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Background: Minimal knowledge exists regarding the outcome, prognosis and optimal treatment strategy for patients with pulmonary large cell neuroendocrine carcinomas (LCNEC) due to their rarity. We aimed to identify factors affecting survival and recurrence after resection to inform current treatment strategies. Methods: We retrospectively reviewed 72 patients who had undergone a curative resection for LCNEC in 8 centers between 2000 and 2015. Univariable and multivariable analyses were performed to identify the factors influencing recurrence, disease-specific survival and overall survival. These included age, gender, previous malignancy, ECOG performance status, symptoms at diagnosis, extent of resection, extent of lymphadenectomy, additional chemo- and/or radiotherapy, tumor location, tumor size, pT, pleural invasion, pN and pStage. Results: Median follow-up was 47 (95%CI 41–79) months; 5-year disease-specific and overall survival rates were 57.6% (95%CI 41.3–70.9) and 47.4% (95%CI 32.3–61.1). There were 22 systemic recurrences and 12 loco-regional recurrences. Tumor size was an independent prognostic factor for systemic recurrence [HR: 1.20 (95%CI 1.01–1.41); p = 0.03] with a threshold value of 3 cm (AUC = 0.71). For tumors ≤3 cm and >3 cm, 5-year freedom from systemic recurrence was 79.2% (95%CI 43.6–93.6) and 38.2% (95%CI 20.6–55.6) (p < 0.001) and 5-year disease-specific survival was 60.7% (95%CI 35.1–78.8) and 54.2% (95%CI 32.6–71.6) (p = 0.31), respectively. Conclusions: A large proportion of patients with surgically resected LCNEC will develop systemic recurrence after resection. Patients with tumors >3 cm have a significantly higher rate of systemic recurrence suggesting that adjuvant chemotherapy should be considered after complete resection of LCNEC >3 cm, even in the absence of nodal involvement.

Objective Neuroendocrine tumors of the lung are currently staged with the 7th edition TNM non–small cell lung cancer staging system. This decision, based on data analysis without data on histology or disease-specific survival, makes its applicability limited. This study proposes a specific staging system for these tumors. Methods We retrospectively analyzed 510 consecutive patients (female/male, 313/197; median age, 61 years; interquartile range, 51-70) undergoing lung resection for a primary neuroendocrine tumor between 2000 and 2015 in 8 centers. Multivariable analysis was performed using a Cox proportional hazard model to identify factors associated with disease-specific survival. A new staging system was proposed on the basis of the results of this analysis. Kaplan–Meier disease-specific survival was analyzed by stage using the proposed and the 7th TNM staging system. Results Follow-up was completed in 490 of 510 patients at a median of 51 months (interquartile range, 18-99). Histology (G1-typical carcinoid vs G2-atypical carcinoid vs G3-large-cell neuroendocrine carcinoma) and pT were independently associated with survival, but pN was not. After regrouping histology and pT, we proposed the following staging system: IA (pT1-2G1), IB (pT3G1, pT1G2), IIA (pT4G1, pT2-3G2, pT1G3), IIB (pT4G2, pT2-3G3), and III (pT4G3). The 5-year survivals were 97.9%, 81.0%, 69.1%, 51.8%, and 0%, respectively. By using the 7th TNM, 5-year survivals were 95.0%, 92.3%, 67.7%, 70.9%, and 65.1% for stage IA, IB, IIA, IIB, and III, respectively. Conclusions Incorporating histology and regrouping tumor stage create a unique neuroendocrine tumor staging system that seems to predict survival better than the 7th TNM classification.

