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Background We aimed to assess the relationship between diet quality and risk of older-onset Crohn's disease [CD] and ulcerative colitis [UC]. Methods We conducted a prospective cohort study of 83 147 participants from the Swedish Mammography Cohort and the Cohort of Swedish Men. We used food frequency questionnaires to calculate adherence scores to multiple derived healthy diet patterns: Alternate Healthy Eating Index [AHEI], Healthy Eating Index-2015 [HEI-2015], Healthful Plant-Based Diet Index [HPDI], and modified Mediterranean Diet Score [mMED] at baseline in 1997 in both cohorts. Diagnoses of CD and UC were retrieved from the Swedish Patient Register. We used Cox proportional hazards modelling to estimate the adjusted hazard ratios [HRs] and 95% confidence intervals [CIs]. Results Through December of 2017, we confirmed 164 incident cases of CD and 395 incident cases of UC. Comparing the highest with the lowest quartiles, the adjusted HRs of CD were 0.73 [95% CI, 0.48, 1.12, p trend = 0.123] for AHEI; 0.90 [0.57, 1.41, p trend = 0.736] for HEI 2015; 0.52 [95% CI 0.32, 0.85, p trend = 0.011] for HPDI; and 0.58 [95% CI 0.32, 1.06, p trend = 0.044] for mMED. In contrast, we did not observe an association between any diet quality score and risk of UC. Conclusions We found that several healthy eating patterns were associated with a lower risk of older-onset CD. Our findings provide a rationale for adapting different healthy dietary patterns based on individuals' food preferences and traditions in designing future prevention strategies for IBD. [ABSTRACT FROM AUTHOR]

It is unclear whether obesity is associated with the development of inflammatory bowel disease despite compelling data from basic science studies. We therefore examined the association between obesity and risk of Crohn's disease (CD) and ulcerative colitis (UC). We conducted pooled analyses of 5 prospective cohorts with validated anthropometric measurements for body mass index (BMI) and waist-hip ratio and other lifestyle factors. Diagnoses of CD and UC were confirmed through medical records or ascertained using validated definitions. We used Cox proportional hazards modeling to calculate pooled multivariable-adjusted HRs (aHRs) and 95% confidence intervals (CIs). Among 601,009 participants (age range, 18-98 years) with 10,110,018 person-years of follow-up, we confirmed 563 incident cases of CD and 1047 incident cases of UC. Obesity (baseline BMI ≥30 kg/m2) was associated with an increased risk of CD (pooled aHR, 1.34; 95% CI, 1.05-1.71, I 2 = 0%) compared with normal BMI (18.5 to <25 kg/m2). Each 5 kg/m2 increment in baseline BMI was associated with a 16% increase in risk of CD (pooled aHR, 1.16; 95% CI, 1.05-1.22; I 2 = 0%). Similarly, with each 5 kg/m2 increment in early adulthood BMI (age, 18-20 years), there was a 22% increase in risk of CD (pooled aHR, 1.22; 95% CI, 1.05-1.40; I 2 = 13.6%). An increase in waist-hip ratio was associated with an increased risk of CD that did not reach statistical significance (pooled aHR across quartiles, 1.08; 95% CI, 0.97-1.19; I 2 = 0%). No associations were observed between measures of obesity and risk of UC. In an adult population, obesity as measured by BMI was associated with an increased risk of older-onset CD but not UC. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate student perceptions of different online course delivery methods. In order to develop the experimental course delivery method, the researchers used universal design for learning (UDL) guidelines as a theoretical framework. Responses to pre- and postsurvey items provided data to examine whether an online course developed using UDL principles afforded a more positive learning experience. This study provides online student perceptions that indicate the online learning environment developed with the UDL framework is preferred by students. [ABSTRACT FROM AUTHOR]

