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This paper describes the dental elements (i.e., teeth and incomplete tooth-like structures) formed by mature cystic teratomas and provide some diagnostic criteria to aid in their paleopathological identification and analysis.Hard tissue structures from 13 clinically-derived mature cystic teratomas excised between 2003 and 2007. All are from female patients (N = 13) between the ages of 17 and 56.A dental and osteological inventory identified number of teeth and tooth types present in each specimen.Of the 13 specimens, nine contained dental elements. The number per teratoma ranged from one to seven. A wide variety of tooth types were present in the teratomas with some teeth independent of, and others embedded within, bony matrices.While some teratoma teeth exhibit distinguishable types and laterality, the majority will exhibit some degree of abnormality in size, form, developmental completion, or association with other irregular bony elements.Give the modern clinical prevalence and yet relatively few paleopathological cases reported, it is likely that mature teratomas are under-identified in the archeological record. The diagnostic criteria presented in this paper can aid paleopathologists in their identification and analysis of these neoplasms.Precise paleopathological identification of teratoma elements can be difficult; particularly when they are no longer constrained or contextualized by unmineralized neoplastic borders. As such, there is a risk that such remnants may be mistaken for fetal parts or disassociated elements.Application of these criteria, paired with careful excavation techniques, is advised.

Background: The “crescent sign” is a hyperattenuating crescent-shaped region on CT within the mural thrombus or wall of an aortic aneurysm. Although it has previously been associated with aneurysm instability or impending rupture, the literature is largely based on retrospective analyses of urgently repaired aneurysms. We strove to more rigorously assess the association between an isolated “crescent sign” and risk of impending aortic rupture. Methods: Patients were identified by querying a single health system PACS database for radiology reports noting a crescent sign. Adult patients with a CT demonstrating a descending thoracic, thoracoabdominal, or abdominal aortic aneurysm and “crescent sign” between 2004 and 2019 were included, with exclusion of those showing definitive signs of aortic rupture on imaging. Results: A total of 82 patients were identified. Aneurysm size was 7.1 ± 2.0 cm. Thirty patients had emergent or urgent repairs during their index admission (37%), 19 had elective repairs at a later date (23%), and thirty-three patients had no intervention due to either patient choice or prohibitive medical comorbidities (40%). Patients without intervention had a median follow up of 275 days before death or loss to follow up. In patients undergoing elective intervention, 6,968 patient-days elapsed between presentation and repair, with zero episodes of acute rupture (median 105 days). Patients undergoing elective repair had smaller aneurysms compared to those who underwent emergent/urgent repair (6.2 ± 1.3 vs 7.7 ± 2.1 cm, p = 0.008). No surgical candidate with an aneurysm smaller than 8 cm ruptured. There were 31 patients with previous axial imaging within 2 years prior to presentation with a “crescent sign”, with mean aneurysm growth rate of 0.85 ± 0.62 cm per 6 months [median 0.65, range 0 – 2.6]. Those with aneurysms sized below 5.5 cm displayed decreased aneurysm growth compared to patients with aneurysm's sized 5.5 – 6.5 cm or patients with aneurysms greater than 6.5 cm (0.12 vs 0.64 vs 1.16 cm per 6 months, p = 0.002). Conclusions: The finding of an isolated radiographic “crescent sign” without other signs of definitive aortic rupture (i.e. hemothorax, aortic wall disruption, retroperitoneal bleeding) is not necessarily an indicator of impending aortic rupture, but may be found in the setting of rapid aneurysm growth. Many factors, including other associated radiographic findings, aneurysm size and growth rate, and patient symptomatology, should guide aneurysm management in these patients. We found that patients with minimal symptoms, aneurysm sizes below 6.5 cm, and no further imaging findings of aneurysm instability, such as peri-aortic fat stranding, can be successfully managed with elective intervention after optimization of comorbid factors with no evidence of adverse outcomes.

We outline the history, implementation and clinical impact of the formation of an Airway Lead Network. Although recommendations to improve patient safety in airway management are published and revised regularly, uniform implementation of such guidelines are applied sporadically throughout the hospital and prehospital settings. The primary roles of an Airway Lead are to ensure supply, quality and storage of airway equipment, promote the use of current practice guidelines as well as the organisation of training and audits. Locally, the Airway Lead may chair a multi-disciplinary airway committee within their organisation; an Airway Lead Network enables Airway Leads to share common problems and solutions to promote optimal airway management on a national level. Support from governing bodies is an essential part of this structure.

The ability for individuals to adapt to local food sources likely allows for regional persistence of aquatic populations. In the Laurentian Great Lakes, invasive species and changing physical conditions have vastly altered local and regional food webs, leading to the potential for variation in energy flow up to large predators. To assess the potential that prey fish condition varies spatially, we examined patterns in proportion dry weight of prey fishes collected from Lake Michigan nearshore areas (

Background Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. Methods Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and—if indicated—lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. Results Mean patient age was 28.4 (12–64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1–137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. Conclusions This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.