Background This study aimed to assess the reliability and the validity of a prognostic model of survival recently developed by the European Society of Thoracic Surgery Neuroendocrine Tumor Working Group to predict 5-year overall survival after surgical resection of pulmonary typical carcinoid. Methods We retrospectively collected data on 240 consecutive patients (164 men, 76 women; median age, 58 years [interquartile range, 47 to 68]) who underwent curative lung resection for pulmonary typical carcinoid in seven centers between 2000 and 2015. For each patient, we calculated the corresponding risk class (A, B, C, D) using the following variables: male, age, previous malignancy, Eastern Cooperative Oncology Group performance status, peripheral tumor, TNM stage. Kaplan-Meier method, and Cox proportional hazards model were used for the statistical analysis. Results During a median follow-up of 42 months (interquartile range, 11 to 84), the 5-year overall survival was 94.2% (95% confidence interval [CI]: 90.2% to 98.2%); 15 of 240 patients died. A significantly decreasing rate of survival was observed from class A to class D (p = 0.004) with rates of 100% (95% CI: 100% to 100%), 96.3% (95% CI: 88.6% to 98.8%), 86.7% (95% CI: 63.0% to 95.7%), and 33.3% (95% CI: 0.9% to 77.4%), respectively, for class A, B, C, and D. This difference persisted also using clinical stage as a variable in the risk class calculation (p = 0.006). No differences were observed in term of overall survival among TNM stage I, II, and III patients (p = 0.94). Conclusions This prognostic model of survival is easily applicable, it is validated by our independent cohort, and it appears to stratify better than the traditional TNM staging. Therefore, it may be useful in counseling patients about their outcomes from surgical treatment and in tailoring treatment for high-risk patients.

Mitchell Kim,1 Steven H Mitchell,1 Medley Gatewood,1 Katherine A Bennett,2 Paul R Sutton,3 Carol A Crawford,4 Itay Bentov,5 Mamatha Damodarasamy,2 Stephen J Kaplan,6 May J Reed2 1Department of Emergency Medicine, University of Washington, 2Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, 3Division of General Internal Medicine, Department of Medicine, University of Washington, 4School of Pharmacy, University of Washington, 5Department of Anesthesiology and Pain Medicine, University of Washington, 6Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA Background: Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED).Patients and methods: ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated (“High doses” were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; “very high doses” were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65–69, 70–74, 75–79, 80–84, and ≥85 years), gender, and hospital.Results: There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses

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Museums seem to be ideal environments for a restorative experience. A collection of objects both aesthetic and fascinating would seem appropriate for aiding the recovery of directed attention, and perhaps for reflection as well. Yet, according to anecdotal reports, museums often seem tedious and tiring. The authors explore this apparent paradox both theoretically, in the context of attention restoration theory, and empirically. Study 1, a content analysis of material generated by focus groups for a Getty Foundation study, yielded categories remarkably consistent with the theorized components. For Study 2, 124 museum visitors completed surveys on restorative aspects of their visit. As with Study 1, results point to the restorative potential of the museum, but suggest that those who are already comfortable in museums are more likely to receive this benefit.

Preferences for unfamiliar urban environments were studied as a function of urban categories, viewing time, and four predictor variables: complexity, coherence, identifiability, and mystery. A nonmetric factor analysis of the preference ratings for the longest viewing-time condition yielded five dimensions: Contemporary Life, Alley/Factory, Urban Nature, Unusual Architecture, and Older Buildings. The five categories differed significantly in preference, with Urban Nature by far the most preferred and Alley/Factory distinctly disliked. The combination of low coherence and high complexity characterizes the least liked Alley/Factory category, while the role of mystery in the urban setting is highlighted by the most preferred Urban Nature category. The results point to various ways in which the urban environment could be more responsive to people's preferences.

This paper presents results from the final phase of a ten-year research program dealing with the dynamics and the impacts of wilderness experiences. Although these data are from participants in shorter trips than those reported on previously, questionnaire data indicate that responses to the different trips were similar, and that responses from participants of different ages and sexes were also similar. Theoretical issues which emerged from earlier analyses of participants' journals are also re-examined in light of the current data. These earlier results had suggested that an individual's growing perceptual understanding of the surrounding wilderness environment was connected to a wide range of personal insights as well as other psychological benefits. Results from the current data concur with this finding. Furthermore, contrary to alternative hypotheses, feelings of control over the environment were not evident either in the original data or in the current participants' journals. These data suggest that an alternative stance, described as feeling 'at one with' or 'part of' the environment, is more frequent and is generalized to nonwilderness surroundings. Other categories of individual response which complement this non-dominant environmental orientation are also documented in the current data.

Imagine yourself running through rough terrain, perhaps fleeing a predator, or perhaps chasing after prey. Your visual system does not have time to scrutinize the countless trees, rocks, and other objects you pass by. What you need most is enough spatial information to avoid obstacles, to orient yourself, to pick a path. In this situation, even a rough sketch of the spatial layout of the environment can provide crucial information.

