Search

Wide QRS complexes during supraventricular rhythms can be caused by fixed bundle branch block, functional (intermittent) bundle branch block, preexcitation, or toxic/metabolic causes. Functional bundle branch block can be caused by long-short aberrancy (usually physiologic), or acceleration/deceleration dependent aberrancy (usually pathologic). Electrocardiogram criteria have been proposed to differentiate aberration from ventricular tachycardia; they are not always accurate. The gap phenomenon “paradox” is that with increasingly premature extrastimuli, progressive proximal conduction delay allows time for distal recovery of excitability. Supernormal conduction may explain unusual conduction phenomena in patients with abnormal His-Purkinje function or poorly conducting accessory pathways.

Objective: Outcomes associated with isolated epicardial left atrial appendage (LAA) exclusion in atrial fibrillation (AF) patients with a contraindication or intolerance to anticoagulation are not clearly defined, especially in patients with prior stroke. This study evaluated the perioperative safety, medication use, and stroke outcomes for isolated thoracoscopic LAA exclusion for stroke prevention.Methods: A single-center retrospective study was performed of adults undergoing isolated thoracoscopic LAA exclusion with an epicardial exclusion device without a concomitant surgical procedure. Descriptive statistics were performed.Results: Twenty-five patients met the inclusion criteria. The cohort was 68% male (n= 17) with a mean age of 76.4 ± 6.5 years, a mean preoperative CHA2DS2-VASc score of 4.2 ± 1.4, and a mean preoperative HAS-BLED score of 2.68 ± 1.03. Seventeen patients (68%) had nonparoxysmal AF. There were 11 patients with intolerance of anticoagulation due to intracranial hemorrhage (44%), 6 due to gastrointestinal bleeding (24%), and 4 due to genitourinary bleeding (16%). All procedures were performed thoracoscopically with 100% technical success—the mean LAA stump length was 5.5 ± 2.3 mm on intraoperative transesophageal echocardiography. The median hospital length of stay was 2 (interquartile range [IQR] 1, 6.5) days. The median follow-up time was 430 (IQR 125, 972) days. During follow-up, 1 patient with cerebral angiopathy had temporary neurologic deficits at an outside institution, with brain imaging showing no evidence of ischemic injury. There were no other thromboembolic events over the 38.8 postoperative patient-years examined. All patients were off anticoagulation at last follow-up.Conclusions: This study shows the perioperative safety, technical success, freedom from anticoagulation, and stroke outcomes of isolated thoracoscopic LAA exclusion in patients with AF at high risk for thromboembolic disease.

Traditional methodologies don't meet the needs of building systems on a chip. Deep-submicron technology delivers access to five million usable gates built with 0.35-[µmeter] geometry. Moore's Law indicates that this […]

Background: Morbidity and recurrence rates are higher in obese patients undergoing open abdominal wall reconstruction (AWR). Historically, body mass index (BMI) ≥ 40 has served as a relative contraindication to open AWR. The purpose of this study is to evaluate the impact of minimally invasive surgery (MIS) on outcomes after AWR for higher versus lower BMI patients. Methods: A retrospective review of a prospectively maintained database was conducted of all patients who underwent MIS AWR between September 2015 and April 2019 at our institution. Patients were subdivided into two groups based on their BMI: BMI ≤ 35 kg/m2and BMI > 35 kg/m2. Patient demographics and perioperative data were evaluated using univariate and multivariate analysis. Results: 461 patients were identified and divided into two groups: BMI ≤ 35 (n= 310) and BMI > 35 (n= 151). The two groups were similar in age (BMI ≤ 35: 56.3 ± 14.1 years vs. BMI > 35: 54.4 ± 11.9, p= .154). BMI > 35 group had more patients with ASA score of 3 (81% vs. 32%, p< .001) and comorbid conditions such as hypertension (70% vs. 45%, p< .001), diabetes mellitus (32% vs. 15%, p< .001), and history of recurrent abdominal wall hernia (34% vs. 23%, p= .008). BMI > 35 group underwent a robotic approach at higher rates (74% vs. 45%, p< .001). Patients who underwent a Rives–Stoppa repair from the higher BMI cohort also had a larger defect size (5.6 ± 2.4 cm vs. 6.7 ± 2.4 cm, p= .004). However, there were no differences in defect size in patients who underwent a transversus abdominus release (BMI ≤ 35: 9.7 ± 4.9 cm vs. BMI > 35: 11.1 ± 4.6 cm, p= .069). Both groups benefited similarly from a short length of stay, similar hospital charges, and lower postoperative complications. Conclusion: Initial findings of our data support the benefits of elective MIS approach to AWR for patients with higher BMI. These patients derive similar benefits, such as faster recovery with low recurrence rates, when compared to lower BMI patients, while avoiding preoperative hernia incarceration, postoperative wound complications, and hernia recurrences. Future follow-up is required to establish long-term perioperative and quality of life outcomes in this patient cohort.

