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Background Context: Studies have found that most patients are satisfied after spine surgery, with rates ranging from 53% to 90%. Patient satisfaction appears to be closely related to achieving clinical improvement in pain and disability after surgery. While the majority of the literature has focused on patients who report both satisfaction and clinical improvement in disability and pain, there remains an important subpopulation of patients who have clinically relevant improvement but report being dissatisfied with surgery.Purpose: To examine why patients who achieve clinical improvement in disability or pain also report dissatisfaction at 1-year after spinal surgery.Study Design: Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.Patient Sample: There were 34,076 participants undergoing elective surgery for degenerative spine pathology who had clinical improvement in disability or pain.Outcome Measures: Satisfaction with surgery was assessed with 1-item from the North American Spine Society lumbar spine outcome assessment. Participants with answer choices other than "treatment met my expectations" were classified as dissatisfied.Methods: Patients completed a baseline and 12-month postoperative assessment to evaluate disability, pain, and satisfaction. Clinical improvement was defined as patients who achieved a 30% or greater improvement in spine-related disability (Oswestry/Neck Disability Index) or extremity pain (11-point Numeric Rating Scale) from baseline to 12-month after surgery. A generalized linear mixed model was used to predict the odds of the patient being dissatisfied 1-year after surgery from demographic, clinical and surgical characteristics, postoperative complications and revision, and return to work and previous physical activity. Random effects were included to model the effect of both site and surgeon on dissatisfaction. Sensitivity analyses were conducted on samples who achieved 30% or greater improvement in (1) disability only, (2) axial (back/neck) pain only, (3) extremity (leg/arm)pain only, (4) both disability and axial pain, and (5) both disability and extremity pain. Results showed the same pattern of findings across all samples.Results: Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% classified as satisfied. For patients with clinical improvement in disability or extremity pain at 1-year, significant predictors of higher odds of dissatisfaction included baseline psychological distress, current smoking status, workers compensation claim, lower education, higher ASA grade, lumbar versus cervical procedure, and increased axial pain, major complication within 30 days, and revision surgery within 12-months. The most important contributors to dissatisfaction were return to work and return to previous physical activity, with the odds of dissatisfaction being over 2 times and 4 times higher for these variables. Site and surgeon explained 3.8% of the variance in dissatisfaction, with more of the variance attributed to site than to surgeon.Conclusions: Several modifiable factors, including psychological distress, current smoking status, and failure to return to work and physical activity, helped explain why patients report being dissatisfied with surgery despite clinical improvement in disability or pain. The findings of this study have the potential to help providers identify at-risk patients, set realistic expectations during preoperative counseling, and implement postoperative management strategies. A multidisciplinary approach to rehabilitation that includes functional goal setting or restoration may help to improve patients psychological distress as well as return to work and previous physical activity after spine surgery. [ABSTRACT FROM AUTHOR]

Borassus flabellifer L. is a tall palm traditionally used for its stimulating, diuretic and anti-inflammatory activities; it is rich in fibers and various pharmacologically important secondary metabolites. This study was undertaken to evaluate the antidiabetic effects of Borassus flabellifer fruit methanol extract (BF-M) on diabetic rats induced with High Fat Diet (HFD)/streptozotocin (STZ). When BF-M (100 or 200 mg/kg) was administered for 21 days orally it led to a sharp decline in triglycerides, total cholesterol, free unsaturated fat, glucose-6-phosphate, fasting blood glucose and fructose 1,6 bisphosphatase in contrast to diabetic control. BF-M also downregulated Protein Tyrosine Phosphatase 1B. In vitro study showed the IC 50 value to be 23.98 μg/mL. BF-M significantly increased serum insulin, glycogen content, and body weight. Western blot analysis exhibited significant inhibition of PTP1B in pancreatic tissue which was confirmed by histology and immunohistological studies. GC-MS analysis revelaled that the presence of major compounds such as 5-hydroxymethylfurfural (47.56%), Guanosine (21.01%) and n-hecxadeconoic acid (25.14%) in BF-M. In short, BF-M exerted antidiabetic property by down regulating PTP1B expression, and eventually enhancing glucose stimulated insulin release; it also exhibited favorable effects in diabetes and its secondary complications. [ABSTRACT FROM AUTHOR]