Numerous studies document the link between education and economic development and improvements in connectivity and access to online learning opportunities highlight academic integrity issues that online educators must address. Academic integrity is defined as a moral code that discourages or prohibits any activity perceived as unethical in an academic setting. This moral code should both value and encourage the high academic standards, while suppressing such unethical behaviors as plagiarism, cheating on exams, and contract cheating. The ubiquity and growth in online learning poses new issues for academics with regard to academic integrity in the virtual classroom. In this paper we review unethical academic behaviors, some which are specific to online learning, and offer strategies to mitigate these behaviors. [ABSTRACT FROM AUTHOR]

Background Pelvic vascular injuries (PVIs) rarely occur in isolation and are often associated with significant morbidity. The purpose of this study was to examine the incidence, trends, and early outcomes of PVIs sustained in combat. Methods The Department of Defense Trauma Registry was queried to identify all patients treated with PVIs during the first 10 years of Operation Enduring Freedom. Patient demographics, mechanism of injury, type of vascular injury, in-theater complications, and early clinical outcomes were examined. Results From 2003 to 2012, 143 patients (99% male) sustained a PVI in Afghanistan. During this period, there was a persistent increase in the percentage of patient visits (0.4% in 2003 to 2.0% in 2012). The mean Injury Severity Score (ISS) was 24. Sixty-six percent of patient injuries were secondary to explosions. Improvised explosive devices (IEDs) encountered by dismounted personnel accounted for 47% of all injuries and were associated with a significantly higher ISS (28) compared with all other mechanisms of injury ( P < .01). There were 85 (43%) arterial and 112 (57%) venous PVIs. The most frequent arterial injury was the common iliac artery. Injury to the femoral vein was associated with a higher median transfusion requirement. One patient died in combat theater. Injuries from IEDs had higher rates of coagulopathy, acidosis, and hypothermia compared with other mechanisms of injury ( P = .03). Forty-two patients (29%) sustained early infectious complications. Injuries from explosions were also associated with a significantly higher rate of infectious complications compared with other mechanisms of injury ( P < .01). Conclusions PVIs have occurred with increasing frequency during Operation Enduring Freedom. Despite a persistently low mortality, complication and infection rates remain high, particularly when injuries are secondary to explosions. IEDs are associated with higher ISS and complication rates. Future studies must continue to focus on the prevention and treatment of PVIs sustained in combat, particularly those caused by explosions. [ABSTRACT FROM AUTHOR]

Objective We aimed to determine the safety and efficacy of antiplatelet/anticoagulation regimens after placement of Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) for the treatment of femoropopliteal occlusive disease. Methods Clinical, angiographic, and procedural data for patients undergoing endovascular treatment of femoropopliteal occlusive disease using Viabahn covered stent grafts at a single institution between 2006 and 2013 were retrospectively reviewed. Graft patency and freedom from thrombolysis, major adverse limb event, and reintervention were determined by Kaplan-Meier analysis. The influence of relevant variables on clinical outcome was determined through univariate and multivariate Cox proportional hazards analyses. Results Viabahn stent grafts were placed in a total of 91 limbs in 61 patients (66% men; mean age, 69 ± 12 years) during the study period. Indication for intervention was either claudication (n = 59) or critical limb ischemia (n = 32), with the majority (70%) classified as TransAtlantic Inter-Society Consensus II C (n = 33) or D (n = 31) lesions. Mean follow-up was 38.3 months (range, 1-91 months). Postprocedural pharmacologic regimens included aspirin, clopidogrel, and warfarin (47%); indefinite aspirin and clopidogrel (46%); or aspirin and temporary clopidogrel (7%). Primary and secondary patency rates were 60%, 44%, and 36% and 95%, 82%, and 74% at 1 year, 3 years, and 5 years, respectively. Kaplan-Meier analysis demonstrated more aggressive antiplatelet/anticoagulation regimens to be associated with improved primary patency and freedom from reintervention. Cox proportional hazards analysis demonstrated TransAtlantic Inter-Society Consensus II D lesions, tobacco use, coronary artery disease, and smaller stent diameter to be independent risk factors for stent graft failure. Bleeding events were limited to those in the aspirin, clopidogrel, and warfarin group (11.6% [n = 5]; P = .052), although the majority of these events were not life-threatening, and only two cases required blood transfusion. Conclusions Increasingly aggressive antithrombotic regimens after Viabahn stent graft placement trended toward improved overall clinical outcomes, although the marginal patency benefit observed with the addition of warfarin to dual antiplatelet therapy was tempered by an observed increased risk of bleeding complications. Longer term follow-up and multicenter studies are needed to further define optimal type and duration of antithrombotic therapy after endovascular peripheral interventions. [ABSTRACT FROM AUTHOR]

