Search

Postoperative day (POD) 1 laboratory tests are routinely ordered after bariatric operations.Determine how often these laboratory tests are abnormal and whether they represent value-added care.Academic medical center, United States.Patients undergoing bariatric operations for obesity and complications from prior bariatric surgery from 1 January 2011 to 12 December 2020 at a single institution were identified. Patients with POD 1 hemoglobin, potassium, creatinine, or glucose serum laboratory tests obtained before 08:00 on POD 1 were reviewed. Laboratory-specific exclusion criteria were applied. Abnormal laboratory test results were a hemoglobin8.0 g/dL or a hemoglobin drop of3.0 g/dL; a potassium3.5 mmol/L (hypokalemia), 5.5-5.9 mmol/L (mild hyperkalemia), or ≥ 6.0 mmol/L (severe hyperkalemia); a creatinine increase of 0.3 g/dL or 1.5X the preoperative value (acute kidney injury); and a glucose180 mg/dL (hyperglycemia). Intervention for abnormal hemoglobin, potassium, and glucose was also assessed.Of 2090 patients who underwent bariatric operations, 1969 met inclusion criteria for hemoglobin analysis, 1223 for potassium analysis, 1446 for creatinine analysis, and 563 for glucose analysis. Only 0.2% (n = 4) of patients had a hemoglobin8.0 g/dLand only 3.1% (n = 62) had a3.0 g/dL hemoglobin drop. Potassium was abnormal in 2.8% of patients (n = 34 total). An acute kidney injury was diagnosed in 1.8% (n = 26) of patients. Hyperglycemia was identified in 2.1% (n = 12) of patients. Of 5227 laboratory test values, only 1.5% were abnormal. Further, of laboratory tests analyzed for intervention (n = 3781), only 14 (0.4%) were actively acted upon.Routine POD 1 laboratory tests after bariatric operations seem to be a continuation of a surgical tradition rather than a clinically valuable tool. POD 1 laboratory tests should be ordered based on specific patient co-morbidities and clinical criteria.

This study aimed to compare the survival of patients with isolated inguinal lymph node metastases from rectal cancer to patients with inguinal and additional synchronous distant metastases from rectal cancer who treated with curative intent. A retrospective review of all consecutive adult patients with rectal adenocarcinoma and inguinal lymph node involvement who underwent curative therapy at our institution from 2002 to 2020 was conducted. Patients were classified as having synchronous inguinal lymph node metastasis (SILNM), or synchronous inguinal lymph node and distant organ metastasis (SILNDOM). Patients in the SILNM group had a median overall survival of 75 months compared to 17.6 months in the SILNDOM group;p-value = 0.09. The recurrence-free survival for patients with SILNM was 19.6 months compared to 2.4 months in the SILNDOM group;p-value = 0.053. In conclusion, SILNM appears to represent a distinct subgroup of patients with metastatic rectal cancer. These patients warrant consideration of treatment with curative intent. Further studies are needed.

BACKGROUND: No previous studies have validated current clinical practice guidelines for the management of non-blanching rashes in children who have received meningococcal B and C vaccinations. The aim of this study was to evaluate the performance of existing clinical practice guidelines in the diagnosis of invasive meningococcal disease in children presenting with a fever and non-blanching rash in the UK.METHODS: The Petechiae in Children (PiC) study was a prospective, multicentre cohort study involving children (aged FINDINGS: Between Nov 9, 2017, and June 30, 2019, 1513 patients were screened, of whom 1329 were eligible and were included in the analysis. The median age of patients was 24 months (IQR 12-48). 1137 (86%) of 1329 patients had a blood test and 596 (45%) received parenteral antibiotics. 19 (1%) patients had confirmed meningococcal disease. All eight clinical practice guidelines had a sensitivity of 1·00 (95% CI 0·82-1·00) for identifying meningococcal disease. The specificities of NICE guidelines CG102 (0·01 [95% CI 0·01-0·02]) and NG51 (0·00 [0·00-0·00]) for identifying meningococcal disease were significantly lower than that of tailored clinical practice guidelines (pINTERPRETATION: Invasive meningococcal disease is a rare cause of non-blanching rashes in children presenting to the emergency department in the UK. Current NICE guidelines perform poorly when compared with tailored clinical practice guidelines. These findings suggest that UK national guidance could be improved by shifting towards a tailored approach.FUNDING: Public Health Agency.

Purpose To determine if there is a role for routine pouchogram before ileostomy reversal after IPAA in pediatric patients. Methods The medical records of pediatric patients who underwent pouchogram between 2007 and 2017 prior to ileostomy reversal after IPAA at two affiliated hospitals were reviewed for concordance between exam under anesthesia (EUA) and pouchogram findings, management of abnormal pouchogram findings, and short and long-term outcomes after ileostomy reversal. Clinical notes were used to find patient-reported symptoms at the time of pouchogram. Results Sixty patients (57% female) underwent pouchogram before planned ileostomy reversal. The median time from IPAA formation to pouchogram was 60.5 days (IQR: 46–77) and median follow-up was 4 years (IQR: 1–6). Fifty-seven patients (95%) were asymptomatic prior to reversal. Of the 40 asymptomatic patients with a normal EUA, pouchogram detected one stricture (3%), but reversal proceeded as planned. In the 16 patients with strictures on EUA, pouchogram only detected six (40%). One of 50 (2%) asymptomatic patients with normal pouchogram had anastomotic dehiscence found on EUA. Despite normal pouchogram and EUA, four asymptomatic patients required subsequent diversion for pouch-related complications between 13 and 60 months after ileostomy reversal. Three patients had pelvic pain prior to pouchogram; associated symptoms included perineal pain (n = 1) hematochezia (n = 1), and tenesmus (n = 1). EUA and pouchogram were concordant in two patients (n = 1 anastomotic complication, n = 1 pouch septum) and ileostomy reversal was delayed. In the remaining symptomatic patient, pouchogram detected an anastomotic leak where EUA detected only a stricture, and this prompted a delay in reversal. Long term, none of these patients required diversion or excision of their pouch. Conclusion Routine pouchogram in asymptomatic pediatric patients does not change management and can be omitted, thereby sparing patients discomfort and unnecessary radiation exposure. Pouchogram may have diagnostic value in symptomatic patients. Level of Evidence III. Type of Study Study of Diagnostic Test.

Readmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a diverting ileostomy contributes to unplanned readmission after IPAA creation.Children (age18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed.Ninety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation. Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone.Readmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates.Level III.

Patients with ulcerative colitis and Crohn's disease often present to surgery malnourished and on combination immunosuppression. These factors affect operation selection and postoperative outcomes. Corticosteroids have a well-established detrimental effect on postoperative outcomes, whereas the impact of biologic agents is more controversial. In a patient exposed to these medications, and in the presence of other risk factors, temporary intestinal diversion is likely the best choice. Enteral nutrition may help optimize malnourished patients at high risk of adverse postoperative outcomes.

Objective\ud \ud Novice driver crash risk diminishes steeply over the first few months of driving. We explore the characteristics of driving over this period to identify behaviours that might underlie this change in risk.\ud \ud \ud \ud Methods\ud \ud We conducted a cross-sectional study of 1456 UK drivers aged 17–21 within six months of gaining their licence. We examined how various forms of driving exposure, such as weekly mileage and driving at night, were related to duration of licencing. We explored the factor structure of the Early Driving Development Questionnaire (EDD-Q); a new instrument designed to measure safety relevant attitudes and behaviours in recently qualified drivers. We examined the relationship of the derived factors to licence duration.\ud \ud \ud \ud Results\ud \ud There was little evidence that greater exposure to risky driving situations was more common in those with shorter licence durations. Exploratory and Confirmatory Factor Analyses identified EDD-Q factors measuring risky style (12 items), skill deficiencies (8 items) and driving confidence (4 items). Licence duration was positively correlated with both risky style and confidence, with these relationships stronger for older novices. Licence duration was also negatively related to skill deficiencies (i.e., positively correlated with perceived driving skill development): this relationship was stronger in younger novices.\ud \ud \ud \ud Conclusions\ud \ud The negative correlation between license duration and skill deficiencies is consistent with the observation of decreasing novice crash involvement as experience is gained. The EDD-Q offers a new brief measure of aberrant driving that is specifically tailored for newly qualified drivers.

Obesity is increasing in prevalence among patients with Crohn's disease, but how body mass index affects disease severity and postoperative outcomes remains unknown.A retrospective review of ileocolic resections for Crohn's disease performed at a single institution between January 2007 and December 2017 was conducted. On the day of surgery, patients were grouped by body mass index into underweight, normal weight, overweight, and obese categories. Intergroup comparisons and trend tests were performed on disease characteristics and postoperative outcomes. A multivariable model for superficial surgical site infection was constructed.A total of 758 patients were identified; 80 (11%) patients were underweight, 372 (49%) were normal weight, 178 (23%) were overweight, and 128 (17%) were obese. Both fistulizing Crohn's phenotype and preoperative immunosuppression occurred less frequently in obese patients compared with other body mass index groups (both P0.01). Conversion to open surgery and superficial surgical site infection were increased in obese patients, and obesity was an independent risk factor for superficial surgical site infection on multivariable analysis (odds ratio 3.0, 95% confidence interval: 1.6-5.6).Although obese patients had less severe Crohn's disease at the time of surgery, they experienced increased postoperative infectious complications. Preoperative weight loss and consideration of alternative wound closure methods may reduce these complications.

Limited knowledge exists as to what impact preoperative biologic therapy has on postoperative complications in pediatric patients undergoing abdominal surgery for Crohn's disease (CD). Therefore, we sought to determine the 30-day postoperative infectious complication rate among pediatric CD patients who received biologic therapy within 12 weeks of an abdominal operation.A retrospective chart review was performed on pediatric (18 years of age) CD patients who underwent an abdominal operation between 1/1/2008 and 12/31/2017. Patients were grouped according to whether they received an anti-TNF (infliximab, adalimumab, certolizumab pegol) or no biologic therapy within 12 weeks prior to the operation. The primary outcome was the overall 30-day postoperative infectious complication rate. Secondary outcomes included 30-day readmission rate and return to the operating room (ROR).A total of 69 pediatric CD patients met inclusion criteria (n = 54 anti-TNF therapy, n = 15 received no biologic therapy). There were no differences between the anti-TNF and no biologic cohorts with respect to demographics or CD characteristics. No significant differences in overall 30-day postoperative infectious complications existed between patients exposed to anti-TNF agents and those with no preoperative exposure, or in its subcategories of surgical infectious complications and nonsurgical infectious complications. There was also no difference in the rate of ileus, readmission, or ROR.Preoperative exposure to anti-TNF biologic therapy does not add to overall or infectious 30-day postoperative morbidity in pediatric CD patients.III.Retrospective review.

