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This essay aims to identify vulnerabilities and exploitation means necessary to use destabilization to support a military, and ultimately political, objective in a potential conflict between China and the governments supporting a liberal rules-based order. Japanese efforts during the Russo-Japanese War of 1904-1905 showed destabilizing a regime as a credible way to support military objectives during a conflict and provided some key insights by which destabilization efforts function. Based on the historical case and contemporary analysis of China, this essay makes recommendations to decision makers in a conflict on how to best execute and support destabilization efforts. [ABSTRACT FROM AUTHOR]

The accuracy of Computed tomographic colonography (CTC) in a large number of participants across multiple centers are assessed. CTC, also known as virtual colonoscopy is reasonably accurate in the diagnosis of colorectal neoplasia in the studies performed.

Doctors describe the use of an antibody that blocks the epidermal growth factor receptor for treating Menetrier's disease. This disease affects the stomach and may be a precursor of stomach cancer. There is evidence that it may be partially caused by increased levels of epidermal growth factor.

Achalasia is a rare disorder that has several treatment options. The gold standard of treatment is a surgical myotomy called a laparoscopic Heller myotomy (LHM). More recently, an endoscopic myotomy has become an option as well, called peroral endoscopic myotomy (POEM). An achalasia registry was queried for patients undergoing either LHM or POEM at Baylor University Medical Center at Dallas. Patient demographics, preoperative and postoperative data points, and Eckardt scores were collected. The patients were further stratified into their follow-up intervals, immediate postoperative and long-term follow-up, to assess surgical success. A subset analysis was done for success of treatment for patients who had redo surgery versus those undergoing the procedure for the first time. There were 12 patients in the POEM group and 11 patients in the LHM group. Both groups demonstrated mean lower esophageal sphincter pressures with failure to relax. Procedure length and hospital length of stay were similar between the two groups. There were three adverse events in each group, but none altered the patient's postoperative clinical course. Eckardt scores, used to assess success of the surgery, were 82% for POEM patients and 66% for LHM patients after 6 months. The outcomes for POEM and LHM in our early experience are similar to those reported in the literature for high-volume centers managing achalasia. [ABSTRACT FROM AUTHOR]

In this study we investigated the ability of sensory input to produce tonic responses in hindlimb muscles to facilitate standing in adult spinal rats and tested two hypotheses: 1) whether the spinal neural networks below a complete spinal cord transection can produce tonic reactions by activating different sensory inputs and 2) whether facilitation of tonic and rhythmic responses via activation of afferents and with spinal cord stimulation could engage similar neuronal mechanisms. We used a dynamically controlled platform to generate vibration during weight bearing, epidural stimulation (at spinal cord level S1), and/or tail pinching to determine the postural control responses that can be generated by the lumbosacral spinal cord. We observed that a combination of platform displacement, epidural stimulation, and tail pinching produces a cumulative effect that progressively enhances tonic responses in the hindlimbs. Tonic responses produced by epidural stimulation alone during standing were represented mainly by monosynaptic responses, whereas the combination of epidural stimulation and tail pinching during standing or epidural stimulation during stepping on a treadmill facilitated bilaterally both monosynaptic and polysynaptic responses. The results demonstrate that tonic muscle activity after complete spinal cord injury can be facilitated by activation of specific combinations of afferent inputs associated with loadbearing proprioception and cutaneous input in the presence of epidural stimulation and indicate that whether activation of tonic or rhythmic responses is generated depends on the specific combinations of sources and types of afferents activated in the hindlimb muscles. [ABSTRACT FROM AUTHOR]

