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Introduction: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy.Materials and methods: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy.Results: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy.Conclusion: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy.

Chronic postsurgical pain (CPSP) is a common and debilitating complication of major surgery. We undertook a pilot study at three hospitals to assess the feasibility of a proposed large multicentre placebo-controlled randomised trial of intravenous perioperative ketamine to reduce the incidence of CPSP. Ketamine, 0.5 mg/kg pre-incision, 0.25 mg/kg/hour intraoperatively and 0.1 mg/kg/hour for 24 hours, or placebo, was administered to 80 patients, recruited over a 15-month period, undergoing abdominal or thoracic surgery under general anaesthesia. The primary endpoint was CPSP in the area of the surgery reported at six-month telephone follow-up using a structured questionnaire. Fourteen patients (17.5%) reported CPSP (relative risk [95% confidence interval] if received ketamine 1.18 [0.70 to 1.98], P=0.56). Four patients in the treatment group and three in the control group reported ongoing analgesic use to treat CPSP and two patients in each group reported their worst pain in the previous 24 hours at ≥3/10 at six months. There were no significant differences in adverse event rates, quality of recovery scores, or cumulative morphine equivalents consumption in the first 72 hours. Numeric Rating Scale pain scores (median [interquartile range]) for average pain in the previous 24 hours among those patients reporting CPSP were 17.5 [0 to 40] /100 with no difference between treatment groups. A large (n=4,000 to 5,000) adequately powered multicentre trial is feasible using this population and methodology.

Allogeneic haematopoietic stem cell transplantation (allo-HSCT) entails long-term morbidities that impair survivors’ quality of life through broad physical and psychosocial sequelae. Current data and survival measurements may be inadequate for contemporary Australian allo-HSCT recipients. This study sought to comprehensively describe survivorship in an up-to-date, local setting through validated measurements and a novel questionnaire designed to complement and address limitations of current instruments. All adults who received an allo-HSCT between 2000 and 2012 in New South Wales were eligible and included, if alive, those literate and consenting to the study, which encompassed seven survey instruments. Four hundred and forty-three survivors participated, which is 76% of contactable (n=583) and 66% of eligible survivors (n=669). Chronic GVHD (cGVHD) and co-morbidity rates were similar to published data. Noteworthy results include prevalent sexual dysfunction (66% females, 52% males), loss of income (low income increased from 21 to 36%, P<0.001) and employment (full-time employment fell from 64 to 33%, P<0.001), suboptimal vaccination (31% complete), and health screening (≈50%). Risk factors for poor vaccination and health screening were cGVHD, younger age, less education, rural/regional residence and transplantation <2 years. This study suggests that improvement in survivorship may necessitate structural changes in the current delivery of health services.

The new generation short-stem hip implants are designed to encourage physiological-like loading, to minimize stress—strain shielding and therefore implant loosening in the long term. As yet there are no long-term clinical studies available to prove the benefits of these short-stem implants. Owing to this lack of clinical data, numerical simulation may be used as a predictor of longer term behaviour. This finite element study predicted both the primary stability and long-term stability of a short-stem implant. The primary implant stability was evaluated in terms of interface micromotion. This study found primary stability to fall within the critical threshold for osseointegration to occur. Longer term stability was evaluated using a strain-adaptive bone remodelling algorithm to predict the long-term behaviour of the bone in terms of bone mineral density (BMD) changes. No BMD loss was observed in the classical Gruen zones 1 and 7 and bone remodelling patterns were comparable with hip resurfacing results in the literature.