The application of controlled fire on post-mine rehabilitation is currently underutilised as an ecological tool throughout fire prone landscapes such as eastern Australia. Despite widely accepted benefits of fuel management and ecological outcomes, mined land managers are generally reluctant to incorporate fire regimes on rehabilitated lands. We applied an experimental fire to 117 ha of 19- to 21-year-old coal mine rehabilitation in sub-tropical, semi-arid Central Queensland, Australia, and assessed the vegetation changes in five successive assessments for the two years following the burn. Vegetation metrics all showed trajectories towards pre-fire levels, or recovered to surpass pre-fire levels. Within two years of the burn, native species richness was significantly higher than pre-fire levels for both grassland and open woodland areas and vegetation cover had returned to pre-fire levels. Woody plant density (

The developmental increase in reported violations at the same time that the accident rate is decreasing (paradoxical violation effect) was investigated. Two explanations of the increase in violations were considered, one involving an increase in normative pressure to violate and the other a release of the tendency to violate. While there was no definitive evidence in favour of the normative pressure hypothesis there was evidence consistent with the release hypothesis. Two general explanations of the paradoxical violation effect were examined. The critical period hypothesis proposes that early in development new drivers are particularly sensitive to violations while the second hypothesis proposes that there is an independent factor that operates early in development to increase accidents but diminishes later. Specific instantiations of these hypotheses were examined. At the general level the two hypotheses make opposing predictions concerning the relationship between violations and accident involvement, with the critical period hypothesis predicting a developmental decrease in the correlation between violations and accident involvement and the independent factor hypothesis predicting a developmental increase in the correlation between violations and accident involvement. A developmental decrease in the correlation between violations and accident involvement was found supporting the critical period hypothesis.

Purpose The purpose of this study was to determine if a laparoscopic approach reduces complications and length of stay (LOS) after total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) in pediatric patients using a multicenter prospective database. Methods The American College of Surgeons National Surgical Quality Improvement Project Pediatric database from 2012 to 2015 was used to identify patients with a diagnosis of chronic ulcerative colitis (CUC) or familial adenomatous polyposis (FAP) undergoing TPC-IPAA. Major complications, minor complications, and prolonged LOS were compared based on laparoscopic versus open approach. Results 195 (108 female) patients underwent TPC-IPAA at a median age of 14 years (IQR: 11–16) for CUC (N = 99) or FAP (N = 96). Two-thirds of cases were laparoscopic. A laparoscopic approach was not associated with major complications, but lower odds of minor complications were observed. A reduced LOS was seen in laparoscopic versus open surgery (median LOS 6 vs 8 days, p 9 days) in the FAP cohort (OR 4.0, 95% CI 1.1–14.0). Conclusion A laparoscopic approach was not associated with increased major complications but was associated with lower odds of minor complications and shorter LOS. The laparoscopic approach should continue to be preferred for pouch procedures in pediatric patients. Type of study Treatment; retrospective study. Level of evidence Level III.

Amici take no position on whether BOOKING.COM is generic, but write to encourage the Court to be cautious in resolving this case, which involves a generic term combined with a common top-level domain name identifier (.com). Trademark applications raise almost infinitely varied scenarios, including generic terms combined with other elements, and the top-level domain name identifier has some specific features that make it analogous to functional matter. Whatever rule the Court adopts should be highly attentive to the risks to competition of overassertion of registered marks that are largely or entirely comprised of generic elements. Because courts deciding infringement cases are often unfamiliar with the context of a trademark registration, they may miss limitations on the scope of the registered mark that the Trademark Office believed existed and, as a result, enforce broader rights than the registrants should actually have. Ordinary businesses receiving cease and desist letters are even more unlikely to have the expertise to understand the limits on a registration. This practical reality should guide the Court’s standards for registrations with generic components. Relatedly, the Court should reaffirm the basic principle that “de facto secondary meaning” does not give rise to protectability as a trademark. Courts have long distinguished between “de facto secondary meaning” and secondary meaning “to which courts will attach legal consequences.” De facto secondary meaning refers to an association between a generic term and a particular producer that is usually the result of an extended period of market dominance, whether achieved through advertising or through lack of competition. Because of the need to protect potential and future competition, a generic term cannot be appropriated as a trademark even if it has de facto secondary meaning The practical exclusivity afforded by domain name registration means that there may often be de facto secondary meaning in domain names, which can be difficult to distinguish from true trademark secondary meaning. This easily elided distinction affects how the Court should evaluate Booking.com’s survey, which purports to show secondary meaning. But the fact that de facto secondary meaning does not lead to trademark status does not mean it is irrelevant to the law. Even when a term is not protectable as a trademark, narrower unfair competition remedies may be available to prevent true passing off. When a term is generic or a product shape is functional, neither can be protected as a trademark and others may not be enjoined from competing using the term or shape.. Those competitors, however, may be required to distinguish themselves in the market by adding identifiers or otherwise differentiating their use, if the competitors’ use might deceive consumers. Thus, a rule that strongly protects competition by denying registration to generic terms does not leave consumers exposed to clever bad actors.

