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For the long-term dynamic simulation of a fluidized bed reactor (FBR), a two-way coupled computational fluid dynamics (CFD)-direct quadrature method of moments (DQMOM) approach is proposed. In this approach, CFD is first used only for hydrodynamic information without simulating any other chemical reactions or physical phenomena. Subsequently, the derived information is applied to the DQMOM calculation in MATLAB. From the calculation, a particle size distribution is obtained and subsequently adopted in a new CFD model to reflect the flow change caused by a change in the particle size distribution. Through several iterative calculations, long-term dynamic simulations are performed. To evaluate the efficacy of the proposed approach, the results from the suggested approach are compared for 60 s with those of the CFD-quadrature method of moments (QMOM) approach, which calculates hydrodynamics and physical phenomena simultaneously in CFD. The proposed approach successfully simulated the FBR for 6 h. The results confirmed that the proposed method can simulate complex flow patterns, which cannot be obtained in conventional CFD models. Another advantage of the approach is that it can be applied to various industrial multiphase reactors without any tuning parameters.

Gait, the style of human walking, has been studied as a behavioral characteristic of an individual. Several studies have utilized gait to identify individuals with the aid of machine learning and computer vision techniques. However, there is a lack of studies on the nature of gait, such as the identification power or the uniqueness. This study aims to quantify the uniqueness of gait in a cohort. Three-dimensional full-body joint kinematics were obtained during normal walking trials from 488 subjects using a motion capture system. The joint angles of the gait cycle were converted into gait vectors. Four gait vectors were obtained from each subject, and all the gait vectors were pooled together. Two gait vectors were randomly selected from the pool and tested if they could be accurately classified if they were from the same person or not. The gait from the cohort was classified with an accuracy of 99.71% using the support vector machine with a radial basis function kernel as a classifier. Gait of a person is as unique as his/her facial motion and finger impedance, but not as unique as fingerprints.

Scrambler therapy is a noninvasive electroanalgesia technique designed to remodulate the pain system. Despite growing evidence of its efficacy in patients with neuropathic pain, little is known about the clinical factors associated with treatment outcome. We conducted a prospective, open-label, single-arm trial to assess the efficacy and safety of scrambler therapy in patients with chronic neuropathic pain of various etiologies. A post-hoc analysis was performed to investigate whether cluster analysis of the Neuropathic Pain Symptom Inventory (NPSI) profiles could identify a subgroup of patients regarding neuropathic pain phenotype and treatment outcome. Scrambler therapy resulted in a significant decrease in the pain numerical rating scale (NRS) score over 2 weeks of treatment (least squares mean of percentage change from baseline, − 15%; 95% CI − 28% to − 2.4%; p

Background This study was performed to investigate leg length discrepancy (LLD), overgrowth, and associated risk factors after pediatric tibial shaft fractures. Materials and methods This study included 103 patients younger than 14 years of age (mean age 7.1 years; 75 boys, 28 girls) with unilateral tibial shaft fracture and a minimum follow-up of 24 months. LLD was calculated as the difference between the lengths of the injured and uninjured limbs. Overgrowth was calculated by adding the fracture site shortening from the LLD. Risk factors were assessed in patients with LLD Results Casting and titanium elastic nailing (TEN) were performed on 64 and 39 patients, respectively. The mean LLD and overgrowth were 5.6 and 6.4 mm, respectively. There were significant differences in sex (p = 0.018), age (p = 0.041), fibular involvement (p = 0.005), injury mechanism (p = 0.006), and treatment methods (p p = 0.029), fibular involvement (p = 0.002), injury mechanism (p = 0.008), and treatment methods (p Conclusions Patients undergoing TEN showed greater LLD and overgrowth than those undergoing casting, with boys showing greater LLD and overgrowth than girls. Surgeons should consider the possibility of LLD and overgrowth after pediatric tibial shaft fractures, especially when performing TEN for boys. Level of evidence Level III

Background Analyzing radiographic changes of pes planovalgus(PV) deformity of cerebral palsy(CP) patients according to age and influencing factors. Methods CP patients with PV deformity younger than 18 years old who had undergone more than a year of follow-up with at least two standing foot radiographs were included. Anteroposterior and lateral talo-first metatarsal(talo-1stMT), talo-second metatarsal(talo-2ndMT), and hallux valgus(HV) angles were measured on the radiographs. The rate of progression was adjusted by multiple factors using the linear mixed model, with the Gross Motor Function Classification System(GMFCS) level as the fixed effect and age and each subject as random effects. Results Overall, 194 patients were enrolled in this study, and 1272 standing foot radiographs were evaluated. The AP talo-2ndMT angle progressed by 0.59° (p p = 0.0007) in GMFCS level II and III patients, respectively; however, there was no significant change in GMFCS level I patients (p = 0.3269). HV was significantly affected by age in all three GMFCS groups; it increased by 0.48° (p p stMT angle (p = 0.0535). Conclusions The GMFCS level was the single most important factor influencing the progression of radiographic indices in PV deformity in CP. The AP talo-1stMT and talo-2ndMT angles progressed in patients with GMFCS levels II and III. Physicians should take this result into consideration when planning the timing of the surgery. Level of evidence Prognostic Level IV.