Background Combat extremity wounds are complex and frequently require an immediate vascular reconstruction in the operational environment followed by delayed tissue coverage at a stateside medical treatment facility. The purpose of this study was to evaluate limb salvage outcomes after combat-related vascular reconstruction that subsequently required delayed soft tissue coverage during the Global War on Terror. Methods Patients who incurred a war-related extremity injury necessitating an immediate vascular intervention followed by definitive limb reconstruction requiring flap coverage from combat injuries were reviewed. Patient demographics, types of vascular and extremity injuries, and surgical interventions were examined. Outcomes included limb salvage, primary and secondary graft patency, flap outcomes, and complications. Differences between upper extremities (UEs) and lower extremities (LEs) were compared. Results From 2003 to 2012, 27 patients were treated for combat-related extremity injuries with an immediate vascular reconstruction followed by delayed tissue coverage. Fifteen LEs and 12 UEs were treated. The mean age was 24 years. An explosion was the cause in 77% of patients, with a mean Injury Severity Score (ISS) of 19. An autogenous vein bypass was the most common reconstruction performed in 20 patients (74%). Other vascular repairs included a primary repair, a patch angioplasty with bovine pericardium, and a bypass with use of a prosthetic graft. Eight patients (30%) had a concomitant venous injury, and 23 (85%) had a bone fracture. Thirty flaps were performed at a mean of 33 days from the original injury. Pedicle flaps were used in 24 limbs and free tissue flaps in six limbs. Muscle, fasciocutaneous, bone, and composite flaps were used for tissue coverage. At a mean follow-up of 16 months, primary patency rates of all arterial reconstructions were 66% in the UE and 53% in the LE ( P = .69). Secondary patency rates were 100% in the UE and 86% in the LE ( P = .48). The overall limb salvage rate was 81%. Limb salvage rates were 66% in the LE and 100% in the UE ( P = .04). Three amputated lower limbs (60%) had inline flow to the foot. The flap success rate was 96%. Reasons for amputation included arterial thrombosis, flap failure, persistent soft tissue infection, osteomyelitis, and debilitating peripheral nerve injuries with associated chronic pain. Conclusions Immediate vascular repair followed by delayed tissue coverage can be performed with a high (>80%) limb salvage rate after combat trauma. Limb salvage rates were higher in the UE despite equivocally high arterial patency rates. Wounded warriors can expect limb salvage by use of this international algorithm. [ABSTRACT FROM AUTHOR]

First described in 1924, necrotizing fasciitis (NF) is a rapidly progressing, severe suppurative infection of the superficial fascia, often associated with vascular thrombosis and necrosis of the overlying skin. Despite advances in medical therapy, the mortality remains high, with rates exceeding 25 to 50% in some studies. Early diagnosis and treatment is paramount in the management of this serious infection and should include wide surgical debridement and drainage of all necrotic tissues, coupled with aggressive parenteral antibiotics. This infectious process has been commonly associated with traumatic events in patients with compromised immune systems, diabetes, chronic steroid use, and alcoholism. The common microbacterial organisms associated with necrotizing fasciitis include Streptococcus pyogenes and Staphylococcus aureus and less commonly, facultative and anaerobic microorganisms. Most cases typically present in the extremities, trunk, and/or groin regions. Although this virulent soft tissue infection can occur within the face and neck areas, cases of isolated periorbital NF have been relatively uncommon. However, head and neck cases of NF have had high associated morbidity and mortality rates. In recent publications, the reported mortality rate for isolated periorbital NF was not insignificant, ranging from 8.5 to 12.5%. The prognosis, morbidity, and mortality rates will be greatly increased in those patients who present late in the infectious phase, have a delay in diagnosis and/or treatment, or who demonstrate extension of this virulent infection into the face, cervical, or sternal/mediastinal regions. An aggressive multimodal approach is required in treating periorbital necrotizing infection, with the main tenant remaining wide and adequate surgical debridement of affected tissues. This difficult clinical situation can create a subsequent challenge with respect to achieving good functional and cosmetic outcomes in those patients with periorbital NF. Delayed reconstruction of the eyelids with skin grafts and/or facial flaps is often required to avoid late complications such as cicatricial lid retraction, lid malposition, exposure keratopathy, and potential loss of vision. We describe a patient who presented to a military combat hospital with a virulent periorbital soft tissue infection. We have outlined his treatment course from the initial presentation through definitive reconstruction. [ABSTRACT FROM AUTHOR]

