Search

Brown kiwi (Apteryx mantelli Bartlett), a ratite endemic to New Zealand, is currently listed as “Vulnerable” under the IUCN classification system due to predation by introduced mammals. Operation Nest Egg (ONE) raises chicks and juveniles in predator-proof enclosures until they are large enough to defend themselves. These facilities experience an environmental accumulation of coccidial oocysts, which leads to severe morbidity and mortality of these kiwi. Four species of coccidia have been morphologically described from sporulated oocysts with additional opportunistic descriptions of endogenous stages. This research continues the morphological descriptions of these species of Eimeria with an additional novel morphotype also morphologically described. It also provides the first genetic characterisation targeting the mitochondrial cytochrome c oxidase I (COI) gene. Based on these findings, it was determined there are at least five morphotypes of Eimeria that infect brown kiwi and co-infections are common at the ONE facilities surveyed. The COI amplicon targeted for this study was sufficient to provide differentiation from other members of this genus. Sanger sequencing yielded ambiguous bases, indicating the need for more in-depth sequencing.

In Sierra Leone, the lack of information on pulmonary embolism (PE) limits the access to evidence-based standard of diagnostic work-up and management of the disease. The objective of this study was to describe the clinical characteristics and management of acute pulmonary embolism in our setting and to determine whether the pre-test probability scoring algorithms were used prior to Computed Tomography Pulmonary Angiogram (CTPA) request.This retrospective observational study was conducted on CTPA-confirmed PE patients admitted to the Intensive Care Unit, Choithrams Memorial Hospital, in Freetown, Sierra Leone between July 2014 to June 2019. Clinical data, and pertinent investigations related to PE were determined. CTPA findings were correlated with the patient's hemodynamic status. The calculated pretest clinical probability scores (PCPS) for each patient were compared to the CTPA results.CTPA-confirmed PE in the study cohort was 79, with a rate of 16 new PE per year. The frequency of PE was 1.9% of the total hospital admission per year. The mean age was 64.1 ± 17.9 years, median age was 63.3years (range: 23-89 years), with 55.7% of the cohort being females. Dyspnea (78.5%) and tachycardia (69.6%) were the commonest signs and symptoms documented, with immobilization (34.2%) being the prevalent risk factor, while hypertension (48.1%) was the most common co-morbidity. The PCPS algorithm was underutilized, as "Wells Score" was documented in only 9.5% while "modified Geneva score" was never used by hospital physicians. PE with hemodynamic stability was significantly more common than PE with unstable hemodynamic status [55 (69.6%) vs 24 (30.4%), p=0.015]. All patients were managed only with anticoagulants. The overall in-hospital mortality was 17.7%.Since PCPS was hardly calculated by doctors in the diagnosis of PE, the study showed that the diagnostic algorithm for suspected PE was infrequently used in clinical practice. The use of empirical judgement by doctors in requesting for CTPA may have accounted for low rate in the diagnosis of PE per year. The establishment of P.E registry in Sierra Leone is imperative.En Sierra Leone, le manque d’informations sur l’embolie pulmonaire (EP) limite l’accès à des normes de diagnostic et de prise en charge de la maladie fondées sur des preuves. L’objectif de cette étude était de décrire les caractéristiques cliniques et la prise en charge de l’embolie pulmonaire aiguë dans notre établissement et de déterminer si les algorithmes de notation de la probabilité pré-test étaient utilisés avant la demande d’angiographie pulmonaire par tomodensitométrie (CTPA).Cette étude observationnelle rétrospective a été menée sur des patients atteints d’EP confirmée par CTPA admis à l’unité de soins intensifs, Choithrams Memorial Hospital, à Freetown, Sierra Leone, entre juillet 2014 et juin 2019. Les données cliniques, et les investigations pertinentes liées à l’EP ont été déterminées. Les résultats du CTPA ont été corrélés avec l’état hémodynamique du patient. Les scores de probabilité clinique prétest (PCPS) calculés pour chaque patient ont été comparés aux résultats du CTPA.Le nombre d’EP confirmées par CTPA dans la cohorte étudiée était de 79, avec un taux de 16 nouvelles EP par an. La fréquence de l’EP était de 1,9 % du nombre total d’hospitalisations par an. L’âge moyen était de 64,1 ± 17,9 ans, l’âge médian de 63,3 ans (fourchette : 23-89 ans), 55,7 % de la cohorte étant des femmes. La dyspnée (78,5 %) et la tachycardie (69,6 %) étaient les signes et symptômes les plus fréquemment documentés, l’immobilisation (34,2%) étant le facteur de risque prévalent, tandis que l’hypertension (48,1 %) était la comorbidité la plus courante. L’algorithme PCPS était sous-utilisé, le “ score de Wells “ n’étant documenté que dans 9,5 % des cas, tandis que le “ score de Genève modifié “ n’était jamais utilisé par les médecins hospitaliers. L’EP avec stabilité hémodynamique était significativement plus fréquente que l’EP avec état hémodynamique instable [55 (69,6 %) vs 24 (30,4 %), p=0,015]. Tous les patients ont été traités uniquement par anticoagulants. La mortalité globale à l’hôpital était de 17,7 %.Étant donné que le PCPS était rarement calculé par les médecins pour le diagnostic de l’EP, l’étude a montré que l’algorithme diagnostique pour l’EP suspectée était rarement utilisé dans la pratique clinique. L’utilisation d’un jugement empirique par les médecins pour demander un CTPA peut expliquer le faible taux de diagnostic de l’EP par an. L’établissement d’un registre de l’E.P. en Sierra Leone est impératif.Embolie pulmonaire, caractéristiques cliniques, gestion, Sierra Leone.