Insulin-secreting pancreatic β-cells are electrically excitable cells that are unusual because their electrical activity is influenced directly by metabolism via ATP-sensitive K+ channels. At the same time, changes in the intracellular Ca2+concentration that result from the cell's electrical activity influence metabolism in several ways. Thus, there is bidirectional coupling between the electrical dynamics and the metabolic dynamics in β-cells. A mathematical model has been previously developed, called the Integrated. Oscillator Model (IOM), to highlight the bidirectional coupling involved in the oscillation mechanism. In this study, we show how this coupling can produce oscillations in β-cell activity. These oscillations have period similar to that of insulin secretion pulses observed in rats, mice, dogs, and humans, which has been shown to facilitate the action of the liver in maintaining glucose homeostasis. In a companion paper we show that the IOM can produce oscillations using two distinct mechanisms, depending on the values of electrical and metabolic parameters. In the present article, we use fast-slow analysis to understand the mechanisms underlying each of these oscillations. In particular, we show why a key variable in the glycolytic pathway generates a pulsatile time course in one type of oscillation, while it generates a sawtooth time course in the other type. The significance of these patterns is that the time course is a reflection of whether an intrinsic glycolytic oscillator is active, or whether the oscillations are a direct consequence of Ca2+ feedback onto glycolysis.

The purpose of this study was to identify preventable reasons for readmission and to delineate risk factors for readmission in the perioperative period for patients with chronic ulcerative colitis undergoing ileal pouch-anal anastomosis (IPAA).Patients with a diagnosis of chronic ulcerative colitis undergoing either total proctocolectomy with IPAA or proctectomy with IPAA were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2012-2015. Unplanned 30-d readmissions were reviewed and categorized by reason for readmission. The unplanned readmission rate within 30 d was calculated by the person-days method. Multivariable Cox proportional hazard regression models determined independent risk factors for overall 30-d unplanned readmissions and readmissions sorted by primary readmission diagnosis.Three thousand four hundred one patients had an IPAA performed during the study period. The overall unplanned readmission rate was 32.9% per 30 person-days. Leading diagnoses for unplanned readmission included infectious complications, dehydration, and venous thromboembolism (VTE). Multivariable analysis found Hispanic white and black/African American race/ethnicity (both versus non-Hispanic white) to be independently associated with unplanned 30-d readmission. Obesity, operative time 330+ min (versus189 min), and Hispanic white race/ethnicity (versus non-Hispanic white) were associated with readmission for infectious complications. Age 57+ y (versus age 18-32 y) and hypertension requiring medication were associated with readmission for dehydration. Total proctocolectomy with IPAA (versus proctectomy with IPAA) was associated with readmission for VTE.One-third of patients undergoing IPAA experience an unplanned 30-d readmission. Infectious complications and dehydration account for most of the unplanned readmissions. Outpatient pathways to prevent dehydration and the use of extended VTE prophylaxis after two-stage IPAA may help reduce the rates of readmission following IPAA.

Summary Background & aims Patients with Type 3 Intestinal Failure (IF) who need Home Parenteral Nutrition (HPN) face several clinical, psychological and social problems. The study was designed to produce and test the first patient-centric measure for HPN (‘PNIQ: Parenteral Nutrition Impact Questionnaire’). The new measure focused on the extent to which patients were able to fulfil their human needs. Methods Questionnaire content was derived from the analysis of transcripts of interviews conducted with UK HPN patients. Cognitive debriefing interviews (CDIs) were performed to ensure patients found the draft scale clear, relevant and accessible. Finally, a test–-retest postal validation survey was conducted to reduce the number of items in the scale and to ensure that; it was unidimensional, reproducible and had construct validity. Results The 30 interview transcripts were analysed to identify issues related to a wide range of needs. Fifteen CDIs showed that patients found the draft scale easy to complete and highly relevant. The postal survey included 233 patients on HPN recruited through two IF units. Items were rejected if they did not fit the Rasch model, had too similar content to other items or displayed differential item functioning related to age, gender or underlying mechanism of IF. A 20-item unidimensional scale was identified with high internal consistency (0.91) and test–retest reliability (0.92). Scores on PNIQ correlated moderately highly with social isolation, emotional reactions and energy level and were related to perceived interference on life of HPN. The underlying cause of IF did not influence the way the scale worked. Conclusions The PNIQ is a scientifically rigorous, unidimensional outcome measure that provides a complete assessment of the effect of HPN on everyday life. It will prove useful for measuring patient value in clinical practice and for determining outcome in clinical trials, audit, economic evaluations and outcomes-based reimbursement.

It is well known that the tendency to violate is associated with accident involvement. What is paradoxical is that across the early development of driving, violations are increasing at the same time that accident liability is decreasing. It is hypothesised that at the early stage of driving low levels of confidence suppress the tendency to violate. As confidence is increased over time the tendency to violate is gradually released. Consistent with this hypothesis an analysis of several thousand new drivers found that as confidence increased so also did the tendency to violate. Implications for testing and training are considered.

The BepiColombo (BC) Mission which will be launched in 2018, will include during its Cruise Phase two flybys of Venus and five Mercury flybys. It will then enter a one Earth year orbit about Mercury (with a possible one-year extension) during which two spacecraft, one provided by ESA (MPO) and one provided by JAXA (MMO), will perform both autonomous and coordinated observations of the Hermean environment at various separations. The measurements will take place during the minimum of solar cycle 24 and the rise of solar cycle 25. At the start of the minimum of solar cycle 23, four major flares, each associated with the production of MeV particle radiation and CME activity occurred. Predictions of the HAFv.2 model of the arrival of particle radiation and a travelling shock at Venus on 6 December 2006 were verified by in-situ measurements made aboard Venus Express (VEX) by the ASPERA 4 instrument. Interplanetary scintillation observations, as well as the ENLIL 3-D MHD model when employed separately or in combination, enable the making of predictions of the solar wind density and speed at various locations in the inner heliosphere. Both methods, which outdate HAFv.2, are utilized in the present paper to predict (retrospectively) the arrival of the flare related, interplanetary propagating shock recorded at Venus on 6 December 2006 aboard VEX with a view to putting in place the facility to make very reliable space weather predictions for BC during both its Cruise Phase and when in the Hermean environment itself. The successful matching of the December 2006 predictions with in-situ signatures recorded aboard Venus Express provide confidence that the predictive methodology to be adopted will be appropriate to provide space weather predictions for BepiColombo during its Venus flybys and throughout the mission.