Background: Emergency physicians rely on the interpretation of radiologists to diagnose and exclude pulmonary embolism (PE) on the basis of computerized tomographic pulmonary angiography (CTPA). Few data exist regarding the interobserver reliability of this endpoint. Objective: To quantify the degree of agreement in CTPA interpretation between four academic hospitals and an independent reference reading (IRR) laboratory. Methods: Hospitalized and emergency department patients who had one predefined symptom and sign of PE and underwent 64‐slice CTPA were enrolled from four academic hospitals. CTPA results as interpreted by board‐certified radiologists from the hospitals were compared against those from the IRR laboratory. CTPAs were read as indeterminate, PE−or PE+, and percentage obstruction was computed by the IRR laboratory, using a published method. Agreement was calculated with weighted Cohen’s kappa. Results: We enrolled 492 subjects (63% female, age 54 ± 1 years, and 16.7% PE+at the site hospitals). Overall agreement was 429/492 (87.2%; 95% confidence interval 83.9–90.0). We observed 13 cases (2.6%) of complete discordance, where one reading was PE+and the other reading was PE−. Weighted agreement was 92.3%, with kappa = 0.75. The median percentage obstruction for all patients was 9% (25th–75th percentile interquartile range: 5% to − 30%). For CTPAs interpreted at the site hospitals as PE−or indeterminate but read as PE+by the IRR laboratory, the median of percentage obstruction was 6% (4–7%). Conclusion: We found in this sample a good level of agreement, with a weighted kappa of 0.75, but with 2.6% of patients having total discordance. Overall, a large proportion of clots were distal or minimally occlusive clots.

The biocatalytic oxidation of o-methoxyphenolic compounds led to a variety of oligophenols (dimers to pentamers) and some of their oxidation products. The reaction was carried out in an aqueous medium at room temperature with hydrogen peroxide as the terminal oxidant in a facile and green route to potentially bioactive compounds. Detailed structural information on the products of peroxidase-catalyzed oxidation of o-methoxyphenols is presented for the first time.

“There are so many variables, that are so unique to your environment that any figure from another organisation on prior probabilities would be next to useless. Traditional risk analysis models or any type of total economic impact (TEI), total cost of ownership (TCO), etc, do not work with many of the eBusiness threat scenarios.” So said Giga when BT asked them to consider future possible attacks on BT. ‘Open for business .... Open for attack’ has been a guiding phrase within the iTrust team over the last 18 months — and there is no doubt that the increasing use of electronic commerce is ensuring that businesses are having to provide on-line access to major computing platforms. This paper describes some of the work involved in helping move BT into an eCommerce world.

Les faux anévrysmes (FA) ou les anévrysmes des artères de la main sont le plus souvent d’étiologie traumatique.

La filariose lymphatique est une maladie tropicale causée par des parasites du genre filaire que sont Wuchereria bancrofti, Brugia malayi ou Brugia timori, tous transmis par le moustique. Elle représente une endémie dans de nombreuses régions tropicales (Afrique, Asie, Amérique du sud, Pacifique), l’OMS estimant le nombre de personnes infectées dans le monde à 120 millions. Chaque filaire passe par deux stades, un stade larvaire « microfilaire » vivant dans le sang ou le tissu sous-cutané et qui devient larve infestante après être passée par l’hôte intermédiaire représenté par le moustique, ainsi qu’un stade adulte « macrofilaire » après infestation d’un nouvel organisme, vivant principalement dans le système lymphatique. L’atteinte lymphatique se déclare plusieurs mois voire années après la contamination par le parasite rendant le diagnostic de la maladie difficile.

Profiles Academy Award nominee Jeremy Irons. Also presents Irons modeling men's fashions. Actor's style; Acting career; Appearance in television series `Brideshead Revisited.'

Expression of plasminogen activator inhibitor type 1 (PAI-1), an important determinant of the pericellular proteolytic environment, was assessed in cultured human orbital and dermal fibroblasts. Bidimensional electrophoretic separation of total cellular [35S]methionine-labeled proteins revealed multiple isoforms of the 50-kDa PAI-1 protein (isoelectric point range 5.6-6.3) expressed in dermal strains but not in orbital cultures. The addition of human recombinant interferon-gamma (100 U/ml) to the media for 48 h resulted in a marked induction of PAI-1 in the orbital cultures (greater than 50-fold above baseline), whereas the expression in dermal cultures was either attenuated or induced modestly (5-fold). The identity of the 50-kDa PAI-1 was verified by immunoprecipitation of secreted proteins. Indirect immunofluorescence localized PAI-1 to aggregates at the ventral undersurface of the monolayer. Interferon-gamma induced several other proteins in cultured cells. The observation that untreated orbital fibroblasts do not express detectable cell-associated PAI-1 suggests that the pericellular proteolytic environment of these cells is regulated ordinarily by other factors. The economy of the extracellular matrix of orbital connective tissue may be particularly susceptible to the influence of inflammatory cytokines such as interferon-gamma.