Coccidia (Eimeria spp.) in brown kiwi (Apteryx mantelli) cause significant morbidity and mortality in captive rearing facilities. Monitoring the abundance of this parasite in individual birds is crucial for successful management of kiwi. This research compares the abilities of centrifugal faecal flotations (CFF) and a modified Mini-FLOTAC protocol to detect oocysts. We hypothesised that the Mini-FLOTAC would detect higher oocyst counts. Kiwi dropping samples (n = 10) were homogenized in MgSO4 (SG 1.28) and oocyst counts made with CFFs and Mini-FLOTAC counting chambers, with three replicates for each method. For CFF, 0.5 g of droppings were examined using standard methods. Mini-FLOTAC counts were made using a modified sample preparation compared with the manufacturer’s protocol but still used a 1:20 dilution of droppings. Oocysts were quantified using light microscopy at ×100–300 magnification. A linear mixed-effects model by REML showed that oocyst per gram estimates via the Mini-FLOTAC method were 3.2 times higher (95% CI 2.4–4.5, p

In sport, athletes are socialized to the expectations of the athlete role (i.e., sport ethic), including those expectations that require them to sacrifice themselves and prioritize their sport. Thr...

Using the framework of multidisciplinary best practice recommendations promoted by the National Collegiate Athletic Association, this study used a mixed-methods approach to investigate Division I student-athletes’ perceived access to and satisfaction with mental health service availability. Participants were asked about their satisfaction with direct (e.g., counseling, psychiatry, assessment) and indirect (e.g., mental health outreach, educational workshops) service availability, both on campus and within athletics. Results from a researcher-generated survey indicated that participants were moderately satisfied with service availability in each of the four contexts. Hierarchical multiple regressions revealed that student-athletes’ satisfaction was predicted by different factors for each service type-location combination. Qualitative data contained requests for more athlete-centered mental health services as well as more preventative outreach in general. These data provide a foundation for understanding factors that influence student-athletes’ satisfaction with mental health service availability and offer practical implications for current best practice recommendations.