Abstract Spine pathology is among the most common, most disabling, and costliest disorders in the US health care system. Traditional reimbursement models in which volume of service rather than quality is incentivized has resulted in an unsustainable rise in cost. The focus for all stakeholders is now on value-based health care. Value is determined by the outcomes achieved per dollar spent to achieve those outcomes. Clinical registries and validated outcome tools are now making it possible for all spine practitioners to define and develop value-based care. Accurate measurement of outcomes and cost and identifying outliers are essential to improving the value in spine surgery. [ABSTRACT FROM AUTHOR]

Abstract Ceramic membranes can serve as viable alternatives to the less mechanically stable polymeric membranes utilized in microbial fuel cells (MFCs). In this work, a series of polymer-derived ceramic (PDC) proton exchange composite membranes with large ion exchange capacity (IEC) values, high cation transport numbers, and low oxygen diffusion coefficients have been synthesized at various pyrolysis temperatures using a pressing technique. These materials were composed of a polysiloxane matrix mixed with proton-conducting fillers such as montmorillonite and H 3 PMo 12 O 40 /SiO 2 at different ratios. By tuning the average pore sizes of the membranes between 0.1 and 1 µm and their hydrophilic/hydrophobic characteristics, the maximum IEC of 0.6072 mequiv/g and cation transport number of 0.6988 were obtained, which is 67% and 72% of polymeric nafion performance, respectively. In addition, the minimal oxygen mass transfer coefficient achieved by this approach was equal to 5.62 × 10−4 cm/s, which is very close to the commercial nafion membrane value. The fabricated PDC composite membranes meet all the essential criteria required for their use in MFC applications and represent a high potential to overcome limitations of polymeric membrane. Graphical abstract Schematic view of a membrane for MFC and synthesized PDC membrane. fx1 Highlights • Novel PDC composite membranes synthesized by simple sol-gel and pressing technique. • Ceramic membranes had hierarchial porous structure and tailored hydrophilicity. • Porous PDC composite ceramic membranes have high ion exchange capacity. • A new material obtained with great potential for MFC application. [ABSTRACT FROM AUTHOR]

Highlights • Severe adverse radiation effects may occur following radiosurgery to brain AVM. • Severe adverse radiation effects may be refractory to medical therapy. • Surgical cytoreduction of treated nidus can result in rapid clinical improvement. • Early surgery may avoid the adverse consequences of prolonged steroid treatment. Abstract Treatment of brain arteriovenous malformations (AVM) with stereotactic radiosurgery is rarely complicated by severe adverse radiation effects (ARE). The treatment of these sequelae is varied and often ineffectual. We present three cases of brain AVMs treated with SRS, all complicated by severe AREs. All three cases failed to respond to what is currently considered the standard treatment – corticosteroids – and indeed one patient died as a result of the side effects of their extended use. Two cases were successfully treated with surgical excision of the necrotic lesion resulting in immediate clinical improvement. Having considered the experience described in this paper and reviewed the published literature to date we suggest that surgical treatment of AREs should be considered early in the management of this condition should steroid therapy not result in early improvement. [ABSTRACT FROM AUTHOR]

Treatment of spinal pathology is a significant contributor to the current rise in health care spending in the United States. To maximize value, the cost of spine care must be analyzed to assess for any inefficiencies. In parallel, outcomes must be tracked to ensure that any potential cost reductions do not have a negative impact on the efficacy of treatments. This article focuses on three primary topics in spinal care. We will begin with a general review of cost analysis methods, highlight specific drivers of cost, and finally offer broad solutions to help improve the value of spine care. [ABSTRACT FROM AUTHOR]

Osteoporosis is responsible for a global medical and economic burden that will grow as the elderly population doubles over the next 20 years. Measuring the cost of the effects of osteoporosis on treatment of spinal disorders is important as we prioritize distribution of resources in the healthcare community. This article examines the monetary cost of osteoporotic disorders associated with spinal care, specifically compression fractures, complications of spinal fusions, and medical treatment of osteoporosis. Examining these costs will allow us to focus further research into the primary cost drivers associated with osteoporosis. [ABSTRACT FROM AUTHOR]

Health care costs are on an unsustainable upward trajectory and spine disorders are one of the most costly disease states worldwide. Value-based care is being implemented across all medical specialties. However, the true meaning of value and how to accurately and precisely measure value poses a significant challenge. The keys to identifying and optimizing value in spine care lies at the individual patient level. Analyzing drivers of cost from all perspectives and identifying patient factors, surgeon factors, and others that lead to increased cost and cost variation is critical to make improvements in value. Equally important, is the ability to accurately measure patient outcomes. Innovative methods are being developed for measuring patient outcomes and developing evidence to guide clinical decision-making. It can no longer be acceptable to only look at population based outcomes when evaluating the value of a spine intervention, rather the factors that drive variation in outcomes in the outliers must be identified and modified. Understanding what drives cost in spine surgery, the ability to accurately measure outcomes following spine intervention, and identifying factors that drive variation in cost and outcomes is critical to improving the value of health care. These concepts are essential in order to strive toward individualized care, which will not only lead to improved benefit to the patient, but also benefit to the surgeon, the hospital, the payer, and society as a whole. [ABSTRACT FROM AUTHOR]