First described in 1924, necrotizing fasciitis (NF) is a rapidly progressing, severe suppurative infection of the superficial fascia, often associated with vascular thrombosis and necrosis of the overlying skin. Despite advances in medical therapy, the mortality remains high, with rates exceeding 25 to 50% in some studies. Early diagnosis and treatment is paramount in the management of this serious infection and should include wide surgical debridement and drainage of all necrotic tissues, coupled with aggressive parenteral antibiotics. This infectious process has been commonly associated with traumatic events in patients with compromised immune systems, diabetes, chronic steroid use, and alcoholism. The common microbacterial organisms associated with necrotizing fasciitis include Streptococcus pyogenes and Staphylococcus aureus and less commonly, facultative and anaerobic microorganisms. Most cases typically present in the extremities, trunk, and/or groin regions. Although this virulent soft tissue infection can occur within the face and neck areas, cases of isolated periorbital NF have been relatively uncommon. However, head and neck cases of NF have had high associated morbidity and mortality rates. In recent publications, the reported mortality rate for isolated periorbital NF was not insignificant, ranging from 8.5 to 12.5%. The prognosis, morbidity, and mortality rates will be greatly increased in those patients who present late in the infectious phase, have a delay in diagnosis and/or treatment, or who demonstrate extension of this virulent infection into the face, cervical, or sternal/mediastinal regions. An aggressive multimodal approach is required in treating periorbital necrotizing infection, with the main tenant remaining wide and adequate surgical debridement of affected tissues. This difficult clinical situation can create a subsequent challenge with respect to achieving good functional and cosmetic outcomes in those patients with periorbital NF. Delayed reconstruction of the eyelids with skin grafts and/or facial flaps is often required to avoid late complications such as cicatricial lid retraction, lid malposition, exposure keratopathy, and potential loss of vision. We describe a patient who presented to a military combat hospital with a virulent periorbital soft tissue infection. We have outlined his treatment course from the initial presentation through definitive reconstruction. [ABSTRACT FROM AUTHOR]

Subclinical microembolization identified on diffusion-weighted magnetic resonance imaging is recognized as an important outcome measure for carotid revascularization procedures. It is generally believed that arch manipulation is the primary reason for developing microemboli in the contralateral hemisphere during carotid artery stenting. However, we identified three patients who developed postprocedure microemboli of the contralateral hemisphere despite a known chronic contralateral internal carotid artery occlusion. Our cases highlight that ipsilateral microemboli may be an underappreciated but an important source of contralateral lesions through patent intracranial collateral pathways. [Copyright &y& Elsevier]