Humans and other natural systems are remarkably adept at extracting spatial information from vision. To better understand this process, it would be useful to know how the visual system can make an initial estimate of where things are in a scene and how they are oriented. Texture is one source of information that the visual system can use for this purpose. It can be used both for segmenting the visual input and for estimating spatial orientations within segmented regions; moreover, each of these two processes can be performed starting with the same mechanisms, namely spatiotemporally-tuned cells in the visual cortex. But little attention has been given to the problem of integrating the two processes into a single system. In this paper, we discuss texture-based visual processing and review recent work in computer vision that offers insights into how a visual system could solve this problem. We then argue that a beneficial extension to these approaches would be to incorporate an initial coarse-scale segmentation step. We offer supporting evidence from psychophysics that the human visual system does in fact perform such a rough segmentation early in vision.

In 1976 a study titled The Use of the Armed Forces as a Political Instrument was completed at The Brookings Institution for the Defense Advanced Research Projects Agency of the U.S. Department of Defense. The study found that between 1 January 1946 and 31 October 1975, U.S. armed forces were used on 215 occasions as a political instrument--i.e., as a means of influencing the decisions of foreign governments. An up-dating of the file in 1977 revealed a total of 226 such actions through 31 December 1976. This manual is designed to allow other researchers to make use of the data that have been collected on these 226 incidents. It includes an extended definition and discussion of the subject of study, a list of the 226 incidents, a description of the variables for which data were collected for each incident, the full data file, and a listing of sources. The data file and a control file containing a description of the variables and their values have also been placed on a computer tape. Information is provided about how copies of this computer tape may be obtained.

This study was conducted in order to determine the historical record of the use of Soviet armed forces as a political instrument since the Second World War; to gain an understanding of the USSR's readiness to use military power in the pursuit of foreign policy objectives and the willingness of Soviet leaders to accept risks in doing so; to evaluate the utility of political- military operations to Soviet interests and foreign policy goals; and to realize the implications of this Soviet behavior for U.S. interests and American foreign and defense policies., See also AD-A073 951.

In 1979 a study titled Mailed Fist, Velvet Glove: Soviet Armed Forces as a Political Instrument was completed for the Defense Advanced Research Projects Agency of the U.S. Department of Defense. The study found between June 1944 and June 1979, Soviet armed forces were used on 187 occasions as a political instrument -- that is, as a means of influencing the decisions of foreign governments. This manual is designed to allow other researchers to make use of the data that were collected on these incidents. It includes an extended definition and discussion of the subject of the study, a list of the incidents, a description of the variables for which data were collected, the full data file, and a listing of sources. The data file and a control file containing a description of the variables and their values have also been placed on a computer tape. Information is provided about how copies of this computer tape may be obtained., See also ADA073950 and ADA073951. Sponsored in part by DARPA.

This study was conducted in order to determine the historical record of the use of Soviet armed forces as a political instrument since the Second World War; to gain an understanding of the USSR's readiness to use military power in the pursuit of foreign policy objectives and the willingness of the Soviet leaders to accept risks in doing so; to evaluate the utility of political-military operations to Soviet interests and foreign policy goals; and to realize the implications of this Soviet behavior for U.S. interests and American foreign and defense policies., See also ADA073950. Sponsored in part by DARPA.

In particular circumstances, demonstrative uses of the armed forces can sometimes be an effective way--at least in the short term--of securing U.S. objectives and preventing foreign situations inimical to U.S. interests from worsening more rapidly than more fundamental policies can be formulated. Thus, at times, and although decisionmakers should view these options with some caution, the demonstrative use of the armed forces for political objectives is a useful step to shore up a situation sufficiently so that more extreme adverse consequences can be avoided, so that domestic and international pressures for more foreceful and perhaps counter-productive actions can be avoided, and so that time can be gained for sounder policies that can deal adequately with the realities of the situation to be formulated and implemented.

The study concludes that the demonstrative and discrete use of the armed forces for political objectives should not be an option which decision-makers turn to frequently, nor quickly, to secure political objectives abroad, except under very special circumstances. Over the longer term these uses of the armed forces were not an effective foreign policy instrument.

The study examines the ways, and the effectiveness with which, the United States and the Soviet Union have employed their armed forces, short of actual violence, during the period 1946-1975. The study further explains the interconnections between demonstrative displays of military force and the success or failure of foreign policy in the postwar period. The study analyzed 300 incidents since 1945 in which either the United States or the USSR has utilized its armed forces, without significant violence, in support of foreign policy objectives., Report on Foreign Policy Studies Program.