Thomas’s Rope Squirrel (Funisciurus anerythrus) and Gambian Sun Squirrel (Heliosciurus gambianus) are two of the eight squirrel species found in Nigeria with overlapping habitats in Southwestern Nigeria. Squirrels are involved in pollination, seed dispersal, vectors of human and domestic animal diseases as well as crop and household pests. These species and the crucial ecosystem services they render are threatened by habitat destruction, human encroachment and the fact that they are being used as a source of protein in Nigeria. Their conservation would be enhanced by availability of accurate genetic information which are scarce for these species. This study seeks to provide baseline data on genetic variation at three allozyme loci in the two species in University of Ibadan, Ibadan, Nigeria. Twenty-nine individual squirrels including eighteen F. anerythrus species and eleven H. gambianus were used in this study. These were obtained from the wild within the University of Ibadan. Observed and expected heterozygosity (Ho and He), Hardy-Weinberg equilibrium (HWE), genetic distance between the species, and inbreeding coefficients were performed using POPGENE and Tools for Population Genetic Analyses (TFPGA). In F. anerythrus, Ho and He were 0.6092 and 0.5635, respectively, while, for H. gambianus, Ho and He were 0.6242 and 0.5745, respectively. There were no deviations from HWE in all the tested loci (p>0.05). Nei genetic distance between the species was 0.0070 and the populations showed fairly high level of outbreeding (FST = 0.0029 ± 0.0017). More robust genetic markers would be required to further ascertain the genetic status of the species.

Many countries do not have a newborn screening (NBS) program, and immigrants from such countries are at risk for late diagnosis of phenylketonuria (PKU). In this international survey, 52 of 259 patients (20%) with late diagnosed PKU were immigrants, and 145 of the 259 (55%) were born before NBS or in a location without NBS. ispartof: JOURNAL OF PEDIATRICS vol:239 pages:231-+ ispartof: location:United States status: published

We wrote and performed this script as part of ICQI’s 2019 conference. This reader’s theatre production allowed us to share our experiences as a faculty member and student in a doctoral Introduction to Qualitative Research Course, in which a reflexivity assignment created a lot of tension and anxiety for the student who has multiple marginalized identities. We hope that by sharing this story, faculty of qualitative methods can be more aware of potential experiences faced by their students and how those experiences can affect their learning in the classroom. We have included stage directions in italics, and have designated when one of us is speaking to each other, and when we have chosen to break the fourth wall and speak directly to the audience/our readers.

Aim There is compelling evidence that magnesium sulfate (MgSO4) given antenatally in threatened preterm labour is neuroprotective and reduces risk of cerebral palsy in offspring. National Neonatal Audit Programme (NNAP) in the UK monitors compliance to antenatal magnesium uptake in births Methods A multidisciplinary improvement team comprising of neonatologists, obstetricians and midwives was formed. This team process mapped a preterm mother’s admission to understand enablers and barriers to timely MgSO4 administration. A driver diagram conceptualised overall aim, primary & secondary drivers to inform change ideas. Change ideas (MgSO4 awareness sessions, clear guideline, preterm labour proforma, Think Mg posters, ward level champions, daily safety huddles, monthly display of compliance figures) were tested in iterative PDSA cycles. Number of preterm births Results In 2016, only 3/20 (15%) preterm mothers received antenatal MgSO4. With improvement efforts and monitoring via PDSA cycles and g charts we saw a steady increase in MgSO4 uptake. In 2017 10/18 (56%) and in 2018, 14/18 (77%) received antenatal MgSO4. Opportunities between events ‘g’ chart tracked number of eligible births between a noncompliant episode. There were a few deliveries with short arrival to delivery intervals in late 2018, with drop in our compliance. Further analysis of these cases highlighted certain delays in triage ward, and they were addressed. Overall, in a 3-year period MgSO4 compliance rose from 16% to 77%. We also involved service users, by providing a parental information leaflet and including a check box in golden hour care checklist. Conclusion Using a well-structured quality improvement plan, we were able to understand the barriers to MgSO4 use and systematically introduce changes that resulted in improved compliance. Collaborative working between multidisciplinary staff across specialties was key to our success and we hope to further scale up and sustain the improvement.