Objectives This study describes the feasibility and accuracy of a novel computed tomography (CT) fractional flow reserve (FFR) technique based on alternative boundary conditions. Background Techniques used to compute FFR based on images acquired from coronary computed tomography angiography (CTA) are described. Boundary conditions were typically determined by allometric scaling laws and assumptions regarding microvascular resistance. Alternatively, boundary conditions can be derived from the structural deformation of coronary lumen and aorta, although its accuracy remains unknown. Methods Forty-two patients (78 vessels) in a single institution prospectively underwent 320-detector coronary CTA and FFR. Deformation of coronary cross-sectional lumen and aorta, computed from coronary CTA images acquired over diastole, was used to determine the boundary conditions based on hierarchical Bayes modeling. CT-FFR was derived using a reduced order model performed using a standard desktop computer and dedicated software. First, 12 patients (20 vessels) formed the derivation cohort to determine optimal CT-FFR threshold with which to detect functional stenosis, defined as FFR of ≤0.8, which was validated in the subsequent 30 patients (58 vessels). Results Derivation cohort results demonstrated optimal threshold for CT-FFR was 0.8 with 67% sensitivity and 91% specificity. In the validation cohort, CT-FFR was successfully computed in 56 of 58 vessels (97%). Compared with coronary CTA, CT-FFR at ≤0.8 demonstrated a higher specificity (87% vs. 74%, respectively) and positive predictive value (74% vs. 60%, respectively), with comparable sensitivity (78% vs. 79%, respectively), negative predictive value (89% vs. 88%, respectively), and accuracy (area under the curve: 0.88 vs. 0.77, respectively; p = 0.22). Based on Bland-Altman analysis, mean intraobserver and interobserver variability values for CT-FFR were, respectively, −0.02 ± 0.05 (95% limits of agreement: −0.12 to 0.08) and 0.03 ± 0.06 (95% limits: 0.07 to 0.19). Mean time per patient for CT-FFR analysis was 27.07 ± 7.54 min. Conclusions CT-FFR based on alternative boundary conditions and reduced-order fluid model is feasible, highly reproducible, and may be accurate in detecting FFR ≤ 0.8. It requires a short processing time and can be completed at point-of-care. Further validation is required in large prospective multicenter settings. [ABSTRACT FROM AUTHOR]

Background: Lumbar epidural steroid injection (LESI) is a valuable therapeutic option when administered to the appropriate patient, for the appropriate disease process, at the appropriate time. There is considerable variability in patient-reported outcomes (PROs) after LESI, creating uncertainty as to who will benefit from the therapy and who will not.Purpose: We set out to identify patient attributes, which are important predictors for the achievement of a minimum clinically important difference (MCID) in the Oswestry Disability Index (ODI) after LESI.Study Design: A prospective cohort study was carried out.Patient Sample: A total of 239 consecutive patients undergoing LESI for back-related disability, back pain (BP), and leg pain (LP) associated with degenerative pathology comprised the patient sample.Outcome Measures: Baseline and 3-month patient self-reported ODI, numeric rating scale-BP and LP, Euro-Qol-5D, and Short Form (SF)-12 scores were recorded.Methods: A total of 239 consecutive patients undergoing LESI for degenerative pathology over a period of 2 years who were enrolled into a prospective web-based registry were included in the study. Using the previously reported anchor-based approach, an MCID threshold of 7.1% was established for ODI after LESI. Each enrolled patient was then dichotomized as a "responder" (achieving MCID) or a "non-responder." Multiple logistic regression analysis was then performed, with the achievement of MCID serving as the outcome of interest. Candidate variables included in the regression analyses were age, gender, employment, insurance type, smoking status, preoperative ambulation, preinjection narcotic use, comorbidities, predominant LP or BP symptoms, symptom duration, diagnosis, number of levels, prior surgery, baseline PROs, type of stenosis (central, lateral recesses, or foraminal), injection route (transforaminal, interlaminar, or caudal), and number of injections. Subsequently, we also randomly selected 80% of the patients to serve as the training data for a multiple logistic regression model. Once this predictive model was built, it was validated using the remaining 20% of patients.Results: There were 124 (62%) patients who achieved MCID for ODI. The existence of central stenosis (p=.006), TF or IL injection route (p=.02) compared with caudal epidural steroid injection, higher baseline ODI (p=.00001), and a diagnosis of disc herniation (p=.02) increase the odds of achieving MCID for ODI at 3 months. Symptom duration for over a year (p=.006), prior surgery (p=.08), and preinjection anxiety (p=.001) decrease the odds of achieving MCID. The area under the curve (AUC) for our predictive model's receiver-operator characteristic was 0.81 when using the 80% training data set, and the AUC was 0.72 when using the 20% validation data.Conclusion: We have identified patient attributes that are important predictors for the achievement of MCID in ODI 3 months after LESI. The use of these attributes, in the form of a predictive model for LESI efficacy, has the potential to improve decision making around LESI. Spine care providers can use the information to gain insight into the likelihood that a particular patient will experience a meaningful benefit from LESI. [ABSTRACT FROM AUTHOR]