Leukoregulin, a 50-kDa T lymphocyte-derived cytokine, influences the synthesis of collagenase, stromelysin-1, collagen, and hyaluronan in human fibroblasts and is thus a determinant of extracellular matrix economy. We studied the effect of leukoregulin on the expression of plasminogen activator inhibitor type 1 (PAI-1) in human orbital and dermal fibroblasts. The lymphokine upregulated 35S-labeled PAI-1 protein expression in orbital fibroblasts in dose-dependent manner. The effect on extracellular matrix-associated PAI-1 evolved over several hours and was maximal at 10 h, when levels were 75-fold higher than controls, and then fell by 24 h. Leukoregulin treatment increased prostaglandin E2 production in orbital cultures after 24 h. When this increase was blocked with indomethacin, peak PAI-1 levels were maintained. Northern analysis demonstrated a substantial induction of steady-state PAI-1 mRNA levels within 6 h of treatment in orbital cultures. In contrast, leukoregulin lowered PAI-1 protein levels dramatically in skin fibroblasts from the abdominal wall. With regard to PAI-1 expression, it would appear that the anatomic site of origin of fibroblasts is a crucial determinant of the cellular response to leukoregulin.

1. A novel triple-isotope method using 3H2O, [14C]-sucrose and 36Cl− for measuring initial Cl− uptake rates in human leucocytes that had been preincubated in 10% (v/v) autologous serum is described. 2. There was a marked dependence of Cl− influx on intracellular pH, the flux at an intracellular pH of 7.20 being about 11.2% of that at an intracellular pH of 7.56. 3. This Cl− influx was inhibited by 4,4-di-isothiocyanatostilbene-2,2-disulphonic acid in a dose-dependent manner. Half-maximal inhibition by 4,4-diisothiocyanatostilbene-2,2-disulphonic acid at an internal pH of 7.56 in the presence or absence of HCO−3 was 0.30 or 0.35 mmol/l, respectively. 4. Depletion of intracellular Cl− resulted in a 70.7% decrease in Cl− influx, whereas depletion of cellular ATP led to a 37.7% decrease in Cl− influx. 5. The phorbol ester 12-O-tetradecanoyl phorbol acetate at a concentration of 0.1 μmol/l reduced Cl− influx, especially the 4,4-di-isothiocyanatostilbene-2,2-disulphonic acid-sensitive component. This effect was independent of intracellular pH changes or Na+/H+ anti-port activity.

Inhalation induction with sevoflurane was compared with propofol or sevoflurane/propofol in 60 unpremedicated adults. Target concentrations for the three groups (with 60% nitrous oxide) were 3% end-tidal sevoflurane, 12 mg/l propofol and 1.5% sevoflurane/6 mg/l propofol respectively, prior to insertion of a laryngeal mask airway (LMA) at 10 minutes. Induction of anaesthesia was satisfactory in each group, but movement response to LMA insertion was observed in 20 patients (least in the sevoflurane group). Cardiovascular responses were similar except for a lower heart rate in the sevoflurane group. EEG bispectral index suggested a greater depth of anaesthesia in the inhalation induction group. A bispectral index of 60 separated patients responding to LMA insertion from nonresponders (P=0.006), and had a sensitivity of 68% and specificity 70%. Movement response was not predicted by cardiovascular changes.