Background: The hybrid approach to abdominal wall reconstruction (AWR) for abdominal wall hernias combines minimally invasive posterior component separation and retromuscular dissection with open fascial closure and mesh implantation. This combination may enhance patient outcomes and recovery compared to the open approach alone. The purpose of this study is to evaluate the operative outcomes of hybrid vs. open abdominal wall reconstruction. Methods: A retrospective review was conducted to compare patients who underwent open versus hybrid AWR between September 2015 and August of 2018 at Anne Arundel Medical Center. Patient demographics and perioperative data were collected and analyzed using univariate analysis. Results: Sixty-five patients were included in the final analysis: 10 in the hybrid and 55 in the open groups. Mean age was higher in the hybrid vs. open group (65.1 vs. 56.2 years, p< 0.05). The hybrid and open groups were statistically similar (p> 0.05) in gender distribution, mean BMI, and ASA score. Intraoperative comparison found hybrid patients parallel to open patients (p> 0.05) in mean operative time (294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area, and drain placement. The mean total hospital cost was lower in the hybrid group compared to the open group ($16,426 vs. $19,054, p= 0.43). The hybrid group had a shorter length of stay (5.3 vs. 3.6 days, p= 0.03) after surgery and was followed for a similar length of time (12.3 vs. 12.6 months, p= 0.91). The hybrid group showed a lower trend of seroma, hematoma, wound infection, ileus, and readmission rates after surgery. Conclusion: A review of patient outcomes after hybrid AWR highlights a trend towards shorter length of stay, lower hospital cost, and fewer complications without significant addition to operative time. Long-term studies on a larger number of patients are definitively needed to characterize the comprehensive benefits of this approach.

AimsThe aim of this study was to identify the origin and development of the threshold for surgical intervention, highlight the consequences of residual displacement, and justify the importance of accurate measurement.MethodsA systematic review of three databases was performed to establish the origin and adaptations of the threshold, with papers screened and relevant citations reviewed. This search identified papers investigating functional outcome, including presence of arthritis, following injury. Orthopaedic textbooks were reviewed to ensure no earlier mention of the threshold was present.ResultsKnirk and Jupiter (1986) were the first to quantify a threshold, with all their patients developing arthritis with > 2 mm displacement. Some papers have discussed using 1 mm, although 2 mm is most widely reported. Current guidance from the British Society for Surgery of the Hand and a Delphi panel support 2 mm as an appropriate value. Although this paper is still widely cited, the authors published a re-examination of the data showing methodological flaws which is not as widely reported. They claim their conclusions are still relevant today; however, radiological arthritis does not correlate with the clinical presentation. Function following injury has been shown to be equivalent to an uninjured population, with arthritis progressing slowly or not at all. Joint space narrowing has also been shown to often be benign.ConclusionKnirk and Jupiter originated the threshold value of 2 mm. The lack of correlation between the radiological and clinical presentations warrants further modern investigation. Measurement often varies between observers, calling a threshold concept into question and showing the need for further development in this area. The principle of treatment remains restoration of normal anatomical position.Cite this article: Bone Joint J2021;103-B(9):1457–1461.