In urban environments, road-side catch basins are common larval habitats of Culex spp. (Diptera: Culicidae) mosquitoes and important targets of larval control in areas subject to West Nile virus (WNv) transmission. We quantified the impact of larviciding basins on Culex spp. populations and WNv infection prevalence by treating basins in and around urban parks in Atlanta, GA, using Mosquito Dunks and Bits (active ingredient, a.i., Bacillus thuringiensis subsp. isrealensis, Dunks-10.31%, Bits-2.86%) and Altosid 30-Day Briquets (a.i., S-methoprene 8.62%) in two separate seasons. Treatments were coupled with WNv surveillance using gravid traps and aspiration of adults resting in basins. Larviciding led to >90% reductions in Culex spp. larval and pupal collections (Dunks/Bits) and >90% pupal mortality (Briquets) in treated sites during treatment periods; however, we did not observe significant reductions in Culex spp. collections in gravid traps (general linear mixed-effects model [GLMM] result, P > 0.1) or in adults collected resting in basins (GLMM, P > 0.5). In addition, WNv infection prevalence in Culex spp. mosquitoes was similar between treated and untreated sites (GLMM, P > 0.05). Larval control remains important for controlling WNv in Atlanta; however, at the scale and frequency applied in our study, larval control alone may not lead to meaningful reductions in adult populations and WNv infection prevalence. A greater understanding of the annual dynamics of Culex spp. breeding and the importance of basins as Culex spp. larval habitats are needed to meaningfully affect WNv in cities such as Atlanta.

Over-the-scope-clip (OTSC) System is a relatively new endoluminal intervention for gastrointestinal (GI) leaks, fistulas, and bleeding. Here, we present a single center experience with the device over the course of 4 years.Retrospective chart review was conducted for patients who received endoscopic OTSC treatment. Primary outcome is the resolution of the original indication for clip placement. Secondary outcomes are complications and time to resolution.Forty-one patients underwent treatment with the OTSC system from 2011 to 2015 with average follow-up of 152 days. The average age is 53.7. The most common site of clip placement was in the stomach (44%). Clips were placed after surgical complication for 28 patients (68%), endoscopic complications for 8 patients (19%), and spontaneous presentation in 5 patients (12%). Technical success was achieved in all patients. Overall, 34 patients (83%) were successfully treated. Nine patients required multiple clips and three patients required additional treatment modalities after OTSC. Four patients used the OTSC as a bridging therapy to surgery. Using OTSC for palliation versus nonpalliative indications was associated with lower rates of treatment success (50% versus 86%, P = .028). Using OTSC for symptoms6 months had higher rates of treatment success than those experiencing longer symptoms (88% versus 65%, P = .045). There were no major morbidities or mortalities directly associated with the OTSC system. Complications from clip use were pain in two patients (5%) and hematemesis in one patient (3%).The OTSC System can be a very successful treatment for iatrogenic or spontaneous GI leaks and bleeds. Treatment success is more likely in patients treated within 6 months of diagnosis and less likely to when used for palliation. It was also successfully used as bridging therapy in several patients.

Annual decreases in soybean (Glycine max L. Merrill) yield caused by diseases were estimated by surveying university-affiliated plant pathologists in 28 soybean-producing states in the United States and in Ontario, Canada, from 2010 through 2014. Estimated yield losses from each disease varied greatly by state or province and year. Over the duration of this survey, soybean cyst nematode (SCN) (Heterodera glycines Ichinohe) was estimated to have caused more than twice as much yield loss than any other disease. Seedling diseases (caused by various pathogens), charcoal rot (caused by Macrophomina phaseolina (Tassi) Goid), and sudden death syndrome (SDS) (caused by Fusarium virguliforme O’Donnell & T. Aoki) caused the next greatest estimated yield losses, in descending order. The estimated mean economic loss due to all soybean diseases, averaged across U.S. states and Ontario from 2010 to 2014, was $60.66 USD per acre. Results from this survey will provide scientists, breeders, governments, and educators with soybean yield-loss estimates to help inform and prioritize research, policy, and educational efforts in soybean pathology and disease management.

The last several decades have seen dramatic advances in the use of technology in everyday life. As expected, these technological advancements have affected all areas of human existence, including s...

Evidence suggests that live sporting events may lead fans to engage in criminal behaviors. The current study examined the relationship between criminal behavior and college football game days. Archival data of criminal offenses were collected from Southeastern Conference member institution police departments to analyze reported criminal offenses during the regular season. Multilevel linear models revealed an increase in criminal behavior. A factorial ANOVA indicated an interaction of team rankings and game outcome was related to specific types of criminal behavior in the host city (F (1, 9142) = 20.07, p < .001). Results provide insight to more effectively allocate resources.