Fibroblasts derived from distinct anatomical regions appear to differ in regard to their behavior in culture. These differences may reflect functions of these cells in vivo that are tissue specific. Moreover, intrinsic differences in fibroblasts may underlie the site-specific connective tissue manifestations associated with systemic disease. We have demonstrated previously that orbital fibroblasts exhibit different cytokine response domains and protein synthetic programs when compared to those emanating from the skin. In the present communication, we demonstrate that prostaglandin E2 (PGE2) elicits in cultured human orbital fibroblasts from patients with Graves ophthalmopathy a rapid and dramatic change in cell morphology in vitro as assessed by phase-contrast and scanning electron microscopy. The central areas of the cells become elevated with respect to the plane of the substratum and are stellate, with long processes that touch neighboring cells. These changes occur within 6 hr of prostanoid addition to culture medium at an apparent concentration threshold of approximately 10 nM. Shape changes are accompanied by marked alterations in monolayer impedance as assessed by electric cell-substrate impedance sensing as described previously. Both morphologic and impedance changes elicited by PGE2 revert over 24 hr toward those found in untreated cells despite the continued presence of the prostanoid in the culture medium. In contrast, dermal fibroblasts fail to respond to PGE2. These observations define a previously unrecognized phenotypic attribute of orbital fibroblasts. Intrinsic differences in these cells may account for the anatomic site-selective vulnerability of the orbit in Graves ophthalmopathy. The culture system described here may be useful for studying the morphogenic actions of prostanoids.

1. The initial rate of uptake of glycine by the tumour cells was measured as a function of the Na+ and K+ concentrations in the solution in which the cells were suspended. When [Gly] was 1mm or 12mm, the rate in the absence of Na+ was independent of [K+] and about 3% or 10% respectively of the rate when [Na+] was 150m-equiv./l. 2. The Na+-dependent glycine entry rate, v, at a given value of [Na+] was successively lowered when [K+] was increased from 8 to 47 to 96m-equiv./l. A kinetic analysis indicated that K+ competitively inhibited the action of Na+. The results were in fair agreement with previous determinations of the kinetic parameters. 3. The presence of 2mm-sodium cyanide and 10mm-2-deoxyglucose lowered the cellular ATP content to less than 3% of the value in the respiring cells. Although v was then about 50% smaller, the relative effects of K+ and Na+ on the system were similar to those observed during respiration. 4. A theoretical analysis indicated that the variation of v with [K+] is not a reliable guide to the extent to which the K+ gradient between the cells and their environment may contribute to the net transport of glycine.

La filariose lymphatique est une maladie parasitaire due à la filaire Wuchereria bancrofti transmise par des moustiques vecteurs des genres Culex, Aedes, Anopheles et Mansonia. Elle fait encore partie des grandes endémies dans de nombreuses régions tropicales et subtropicales (Afrique, Asie, Amérique du Sud, Pacifique). L’ OMS estime que 120 millions de personnes en sont infectées dans le monde. Chez de nombreux sujets, la maladie est asymptomatique. Dans les formes chroniques, les manifestations les plus importantes sont des lymphoedèmes, éléphantiasis des membres et des organes génitaux chez l’homme, dues à l’atteinte du système lymphatique et à des surinfections locales. Le traitement est médical par la compression multicouche et les soins locaux. Dans certains cas, la chirurgie est indiquée. La maladie de Kaposi classique ou encore appelée sarcome de kaposi méditerranéen, est une maladie proliférative multifocale, d’expression cutanée et viscérale, impliquant diverses cellules mésenchymateuses et induite par des facteurs viraux de l’herpès virus humain type 8. Elle a été décrite pour la première fois par le dermatologue hongrois, Moritz Kaposi Kohn en 1872 sous le nom d’hémangiome ou sarcome pigmenté cutané multiple. Il s’agit d’une forme classique, sporadique, d’évolution lente, bénigne, rare, touchant plutôt des hommes âgés de 50 à 70 ans, originaires de l’Europe de l’est et du bassin méditerranéen, souvent juifs ashkénazes. Cette maladie peut provoquer une atteinte lymphatique des membres inférieurs et supérieurs. Elle est traitée par chimio-, radio- ou cryothérapie et dans certains cas la chirurgie est indiquée.