Thermal energy storage coupled with phase change materials is a technology that offers the potential to shift and in some case reduce building cooling loads and increase energy efficiency. This simulation study uses a TRNSYS building and HVAC system model to investigate whether partially charging and discharging a phase change material thermal energy storage tank can improve the operational characteristics required by a light-weight commercial building located in a Mediterranean climate. The results indicate that partial charging and discharging can lead to better energy performance of the phase change material thermal energy storage HVAC system. If the phase change material thermal energy storage tank is not required to operate at maximum capacity (i.e., maximum charge), energy savings are possible by only partially charging the tank. Further energy efficiency gains are also possible by control of the heat transfer fluid flow rates in the HVAC thermal energy storage system loops. Generally, higher charging loop flow rates and lower discharge loop flow rates produce better energy performance. Charging a phase change material thermal energy storage tank above 90% is not recommended, as at very high charge fractions, the energy performance decreases considerably, while the charging time increases significantly.

Resumen Introduccion y objetivos El cuestionario CAMPHOR (Cambridge Pulmonary Hypertension Outcome Review) es un instrumento de calidad de vida relacionado con esta y la salud informado por el paciente y especifico para pacientes con hipertension pulmonar (HP). En esta area, el CAMPHOR se ha demostrado superior a otros instrumentos que evaluan aspectos similares. El objetivo del presente estudio es adaptar y validar la version espanola del CAMPHOR. Metodos La adaptacion consistio en 3 etapas: traduccion del ingles al espanol por medio de paneles bilingues y laicos, cognitive debriefing con los pacientes y la evaluacion de las propiedades psicometricas por medio de una encuesta postal de validacion. Resultados Los paneles de traduccion produjeron una version del CAMPHOR adecuada para que la utilicen pacientes con HP espanoles. La relevancia, la exhaustividad y la aceptabilidad de esta version se confirmaron en entrevistas con pacientes con HP. Por ultimo, el estudio de validacion (n = 70) revelo que las 3 escalas CAMPHOR (sintomas, actividades y calidad de vida) muestran fuertes propiedades psicometricas. Los coeficientes de consistencia interna (alfa de Cronbach) de las escalas estuvieron por encima de 0,89 y la fiabilidad test-retest, por encima de 0,87. La validez convergente y de grupos conocidos de las escalas CAMPHOR tambien se confirmaron. Conclusiones La version espanola del CAMPHOR es un instrumento valido y fiable para la evaluacion de la calidad de vida relacionada con la salud y la calidad de vida de los pacientes con HP espanoles. Por lo tanto, se recomienda su uso en futuros estudios y la practica clinica en la poblacion espanola de pacientes con HP.

Introduction and objectives The Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) is a patient-reported outcome measure of health-related quality of life and quality of life specific to individuals with pulmonary hypertension (PH). This questionnaire has demonstrated superiority over other instruments assessing similar domains. The objective of the present study was to adapt and validate the Spanish version of the questionnaire. Methods The adaptation consisted of 3 stages: translation from English to Spanish using bilingual and lay panels, cognitive debriefing interviews with patients, and assessment of psychometric properties by means of a postal validation survey. Results The translation panels produced a version of the CAMPHOR that was considered suitable for use by Spanish PH patients. The relevance, comprehensiveness, and acceptability of this version were confirmed in interviews with PH patients. Finally, the validation survey (n = 70) revealed that the 3 CAMPHOR scales (Symptoms, Activities, and Quality of life) showed strong psychometric properties. The internal consistency (Cronbach α) coefficients of the scales were above 0.89, and the test-retest reliability was above 0.87. The convergent and known group validity of the CAMPHOR scales was also demonstrated. Conclusions The Spanish version of the CAMPHOR is a valid and reliable instrument for the assessment of health-related quality of life and quality of life in Spanish PH patients. Therefore, it is recommended for use in future research and clinical practice in the Spanish population of PH patients.

Rehabilitated lands created by open-cut coal mines are generally protected by land managers from fire and grazing disturbances. This practice is employed to reduce negative impacts, such as erosion, on the developing ecosystems. However, fire exclusion over long periods inadvertently contributes to increased fire risk on rehabilitated landforms, particularly when high biomass, mono-dominant grasses form a major component of these new ecosystems. In May 2015, an experimental fire burnt 117 ha of rehabilitation at a coal mine site in the Bowen Basin, Australia. Standing grass fuel loads, dominated by buffel grass (Cenchrus ciliaris L.), were up to 9.3 t/ha in grassland areas and 5.3 t/ha in areas of open woodland. Average litter fuel loads were 2.4 and 3.6 t/ha for grassland and open woodland, respectively. Calculated fire intensity was higher in grassland (4612 ± 502 kW m−1) than open woodland areas (1977 ± 804 kW m−1) indicating that rehabilitated landforms dominated by buffel grass may represent a higher fire risk to mine sites and regional areas in the Bowen Basin when compared to the original vegetation. Fire behaviour reflected the varying underlying terrain, fuel loads and surface soil or overburden conditions. Further research is recommended to investigate fire behaviour in buffel grasslands across a range of fuel load and curing conditions, with the aim to develop an invasive grass fire spread model that can be used inform both landscape reconstruction prescriptions for ecological engineers and more broadly in managing the fire risk across landscapes dominated by these vegetation types.