Background Context: Pelvic fixation improves fusion and stability for thoracolumbar constructs that extend across the L5-S1 junction. No patient-reported outcomes have been published to evaluate patients' functional outcomes following these procedures compared with pelvis-sparing procedures.Purpose: The goal of this study is to identify the effect of pelvic fixation on both objective and patient-reported outcomes.Study Design/setting: This was a retrospective, matched cohort study.Patient Sample: The sample comprised adult patients undergoing spine surgery at our institution who had complete 1-year postoperative follow-up.Outcome Measures: Patient-reported outcome instruments (Oswestry Disability Index [ODI], Short-Form 12-item survey, and EuroQol-5D) and objective measures (length of hospital stay, discharge disposition, postoperative complications, and readmission rates) were considered.Methods: We identified patients in our outcomes registry undergoing instrumented spinal fusion involving the pelvis between October 2010 and May 2014 who had 1-year follow-up data. Nearest-neighbor 1:1 matched controls were identified using propensity scoring from the cohort of patients undergoing any spinal procedure which extended caudally to the lumbar spine or sacrum. Objective and patient-reported outcomes were compared between cases and controls.Results: There were 44 patients who underwent spinal procedures involving the pelvis and had 1-year follow-up data. An equal number of controls were identified and had similar baseline demographic and clinical characteristics. No significant differences were found among operative variables or objective complication rates. Patients undergoing pelvic fixation had moderately greater improvement at 3 months as measured by ODI, but this difference was not present at 1 year. Other patient-reported outcome measures were equivocal between groups.Conclusions: This matched cohort study demonstrates that inclusion of the pelvis in spinal hardware constructs is not associated with increased complications and may slightly improve patient disability at 1 year. Given that pelvic fixation may reduce L5-S1 breakdown and improve biomechanics, surgeons should more readily include the pelvis in instrumented fusion procedures. [ABSTRACT FROM AUTHOR]

Background Context: Only Level 3 evidence exists for the diagnosis and treatment of atlantooccipital dislocation (AOD) with few studies examining mortality, neurologic improvement, and patient-reported outcomes (PROs).Purpose: First, the aim was to determine: the incidence of AOD, 90-day surgical morbidity and mortality after AOD, patient factors that may be associated with delayed or missed diagnosis, and factors that were associated with mortality and neurologic improvement after AOD. Secondly, the aim was to quantify the pain, disability, and quality of life experienced by patients surviving AOD.Study Design/setting: This was a retrospective cohort study.Patient Sample: A total of 5,337 consecutive spine computed tomography traumagrams from 1997 to 2012 were included.Outcome Measures: Mortality, neurologic improvement, complications, EuroQol five dimensions (EQ-5D), Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck, NRS-arm, and return-to-work were the outcome measures.Methods: Patients were considered to have AOD if they met one of the following radiographic criteria: basion-dens interval greater than 10 mm; basion-axial interval: anterior displacement greater than 12 mm or posterior displacement greater than 4 mm between the basion and posterior C2 line; and condyle to C1 interval greater than 1.4 mm. Linear regression analysis was performed to identify factors associated with 90-day mortality, neurologic improvement, and missed diagnosis. Patient-reported outcomes were assessed via phone interview.Results: Thirty-one patients met radiographic criteria for AOD; an incidence of 0.6% over 15 years. Twenty-one (68%) patients were treated with occipital cervical fusion. At 90 days postoperatively, there were no new neurologic deficits or reoperations. Eight (26%) patients died within 90 days. All patients who died had no documented AOD diagnosis and were not treated surgically. Missed AOD diagnosis was the strongest predictor of mortality. Younger age, lower Glasgow Coma Score, lower Injury Severity Score (ISS) score, and worse initial American Spinal Injury Association (ASIA) score were significantly associated with greater neurologic improvement. Higher ISS score and better ASIA score were significantly associated with missed AOD diagnosis. The average PROs metrics at time of telephone follow-up were as follows: EQ-5D=0.73±0.19, NDI=30.89±18.57, NRS-neck=2.33±2.21, NRS-arm=2.00±2.54. Of the patients with follow-up data, four were employed full-time, and five were receiving disability.Conclusions: Our work suggests that failure to diagnose AOD is a powerful predictor of mortality. Higher ISS scores and better neurologic presentation were significantly associated with missed diagnosis. Craniocervical arthrodesis preserved neurologic function with low complication rate and unexpectedly high PROs and return-to-work. These results must be carefully interpreted because it is unclear whether missed AOD diagnosis accompanies another death-causing injury (eg, traumatic brain injury) or if failure to treat AOD contributes to mortality in a multifactorial manner. [ABSTRACT FROM AUTHOR]

