prospective, cohort study. Setting--All National Health Service and independent hospitals in Northern, Wessex, Mersey, and South West Thames health regions. Patients--5361 men undergoing prostatectomy identified by 103 of the 107 urologists and general surgeons performing prostatectomy in the study regions. Main measures-- Rates of participation by surgeons and patients; completeness of clinical data provided by surgeons; patient response rate and completeness of patient derived data; and cost. Results--Most surgeons (103,96%) agreed to participate. Overall, the proportion of eligible patients invited to take part was high (89%), although this was only measured in South West Thames, where dedicated data collectors were employed. Few men (80, 1.5%) declined to participate. Of those surviving for three months after surgery, 82.4% (4226) completed and returned the postal questionnaire. The response rate was higher in South West Thames (86.7%) than in the other regions (80.6%-80.8%). The audit was well received: 91% of patients found the questionnaire easy to complete and only 2.3% of them disapproved. Completeness of data was high with both the hospital and patient questionnaires. Missing data occurred in less than 5% of responses to most questions. The attributable cost was 34.50 pounds per patient identified or 44 pounds for patients in whom either the treatment outcome or vital status was known three months after their prostatectomy. Conclusions--This multicentre audit of process and outcome of prostatectomy proved feasible in terms of surgeon participation, patient identification, and the quantity and quality of data collection. Whether the cost was warranted will depend on how surgeons use the audit data to modify their practice.

Objective: To determine everyday practice in the hospital management of men undergoing prostatectomy and the extent of its variation., Patients and Methods: A total of 5361 patients, who represented 89% of all those undergoing prostatic procedures in four health regions (Mersey, Wessex, Northern and South West Thames) and one test site (within Trent) were recruited by 103 (97%) surgeons. Clinical information was collected on a pre-coded data collection form which was completed during the hospital stay by the principal operator. Patient identification occurred at the time of surgery., Results: Important findings included: (i) both older men and those of higher social class were more likely to undergo prostatectomy with fewer symptoms; (ii) men who waited longer for surgery had worse symptoms by the time of their operation; (iii) there were unexplained differences in routine pre- and post-operative investigation and treatment. Half the men had their flow rate or residual urine measured as part of their pre-operative assessment. About half the men received prophylactic antibiotics; (iv) when large groups were analysed, a consistent proportion of men throughout the study (12%) were undergoing the operation for a second time. The clinical course of men having a repeat operation differed in many ways from those having a first time procedure; (v) the larger proportion of men (62%) had surgery for strong indications as opposed to symptoms alone; (vi) although most operations were performed by consultants, emergency admissions, though symptomatically more severe and sicker, were more likely to be operated on by trainee surgeons; (vii) significant variation in mean pre-operative symptom severity and bother scores were seen between surgeons., Conclusion: The clinical management of prostatectomy has been defined in a large and representative UK sample. In some circumstances consistent variations have been identified. It is not yet clear whether these variations influence outcome. These data can be used by surgeons wishing to compare their own patient management with that described here.

Carbon-isotope ratios ([delta]13Cs) were measured for various bio-chemical fractions quantitatively extracted from naturally exposed and shaded leaves of the C3-Crassulacean acid metabolism (CAM) intermediate Clusia minor, sampled at dawn and dusk on days during the wet and dry seasons in Trinidad. As the activity of CAM increased in response to decreased availability of water and higher photon flux density, organic acids and soluble sugars were enriched in 13C by approximately 3.5 to 4%[per mille (thousand) sign] compared to plants sampled during the wet season. The induction of CAM was accompanied by a doubling in size of the reserve carbohydrate pools. Moreover, stoichiometric measurements indicated that degradation of both chloroplastic reserves and soluble sugars were necessary to supply phosphoenolpyruvate for the synthesis of organic acids at night. Results also suggest that two pools of soluble sugars exist in leaves of C. minor that perform CAM, one a vacuolar pool enriched in 13C and the second a transport pool depleted in 13C. Estimates of carbon-isotope discrimination expressed during CAM, derived from the trafficking among inorganic carbon, organic acids, and carbohydrate pools overnight, ranged from 0.9 to 3.1%[per mille (thousand) sign]. The [delta]13C of structural material did not change significantly between wet and dry seasons, indicating that most of the carbon used in growth was derived from C3 carboxylation.

There is increasing interest in the acquisition and measurement of physical fitness in general populations (Bassey and Fentem 1981). Measuring fitness can be uncomfortable and exhausting for subjects and expensive and time-consuming for experimenters (Andersen et al. 1971). Various authors have described and/or evaluated methods for the prediction of VO2 max (Astrand and Rhyming 1954, Davies 1968, Fitchett 1985, Harrison et al. 1980, Jette 1979, Jette et al. 1982, Shephard 1975, Shephard et al. 1979). A valid, safe, socially-acceptable alternative for such measurements applicable to a population would be of benefit. Asking subjects how they perceive their own physical fitness might be such an alternative. The validity and reliability of the data contained from such a questionnaire could be tested against conventional measures of physical fitness. A study which incorporated questionnaire surveys as one method of determining physical fitness in a large population was undertaken on Fire Service personnel in England, Scotland, and Wales (Ellam et al. 1985); a subsample of the population were questioned in the same way but in addition their fitness was assessed by physiological measurements. This paper describes the characteristics of the physical fitness of an average fireman as revealed by responses to questionnaires and how firemen felt their fitness was related to their working duties; it further examines these in relation to objective measurements.