Objective To determine factors associated with increased research productivity, satisfaction, and perceived barriers to research within residency from the experience of pediatric chief residents. Methods An online cross-sectional survey was administered to academic year 2014–15 chief residents. Topics assessed included program demographic characteristics, career intentions, research productivity, satisfaction with research training and opportunities, and research barriers. Chi-square and Fisher exact tests were used for descriptive statistics. Multivariable logistic regression analysis was used to determine factors associated with productivity and research satisfaction. Results The response rate was 63% (165 of 261). Half (82 of 165) were productive in research. Most were satisfied with their quality of research training (55%; 90 of 165) and research opportunities (69%; 114 of 165). Chiefs reporting interest in research were 5 times more likely to be productive than those who did not (odds ratio [OR] = 5.2; 95% confidence interval [CI], 2.3–11.8). Productive chiefs were more likely to report including research time in future careers ( P = .003). Most (83%; 137 of 165) thought their programs were supportive of resident research, but lack of time was frequently cited as a major barrier. Those satisfied with research opportunities were less likely to find lack of training (OR = 0.3; 95% CI, 0.1–0.7) or faculty mentorship (OR = 0.2; 95% CI, 0.0–0.9) as a major barrier. Conclusions Pediatric chief resident interest in research is strongly associated with research productivity during residency, and research productivity is strongly associated with career plans including research time. By cultivating research interest through faculty mentorship, research training, and dedicated time, pediatric residency programs might help foster early research success and, potentially lead to continued engagement with research in trainees' future careers.

This Chapter address the topic of trademark dilution — the additional protection granted to famous trademarks under United States (U.S.) law. In particular it considers whether either form of dilution (dilution by blurring or by tarnishment) is an unconstitutional restriction on speech in light of recent U.S. Supreme Court caselaw. I argue that dilution by tarnishment is likely unconstitutional under now-prevailing law, and that there’s at least a plausible argument that dilution by blurring is unconstitutional as well. I do not necessarily predict that courts will hold either form of dilution unconstitutional. But to avoid that conclusion, courts will have to develop distinctions that are not now apparent in the law.

Mongolia is an example of a nation where the rapidity of mining development is outpacing capacity to manage the potential land and water resources impacts. Further, Mongolia has a particular social and economic reliance on traditional uses of land and water, principally livestock herding. While some mining operations are setting high standards in protecting the natural resources surrounding the mine site, others have less incentive and capacity to do so and therefore are having adverse effects on surrounding communities. The paper describes a case study of the Sharyn Gol Soum in northern Mongolia where a range of mining types, from artisanal, small-scale mining to a large coal mine, operate alongside traditional herding lifestyles. A multi-disciplinary approach is taken to observe and attribute causes to the water resources impacts in the area. Surveys of the herding household community, land use mapping, and monitoring the spatial variations in water quality indicate deterioration of water resources. Collectively, the different sources of evidence suggest that the deterioration is mainly due to small-scale gold mining. The evidence included the perception of 78% of the interviewed herders that water quality had changed due to mining; a change in the footprint of small-scale gold mining from 2.8 to 15.2 km2 during the period 1999 to 2015; and pH and sulphate values in 2015 consistently outside the ranges observed at a baseline site in the same region. It is concluded that the lack of baseline data and effective governance mechanisms are fundamental challenges that need to be addressed if Mongolia's transition to a mining economy is to be managed alongside sustainability of herder lifestyles.

Pancreatic islets respond to elevated blood glucose by secreting pulses of insulin that parallel oscillations in β-cell metabolism, intracellular Ca(2+) concentration, and bursting electrical activity. The mechanisms that maintain an oscillatory response are not fully understood, yet several models have been proposed. Only some can account for experiments supporting that metabolism is intrinsically oscillatory in β-cells. The dual oscillator model (DOM) implicates glycolysis as the source of oscillatory metabolism. In the companion article, we use recently developed biosensors to confirm that glycolysis is oscillatory and further elucidate the coordination of metabolic and electrical signals in the insulin secretory pathway. In this report, we modify the DOM by incorporating an established link between metabolism and intracellular Ca(2+) to reconcile model predictions with experimental observations from the companion article. With modification, we maintain the distinguishing feature of the DOM, oscillatory glycolysis, but introduce the ability of Ca(2+) influx to reshape glycolytic oscillations by promoting glycolytic efflux. We use the modified model to explain measurements from the companion article and from previously published experiments with islets.

Display Omitted HighlightsWe construct and optimize TiN(111)/HfO2(001) and Pt(111)/HfO2(001) interfaces.We calculate free energies of the interfaces with varying oxygen terminations.The band offsets of the stable terminations were calculated with the HSE functional.We show that O atoms are unlikely to incorporate into both TiN and Pt from HfO2.Interfacial O atoms may incorporate in N vacancies in TiN from HfO2. The behavior of oxygen atoms and vacancies at interfaces between hafnia (HfO2) and gate electrodes, titanium nitride (TiN) and Pt, has been studied using density functional theory (DFT). Interface models were developed and the band offsets calculated. In both metals, the incorporation of oxygen atoms from the oxide into the metallic layer was energetically unfavorable, except in the case of interfacial oxygen moving into a N vacancy in TiN.

This brief essay reviews some of the most significant developments in trademark law during the past year. In most cases we have interpreted “year” fairly liberally, particularly to highlight some longer-term trends. We focus on six areas: (1) the constitutionality of § 2(a) of the Lanham Act; (2) the Fourth Circuit’s Belmora decision and the availability of § 43(a) claims when the plaintiff has not used a mark in the United States; (3) the effect of BB (4) injunctive relief and the presumption of irreparable harm; (5) nominative fair use; and (6) initial interest confusion.