Background Conus medullaris arteriovenous malformations (AVMs) are rare spinal vascular malformations presenting most frequently with features of myelopathy (Foix-Alajounine syndrome), radiculopathy, bowel/bladder dysfunction, or acute spinal hemorrhage (Coup de poignard of Michon) causing profound neurological deficit. Here we present the case of a young patient with progressive dysphagia and intractable hiccups as a rare first presentation symptom of later verified conus medullaris AVM. Case Description A 21-year-old male patient presented with acute onset of dysphagia and persistent hiccups. His magnetic resonance imaging of the spine demonstrated a lesion at the T11 and T12 levels with an associated holocord syrinx and syringobulbia to the level of the medulla. The patient underwent a decompressive suboccipital craniectomy and C1 (atlas) laminectomy with wide myelotomy of the medulla followed by T11 and T12 laminectomy and AVM reduction. Two days after partial AVM occlusion the patient developed transient worsening of his symptoms. Repeat magnetic resonance imaging showed recurrence of dilatation of the central canal. A syringo-subarachnoid shunt was sited at the level of the previous myelotomy of the medulla, after which his neurological symptoms resolved completely. Conclusions This is the first case report in the English literature to date of a conus AVM presenting with intractable hiccups. These are extremely rare sporadic vascular malformations, and although their natural history is poorly understood, symptomatic patients generally deteriorate, culminating in severe disability. Management requires a multimodality approach including combined endovascular and microsurgical treatment. The patient in our case made a full recovery confirmed at 2-year follow-up. [ABSTRACT FROM AUTHOR]

Radiation-induced multiple bit upsets (MBUs) degrade the reliability of scaled static random access memory (SRAM)-based field programmable gate arrays (FPGAs). Reducing the correction time for MBU and preventing the error accumulation are the challenges faced by error correction code (ECC) integrated FPGAs. In this paper, a novel built-in ECC using encode-and-compare of the data and parity bits is proposed to reduce the correction time and improve the reliability of FPGA. Implementation has been carried out in FPGA to confirm its effectiveness. The proposed method is 5 times faster than existing CRC based inbuilt error mitigation solution. This work opens a door for 2-D ECC to be universally used in FPGAs for safety-critical applications. [ABSTRACT FROM AUTHOR]

In the UK approximately 1000 new patients are diagnosed with a pituitary tumour every year. Although this is predominantly a benign condition, if untreated, visual compromise and endocrine effects of hypersecretion or hypopituitarism can result. This is associated with significant morbidity and mortality. This article provides an overview of the presentation and management of pituitary tumours. [ABSTRACT FROM AUTHOR]