Annual decreases in corn yield caused by diseases were estimated by surveying members of the Corn Disease Working Group in 22 corn-producing states in the United States and in Ontario, Canada, from 2012 through 2015. Estimated loss from each disease varied greatly by state and year. In general, foliar diseases such as northern corn leaf blight, gray leaf spot, and Goss's wilt commonly caused the largest estimated yield loss in the northern United States and Ontario during non-drought years. Fusarium stalk rot and plant-parasitic nematodes caused the most estimated loss in the southern-most United States. The estimated mean economic loss due to yield loss by corn diseases in the United States and Ontario from 2012 to 2015 was $76.51 USD per acre. The cost of disease-mitigating strategies is another potential source of profit loss. Results from this survey will provide scientists, breeders, government, and educators with data to help inform and prioritize research, policy, and educational efforts in corn pathology and disease management. Accepted for publication 26 August 2016.

Laparoscopic ventral hernia repair (LVHR) was developed as a minimally invasive approach to the gold standard Rives-Stoppa repair. The Rives-Stoppa repair revolutionized abdominal wall reconstruction by markedly decreasing hernia recurrence with widely overlapping retromuscular mesh. The first description of laparoscopic ventral herniorrhaphy was published by LeBlanc in 1993. By 1999, there were 40 manuscripts highlighting this advance in hernia repair and several comparative analyses noting reduced hospitalization and a decrease in wound complications and surgical site infection. However, it was not until after 2000 that the technique was popularized with the publication by Heniford, Park, Ramshaw, and Voeller of a large multicenter series of laparoscopic ventral hernia repairs with a low complication rate and hernia recurrence rate of 3.4%. While the landscape of ventral hernia repair has shifted remarkably since that landmark publication due to increasing patient complexity, obesity, and innovative technology, laparoscopic ventral hernia repair continues to play a major role in the care of ventral hernia patients.

Nanotechnology is a rapidly growing field that has made numerous impacts in our everyday life. Nanoparticles have found applications in biomedical, optical, electronics, and environmental remediation as well as numerous consumer products. Despite the numerous benefits of nanoparticles, there are concerns about their toxicity, especially when in contact with biological systems at chronic doses and frequencies. Nanoparticles interact either directly with the DNA or indirectly with cellular proteins, and generate reactive oxygen species (ROS) which subsequently lead to DNA damage. Several methods such as Ames, comet, chromosome aberration, micronucleus, hydroyx—deoxyguanosine, γ-H2AX, and HPRT tests have been used by various researchers to evaluate the genotoxicity and mutagenicity of nanoparticles both in vitro and in vivo. Several reports using plant and animal models as well as cell lines show that nanoparticles’ size, type, shape, coating, surface charge, agglomeration, cell type, and methods of preparation are some of the factors affecting nanoparticle genotoxicity. This chapter presents a review of different models and genetic end-points used in the evaluation of nanoparticle genotoxicity. In line with this, we also present a case study of in vivo reproductive genotoxicity and cytotoxicity assessment of metal (silver) and metal oxide (copper oxide) nanoparticles in mice.

As the popularity of a laparoscopic Roux-en-Y Gastric Bypass (RYGB) surpassed that of an open approach, practice of concomitant cholecystectomy declined. Low rates of gallbladder disease following RYGB and high complication rates of concomitant cholecystectomy have been published, but these population-based studies have lacked long-term outcomes and survival data. The California Office of Statewide Health Planning and Development longitudinal database was queried for patients who underwent RYGB with or without cholecystectomy between 1995 and 2009. Additionally, patients who underwent cholecystectomy after RYGB were compared to all cholecystectomy patients. Primary outcome was survival; secondary long-term outcomes included cholangitis, common duct stones, dumping syndrome, metabolic derangements, ventral hernia, any hernia, marginal ulcers, and reoperation. Cox proportional hazard analysis was performed to determine adjusted survival and outcomes. Of 134,584 RYGB patients, 21,022 underwent concomitant cholecystectomy. Concomitant cholecystectomy improved both survival (HR[95 % CI] 0.51[.48–.54]) and long-term outcomes (HR 0.84[.77–.91]). Incidence of gallbladder disease following RYGB was 6.8 and 15.2 % at 1 and 5 years. In subsequent analysis of 829,333 cholecystectomy patients, 7,099 underwent prior RYGB with higher risk of conversion to open (HR 1.58[1.41–1.78]), post-operative complication (HR 1.47[1.36–1.6]) and death (HR 1.32[1.17–1.5]). Concomitant cholecystectomy is safe for RYGB patients. Given high rates of gallbladder disease and increased risk when cholecystectomy is performed following RYGB, cholecystectomy should be considered at the time of RYGB.