Objective The living with chronic obstructive pulmonary disease (LCOPD) scale was developed in the United Kingdom and the United States to assess the quality of life (QoL) of people with chronic obstructive pulmonary disease. The scale was shown to be well accepted by patients, to be unidimensional, and to have very good psychometric properties. This article reports on the adaptation of the measure for use in representative Southern European (Italian and Spanish) and Eastern European (Russian) languages. Study Design and Setting The same methodology was used in each country: translation panels were held to produce new language versions. These were then tested with patients to ensure face and content validity. Finally, test–retest postal surveys were conducted to establish internal consistency, reproducibility, and construct validity. Results Few problems were found in translating the LCOPD, and patient interviews indicated that the measure was considered relevant and easy to complete. The validation surveys showed that the new versions of the LCOPD were consistent, reproducible, and had good construct validity. The psychometric properties of the new versions were similar to those found for the original U.K. and U.S. versions. Conclusion The study was successful in adapting the LCOPD for use in Southern and Eastern European languages.

On July 10, 2010, the ROSETTA spacecraft performed a flyby at asteroid (21)Lutetia at a solar distance of 2.72 AU. The spacecraft–asteroid distance at closest approach was 3120 km. The magnetometers onboard ROSETTA were operating but did not detect any conclusive signature of the asteroid. Any magnetic field signature which could possibly be attributed to the asteroid was below 1 nT. Consequently an upper limit for the global magnetic properties of asteroid (21)Lutetia could be derived: maximum dipole moment ≤ 1.0 × 10 12 A m 2 , global maximum magnetization ≤ 2.1 × 10 − 3 A / m , specific moment ≤ 5.9 × 10 − 7 A m 2 / kg . Draping of magnetic fields around the nucleus was sought, but evidence for this could not be clearly identified in the data. Plasma simulations taking into account the estimated upper limit of the magnetization and possible outgassing revealed interesting structures very close to the asteroid. The results obtained at Lutetia are contrasted with the results of other asteroid flyby results.

The Dermatology Life Quality Index (DLQI) is a widely used health-related quality of life measure. However, little research has been conducted on its dimensionality. The objectives of the current study were to apply Rasch analysis to DLQI data to determine whether the scale is unidimensional, to assess its measurement properties, test the response format, and determine whether the measure exhibits differential item functioning (DIF) by disease (atopic dermatitis versus psoriasis), gender, or age group. The results show that there were several problems with the scale, including misfitting items, DIF by disease, age, and gender, disordered response thresholds, and inadequate measurement of patients with mild illness. As the DLQI did not benefit from the application of Rasch analysis in its development, it is argued that a new measure of disability related to dermatological disease is required. Such a measure should use a coherent measurement model and ensure that items are relevant to all potential respondents. The current use of the DLQI as a guide to treatment selection is of concern, given its inadequate measurement properties.

Haemic neoplasia (HN) is a leukemia-like disease that affects at least 20 species of marine bivalves including soft shell clam, Mya arenaria. Since the disease was discovered in 1969, the etiology remains unknown. A retroviral etiology has been suggested based on the detection of reverse transcriptase activity and electron microscopic observation of retroviral-like particles using negative staining. To date, however no virus isolate and no retroviral sequence from HN has been obtained. Moreover, transmission of the disease by cell-free filtrate from affected clams has not been reproduced. In the current study, we reinvestigated the association of HN with a putative retrovirus. Sucrose gradient centrifugation followed by assessment of reverse transcriptase activity, electrophoretic analysis of protein and RNA, and electron microscopic examinations of fractions corresponding to retroviral density were employed. Detection of retroviral pol sequences using degenerate RT-PCR approaches was also attempted. Our results showed visible bands at the expected density of retrovirus in HN-positive and HN-negative clam tissues and both with reverse transcriptase activity. Electron microscopy, RNA analysis, protein analysis, and PCR systems targeting the pol gene of retroviruses did not however provide clear evidence supporting presence of a retrovirus. We point out that the retrovirus etiology of HN of Mya arenaria proposed some 25 years ago should be reconsidered in the absence of a virus isolate or virus sequences.

In this work, we combine conductive atomic force microscopy (CAFM) and first principles calculations to investigate leakage current in thin polycrystalline HfO"2 films. A clear correlation between the presence of grain boundaries and increased leakage current through the film is demonstrated. The effect is a result of a number of related factors, including local reduction in the oxide film thickness near grain boundaries, the intrinsic electronic properties of grain boundaries which enhance direct tunnelling relative to the bulk, and segregation of oxygen vacancy defects which increase trap assisted tunnelling currents. These results highlight the important role of grain boundaries in determining the electrical properties of polycrystalline HfO"2 films with relevance to applications in advanced logic and memory devices.