BACKGROUND The age of patients with pulmonary arterial hypertension (PAH) has increased, with registries now reporting mean ages of 50 to 65 years old. Limited data exist on age-related differences in hemodynamic and functional assessments in PAH. METHODS Adults with PAH in the Pulmonary Hypertension Association Registry were divided into 3 groups (18–50, 51–65, and >65 years old). Analysis of variance and chi-square testing were used to assess for baseline differences. Linear regression was used to examine the association of age with continuous hemodynamic and functional variables. RESULTS A total of 769 patients with mean age of 56 ± 16 years were included. Older patients had more connective tissue disease–associated PAH and less drug-associated PAH. In linear regression models, each year of increased age was associated with shorter 6-minute walk distance (−3.37 meters; 95% CI, −3.97 to −2.76), lower mean pulmonary arterial pressure (−0.21 mm Hg; 95% CI, −0.27 to −0.15), and lower pulmonary vascular resistance (−0.06 Wood units; 95% CI, −0.09 to −0.04). Pulmonary arterial compliance, cardiac index, right ventricular stroke work index, and percent predicted 6-minute walk distance were unrelated to age; resistance-compliance time was negatively related to age (−3 milliseconds per year; 95% CI, −4 to −2). CONCLUSIONS Relative to their pulmonary vascular resistance, older patients have lower pulmonary artery compliance and worse right ventricular performance. Based on these findings, we suspect that age influences right ventricular loading conditions and the response of the right ventricle to increased afterload.

Intravascular ultrasound (IVUS) examination is an integral technique used for treating type B aortic dissection (TBAD) because it verifies true lumen access. The purpose of this study was to evaluate the use of IVUS, to determine factors associated with IVUS use, and to investigate the potential survival benefit associated with IVUS in the treatment of TBAD.A retrospective review of TEVARs performed for TBAD in the national Vascular Quality Initiative was performed from January 2010 to August 2018. Data collected included demographics, intraoperative and postoperative variables, and long-term mortality. Multivariable logistic regression evaluated variables associated with IVUS the use and mortality, and Cox regression was performed for adjusted survival analysis.In this study of 2686 patients, the average age was 60.4 years, 69.3% were male, and IVUS examination was used in 74.6% of cases. IVUS patients were younger (60.0 years vs 61.7 years; P = .004), more often male (72.1% vs 61.3%; P .001), exhibited less coronary disease, but had higher preoperative creatinine (1.27 ± 0.89 mg/dL vs 1.14 ± 0.68 mg/dL; P .001) and were more often treated in the acute setting (55.2% vs 49.7%; P = .03). Interestingly, there were no differences in contrast use (117.4 ± 77.6 mL vs 123.0 ± 81.90.1 mL; P = .11) or fluoroscopy time (20.3 ± 16.5 minutes vs 19.0 ± 22.1 minutes; P = .10). However, IVUS cases had a greater number of devices implanted (1.84 vs 1.65; P .001), higher rates of Zone 0 to 2 proximal seal (43.9% vs 30.7%; P .001), higher rates of distal seal zones beyond the diaphragm (53.9% vs 37.4%; P = .001), and larger proximal and distal graft diameters, with no differences in postoperative renal function. IVUS patients notably also had higher rates of follow-up imaging (61.3% vs 54.8%; P = .003), larger maximum aortic diameters at follow-up, and more reinterventions over time. The number of aortic devices (odds ratio [OR] 1.56; 95% confidence interval [CI], 1.24-1.97; P .001), malperfusion indication (OR, 1.68; 95% CI, 1.17-2.42; P = .005) and distal seal zone beyond the diaphragm (OR, 1.64; 95% CI, 1.30-2.07; P .001) were independently associated with IVUS use, whereas female gender showed a trend towards less IVUS use (OR, 0.79; 95% CI, 0.62-1.01; P = .063). Even after controlling for age, preoperative comorbidities, and postoperative complications like spinal cord ischemia, IVUS was associated with a 61% decrease in the odds of mortality (OR, 0.39; 95% CI, 0.20-0.78; P = .008), with a clear survival advantage shown in adjusted survival curves.IVUS examination was used in the majority of TBAD, although not universally. IVUS examination was used more often in acute TBAD and more complex aortic repairs, and was independently associated with improved long-term survival. Further study is needed to understand these patterns.