Background Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia. Methods This is an institutional review board approved, retrospective case series report. Results TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m2. Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1). Conclusion TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.

To demonstrate the feasibility of an innovative technique for the surgical management of rectal cancer, we performed transanal minimally invasive surgery assisted low anterior resection with total mesorectal excision (TAMIS-assisted LAR with TME) in a cadaver model. Transanal LAR via natural orifice transluminal endoscopic surgery has been reported in cadaveric series using rigid transanal platforms. This procedure has not been described using a combination of a single incision laparoscopy and TAMIS transanal endoscopic platform. We describe the first cadaveric series of TAMIS-assisted LAR with TME.TAMIS-assisted LAR with TME was successfully performed in five fresh human cadavers. The procedure was performed using the mini-Gelpoint single incision platform and the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA). The variables recorded were age, body mass index (BMI), operative time, complications, and specimen length. The grade of the TME was determined by evaluation of the specimen by photo documentation by a gastrointestinal pathologist.All cadavers were male with a mean age of 71 ± 8 years and mean BMI of 28 ± 3 kg/m(2). The mean operative time was 200 ± 55 min (range 128-249 min). The quality of the TME was grade I (complete) with intact mesorectum in all five cases. The mean specimen length was 36.8 ± 3.4 cm.TAMIS-assisted LAR with TME was feasible. A high-quality TME can be achieved using this innovative technique. Transanal endoscopic total mesorectal dissection may revolutionize the surgical management of rectal cancer. However, multicenter clinical trials are needed to further evaluate the oncologic safety and surgical outcomes of transanal endoscopic TME using various platforms before widespread application of this new technique.

Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage.We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality.From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P .05).Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Transanal endoscopic microsurgical (TEM) resection is associated with improved outcomes compared to transanal excision of rectal lesions. However, TEM equipment requires additional operative setup time, and tumor location dictates patient positioning. In 2010, Drs. Attallah, Albert, and Larach developed an alternative technique, transanal minimally invasive surgery (TAMIS). Herein, we describe our novel experience using endoscopic visualization to perform TAMIS (eTAMIS) to remove a large rectal polyp. This is a technical note describing a new surgical technique, eTAMIS. The technique is performed with the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA) and a standard single-channel endoscope for visualization. Patient demographics, operative data, and pathologic data were recorded. eTAMIS was initially performed in a 50-year-old woman with an endoscopically defiant rectal mass discovered on routine screening colonoscopy. The lesion was a tubulovillous adenoma, 10 cm from the anal verge, anterior, and occupied 15–20 % of the circumference. The rectal mass was removed by eTAMIS. The operative time was 101 minutes, and the patient was discharged within 24 h without event. Final pathology revealed a focus of well-differentiated rectal adenocarcinoma with focal invasion into the muscularis mucosa (Haggit level 0, pTis) arising in the head of a pedunculated tubulovillous adenoma. At 1-year follow-up endoscopy, the patient had no evidence of recurrent mass or polyp. This is the first technical report describing endoscopic visualization for TAMIS. Endoscopic visualization facilitates intraluminal articulation and lens cleaning while minimizing extraluminal instrument collisions. eTAMIS is a practical and logical evolution of the visual approach to natural orifice transluminal endoscopic surgery and laparoendoscopic surgery.