Background: Few options exist for patients with localized esophageal cancer ineligible for conventional therapies. Endoscopic spray cryotherapy with low-pressure liquid nitrogen has demonstrated efficacy in this setting in early studies. Objective: To assess the safety and efficacy of cryotherapy in esophageal carcinoma. Design: Multicenter, retrospective cohort study. Setting: Ten academic and community medical centers between 2006 and 2009. Patients: Subjects with esophageal carcinoma in whom conventional therapy failed and those who refused or were ineligible for conventional therapy. Interventions: Cryotherapy with follow-up biopsies. Treatment was complete when tumor eradication was confirmed by biopsy or when treatment was halted because of tumor progression, patient preference, or comorbid condition. Main Outcome Measurements: Complete eradication of luminal cancer and adverse events. Results: Seventy-nine subjects (median age 76 years, 81% male, 94% with adenocarcinoma) were treated. Tumor stage included T1-60, T2-16, and T3/4-3. Mean tumor length was 4.0 cm (range 1-15 cm). Previous treatment including endoscopic resection, photodynamic therapy, esophagectomy, chemotherapy, and radiation therapy failed in 53 subjects (67%). Forty-nine completed treatment. Complete response of intraluminal disease was seen in 31 of 49 subjects (61.2%), including 18 of 24 (75%) with mucosal cancer. Mean (standard deviation) length of follow-up after treatment was 10.6 (8.4) months overall and 11.5 (2.8) months for T1 disease. No serious adverse events were reported. Benign stricture developed in 10 (13%), with esophageal narrowing from previous endoscopic resection, radiotherapy, or photodynamic therapy noted in 9 of 10 subjects. Limitations: Retrospective study design, short follow-up. Conclusions: Spray cryotherapy is safe and well tolerated for esophageal cancer. Short-term results suggest that it is effective in those who could not receive conventional treatment, especially for those with mucosal cancer. [Copyright &y& Elsevier]

Background: Endoscopic ablation to treat Barrett''s esophagus (BE) with high-grade dysplasia (HGD) is associated with a decreased incidence of esophageal adenocarcinoma. Endoscopic spray cryotherapy (CRYO) demonstrates promising preliminary data. Objective: To assess the safety and efficacy of CRYO in BE with HGD. Design: Multicenter, retrospective cohort study. Setting: Nine academic and community centers; treatment period, 2007 to 2009. Patients: Subjects with HGD confirmed by 2 pathologists. Previous EMR was allowed if residual HGD remained. Interventions: CRYO with follow-up biopsies. Main Outcome Measurements: Complete eradication of HGD with persistent low-grade dysplasia, complete eradication of all dysplasia with persistent nondysplastic intestinal metaplasia, and complete eradication of all intestinal metaplasia. Results: Ninety-eight subjects (mean age 65.4 years, 83% male) with BE and HGD (mean length 5.3 cm) underwent 333 treatments (mean 3.4 treatments per subject). There were no esophageal perforations. Strictures developed in 3 subjects. Two subjects reported severe chest pain managed with oral narcotics. One subject was hospitalized for bright red blood per rectum. Sixty subjects had completed all planned CRYO treatments and were included in the efficacy analysis. Fifty-eight subjects (97%) had complete eradication of HGD, 52 (87%) had complete eradication of all dysplasia with persistent nondysplastic intestinal metaplasia, and 34 (57%) had complete eradication of all intestinal metaplasia. Subsquamous BE was found in 2 subjects (3%). Limitations: Nonrandomized, retrospective study with no control group, short follow-up (10.5 months), lack of centralized pathology, and use of surrogate outcome for decreased cancer risk. Conclusions: CRYO is a safe and well-tolerated therapy for BE and HGD. Short-term results suggest that CRYO is highly effective in eradicating HGD. [Copyright &y& Elsevier]