Length of stay (LOS) is a commonly used metric to optimize value in medical care. Although pathways have been developed for some procedures in vascular surgery to reduce LOS, they do not yet exist for thoracic endovascular aortic repair (TEVAR). The purpose of this study is to identify and define the risk factors for prolonged LOS in patients undergoing TEVAR to facilitate pathway development.We included TEVAR patients in the National Surgical Quality Improvement Program database from 2005 to 2015. Prolonged LOS was defined as LOS75th percentile of the overall cohort (11 days). Because initial analysis revealed the distinct clinical differences between dissection and aneurysm patients, further analysis was stratified by aortic pathology. Student's t-test and Chi-square tests were used to compare demographic and perioperative variables between dissection and aneurysm patients, respectively. Multivariable logistic regression was used to evaluate the predictors for prolonged LOS.A total of 3,021 patients underwent TEVAR, with 858 patients (28.4%) undergoing TEVAR for dissection and 2,163 (71.6%) undergoing TEVAR for aneurysm. An initial analysis with logistic regression identified dissection indication (odds ratio [OR], 2.87; 95% confidence interval [CI], 1.1-7.3) as an independent predictor of prolonged LOS. Further analysis for prolonged LOS was subsequently performed separating dissection and aneurysm patients. Aneurysm patients were older (71.2 ± 11.7 vs. 63.1 ± 13.6 years, P 0.001), more often Caucasian (76.8% vs. 61.8%, P 0.001), and had more medical comorbidities (chronic obstructive pulmonary disease, cardiac history, diabetes, peripheral vascular disease, transient ischemic attack [TIA], P 0.001). In contrast, dissection patients had higher American Society of Anesthesiology (ASA) classification score (58.5% had3 ASA vs. 45.5%, P 0.001), longer hospitalizations (10.2 ± 9.3 vs. 8.5 ± 10.4 days, P 0.001), were more likely to have been transferred from another hospital or emergency room (58.4% vs. 48.3%, P 0.001), and were more often emergent (32.4% vs. 15.4%, P 0.001). In dissection patients, ASA classification score (OR, 1.49; 95% CI, 1.1-2.1) and dialysis (OR, 1.98; 95% CI, 1.0-3.9) were independent predictors for prolonged LOS. In aneurysm patients, dependent functional status (OR, 2.03; 95% CI, 1.4-2.8), diabetes (OR, 1.75; 95% CI, 1.1-2.8), cardiac history (OR, 1.37; 95% CI, 1.0-1.9), emergency status (OR, 1.98; 95% CI, 1.4-2.8), and dialysis (OR, 2.08; 95% CI, 1.2-3.7) predicted prolonged LOS. Postoperative complications including stroke/TIA; failure to wean from ventilator, sepsis, and pneumonia; and need for reoperation similarly increased LOS in both dissection and aneurysm patients.Dissection and aneurysm patients undergoing TEVAR are comprised of different patient populations, with dissection patients more often enduring prolonged hospitalizations. In contrast, TEVAR performed for nonemergent aneurysm repair had the shortest LOS. These data support the development of separate pathways defined by indication and acuity for patients undergoing TEVAR.

Virtual X-ray diffraction (XRD) and atomistic simulations are used to probe the relationship between XRD phenomena and the strain accommodation methods associated with deformation. Twinned and untwinned nanocrystalline (NC) samples loaded in tension reveal distinct XRD responses. In initially untwinned samples, peak splitting occurs precisely as dislocation mediated deformation mechanisms initiate at approximately 2.9% strain. However, initially pre-twinned samples reveal less dislocation mediated deformation and no observable XRD peak splitting. XRD responses from control sets of ideal defect structures representing bulk and unloaded NC samples are analyzed. This study shows that the peak splitting during deformation of the initially untwinned NC sample can be traced to both the high density of planar defects and the complex internal strain state present under external load.

Freshwater submarine groundwater discharge (SGD) frequently occurs in areas of karst coastline where karst aquifers are hydraulically connected to the sea. Though up to 25% of the world's coastline is karst, little work has been done to determine the ecological impacts of karst-channelled freshwater SGD. Reported herein are the effects of karst-channelled freshwater SGD on the rock pool sessile assemblage in the locale of Olhos de Agua on the south Portuguese coast. Two quadrat surveys were conducted in eight intertidal rock pools, which ranged in freshwater SGD content from 0 to 57.3%. Salinity and nitrogen (NO3− and NO2−) concentrations were measured in the eight surveyed rock pools, as well as a further three rock pools on the same plateau, three inland groundwater boreholes and the adjacent coastal marine environment. There was a strong negative correlation between salinity (used as a proxy for freshwater SGD) and nitrogen concentration (r2 = 0.98; p

The formation of weak, localized shear zones in the lithosphere via tectonic forces is a requirement for the operation of plate tectonics on Earth. However, how shear zones form is not well understood. Shear heating and grain size reduction are two commonly cited mechanisms, and both processes are likely to be active in lithospheric shear zones. However, shear heating and grain size reduction can potentially act against each other, as elevated temperatures increase grain growth rates, and fast grain growth can eliminate weak shear zones formed via grain size reduction. Here, an effectively one-dimensional simple shear model that considers shear heating and grain size evolution is used to determine how grain size reduction and shear heating interact. The results indicate that for constant velocity boundary conditions at typical tectonic strain rates and mid- to lower-lithosphere temperatures, grain size reduction suppresses shear heating by weakening the shear zone. As a result shear heating at these conditions is small (∼10 K or less), unless grain size reduction via damage is significantly less effective than the models assume. For constant stress boundary conditions, grain size reduction enhances shear heating and lowers the stress threshold required to trigger thermal runaway instabilities, as previous studies have found. Finally, combining shear heating and grain size reduction allows weak shear zones to form over a wider range of conditions than would result from either mechanism acting in isolation; coupling between shear heating and grain size reduction does not impede weak shear zone formation.

Optical nanostructures can control the optical absorption and emission properties of surfaces and are therefore being investigated for solar thermophotovoltaics, thermophotovoltaics, solar thermal, infrared sensing, infrared sources, incandescent light sources, and thermal imaging applications, among many others. This review article describes various modeling methods available for design of optical nanostructures to control light absorption and emission properties of surfaces, as well as various methods available for the fabrication of large area nanostructured surfaces. Throughout the review, we provide examples of state of the art energy generation devices using such optical nanostructures. A discussion of outstanding obstacles for the achievement of high efficiency solar thermophotovoltaics systems is provided along with examples of systems showing exceptional promise.