Background: Gastroesophageal reflux disease (GERD) is a common chronic disorder of the gastrointestinal tract, affecting more than 50% of Americans. The development of GERD may be associated with ineffective esophageal motility (IEM). The impact of esophageal motility on outcomes post laparoscopic antireflux surgery (LARS), including quality of life (QOL), remains to be defined. The purpose of this study is to analyze and compare QOL outcomes following LARS among patients with and without ineffective esophageal motility (IEM). Methods: This is a single-institution, retrospective review of a prospectively maintained database of patients who underwent LARS, from January 2012 to July 2019, for treatment of GERD at our institution. Patients undergoing revisional surgery were excluded. Patients with normal peristalsis (non-IEM) were distinguished from those with IEM, defined using the Chicago classification, on manometric studies. Four validated QOL surveys were used to assess outcomes: Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL), Laryngopharyngeal Reflux Health-Related QOL (LPR-HRQL), and Swallowing Disorders (SWAL) survey. Results: 203 patients with complete manometric data were identified (75.4% female) and divided into two groups, IEM (n= 44) and non-IEM (n= 159). IEM and Non-IEM groups were parallel in age (58.1 ± 15.3 vs. 62.2 ± 12 years, p= 0.062), body mass index (27.4 ± 4.1 vs. 28.2 ± 4.9 kg/m2, p= 0.288), distribution of comorbid disease, sex, and ASA scores. The groups differed in manometry findings and Johnson–DeMeester score (IEM: 38.6 vs. Non-IEM: 24.0, p= 0.023). Patients in both groups underwent similar rates of Nissen fundoplication (IEM: 84.1% vs. Non-IEM: 93.7%, p= 0.061) with greater improvements in dysphagia (IEM: 27.4% vs. 44.2%) in Non-IEM group but comparable benefit in reflux reduction (IEM: 80.6% vs. 72.4%) in both groups at follow-up. There were no differences in postoperative outcomes. Satisfaction rates with LARS were similar between groups (IEM: 80% vs. non-IEM: 77.9%, p> 0.05). Conclusion: Patients with ineffective esophageal motility derive significant benefits in perioperative and QOL outcomes after LARS. Nevertheless, as anticipated, their baseline dysmotility may reduce the degree of improvement in dysphagia rates post-surgery compared to patients with normal motility. Furthermore, the presence of preoperative IEM should not be a contraindication for complete fundoplication. Key to optimal outcomes after LARS is careful patient selection based on objective perioperative data, including manometry evaluation, with the purpose of tailoring surgery to provide effective reflux control and improved esophageal clearance.

HUNTLEY MEADOWS IS WHERE I FIRST BEGAN TO LEARN, and continue to develop, the skills and art of birding. I never tire of walking its trails. The place seems ever […]

This investigation essentially highlights development of novel high-performance fire-resistant polymeric nanocomposite with respect to its orientation towards future generation aviation. Therefore, an attempt has been made to increase thermal stability and fire resistivity of phenolic/cotton fabric reinforced polymer composite, which is desirable for aircraft interiors. There is considerable increase in adhesion characteristics of phenolic fabric reinforced polymer composite due to atmospheric pressure plasma treatment. The phenolic fabric reinforced polymer is subsequently coated with nanosized calcium silicate reinforced polybenzimidazole composite in order to increase thermal stability and fire resistance property. Thermogravimetric analysis reveals that polybenzimidazole-coated fabric reinforced polymer shows significantly better thermal stability than the uncoated phenolic fabric reinforced polymer. There is a significant increase in the limiting oxygen index characteristics of polybenzimidazole-coated fabric reinforced polymer when compared to the uncoated phenolic composite resulting in considerable improvement in fire resistivity of the polymers.

Determining the underlying cause of persistent eosinophilia is important for effective clinical management but remains a diagnostic challenge in many cases. We identified STAT5BN642H, an established oncogenic mutation, in 27/1715 (1.6%) cases referred for investigation of eosinophilia. Of the 27 mutated cases, a working diagnosis of hypereosinophilic syndrome (HES; n= 7) or a myeloid neoplasm with eosinophilia (n= 20) had been made prior to the detection of STAT5BN642H. Myeloid panel analysis identified a median of 2 additional mutated genes (range 0–4) with 4 cases having STAT5BN642H as a sole abnormality. STAT5BN642H was absent in cultured T cells of 4/4 positive cases. Individuals with SF3B1mutations (9/27; 33%) or STAT5BN642H as a sole abnormality had a markedly better overall survival compared to cases with other additional mutations (median 65 months vs. 14 months; hazard ratio = 8.1; P< 0.001). The overall survival of STAT5B-mutated HES cases was only 30 months, suggesting that these cases should be reclassified as chronic eosinophilic leukemia, not otherwise specified (CEL-NOS). The finding of STAT5BN642H as a recurrent mutation in myeloid neoplasia with eosinophilia provides a new diagnostic and prognostic marker as well as a potential target for therapy.