Summary Analgesia usually occurs within 5 min after administration of local anaesthetic solution into joints or around nerves in the distal portion of the limb. Gait should be assessed within 10 min after diagnostic regional analgesia of the distal portion of the limb because rapid diffusion of anaesthetic solution can result in anaesthesia of other nerve branches, thus confusing results of the examination. A palmar digital nerve block (PDNB) anaesthetises most of the foot, including the distal interphalangeal (DIP) joint (coffin joint), rather than just the palmar half of the foot, as was once commonly believed. To avoid partially anaesthetising the proximal interphalangeal joint (pastern joint), the palmar digital nerves should be anaesthetised near or distal to the proximal margin of the collateral cartilages. Clinicians should be aware that an abaxial sesamoid nerve block (ASNB) may ameliorate or abolish pain within the metacarpo/metatarso-phalangeal joint (fetlock joint). Mepivacaine administered into the DIP joint desensitises the DIP joint and probably the palmar digital nerves to also cause anaesthesia of the navicular bursa, the navicular bone, the toe region of the sole, the digital portion of the deep digital flexor tendon (DDFT) and the distal portions of the collateral ligaments of the DIP joint. When a large volume of mepivacaine HCl (e.g. 10 ml) is administered, the heel region of the sole may also be desensitised. Only a small percentage of horses with disease of the collateral ligament(s) of the DIP joint show a significant improvement in lameness after intra-articular analgesia of the DIP joint, and no horse is likely to improve after intrabursal analgesia of the navicular bursa. A PDNB, however, improves lameness substantially in most horses that are lame because of disease of the collateral ligament(s) of the DIP joint, and all affected horses are likely to become sound after an abaxial sesamoid nerve block. The degree of improvement in lameness associated with injury to one or both collateral ligaments of the DIP joint after PDNB is determined by the extent of the injury and the level at which the palmar digital nerves are anaesthetised. The further proximal the level of the injury within the collateral ligament, the less likely that lameness is ameliorated by analgesia of the DIP joint or a PDNB. Verschooten's technique appears to be the most accurate technique for centesis of the navicular bursa. Even though analgesia of the DIP joint results in analgesia of the navicular bursa, analgesia of the navicular bursa does not result in analgesia of the DIP joint. Pain arising from the DIP joint can probably be excluded as a cause of lameness when lameness is attenuated by analgesia of the navicular bursa. Analgesia of the digital flexor tendon sheath (DFTS) is likely to desensitise only structures that are contained within or border on the sheath itself (i.e. the superficial and deep digital flexor tendons, the straight and oblique distal sesamoidean ligaments, the annular ligaments of the fetlock and pastern, and the portion of the DDFT that lies within the foot). Because lameness caused by disease of the DDFT within the foot may fail to improve appreciably after analgesia of the palmar digital nerves, the DIP joint, or the navicular bursa, a portion of the DDFT within the foot and distal to the DFTS probably receives its sensory supply from more proximal deep branches of the medial and lateral palmar digital nerves that enter the DFTS. Performing intrathecal analgesia of the DFTS on horses with lameness that is unchanged after anaesthesia of the palmar digital nerves but resolves after an ASNB, may be useful in localising lameness to that portion of the DDFT that lies within the foot. Resolution of lameness after intrathecal analgesia of the DFTS justifies suspicion of a lesion within the digital portion of the DDFT or within structures contained within the DFTS. The belief that concurrent or sequential intra-articular administration of medication substantially increases the risk of joint infection or that inflammation caused by the local anaesthetic solution may dampen the therapeutic response to intra-articular medication appears to be unfounded.

Complete duplication of the bladder and urethra is a rare entity. It may occur in the coronal and sagittal planes, and is often associated with other organ system anomalies, in particular of the gastrointestinal tract. We report an unusual variant of sagittal duplication of the bladder, in a male, associated with rudimentary hindgut duplication, and review the literature pertaining to this unusual anomaly.

With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report.A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME.A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes.Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

Successful community mental health programs depend on strong social networks and cooperation between resource providers, both of which are complex products of local culture and history. The results of an ethnographic study of an unplanned urban neighborhood in Cairo, Egypt emphasize the importance of the political, social and historical context to community service development. The informal nature of the community, characterized by migrants from different ethnic and religious groups and a relative lack of governmental services, produced a culture of service provision that indirectly serves to accentuate reli- gious and ethnic tensions. The findings are relevant not only to the developing world, but also to community program development in large, multicultural urban centers anywhere.