Purpose The majority of type 2 endoleaks (T2EL) are identified on computed tomography angiography (CTA) both on arterial and venous phase. There is a subset of T2EL that are demonstrated only on venous phase CTA. This study was done to report the outcomes of T2EL detected only on venous phase CTA. Materials and methods A total of 261 consecutive T2EL treated via embolization were reviewed for the presence of endoleak demonstrated only on venous phase CTA. A group of 16 patients (12 men, 4 women; mean age, 80.1 years) was identified who had pre-embolization venous phase T2EL. Patients were evaluated for presence of T2EL after embolization, change in aneurysm diameter, and need for further intervention. Results The prevalence of venous phase T2EL was 6.1% (16/261; 95%CI: 3.2%–9.0%). On post-embolization CTA, the rate of successful embolization at 6 months was 2/12 (17%; 95%CI: 0%–38%). At 6-month follow-up, mean change in aneurysm diameter was +2.3 mm (n = 12; 95%CI: −0.5 mm to +5.0 mm). In total, 4/16 (25%; 95%CI: 4%–46%) underwent re-embolization and 4/16 (25%, 95%CI: 4%–46%) underwent conversion to open repair. There was one aneurysm rupture, which was successfully treated surgically. Conclusion These results suggest that venous phase T2EL are not as responsive to embolization as standard T2EL and emphasize the need to follow patients with venous phase T2EL closely.

Published rates of reintervention after endovascular aneurysm repair (EVAR) range from 10% to 30%. We evaluated a single university center's experience with reinterventions in the context of Food and Drug Administration (FDA)-approved and trial devices.Retrospective data collection was performed for patients who underwent infrarenal EVAR and required reintervention from 2000 to 2016. Trial devices included those used in FDA feasibility and pivotal trials. Time-to-event analysis was performed using Cox regression. Predictors of mortality and explantation were evaluated using logistic regression; survival analysis was performed using Kaplan-Meier methods.From 2000 to 2016, there were 1835 EVARs performed, and 137 patients (116 men; mean age, 72.2 ± 10.0 years) underwent reintervention with a mean aneurysm size of 5.9 ± 1.2 cm. The median follow-up was 5 years with an overall survival of 70.1%. The overall reintervention rate was 7.5%. FDA-approved devices had a reintervention rate of 6.4%, whereas trial devices had a rate of 14.4% (P .001). For all devices, the most common cause of reintervention was type II endoleak (52.5%), followed by type I endoleak (18.2%), type III endoleak (9.5%), limb kink (7.3%), iliac occlusive disease (5.8%), endotension (1.5%), and other. The overall mean time to first reintervention was 2.3 ± 2.5 years, and univariate Cox regression identified male gender (hazard ratio, 1.91; 95% confidence interval [CI], 1.17-3.10; P = .010) and age at the time of EVAR (hazard ratio, 1.03; 95% CI, 1.01-1.05; P = .006) as risk factors for time to first reintervention. Among patients requiring reintervention, the mean number of reinterventions for trial devices was significantly greater than that for FDA-approved devices (2.18 vs 1.65; P = .01). Trial devices requiring reintervention had a nearly threefold higher odds for the need for more than two reinterventions (odds ratio, 2.88; 95% CI, 1.12-7.37; P = .034). Trial device, cause of reintervention, and type of reintervention were not predictive of the need for explantation or mortality, but the number of reinterventions was significantly associated with the need for explantation (odds ratio, 1.86; 95% CI, 1.17-2.96; P = .012). EVAR device and the need for explantation did not have an impact on mortality.Despite the rigorous nature of patient enrollment in clinical trials and the development of newer iterations of investigational devices, patients undergoing EVAR with trial devices are more likely to undergo a greater number of reinterventions than with FDA-approved devices. Although mortality and the need for explantation were not significantly associated with trial devices, the finding of a greater number of reinterventions highlights the need to properly inform patients willing to partake in investigational device trials.

Many studies quantify total phenolics or total tannins, but understanding the ecological role of polyphenolic secondary metabolites requires at least an understanding of the diversity of phenolic groups present. We used UPLC-MS/MS to measure concentrations of different polyphenol groups - including the four most common tannin groups, the three most common flavonoid groups, and quinic acid derivatives - in foliage from 628 eucalypts from the genera Eucalyptus, Angophora and Corymbia. We also tested for phylogenetic signal in each of the phenolic groups. Many eucalypts contained high concentrations of polyphenols, particularly ellagitannins, which have been relatively poorly studied, but may possess strong oxidative activity. Because the biosynthetic pathways of many phenolic compounds share either precursors or enzymes, we found negative correlations between the concentrations of several of the constituents that we measured, including proanthocyanidins (PAs) and hydrolysable tannins (HTs), HTs and flavonol derivatives, and HTs and quinic acid derivatives. We observed moderate phylogenetic signal in all polyphenol constituents, apart from the concentration of the prodelphinidin subunit of PAs and the mean degree of polymerisation of PAs. These two traits, which have previously been shown to be important in determining plants' protein precipitation capacity, may have evolved under selection, perhaps in response to climate or herbivore pressure. Hence, the signature of evolutionary history appears to have been erased for these traits. This study is an important step in moving away from analysing "totals" to a better understanding of how phylogenetic effects influence phenolic composition, and how this in turn influences ecological processes.