Metodos La version inglesa del RAQoL fue traducida al espanol por un panel bilingue. Un segundo panel de individuos reviso y adapto el fraseo de las preguntas al espanol cotidiano. Se realizaron entrevistas a 15 pacientes con artritis reumatoide (AR) para evaluar la validez de aspecto y contenido. El cuestionario fue aplicado en 2 ocasiones a 57 pacientes con AR para evaluar su reproducibilidad y validez de constructo. Resultados Se encontraron pocas dificultades en las etapas de traduccion y adaptacion del cuestionario. Las versiones preliminar y final fueron bien recibidas por el panel de referencia y por los pacientes entrevistados respectivamente. Un total de 57 pacientes participaron en la evaluacion del instrumento final (73,8% mujeres, edad promedio 52,4 anos, DE 14,1, duracion de la AR de 2�27 anos). El a de Cronbach para el RAQoL en espanol de Mexico fue de 0,91 y la fiabilidad aplicacion-reaplicacion de 0,92, lo que sugiere que el cuestionario muestra interrelacion homogenea entre sus componentes y que tiene niveles bajos de errores aleatorios de medicion. El RAQoL en espanol de Mexico pudo discernir a pacientes que difirieron en relacion a la percepcion de la severidad de su enfermedad, estado general de salud, calificacion de su enfermedad el mismo dia y si cursaban o no con una recaida al momento de la evaluacion. Conclusiones El RAQoL en espanol de Mexico fue bien recibido por pacientes con AR. La calidad del cuestionario adaptado lo muestra como un instrumento util para ensayos clinicos de pacientes con AR.

Objective To develop and validate the Mexican-Spanish version of the Rheumatoid Arthritis Quality of Life questionnaire (RAQoL). Methods The original UK English version of RAQoL was translated into Mexican-Spanish version by a bilingual translation panel. An independent lay panel reviewed the instrument's item phrasing to ensure comprehensiveness and appropriateness in colloquial Mexican-Spanish. Structured cognitive debriefing interviews were conducted with 15 Rheumatoid Arthritis (RA) patients to assess face and content validity. Finally, an independent sample of RA patients completed the RAQoL and additional assessments were performed to assess reproducibility and construct validity. Results Translation and adaptation was successful as both the lay panel and cognitive debriefing participants considered the new language version to be appropriate. Fifty-seven patients were included in the final evaluation of the Mexican-Spanish version of RAQoL (73.8% female, mean age 52.4 years, SD 14.1, RA duration range 2–27 years). Cronbach's αfor the new RAQoL was 0.91 and the test-retest reliability 0.92, indicating that the measure has good internal consistency and low random measurement error. The Mexican-Spanish version of RAQoL could discriminate between patients who differed on their perception of disease activity, general health status, current rating of perceived RA severity and whether or not they were experiencing a disease flare. Conclusions The Mexican-Spanish version of RAQoL was well accepted by RA patients. The psychometric quality of the adapted questionnaire shows that it is suitable for use in clinical studies and trials of patients with RA.

Background: The Patient-Reported Indices for Multiple Sclerosis (PRIMUS) comprises a suite of three scales for assessing symptoms, activity limitations, and quality of life in multiple sclerosis (MS). It was developed in the UK and has been shown to have excellent psychometric properties. This study describes the adaptation of eight language versions for Canadian English, Canadian French, French, German, Italian, Spanish, Swedish, and US English. Methods: The PRIMUS was translated using the dual-panel process. Cognitive debriefing interviews conducted with MS patients assessed face and content validity. Psychometric and scaling properties were assessed via a two-administration postal survey conducted in each country involving the PRIMUS, the Nottingham Health Profile (NHP), the Unidimensional Fatigue Impact Scale (U-FIS), and demographic questions. Results: Cognitive debriefing interviews demonstrated the acceptability of the new language versions. Analysis of survey data showed that the new language versions of the three PRIMUS scales were unidimensional (as indicated by fit to the Rasch model) and that they had good internal consistency and reproducibility. PRIMUS scale scores correlated as expected with those on the NHP and the U-FIS. The scales in all countries were able to discriminate between groups of patients on the basis of their self-reported MS severity, general health, and employment status. Conclusions: The PRIMUS was successfully adapted into eight new languages. Most of the tests showed the PRIMUS to have good unidimensionality and to have good internal consistency, reproducibility, and construct validity. The measure is now available for use in clinical studies and trials involving these countries and the UK. Further work is required to assess the measure's responsiveness.

Summary Background & aims Home parenteral nutrition (HPN) provides life sustaining treatment for people with chronic intestinal failure. Individuals may require HPN for months or years and are dependent on regular intravenous infusions, usually 12–14 h overnight between 1 and 7 days each week. This regime can have adverse impact on the life of people dependent on the treatment. The aim of this study was to establish mean values for the Parenteral Nutrition Impact Questionnaire (PNIQ) and to determine the effect of disease, frequency of infusions per week and patient characteristics on quality of life of patients fed HPN. Method The PNIQ was distributed to patients across nine UK HPN clinics. Data were analysed using linear regression, with PNIQ score as the dependent variable and potential confounders as independent variables. Unadjusted and adjusted models are presented. Higher PNIQ scores reflect poorer quality of life. Results Completed questionnaires were received from 466 people dependent on HPN. Mean PNIQ score was 11.04 (SD 5.79). A higher PNIQ score (effect size 0.52, CI 0.184 to 0.853) was recorded in those dependent on a higher frequency of HPN infusions per week. Respondents with cancer had a similar mean PNIQ score to those with inflammatory bowel disease (mean 10.82, SD 6.00 versus 11.04, SD 5.91). Those with surgical complications reported a poorer QoL (effect size 3.03, CI 0.642 to 5.418) and those with severe gastro-intestinal dysmotility reported a better QoL (effect size −3.03, CI −5.593 to −0.468), compared to other disease states. Conclusions This large cohort study of quality of life in chronic intestinal failure demonstrates that HPN impacts individuals differently depending on their underlying disease. Furthermore, since the number of HPN infusions required per week is inversely related to an individual's needs-based quality of life, therapies that reduce PN burden should lead to an improvement in QoL.