La sangsue est très intéressante. Lorsqu’elle mord sa proie, elle injecte de la salive qui contient plus de 30 substances antalgiques, anticoagulantes et cicatrisantes. Certaines, comme l’hirudine et la caline, sont capables de fluidifier le sang et d’empêcher l’agrégation des plaquettes. Les sangsues utilisées en thérapeutique sont des Hirudo Medicinalis.

Les fistules congénitales entre l’artère et la veine mammaire interne sont très rares.

Normalement la compression élastique (CE) est contre-indiquée chez les patients atteints d’une artériopathie périphérique sévère des membres inférieurs (APMI). Le problème devient sérieux quand l’APMI est associée à des lymphœdèmes des membres inférieurs (LMI).

The performance of an infra-red analyser (Beckman LB-2) in sampling alveolar gas at ventilatory frequencies and volumes occuring in the human neonate has been examined. The optimum sampling flow rate was found to be 300 ml/min; at this flow the 90% response time of the analyser-catheter system was 140 ms. Correlation of estimated alveolar P2 and arterial PCO2 was performed in the rabbit which has a ventilatory rate and tidal volume similar to those of the human neonate. There was a good correlation between maximum end-expired PCO2 (PÉCO2) and arterial PCO2 over a wide range of ventilatory rates (10–100 b.p.m.); maximum PÉCO2 was a better index than mean PÉCO2 or alveolar plateau PÉCO2

In seven neonates, whose mothers were given pethidine during labour, urine was collected for the first 24–40 h of life. Urinary volume and pH, and concentrations of pethidine and norpethidine in the urine were measured. Urine flow rate was low for the first 7–22 h, and then high for about 12 h. The rate of excretion of pethidine and norpethidine was approximately parallel to the urine flow rate. However, the ratio of the rate of excretion of norpethidine to that of pethidine increased with time and the concentration of norpethidine in urine decreased first and then, after 18 h, increased significantly. These findings indicate that the neonate can metabolize pethidine, although the rate of metabolism is probably less than in the adult. The total amounts of pethidine and norpethidine excreted in the first 24 h after birth were positively related to the does-delivery interval in the mother for intervals up to at least 5 h. From the data it is estimated that 95% of the total pethidine transferred from the mother would be eliminated by the baby by the 2nd to 3rd day after birth.

A system is described for measuring carbon dioxide output and alveolar carbon dioxide concentration in the neonate and for deriving the volume of alveolar ventilation. Air is drawn through a soft rubber face mask applied loosely to the face so that all expired gas is entrained. A fraction of the flow is sampled by an infra-red analyser, the signal from which is integrated to provide a measure of carbon dioxide output. Alveolar carbon dioxide concentration is measured by continuous sampling of expired gas through a nasal catheter. The response time of the catheter-analyser system is 140 ms. In 20 healthy 1-day-old neonates the mean carbon dioxide excretion was 5.86 ml/min.kg-1(STPD) and the mean alveolar Pco2 was 4.85 kPa. From these measurements mean alveolar ventilation 147ml/min.kg-1 (BTPS) was calculated. These results are similar to those obtained by other methods.

In mothers nursed in a semi-recumbent position, arterial oxygen tension was measured at rhe beginning and end of an intermittent period of inhalation, lasting for six contractions, during the first stage of labour. Ten mothers had methoxynurane 0.35% and air, followed by methoxyflurane 0.35% with approximately 50% oxygen. Another 10 mothers had 50% nitrous oxide and 50% oxygen (Entonox). The mean values of Pao2 at the beginning of periods of inhalation in those who received methoxyflurane in air, methoxyflurane in 50% oxygen, and nitrous oxide in oxygen were 109, 120 and 106 mm Hg respectively. The mean increases in Pao2 by the ends of periods of inhalation were 18, 43 and 63 mm Hg respectively. On average, increasing the inspired concentration of oxygen to 50% significantly and substantially increased maternal Pao2 with both agents by the end of inhalation. There would therefore be some increase in available oxygen during the phase of higher blood flow following a uterine contraction. However, the lowest maternal Pao2 measured was 72 mm Hg; therefore additional oxygen is unlikely to offer much advantage except in patients with respiratory or cardiac deficiencies. In the intervals between inhalations of the analgesic mixture the Pao2 decreased to about the level found during air breathing. Consequently it would be necessary to breathe additional oxygen continuously, between as well as during contractions, to ensure an increased maternal Pao2, throughout labour.