There has been growing scrutiny in the treatment of patients with peripheral artery disease due to the utilization of resources to manage this complex patient population. The purpose of this study was to determine the factors associated with prolonged length of stay (LOS7 days) following lower extremity bypass using data from the Vascular Quality Initiative as well as to define the additional costs incurred due to prolonged LOS in our health system.Summary statistics were performed of patients undergoing lower extremity bypass from 2010 to 2015. Student's t-tests and χThis study included 334 patients with a mean age of 66.4 ± 12.4 years, 64.7% males, 58.5% of white race, 11.1% on dialysis, 80.5% smokers, and 53.6% with diabetes. The mean LOS was 15.7 ± 12.2 days. Prolonged LOS was associated with transfer (15.4% vs. 2.3%, P = 0.001), diabetes (58.3% vs. 40.2%, P = 0.004), critical limb ischemia (71.3% vs. 49.4%, P 0.001), preoperative need for ambulatory assistance (44.5% vs. 16.1%, P 0.001), prior ipsilateral bypass (6.9% vs. 1.1%, P = 0.042), urgent surgery (39.7% vs. 9.8%, P 0.001), tibial or distal target vessel (52.7% vs. 28.0%, P 0.001), use of vein (65.4% vs. 46.3%, P = 0.002), return to operating room (42.6% vs. 1.2%, P 0.001), ambulatory assistance (65.0% vs. 34.1%, P 0.001) as well as discharge anticoagulant (22.8% vs. 9.8%, P = 0.010). Multivariable logistic regression identified urgency (odds ratio [OR] = 5.09, 95% confidence interval [CI] 2.16-12.02, P 0.001), critical limb ischemia (OR = 3.12, 95% CI 1.65-5.90, P 0.001), return to OR (OR = 40.30, 95% CI 5.36-303.20, P 0.001), use of vein (OR = 2.19, 95% CI 1.18-4.07, P = 0.013), and the need for anticoagulation at discharge (OR = 2.56, 95% CI 1.03-6.33, P = 0.043) as independent predictors of LOS7 days. Prolonged hospital stays accounted for an additional $40,561.64 in total cost and $26,028 in direct costs incurred. Despite these increased costs, limb salvage and overall survival were not adversely impacted in the prolonged LOS group in follow-up.Lower extremity bypass is associated with a longer than expected LOS in our health system, much of which can be attributed to return to the OR for minor amputations and wound issues. This led to added total and direct costs, where the majority of this increase was attributable to prolonged LOS. Limb salvage and overall survival were preserved, however, in this subset of patients in follow-up. These findings suggest that lower extremity bypass patients are a resource-intensive population of patients, but that these costs are worthwhile in the setting of preserved limb salvage and overall survival.

Background To describe a large single-institutional experience in managing challenging access situations during endovascular aneurysm repair (EVAR). Methods Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 were collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access (DA), and outcomes. The median follow-up was 38 months. DA was defined as iliac arteries with a diameter of less than 7 mm bilaterally. Fenestrated and snorkel repairs were excluded. Results Of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of the DA patients, 35 (18.3%) underwent 42 adjuncts before the introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 aortouniiliac devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown, and 3 iliac stents. In another 29 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 4.6 mm in the group of patients requiring adjuncts and 5.4 mm in the remainder of the patients with small iliac arteries (P = 0.008). The median size of the main body device was 28 mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3 (1.6%) instances of limb ischemia, and 5 (2.6%) patients needed early reoperation (within 30 days). Two patients (1%) had type I endoleaks at the conclusion of EVAR. During follow-up, 12 (6.3%) patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (P = 0.12). Conclusions EVAR can be successfully performed in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients and should definitely be considered in patients with iliac arteries less than 5 mm in diameter. Next generation and “low-profile” devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients.

The style of tectonics on the Hadean and Archean Earth, particularly whether plate tectonics was in operation or not, is debated. One important, albeit indirect, constraint on early Earth tectonics comes from observations of early-formed geochemical heterogeneities: 142Nd and 182W anomalies recorded in Hadean to Phanerozoic rocks from different localities indicate that chemically heterogeneous reservoirs, formed during the first ∼500 Myrs of Earth's history, survived their remixing into the mantle for over 1 Gyrs. Such a long mixing time is difficult to explain because hotter mantle temperatures, expected for the early Earth, act to lower mantle viscosity and increase convective vigor. Previous studies found that mobile lid convection typically erases heterogeneity within ∼100 Myrs under such conditions, leading to the hypothesis that stagnant lid convection on the early Earth was responsible for the observed long mixing times. However, using two-dimensional Cartesian convection models that include grainsize evolution, we find that mobile lid convection can preserve heterogeneity at high mantle temperature conditions for much longer than previously thought, because higher mantle temperatures lead to larger grainsizes in the lithosphere. These larger grainsizes result in stronger plate boundaries that act to slow down surface and interior convective motions, in competition with the direct effect temperature has on mantle viscosity. Our models indicate that mobile lid convection can preserve heterogeneity for ≈0.4–1 Gyrs at early Earth mantle temperatures when the initial heterogeneity has the same viscosity as the background mantle, and ≈1–4 Gyrs when the heterogeneity is ten times more viscous than the background mantle. Thus, stagnant lid convection is not required to explain long-term survival of early formed geochemical heterogeneities, though these heterogeneities having an elevated viscosity compared to the surrounding mantle may be essential for their preservation.