Objective: Higher benchmarks in safety for patients undergoing neurosurgery have been introduced. With these principles, new tools and techniques were established, including intraoperative neurophysiological monitoring (IONM). Current trends as a function of patient-, surgeon-, and procedure-related factors and complication rates in the utilization of IONM as an adjunct to the practice of pediatric neurosurgery have not been investigated previously. Methods: Between 2008 and 2011, 4467 neurosurgical procedures were performed on 2352 patients at Texas Children's Hospital. A retrospective chart review was performed in which surgeon, procedure, and patient characteristics, as well as perioperative complications, were recorded for IONM and non-IONM cases. Results: Neurosurgical procedures performed with IONM steadily increased. Surgeon-related factors associated with IONM use included surgeons with <10 years of practice (P < .0001), and subspecialty interest in spine (P < .0001) and oncology (P = .0048). Procedure-related factors associated with IONM use included operations involving the spinal cord (P < .0001). Patient-related factors associated with IONM use included children older than 3 years of age and with increased American Society of Anesthesiologists score (P < .0001). The neurological complication rate in the IONM cohort (range 3.4% to 11.3%; mean 6.4%) was significantly higher compared to the non-IONM cohort (range 1.1% to 1.8%; mean 1.5%) (P < .0001). Conclusions: The percent of procedures performed with IONM increased. However, these trends do not seem governed by improvement to patient outcomes because the complication rates were higher in the IONM cohort than the non-IONM cohort. [Copyright &y& Elsevier]

Summary: Hydrological or hydraulic flood routing methods can be used to predict the floodplain influences on a flood wave as it passes along a river reach. While hydraulic routing uses both the equation of continuity and the equation of momentum to describe the dynamics of river flows, the simpler data requirements of hydrological routing makes it useful for preliminary estimates of the time and shape of a flood wave at successive points along a river. This paper presents a modified linear Muskingum hydrological routing method where the floodplain effects on flood peak attenuation and flood wave travel time are included in routing parameters. Developing the routing parameters initially involved routing hydrographs of different flood peak and duration through a 1-dimensional model of a generalised river reach in which a range of geometrical and resistance properties were varied. Comparison of upstream and simulated downstream hydrographs for each condition investigated, allowed the attenuation and travel time (storage constant, K, in standard Muskingum routing) of the flood wave to be estimated. Standard Muskingum routing was then used to develop downstream hydrographs for each K value together with assumed storage weighting factors (x) ranging from 0 to 0.5. Flood peak attenuations were again determined through comparison of the upstream and routed downstream hydrographs and with these, linear relationships between x and these attenuations were developed. Actual weighting factors, corresponding to storage constants, were subsequently determined using these relationships for all attenuations determined from the 1-dimensional model simulations. Using multi-variate regression analysis, the computed values of K and x were correlated to catchment and hydrograph properties and expressions for determining both K and x in terms of these properties were developed. The modified Muskingum routing method based on these regressed expressions for K and x was applied to a case study of the River Suir in Ireland where good agreement between measured and routed hydrographs was observed. [Copyright &y& Elsevier]

Summary: Aims: This paper is a report of a study of quality of care delivered by an emergency department fast track unit where both doctors and an emergency nurse practitioner treated patients. Background: Fast track units were established in Australian emergency departments to meet the needs of low complexity emergency department patients. Few studies have reported on the overall quality of care delivered by these units. Methods: A convenience sample of adult patients triaged to an Australian emergency department fast track unit between April 2010 and April 2011 were randomised to care by a doctor or an emergency nurse practitioner. Quality of care was measured using patient satisfaction, follow up health status using Short Form 12 and adverse event rate (missed fractures or unplanned representations). Results: A total of 320 patients were enrolled into the study. Of the 236 patients who submitted completed survey forms, median satisfaction scores were 22 out of 25 with 84% of patients rating care as “excellent” or “very good”. At two week follow up, health status score was comparable to normal healthy populations. When comparing study groups, patient satisfaction scores were significantly higher in the ENP group compared to DR group. Conclusions: Patients received high quality of care in this fast track unit where both nurse practitioner and doctors treated patients. Emergency nurse practitioners were associated with higher patient satisfaction. [Copyright &y& Elsevier]

Abstract: In the UK approximately 1000 new patients are diagnosed with a pituitary tumour every year. Although a predominantly benign condition, untreated it can lead to visual compromise, endocrine effects of hypersecretion or hypopituitarism, resulting in significant morbidity and mortality. This article provides an overview of the presentation and management of pituitary tumours. [Copyright &y& Elsevier]

Abstract: This paper examines socioeconomic (socioeconomic status, SES) disparities in self-rated health and hypertension among 29,816 US adults aged 25 and older using data from the 2001 wave of the National Health Interview Survey. Our purpose is to examine how influential measures of social support and social integration are for each health outcome, and whether support and integration operate by mediating, or buffering, the effects of SES on health. Multivariate regression models show no significant influence of emotional support, but do indicate that many aspects of social integration are directly associated with self-rated health and hypertension, although these measures do not mediate the relationship between SES and health. However, interaction tests show substantial evidence that measures of social integration buffer some of the negative effects of low SES, particularly the negative influence of not working on self-rated health. In addition, findings indicate potential evidence of help-seeking behavior among adults who did not finish high school or who report financial barriers to medical care. Overall, our findings suggest that social programs designed to foster social integration (e.g., free or low-cost bus fare to promote visits with friends and family) may improve health among persons with low levels of education, who are not working, or who have problems accessing medical care because of financial problems. [Copyright &y& Elsevier]