Psychiatric stigma is a concept that is often used uncritically by policy-makers to explain the underutilization of professional psychiatric services in non-Western societies. Stigma, however, is a multi-determined process manifestations and effects of which cannot be viewed separately from the larger social and cultural context. The present paper presents the results of a qualitative study of psychiatric stigma in Egypt from the perspective of lay respondents. A vignette method was used to elicit judgments of social distance and qualitative responses to stories depicting psychosis, depression, alcohol abuse and a 'possession state' from 208 respondents recruited through their places of work. The results indicated that while stigma does exist in Egypt, the form that it takes must be understood with reference to Egyptian notions of selfhood that locate behavioral disturbances in the intersubjective rather than intrapsychic realm. On the one hand, individual blame is diffused as responsibility for the illness and its cure is placed in the social, not personal (or biological) realm. On the other, behavioral disorders that threaten the social fabric of society are particularly stigmatized and often met with social rejection.

This paper explores the use of religious symbols and metaphors in Egyptian psychiatric inpatient charts to portray psychiatric pathology and, by extension, the role that religious symbols play in constructing psychiatric illnesses. This represents a deconstruction of patient charts, assuming that the psychiatrist chooses aspects of family and patient discourse which best represent unexamined cultural ideas of person and illness, normality and abnormality. All of the psychiatrists writing the charts were Egyptian and shared much of the same cultural background with their patients, excluding their medical training. Therefore, while chart discourse is used to justify a psychiatric diagnosis, it is also the product of a shared cultural history; a tacit agreement about what constitutes a meaningful story. This paper focuses mainly upon discourse that has religious connotations, for the reason that these seemed to be more invested with cultural meaning than other delusional themes. These religious symbols and m...

The organizing goal of the present study was to analyze and understand the 'discursive presentation' of the Egyptian psychiatric patient through the texts, or narratives, contained within the patient medical charts. It is argued that the medical record, as a written document blending overt medical imperatives with more unexamined cultural assumptions about self-hood and abnormality, is an unusually rich source of discursive data concerning the 'cultural negotiations' implicit in the construction of the patient according to the two (often competing) world views represented by western biomedicine and traditional Egyptian culture. Psychiatry in Egypt is much more than a 'foreign transplant'; to assume this is to deny the culturally constructed nature of western biomedicine and psychiatry, which have their roots in historical and cultural notions of self, society, the individual, and normality versus abnormality (Transcultural Psychiat. 35(3) (1998) 352). Egyptian psychiatry is the product of an ongoing active blending of two very different conceptualizations of these issues.

Laparoscopic and endoluminal surgical techniques have evolved and allowed improvements in the methods for treating benign and malignant gastrointestinal diseases. To date, only case reports have been reported on the application of a laparo-endoscopic approach for resecting gastric submucosal tumors (SMT). In this study, we aimed to evaluate the efficacy, safety, and oncologic outcomes of a laparo-endoscopic transgastric approach to resect tumors that would traditionally require either a laparoscopic or open surgical approach. Herein, we present the largest single institution series utilizing this technique for the resection of gastric SMT in North America.We performed a retrospective review of a prospectively collected patient database. Patients who presented for evaluation of gastric SMT were offered this surgical procedure and informed consents were obtained for participation in the study.Fourteen patients were included in this study between August/2010 and January/2013. Eight (8) patients (57.1 %) were female and the median age was 56 years (range 29-78). Of the 14 cases, 8 patients (57.1 %) underwent laparo-endoscopic resection of SMTs with transgastric extraction, 5 patients (35.7 %) had conversions to traditional laparoscopic surgery, and 1 patient (7.2 %) was abandoned intraoperatively. The median operative time for this cohort was 80 min (range 35-167). Ten patients (71.4 %) had GISTs, 3 (21.4 %) had leiomyomas, and 1 (7.1 %) had schwannoma. There were no intraoperative complications. Two patients had postoperative staple line bleeding that required repeat endoscopy. The median hospital stay was 1 day (range 1-6) and there were no postoperative mortalities. At 12-month follow-up visit, only one GIST patient (10 %) had tumor recurrence.Our experience suggests that this surgical approach is safe and efficient in the resection of gastric SMT with transgastric extraction. This study found no intraoperative complications and optimal oncologic outcomes during the follow-up period. Minimally invasive surgical approaches are emerging as a valid and potentially better approach for resecting malignancies; however, continued investigation is underway to further validate this data.