Eucalyptus oil is produced from a number of “oil mallee” species with high concentration of foliar essential oils, high proportion of 1,8-cineole and the ability to re-sprout with multiple stems from lignotubers after coppicing. Eucalyptus polybractea is one of the most planted mallees in Australia, but few efforts have been made to improve crop yields through selection or breeding programs, with the exception of seed collection from trees with high oil and 1,8-cineole concentration. The yield of essential oil from commercial eucalypt plantations is subject to several quantitative traits that interact, both positively and negatively. Using non-destructive methods we assessed traits relating to oil yield (quantitative and qualitative variation of foliar essential oils and biomass-related parameters) for their variability, heritability as well as phenotypic and genetic interactions in an open-pollinated progeny trial with 40 families and 480 individuals of E. polybractea. From this we built models to predict family yield performance and compared our predictions to commercial scale harvests of the same trial. Our models show that relying on oil concentration and 1,8-cineole proportion alone is not ideal for selection of top performing families. Rather a mixture of biomass related traits, foliar oil concentration, 1,8-cineole proportion and leaf architecture contribute to the top performing families in varying ways.

The ciliate protozoan Cryptocaryon irritans parasitizes marine fish and causes lethal white spot disease. Sporadic infections as well as large-scale outbreaks have been reported globally and the parasite's broad host range poses particular threat to the aquaculture and ornamental fish markets. In order to better understand C. irritans' population structure, we sequenced and compared mitochondrial cox-1, SSU rRNA, and ITS-1 sequences from 8 new isolates of C. irritans collected in China, Japan, and Taiwan. We detected two SSU rRNA haplotypes, which differ at three positions, separating the isolates into two main groups (I and II). Cox-1 sequences also support the division into two groups, and the cox-1 divergence between these two groups is unexpectedly high (9.28% for 1582 nucleotide positions). The divergence is much greater than that detected in Ichthyophthirius multifiliis, the ciliate protozoan causing freshwater white spot disease in fish, where intraspecies divergence on cox-1 sequence is only 1.95%. ITS-1 sequences derived from these eight isolates and from all other C. irritans isolates (deposited in the GenBank) not only support the two groups, but further suggest the presence of a third group with even greater sequence divergence. Finally, a small Ka/Ks ratio estimated from cox-1 sequences suggests that this gene in C. irritans remains under strong purifying selection. Taken together, the C. irritans species may consists of many subspecies and/or syngens. Further work is needed to determine if there is reproductive isolation between the groups we have defined.

Understanding trophic interactions of non-native species is a key step in elucidating their ecological role in recently invaded systems. The benthic fish species round goby ( Neogobius melanostomus ) has successfully established in aquatic systems across the world, with abundances increasing dramatically over relatively short time periods. Though this (at times) voracious benthivore can become an increasingly important forage fish for piscivores, relatively little is known about how prey and production pathways that support round gobies vary in space and time. In 2010, we collected round gobies from ten nearshore sites, over three seasons, in Lake Michigan, U.S.A. Due to recent changes in Lake Michigan, the dynamic nearshore region may be crucial for stability of the whole-lake food web. We assessed the role of round gobies in the nearshore Lake Michigan food web using stomach contents, fatty acid profiles, and δ 13 C and δ 15 N stable isotopes. Patterns in all of these measures were highly influenced by site, suggesting that local conditions, such as substrate composition or proximity to riverine inputs, were important in structuring round goby trophic interactions. By contrast, season of sampling and depth of collection had relatively weak associations with observed patterns. Few broad, regional patterns were evident, including a relatively high reliance on benthic production pathways on the western side of Lake Michigan. The observed variety in feeding patterns of round gobies, including potential for exploitation of different production pathways, may contribute to long-term persistence of this aquatic invader in new habitats.

Invasive dreissenid mussels (D. polymorpha and D. r. bugensis) have fundamentally altered Laurentian Great Lake ecosystems, however in many areas their abundances have declined since the mid-1990s. Another invader, the benthic fish round goby (Neogobius melanostomus), is morphologically adapted to feed on dreissenids and likely affects dreissenid populations; however, the degree of this predatory effect is variable. In 2009 and 2010, we examined round goby abundances, size distributions, diet contents, and diet selectivity in Saginaw Bay, Lake Huron; a shallow bay that has been subjected to numerous anthropogenic stressors. We further used a consumption model to estimate dreissenid consumption by three different size classes of round goby. Round gobies were found throughout the bay and most were smaller than 80 mm total length. Round gobies of all sizes consumed dreissenids (including fish as small as 30 mm total length), though dreissenids were rarely preferred. The relative proportion of dreissenids (by biomass) present in diets of round gobies increased with fish size, but also throughout the year for all size classes. Despite this, overall consumptive effects of round gobies on dreissenids in Saginaw Bay were low. Many dreissenids present in the bay were larger than those consumed by round gobies. Bioenergetics-based model estimates suggest that the smallest round gobies are responsible for the majority of dreissenid consumption. While our findings are limited to soft substrates and influenced by sampling restrictions, our study design allowed us to put bounds on our estimates based upon these multiple sources of uncertainty.