Abstract: The macrocyclic spermidine alkaloid lunarine 1 from Lunaria biennis is a competitive, time-dependent inhibitor of the protozoan oxidoreductase trypanothione reductase (TryR), a promising target in drug design against tropical parasitic diseases. Various molecules related to 1 and the alkaloid itself have been synthesized in racemic form and evaluated against TryR in order to determine the key features of 1 that are associated with time-dependent inhibition. Kinetic data are consistent with an inactivation mechanism involving a conjugate addition of an active site cysteine residue onto the C-24–C-25 double bond of the tricyclic nucleus of 1. Comparison of data for synthetic (±)-1, the natural product, and other derivatives 7–10 from L. biennis confirms the importance of the unique structure of the tricyclic core as a motif for inhibitor design and reveals that the non-natural enantiomer may be a more suitable scaffold upon which thiophilic groups may be presented. [Copyright &y& Elsevier]

Trypanothione reductase is a key enzyme in the trypanothione-based redox metabolism of pathogenic trypanosomes. Because this system is absent in humans, being replaced with glutathione and glutathione reductase, it offers a target for selective inhibition. The rational design of potent inhibitors requires accurate structures of enzyme-inhibitor complexes, but this is lacking for trypanothione reductase. We therefore used quinacrine mustard, an alkylating derivative of the competitive inhibitor quinacrine, to probe the active site of this dimeric flavoprotein. Quinacrine mustard irreversibly inactivates Trypanosoma cruzi trypanothione reductase, but not human glutathione reductase, in a time-dependent manner with a stoichiometry of two inhibitors bound per monomer. The rate of inactivation is dependent upon the oxidation state of trypanothione reductase, with the NADPH-reduced form being inactivated significantly faster than the oxidized form. Inactivation is slowed by clomipramine and a melarsen oxide-trypanothione adduct (both are competitive inhibitors) but accelerated by quinacrine. The structure of the trypano-thione reductase-quinacrine mustard adduct was determined to 2.7 Å, revealing two molecules of inhibitor bound in the trypanothione-binding site. The acridine moieties interact with each other through π-stacking effects, and one acridine interacts in a similar fashion with a tryptophan residue. These interactions provide a molecular explanation for the differing effects of clomipramine and quinacrine on inactivation by quinacrine mustard. Synergism with quinacrine occurs as a result of these planar acridines being able to stack together in the active site cleft, thereby gaining an increased numbet of binding interactions, whereas antagonism occurs with nonplanar molecules, such as clomipramine, where stacking is not possible. [ABSTRACT FROM AUTHOR]

The synthesis and evaluation of 3,5-disubstituted benzofuran derivatives as time-dependent inhibitors of the protozoan oxidoreductase trypanothione reductase are reported. These molecules were designed as simplified mimetics of the naturally occurring spermidine-bridged macrocyclic alkaloid lunarine 1, a known time-dependent inhibitor of trypanothione reductase. In this series of compounds the bis-polyaminoacrylamide derivatives 2–4 were all shown to be competitive inhibitors, but only the bis-4-methyl-piperazin-1-yl-propylacrylamide derivative 4 displayed time-dependent activity. The kinetics of time dependent inactivation of trypanothione reductase by 1 and 4 have been determined and are compared and discussed herein. [Copyright &y& Elsevier]