Background & Aims: Photodynamic therapy with porfimer sodium combined with acid suppression (PHOPDT) is used to treat patients with Barrett''s esophagus (BE) with high-grade dysplasia (HGD). A 5-year phase 3 trial was conducted to determine the extent of squamous overgrowth of BE with HGD after PHOPDT. Methods: Squamous overgrowth was compared in patients with BE with HGD randomly assigned (2:1) to receive PHOPDT (n = 138) or 20 mg omeprazole twice daily (n = 70). Patients underwent 4-quadrant jumbo esophageal biopsies every 2 cm throughout the pretreatment length of BE until 4 consecutive quarterly follow-up results were negative for HGD and then biannually up to 5 years or treatment failure. Endoscopies were reviewed by blinded gastroenterology pathologists. Results: Histologic assessment of 33,658 biopsies showed no significant difference (P > .05) in squamous overgrowth between groups when compared per patient (30% vs 33%) or per biopsy (0.5% vs 1.3%), or when the average number of biopsies with squamous overgrowth were compared per patient (0.48 vs 0.66). The highest grade of neoplasia per endoscopy was not found exclusively beneath squamous mucosa in any patient. Conclusions: No difference was observed in squamous overgrowth between patients given PHOPDT plus omeprazole compared with only omeprazole. Squamous overgrowth did not obscure the most advanced neoplasia in any patient. Treatment of HGD with PHOPDT in patients with BE does not present a long-term risk of failure to detect subsquamous dysplasia or carcinoma. [Copyright &y& Elsevier]

More than 92000 Americans are on waiting lists for organ transplants, and an average of 17 of them die each day while waiting. The US Organ Donation Breakthrough Collaborative (ODBC), which began in 2003 at the request of the Secretary of the US Department of Health and Human Services, was a formal, concerted effort of the donation and transplantation community to bring about a major change to improve the organ donation system. The nationwide Collaborative was housed within a Health and Human Services agency, the Health Resources and Services Administration (HRSA) Division of Transplantation, and included participation of the organ procurement organizations (OPOs) throughout the United States and the American hospitals with the largest organ-donor potential. HRSA leaders used the Breakthrough Series Collaborative method, originally developed by the Institute for Healthcare Improvement, as the model for the intervention. Expert practitioners drawn from hospitals and OPOs that had already demonstrated their ability to achieve and sustain high organ donation rates were chosen as faculty for the collaborative and best practices were gleaned from their institutions. The number of organ donors in Collaborative hospitals increased 14.1% in the first year, a 70% greater increase than the 8.3% increase experienced by non-Collaborative hospitals. Moreover, the increased organ recovery continued into the post-Collaborative periods. Between October 2003 and September 2006, the number of total US organ donors increased 22.5%, an increase 4-fold greater than the 5.5% increase measured over the same number of years in the immediate pre-Collaborative period. The study did not involve a randomized design, but time-series analysis using statistical process control charts shows a highly significant discontinuity in the rate of increase in participating hospitals concurrent with the Collaborative program, and strongly suggests that the activities of the Collaborative were a major contributor to this increase. Given the stable nature of the historical increases over many years, the HRSA estimates that more than 4000 annual additional transplants have occurred in association and apparently as a result of these increases in organ donation. [ABSTRACT FROM AUTHOR]

This paper considers the stability of an object supported by several frictionless contacts in a potential field such as gravity. The bodies supporting the object induce a partition of the object's configuration space into strata corresponding to different contact arrangements. Stance stability becomes a geometric problem of determining whether the object's configuration is a local minimum of its potential energy function on the stratified configuration space. We use Stratified Morse Theory to develop a generic stance stability test that has the following characteristics. For a small number of contacts—less than three in 2-D and less than six in 3-D—stance stability depends both on surface normals and surface curvature at the contacts. Moreover, lower curvature at the contacts leads to better stability. For a larger number of contacts, stance stability depends only on surface normals at the contacts. The stance stability test is applied to quasi-static locomotion planning in two dimensions. The region of stable center-of-mass positions associated with a k-contact stance is characterized. Then, a quasi-static locomotion scheme for a three-legged robot over a piecewise linear terrain is described. Finally, friction is shown to provide robustness and enhanced stability for the frictionless locomotion plan. A full maneuver simulation illustrates the locomotion scheme. [ABSTRACT FROM AUTHOR]