The resistances of thirteen Entonox valves were measured. Although there was a wide variation between them, this is unlikely to interfere with their performance when used in labour. During the passage of continuous high flows, freezing occurred in two valves, causing a reduction in flow after 5 minutes. It is very unlikely that this would occur in clinical use. Measurements of the resistances of eight of the valves were compared using a static tube or a wide-bore needle to measure pressure changes. There was no significant difference between the two methods at flows of up to 100 1./min.

In 37 mothers at the end of the first stage of labour, the effects were studied of deliberately increasing the inspiratory resistance of two types of inhalation apparatus, the Entonox apparatus and the Cardiff Penthrane Inhaler. The additional resistance consisted of one of four circular metal discs with a central hole of diameter varying from 5 mm to 9.5 mm. No mother rejected the apparatus when any of the resistances was added. Only on direct questioning did a small proportion of those who breathed through the higher resistances admit that they noticed any difference. The apparatus with the lowest resistance (9.5 mm orifice) satisfied all the physiological parameters studied. Changes in intrathoracic pressure were small and there was no significant effect upon frequency of breathing, mean ventilation, or peak flow. Mean ventilation was significantly reduced only when the highest resistance was added. It would seem that the Entonox apparatus and the Cardiff Penthrane Inhaler, even with added resistance, would satisfy the mothers and be acceptable physiologically. There is therefore no evidence that the resistance of the present inhalation apparatus is excessive.

A specification for the upper limit of the inspiratory resistance for inhalation-analgesia apparatus used in labour has been derived by considering the additional respiratory power required to overcome the apparatus resistance. It is recommended that the additional power required to inspire through the apparatus, with the ventilation occurring in mothers having analgesia, should not be greater than the additional power involved in breathing without apparatus, at the greater ventilation found in mothers without analgesia. From data in the literature it is deduced that this general requirement will be satisfied for 99.9% of the population if the power dissipated in the apparatus is less than 1.68 watts at a ventilation of 40 1./min. This specific requirement is just met by a laminar-flow resistance of 0.26 cm H2O/(1./min). The Entonox apparatus and the Cardiff Penthrane Inhaler meet this requirement easily although they do not conform to British Standard Specification 4272, Part 2 (1968).

Superfluid hydrodynamics affects the spin evolution of mature neutron stars and may be key to explaining timing irregularities such as pulsar glitches. However, most models for this phenomenon exclude the global instability required to trigger the event. In this paper we discuss a mechanism that may fill this gap. We establish that small scale inertial r-modes become unstable in a superfluid neutron star that exhibits a rotational lag expected to build up due to vortex pinning as the star spins down. Somewhat counterintuitively, this instability arises due to the (under normal circumstances dissipative) vortex-mediated mutual friction. We explore the nature of the superfluid instability for a simple incompressible model allowing for entrainment coupling between the two fluid components. Our results recover a previously discussed dynamical instability in systems where the two components are strongly coupled. In addition, we demonstrate for the first time that the system is secularly unstable (with a growth time that scales with the mutual friction) throughout much of parameter space. Interestingly, large scale r-modes are also affected by this new aspect of the instability. We analyze the damping effect of shear viscosity, which should be particularly efficient at small scales, arguing that it will not be sufficient to completely suppress the instability in astrophysical systems. [ABSTRACT FROM AUTHOR]