Explaining the evidence for surface liquid water on early Mars has been a challenge for climate modelers, as the sun was ∼ 30% less luminous during the late-Noachian. We propose that the additional greenhouse forcing of C O 2 - H 2 collision-induced absorption is capable of bringing the surface temperature above freezing and can put early Mars into a limit-cycling regime. Limit cycles occur when insolation is low and C O 2 outgassing rates are unable to balance with the rapid drawdown of C O 2 during warm weathering periods. Planets in this regime will alternate between global glaciation and transient warm climate phases. This mechanism is capable of explaining the geomorphological evidence for transient warm periods in the martian record. Previous work has shown that collision-induced absorption of C O 2 - H 2 was capable of deglaciating early Mars, but only with high H 2 outgassing rates (greater than ∼ 600 Tmol/yr) and at high surface pressures (between 3 to 4 bars). We used new theoretically derived collision-induced absorption coefficients for C O 2 - H 2 to reevaluate the climate limit cycling hypothesis for early Mars. Using the new and stronger absorption coefficients in our 1-dimensional radiative convective model as well as our energy balance model, we find that limit cycling can occur with an H 2 outgassing rate as low as ∼ 300 Tmol/yr at surface pressures below 3 bars. Our results agree more closely with paleoparameters for early martian surface pressure and hydrogen abundance.

The identification of stress indicators in archaeological human remains is confounded not only by how paleopathologists define “stress”, but also by our understanding of how stress impacts the body. With the interpretation of commonly used osteological stress indicators being cautioned, if not challenged, the door is open for bioarchaeologists to explore new ways of identifying stress in past populations. One potentially identifiable stress response is bruxism. A behavior disorder characterized by the unconscious grinding and/or clenching of teeth, bruxism is often associated with acute and chronic psychosocial stress. This disorder is quite common; international clinical literature shows the disorder affecting up to 31% of adults and 20% of children. Though the frequency and severity of bruxism varies by individual, the long-term pathological impact of bruxing can be severe. Bruxism is associated with excessive dental attrition, abfraction, fracture, hypercementosis, occlusal pits, myofascial pain, hypertrophy of masticatory muscles, and possibly with mandibular and maxillary tori and temporomandibular disorder (TMD). However, despite its prevalence, associated pathologies, and association with stress, bruxism is rarely discussed in the osteological “stress” literature. This lack of attention is likely due to the challenges inherent in differential diagnosis. Evidence of bruxism may be obscured, exacerbated, and/or confounded by masticatory wear, malocclusion, tooth-loss, and general aging. Furthermore, the idiosyncratic nature of the disorder and the variability in the biomechanical forces associated with it (clenching vs. grinding) suggest that the dental effects will present differently within and between individuals, which may further complicate diagnosis. Despite these obstacles, as a clinically-correlated stress response, bruxism is a potentially useful new avenue for conceptualizing and identifying stress in past populations.

Manufacturers in the western world need to exploit and perfect all their strengths to reduce the flight of manufacturing to global outsourcing destinations. Use of automated manufacturing systems (AMSs) is one such strength that needs to be improved to perfection. One area for improvement is the management of uncertainties on the production floor. This paper explores strategies for modifying detailed event list schedules following the occurrence of an interruption. Advanced planning and scheduling (APS) software packages provide a detailed advance plan of production events. However, the execution of this advance plan is disrupted by a myriad of unanticipated interruptions, such as machine breakdowns, yield variations, and hot jobs. The alternatives available to respond to such interruptions can be classified in four groups: regenerating the complete schedule using APS, switching to dispatching mode, modifying the existing schedule, and continuing to follow the schedule and letting the production system gradually absorb the impact of the interruption. Regeneration of the complete schedule using APS requires a large computation effort, may result in large changes in the schedule, and hence is not recommended. This paper reports on an experimental study for evaluating 10 strategies for responding to machine failures in AMSs that broadly fall in the latter three groups. The strategies are evaluated using simulation under an experimental design with manufacturing scenario, load level, severity and duration of interruptions as factors. The results are analyzed to understand the strengths and weaknesses of the considered strategies and develop recommendations.

Objective We report our institutional experience of various venous reconstruction methods during oncologic resections, especially examining the patency of venous reconstructions and the conduits used. Methods All patients undergoing venous repair or reconstruction for oncologic resections between 2008 and 2014 were identified by a retrospective search of a prospectively maintained database at a single university hospital. Extent and manner of venous reconstruction and conduit or patch material were recorded. Need for intraoperative venovenous bypass or cardiopulmonary bypass was also recorded. Whereas no prescribed follow-up protocol has been instituted, patency and survival data as available were analyzed. Results During the study period, 127 patients were identified. Five patients had primary ligations, without limb loss. Of the remaining 122 patients, 77 (63%) underwent primary repairs, 23 (19%) had patch repair, and 22 (18%) had bypasses. Of these, 27 (22%) were for portal vein reconstruction during a Whipple procedure, 47 (39%) were for caval repair during caval thrombectomy in the setting of renal cell cancer, and 28 (23%) were for caval repair during resection for other abdominal malignant neoplasms. Venovenous bypass was used in 16 repairs and cardiopulmonary bypass in 10. The 1-year patency rates were 100% for primary and patch repairs and 86% for bypass graft reconstructions. Occlusions were suffered only in the prosthetic grafts group. There was no limb loss or significant long-term morbidity in patients with occluded grafts. Rate of infection was 0%, and there was no evidence of an increased infection rate in prosthetic or bioprosthetic conduits or patches. Perioperative mortality was 5.5%. Conclusions Overall, venous reconstruction for oncologic resection can be done safely with very low complication rates and low perioperative mortality. Prosthetic grafts can be used for most reconstructions with no infections and good patency rates.