Background: Barrett''s esophagus (BE) with high-grade dysplasia (HGD) is a risk factor for development of esophageal carcinoma. Photodynamic therapy (PDT) with Photofrin (PHO) has been used to eliminate HGD in BE. Objective: Our purpose was to compare PHOPDT plus omeprazole with omeprazole only (OM). Design: Five-year follow-up of a randomized, multicenter, multinational, pathology-blinded HGD trial. Setting: 30 sites in 4 countries. Patients: 208. Interventions: Patients with BE and HGD were randomized (2:1) to PHOPDT (n = 138) or OM (n = 70) into a 2-year trial followed up for 3 more years. PHOPDT patients received 2 mg/kg PHO intravenously followed by endoscopic laser light exposure of Barrett''s mucosa at a wavelength of 630 nm within 40 to 50 hours to a maximum of 3 courses at least 90 days apart. Both groups received 20 mg of OM twice daily. Pathologists at one center assessed biopsy specimens in a blinded fashion. Main Outcome Measurement: HGD ablation status over 5 years of follow-up. Results: At 5 years PHOPDT was significantly more effective than OM in eliminating HGD (77% [106/138] vs 39% [27/70], P < .0001). A secondary outcome measure preventing progression to cancer showed a significant difference (P = .027) with about half the likelihood of cancer occurring in PHOPDT (21/138 [15%]) compared with OM (20/70 [29%]), with a significantly (P = .004) longer time to progression to cancer favoring PHOPDT. Limitations: Not all patients were available for follow-up. Conclusions: This 5-year randomized trial of BE patients with HGD demonstrates that PHOPDT is a clinically and statistically effective therapy in producing long-term ablation of HGD and reducing the potential impact of cancer compared with OM. [Copyright &y& Elsevier]

Background: The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience. Objective: To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy. Design: Randomized, controlled, blinded, multicenter trial. Setting: Academic medical centers with accredited gastroenterology training programs. Patients: First-year GI fellows. Interventions: Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure. Main Outcome Measurements: A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time. Results: Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar. Conclusions: Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training. [Copyright &y& Elsevier]

AIM: Children under 6 yr have the highest incidence of severe hypoglycemia (SH) and the greatest likelihood of brain damage from SH. The purpose of this study is to evaluate the use of insulin glargine (Lantus in children under age 6 with type 1 diabetes (T1D). METHODS: The electronic medical records were reviewed for patients under age 6 during the first 6 months of insulin glargine therapy and compared with age, sex, and duration of diabetes for matched control patients on neutral protamine Hagedorn (NPH) insulin. Data from 128 subjects (32 male pairs and 32 female pairs) were collected relating to the incidence of severe and non-severe hypoglycemic events, hemoglobin A1c (HbA1c) values, body mass index (BMI), and daily insulin dose. Additionally, parents were asked to complete a diabetes Quality of Life (QoL) survey. RESULTS: In the 6 months before the study period, the glargine group had 16 SH events compared with three in the 6 months post-glargine. The comparison (NPH) group had seven and six SH events in their respective 6-month periods. Nighttime SH events in the glargine group decreased from 12 prestudy events to one during the study period. The average daily insulin dose in the glargine group was higher than that in the NPH group (0.8+/- 0.2 vs. 0.7+/- 0.2 U/kg/day; p=0.03). The HbA1c values, BMI, and QoL responses were not significantly different between the two groups. CONCLUSIONS: SH was decreased, particularly at night (from 12 episodes to one), after the introduction of glargine in young children with T1D. [ABSTRACT FROM AUTHOR]

PURPOSE: To redefine the clinical remission period for different aged children receiving the current standard of diabetes care. METHODS: An electronic patient records system was used to identify 552 children newly diagnosed with type 1 diabetes (T1D) from 1997 to 2001 who had an initial hemoglobin A1c (HbA1c) value at the time of diagnosis and at least one other value measured in the ensuing year. The insulin dosage previously used to define the remission period [<0.5 units per kg body weight per day (U/kg/d)] was evaluated for the different aged children. RESULTS: The mean insulin dosages for all age groups were >0.5 U/kg/d by 9 months after diagnosis. The mean HbA1c values were above 8% by 6 months after diagnosis for the 6-9 and the 10-12 yr age groups and by 9 months after diagnosis for the >or=13 yr age group. The percentage of children