Objective: Reintervention rates after repair of abdominal aortic aneurysm (AAA) are higher for endovascular repair (EVAR) than for open repair, mostly due to treatment for endoleaks, whereas open surgical operations for bowel obstruction and abdominal hernias are higher after open repair. However, readmission rates after EVAR or open repair for nonoperative conditions and complications that do not require an intervention are not well documented. We sought to determine reasons for all-cause readmissions within the first year after open repair and EVAR. Methods: Patients who underwent elective AAA repair in California during a 6-year period were identified from the Health Care and Utilization Project State Inpatient Database. All patients who had a readmission in California ≤1 year of their index procedure were included for evaluation. Readmission rates and primary and secondary diagnoses associated with each readmission were analyzed and recorded. Results: From 2003 to 2008, there were 15,736 operations for elective AAA repair, comprising 9356 EVARs (60%) and 6380 open repairs (40%). At 1 year postoperatively, the readmission rate was 52.1% after open repair and 55.4% after EVAR (P = .0003). The three most common principle diagnoses associated with readmission after any type of AAA repair were failure to thrive, cardiac issues, and infection. When stratified by repair type, patients who underwent open repair were more likely to be readmitted with primary diagnoses associated with failure to thrive, cardiac complications, and infection compared with EVAR (all P < .001). Those who underwent EVAR were more likely, however, to be readmitted with primary diagnoses of device-related complications (P = .05), cardiac complications, and infection. Conclusions: Total readmission rates within 1 year after elective AAA repair are greater after EVAR than after open repair. Reasons for readmission vary between the two cohorts but are related to the magnitude of open surgery after open repair, device issues after EVAR, and the usual cardiac and infectious complications after either intervention. Systems-based analysis of these causes of readmission can potentially improve patient expectations and care after elective aneurysm repair. [Copyright &y& Elsevier]

Abstract: Flexion following total knee arthroplasty in the US population generally falls between 100° and 120°. Because of these relatively low flexion arcs, total knee arthroplasty prosthetic designs emerged allowing “high flexion” (≥125°). We hypothesized that a high-flexion implant design, Scorpio Non-Restrictive Geometry cruciate-retaining knee prosthesis, would allow clinical early maximum flexion of at least 125°. A prospective observational cohort study enrolled 87 unselected patients (94 knees) evaluated preoperation and 3 months and 1 year postoperation for clinical flexion, arc of motion, and Knee Society scores. At 1 year, 67% of knees had improved flexion and 23% achieved flexion of at least 125°. Clinically, flexion improved by 6.9° and total arc of motion improved by 10.6° from preoperation to 1-year postoperation. Although this high-flexion design allows increased flexion, many patients fail to achieve flexion of at least 125°. [Copyright &y& Elsevier]

Objectives: Although the performance of basilic vein transpositions for dialysis access is well established, the utility and patency rates of brachial vein transpositions are poorly characterized. The brachial vein is being used increasingly as an alternative vein for transposition in an effort to increase the percentage of autogenous fistula utilization. The purpose of this study was to review a single-center comparative experience with these fistulas. Methods: A retrospective chart review was performed on 59 patients who received basilic and brachial vein transpositions between January 2000 and December 2006. Patient demographics, comorbidities, mortality, and morbidity were evaluated. Patency rates were calculated using Kaplan-Meier life-table analysis. Results: Of 59 vein transpositions, there were 42 basilic (71%) and 17 brachial (29%). The 30-day mortality was 0%. Maturation rates were 74% for basilic vein transpositions and 47% for brachial (P = .049). The mean time to maturation was 11.9 ± 8.8 weeks. Primary patency rates at 12 months were 50% for basilic vein transpositions vs 40% for brachial (P = .115). The mean vein size was 4.9 ± 0.9 mm. The mean basilic vein transposition diameter of 4.9 ± 1.0 mm and brachial vein transposition diameter of 5.0 ± 0.8 mm were not significant (P = .39). Conclusions: Despite a higher rate of initial maturation in basilic vein transpositions, brachial and basilic vein transpositions had comparable patency rates at 12 months. These preliminary results require further follow-up and a larger cohort of patients for confirmation. Broader use of the brachial vein transposition for dialysis appears justified and can increase the overall percentage of autogenous fistula placement. [Copyright &y& Elsevier]

Comments about means-plus function claim limitations in patent lawsuits, citing the 1996 Supreme Court case, Markman v. Westview Instruments Incorporated. Excerpts from the sixth and final paragraph of Section 112 of Title 35 of the United States Codes; Question of infringement under the doctrine of equivalents; Reference to the Patent Act of 1952.