In rivers, lakes, and other aquatic systems throughout the world, intake pipes withdraw huge volumes of water for industrial purposes, including power plant cooling. During this process, large numbers of small-bodied, early life-stages of fish are pulled into pipes (i.e., entrained) and may be subjected to physical, thermal and chemical stress. As a result of such entrainment, these organisms can suffer direct or indirect mortality. However, given that the vast majority of larval fish are likely to die during early life due to natural processes, it is not obvious that entrainment-related mortality will have a strong influence on subsequent adult population sizes. The ability to evaluate if larval fish are dead on arrival, moribund, or in poor condition (i.e., likely to die through natural processes) at the time of entrainment could shed light on likely population-level impacts. To this end, we review the potential use of RNA:DNA ratios to index condition of entrained larval fish. Through a meta-analysis of published research studies, we demonstrate that RNA:DNA ratios of larval fish are responsive to starvation stress, with effect size increasing with duration of starvation. We relate these results to a surrogate measure of irreversible long-term negative impacts to fish populations, and demonstrate that the timescale over which RNA:DNA ratios respond to stress may not be long enough to reflect before-and-after entrainment stress. We also highlight the diverse factors contributing to variation of RNA:DNA ratios, including methodological, ontogenetic, and thermal influences. We believe that the need to account for these influences when comparing among RNA:DNA values limits the utility of broadly using RNA:DNA ratios to evaluate entrainment effects. However, the method shows promise as a quick and efficient means of determining fish condition and, used in proper context (e.g., specific to a given set of environmental conditions; in conjunction with other assessment techniques), may provide a powerful tool in assessing the effects of entrainment on fish populations. Assuming that researchers can account for sources of background variation, RNA:DNA analyses may be most useful for assessing the condition of fish larvae susceptible to entrainment (i.e., physically in the vicinity of the water intake) and/or evaluating whether fish larvae are likely to die from natural processes independent of entrainment.

Near-infrared reflectance spectroscopy (NIRS) was used to predict the nutritional quality of tree foliage from a New Zealand forest inhabited by the introduced common brushtail possum (Trichosurus vulpecula) as part of a study to understand the relationship between possum browsing and the nutritional quality of foliage. The traits of interest were the foliar concentrations of total nitrogen, in vitro dry matter digestibility, and available nitrogen (with and without incubation with polyethylene glycol to indicate the effect of tannins). A total of 1399 samples from five plant species were studied, with 650 included in a calibration set and 50 in a separate validation set. We evaluated the performance of classic (GLOBAL) and alternative (LOCAL) calibration techniques. Both were successful, although a GLOBAL equation incorporating all calibration samples was used for the final predictions. Modelling of the spectra enabled the nutritional quality of the foliage samples to be estimated with coefficients of determination (r2) of 0.83–0.99 using modified partial least-squares regression. Nutritional quality varied both within and between five tree species for which possums show varied preferences. The predictive models developed in this study facilitate landscape-scale ecological investigations into the role of plant nutrients on the behaviour and demography of introduced herbivores. This provides new opportunities to test theories on invasiveness and to prioritize landscapes for conservation and possum control.

The koala (Phascolarctos cinereus), one of the world's most iconic faunal species, was recently listed under Australian government legislation as vulnerable in the northern states of Queensland and New South Wales and in the Australian Capital Territory, but not in the southern states of Victoria and South Australia. This review synthesises empirical evidence of regional koala population trends, their conservation outlook, and associated policy challenges. Population declines are common in the northern half of the koala's range, where habitat loss, hotter droughts, disease, dog attacks and vehicle collisions are the major threats. In contrast, some southern populations are locally overabundant and are now subject to managed declines. The koala presents the problem of managing a wide-ranging species that now primarily occurs in human-modified landscapes, some of which are rapidly urbanising or subject to large-scale agricultural and mining developments. Climate change is a major threat to both northern and southern populations. The implementation of policy to conserve remaining koala habitat and restore degraded habitat is critical to the success of koala conservation strategies, but habitat conservation alone will not resolve the issues of koala conservation. There needs to be concerted effort to reduce the incidence of dog attack and road-related mortality, disease prevalence and severity, and take into account new threats of climate change and mining. Many of the complex conservation and policy challenges identified here have broader significance for other species whose population trends, and the nature of the threatening processes, vary from region to region, and through time.

This paper presents the conceptual design and analysis of a system intended to increase the range, scientific capability, and safety of manned lunar surface exploration, requiring only a modest increase in capability over the Apollo mission designs. The system is intended to enable two astronauts, exploring with an unpressurized rover, to remove their space suits for an 8-h rest away from the lunar base and then conduct a second day of surface exploration before returning to base. This system is composed of an Environmental Control and Life Support System on the rover, an inflatable habitat, a solar shield and a solar power array. The proposed system doubles the distance reachable from the lunar base, thus increasing the area available for science and exploration by a factor of four. In addition to increasing mission capability, the proposed system also increases fault tolerance with an emergency inflatable structure and additional consumables to mitigate a wide range of suit or rover failures. The mass, volume, and power analyses of each subsystem are integrated to generate a total system mass of 124 kg and a volume of 594 L, both of which can be accommodated on the Apollo Lunar Roving Vehicle with minor improvements.

Documentation and dissemination of patient information characterizing a difficult airway encounter is a critical safety link between past, present, and future health care providers. Effective communication of the nature of the difficulty encountered and the airway management techniques used consists of documentation in the patient's medical record for concurrent care providers and dissemination of that information to the patient and future providers for use during subsequent episodes of care. Significant progress has been made with developing national and international electronic patient record systems and airway databases, but full integration has yet to be achieved.