Elective lumbar fusions have received criticism for inappropriate utilization. Here, we use a novel Operative Value Index (OVI) to assess whether "indicated," evidence-based lumbar fusions are associated with increased value (outcomes per dollar spent). This study is a retrospective analysis of a prospective observational cohort of 294 patients undergoing elective lumbar fusions at a single large academic institution. All patients were preoperatively evaluated by a panel of neurosurgeons for concordance with evidence-based medicine (EBM), determined through guidelines from the North American Spine Society. Oswestry Disability Index (ODI) scores were collected for all patients both preoperatively and at 6-months postoperatively. Time-driven activity-based costing was employed to determine both direct and indirect intraoperative costs. The OVI was defined as the percent improvement in ODI per $1000 spent intraoperatively. Generalized linear mixed model regression, adjusting for confounders, was performed to assess whether EBM-concordant surgeries were associated with higher OVI. Of 294 elective lumbar fusions, 92.9% (n = 273) were EBM-concordant. The average total cost of an EBM-concordant lumbar fusion was $17,932 (supplies: $13,020; personnel: $4314), compared to $20,616 (supplies: $15,467; personnel: $4758) for an EBM-discordant fusion. Average OVI was 2.27 for a concordant fusion, compared to 0.11 for a discordant fusion. Generalized linear mixed model analysis revealed that EBM-concordant cases were associated with significantly higher OVI (β-coefficient 2.0, P < 0.001). EBM-concordant fusions were associated with 2% greater improvement in ODI scores from baseline for every $1000 spent intraoperatively. Systematic methods for increasing guideline adherence for lumbar fusions could therefore improve value at scale. [ABSTRACT FROM AUTHOR]

• Garden Cities are key for sustainable urban growth and water resource management. • Ebbsfleet stakeholders co-produced a participatory System Dynamics Model. • The model investigated different policies for sustainable Urban Water Management. • The participatory nature of the modelling supported a collective learning process. • System Dynamics modelling allowed stakeholders to explore multiple future scenarios. Growing urban populations, changes in rainfall patterns and ageing infrastructure represent significant challenges for urban water management (UWM). There is a critical need for research into how cities should adapt to become resilient to these impacts under uncertain futures. UWM challenges in the Ebbsfleet Garden City (UK) were investigated via a participatory process and potential sustainable solutions were explored using a System Dynamics Model (SDM). Collaborative development of the SDM by the Ebbsfleet Learning and Action Alliance developed stakeholders' understanding of future UWM options and enabled a structured exploration of interdependencies within the current UWM system. Discussion by stakeholders resulted in a focus on potable water use and the development of the SDM to investigate how residential potable water consumption in the Ebbsfleet Garden City might be reduced through a range of interventions, e.g., socio-environmental and economic policy incentives. The SDM approach supports decision-making at a strategic, system-wide level, and facilitates exploration of the long-term consequences of alternative strategies, particularly those that are difficult to include in quantitative models. While an SDM can be developed by experts alone, building it collaboratively allows the process to benefit from local knowledge, resulting in a collective learning process and increased potential for adoption. [ABSTRACT FROM AUTHOR]

• To design and develop effective kidney disease detection approach. • An artificial neural network and multi-kernel k-means clustering algorithms were used. • Stone and tumor were effectively identified by medical ultra sound images. • Performance of linear + Quadratic kernel approach is analyzed with sensitivity, specificity and accuracy. • The proposed linear + Quadratic kernel approach achieves the maximum accuracy compare to other methods. The main aim of this paper is to design and develop an approach for kidney disease detection and segmentation using a combination of clustering and classification approach. Nowadays, kidney stone detection and segmentation is one of the crucial procedures in surgical and treatment planning for ultrasound images. However, at present, kidney stone segmentation in ultrasound images is mostly performed manually in clinical practice. Apart from being time-consuming, manual stone delineation is difficult and depends on the individual operator. Therefore, in this work, we proposed a kidney stone detection using artificial neural network and segmentation using multi-kernel k-means clustering algorithm. Normally, the system comprises of four modules like (i) preprocessing, (ii) feature extraction, (iii) classification and (iv) segmentation. Primarily, we eliminate the noise present in the input image using median filter. Then, we extract the important GLCM features from the image. After that, we classify the image as normal or abnormal using neural network classifier. Finally, the abnormal images are given to the segmentation stage to segment the stone and tumor part separately using multi. Kernel K-means clustering algorithm. The experimentation results show that the proposed system as linear + quadratic based segmentation achieves the maximum accuracy of 99.61%, compare with all other methods. [ABSTRACT FROM AUTHOR]

The role of ECG is pivotal in medical field for the analysis of cardiac physiology and abnormalities. The interpretation of ECG signal is performed by signal processing algorithms for diagnosis of cardiac diseases. This work analyses filtering approaches, component extraction, classification and compression algorithms for the ECG signal. The portable ECG systems are also analysed; results and discussion comprises of IIR notch filter for the removal of power line interference, hybrid wavelet filter for removal of baseline wander, FFT algorithm for R peak detection and hybrid filtering approach for the detection of P, QRS and T components. The outcome of this research work is an aid for researchers developing novel algorithms in ECG filtering, segmentation and classification. The algorithms are developed in Matlab 2015b and tested on fantasia database data sets. [ABSTRACT FROM AUTHOR]