Ion transport in nanoconfinement differs from that in bulk and has been extensively researched across scientific and engineering disciplines1–4. For many energy and water applications of nanoporous materials, concentration-driven ion diffusion is simultaneously subjected to a local electric field arising from surface charge or an externally applied potential. Due to the uniquely crowded intermolecular forces under severe nanoconfinement (<2 nm), the transport behaviours of ions can be influenced by the interfacial electrical double layer (EDL) induced by a surface potential, with complex implications, engendering unusual ion dynamics5–7. However, it remains an experimental challenge to investigate how such a surface potential and its coupling with nanoconfinement manipulate ion diffusion. Here, we exploit the tunable nanoconfinement in layered graphene-based nanoporous membranes to show that sub-2 nm confined ion diffusion can be strongly modulated by the surface potential-induced EDL. Depending on the potential sign, the combination and concentration of ion pairs, diffusion rates can be reversibly modulated and anomalously enhanced by 4~7 times within 0.5 volts, across a salt concentration gradient up to seawater salinity. Modelling suggests that this anomalously enhanced diffusion is related to the strong ion–ion correlations under severe nanoconfinement, and cannot be explained by conventional theoretical predictions.

Introduction:

The increasing concerns about drug safety and the realization for the need of vigilance by the pharmaceutical industries are discussed. The ways to tighten safety monitoring systems are presented.

Without opining on specific state laws and rules, the Opinion allows that lawyers may practice pursuant to the jurisdictions in which they are licensed even from a physical location where the lawyer is not licensed, under specific parameters. Additionally, the opinion states that Model Rule 5.5(b) prohibits a lawyer from "establish[ing] an office or other systematic and continuous presence in [the] jurisdiction [in which the lawyer is not licensed] for the practice of law", or holding out to the public that the lawyer is admitted to practice in those jurisdictions. [Extracted from the article]

You are director of a large multi-disciplinary ICU. You have recently read that hospital-wide antibiotic stewardship programs have the potential to improve the quality and safety of care, and to reduce the emergence of multi-drug resistant organisms and overall costs. You are considering starting one of these programs in your ICU, but are concerned about the associated infrastructure costs. You are debating whether it is worth bringing the concept forward to your hospital's administration to consider investing in.

A biography of composer Philip Glass is presented. He was born on January 31, 1937 in Baltimore, Maryland and studied at the Peabody Conservatory of Music. He then enrolled at University of Chicago's accelerated college program. He is the founder of the Orange Mountain Music company, and worked with Leonard Cohen in 2007. His compositions were also presented including Sonata for Violin and Piano and Violin Concerto No. 2.

Provides information on the development of several campaign tchotchkes in the U.S. presidential campaigns. Discussion on how debates centering in personality started in the U.S. political campaigns; Production of local campaign materials before modern mass media; Description of campaign symbols used by former political candidates during campaign period.

Discuses the completion of the National World War II Memorial in the federal land of District of Columbia. Information on the planning and construction of the Memorial; Description of the Memorial; Environmental concerns raised during the construction of the Memorial.

This article was updated to correct the labeling of major column 3 in Table 2 to read “BMI > 35,” not “BMI ≤ 35.”

The geometry and energy of aniline have been calculated using the 6-31G and 6-31G*(5D) basis sets for the planar structure and various pyramidal structures, assuming that the ring and the N-atom bonded to it lie in the same plane, but otherwise with full geometry optimization. With the 6-31G basis set the planar structure is predicated to be the most stable, whereas the inclusion of polarization functions in the 6-31G*(5D) basis set finds a pyramidal structure with the out-of-plane angle f=42.3° to be most stable and the energy barrier to inversion via the planar transition state to be 1.59±0.02 kcal mol-1, in close agreement with experiment. Completing the optimization, allowing the N-atom and the C- and H-atoms of the ring to take up equilibrium out-of-plane positions increases the calculated energy carrier to inversion by less than 0.1 kcal mol-1 to 1.66 kcal mol-1. The ring adopts a very shallow inverted boat-type conformation with ?N7-C1?C4 = 2.0°.