Seasonal changes in precipitation characteristics over India were projected using a high-resolution (40-km) atmospheric general circulation model (AGCM) during the near- (2010–2039), mid- (2040–2069), and far- (2070–2099) futures. For the model evaluation, we simulated an Atmospheric Model Intercomparison Project-type present-day climate using AGCM with observed sea-surface temperature and sea-ice concentration. Based on this simulation, we have simulated the current climate from 1979 to 2009 and subsequently the future climate projection until 2100 using a CMCC-CM model from Coupled Model Intercomparison Project phase 5 models based on RCP4.5 and RCP8.5 scenarios. Using various observed precipitation data, the validation of the simulated precipitation indicates that the AGCM well-captured the high and low rain belts and also onset and withdrawal of monsoon in the present-day climate simulation. Future projections were performed for the above-mentioned time slices (near-, mid-, and far futures). The model projected an increase in summer precipitation from 7 to 18% under RCP4.5 and from 14 to 18% under RCP8.5 from the mid- to far futures. Projected summer precipitation from different time slices depicts an increase over northwest (NWI) and west-south peninsular India (SPI) and a reduction over northeast and north-central India. The model projected an eastward shift of monsoon trough around 2° longitude and expansion and intensification of Mascarene High and Tibetan High seems to be associated with projected precipitation. The model projected extreme precipitation events show an increase (20–50%) in rainy days over NWI and SPI. While a significant increase of about 20–50% is noticed in heavy rain events over SPI during the far future.

The present paper examined the teleconnections between two huge Asian summer monsoon components (South and East Asia) during three time slices in future: near-(2010–2039), mid-(2040–2069) and far-(2070–2100) futures under the RCP4.5 and RCP8.5 scenarios. For this purpose, a high-resolution atmospheric general circulation model is used and integrated at 40 km horizontal resolution. To get more insight into the relationships between the two Asian monsoon components, we have studied the spatial displaying correlation coefficients (CCs) pattern of precipitation over the entire Asian monsoon region with that of South Asia and three regions of East Asia (North China, Korea–Japan and Southern China) separately during the same three time slices. The possible factors responsible for these teleconnections are explored by using mean sea level pressure (MSLP) and wind fields at 850 hPa. The CC pattern of precipitation over South Asia shows an in-phase relationship with North China and an out-of-phase relationship with Korea–Japan, while precipitation variations over Korea–Japan and Southern China exhibit an out-of-phase relationship with South Asia. The CCs analysis between the two Asian blocks during different time slices shows the strongest CCs during the near and far future with the RCP8.5 scenario. The CC pattern of precipitation over Korea–Japan and Southern China with the wind (at 850 hPa) and MSLP fields indicate that the major parts of the moisture over Korea–Japan gets transported from the west Pacific along the western limb of NPSH, while the moisture over Southern China comes from the Bay of Bengal and South China Seas for good monsoon activity.

Recent studies reported that parapapillary microvascular dropout (MvD) was significantly associated with glaucoma and glaucoma progression. To understand the clinical relevance/importance of MvD, it is essential to know the exact vascular anatomy of optic nerve head (ONH). Although it is known that parapapillary choroid and the deep ONH structure including prelaminar tissue are both supplied by branches of short posterior ciliary artery, it remains controversial whether parapapillary choroid provides a major contribution to the prelaminar tissue perfusion. This study investigated perfusion within and around the ONH using indocyanine green angiography. Thirty-three eyes from 33 patients with primary open-angle glaucoma and 10 eyes from 10 normal subjects were included. The temporal sequence of dye appearance in various tissues was analyzed. We also sought the microvessels directly responsible for blood supply to the prelaminar tissue. The perfusion of the prelaminar tissue, which occurred in a sectoral fashion, was dependent on the dye appearance in the adjacent parapapillary choroid. In addition, microvessels crossing over the optic disc margin from the parapapillary choroid to the ONH were found. The findings suggest that the centripetal flow from the parapapillary choroid is an important source of prelaminar tissue perfusion.

Background Dega pelvic osteotomy is commonly performed procedure in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for hip displacement. However, there has been no study investigating the outcomes after Dega pelvic osteotomy using allograft in patients with CP. This study investigated the outcomes of Dega pelvic osteotomy using iliac crest allograft in CP with hip displacement and the factors affecting allograft incorporation. Methods This study included 110 patients (150 hips; mean age 8y7mo; 68 males, 42 females) who underwent hip reconstructive surgeries including Dega pelvic osteotomy using iliac crest allograft. To evaluate the time of allograft incorporation, Goldberg score was evaluated according to the follow-up period on all postoperative hip radiographs. The acetabular index, migration percentage, and neck-shaft angle were also measured on the preoperative and postoperative follow-up radiographs. Results The mean estimated time for allograft incorporation (Goldberg score ≥ 6) was 1.1 years postoperatively. All hips showed radiographic union at the final follow-up and there was no case of graft-related complications. Patients with Gross Motor Function Classification System (GMFCS) level V had 6.9 times higher risk of radiographic delayed union than those with GMFCS level III and IV. Acetabular index did not increase during the follow-up period (p = 0.316). Conclusions Dega pelvic osteotomy using iliac crest allograft was effective in correcting acetabular dysplasia, without graft-related complications in patients with CP. Furthermore, the correction of acetabular dysplasia remained stable during the follow-up period.

Background Although several studies have investigated the outcomes after distal hamstring lengthening (DHL), no study has undertaken an approach that included all or most of the important factors that could influence the results. This study was performed to evaluate the outcomes after DHL and analyze the factors that influence the improvement and serial change in knee motion after surgery in patients with cerebral palsy (CP), using a linear mixed model (LMM). Methods The study included 314 ambulatory CP patients (594 limbs) with spsastic diplegia who were followed up after undergoing DHL as part of a single-event multilevel surgery and who underwent preoperative and postoperative 3-dimensional (3D) gait analyses. Relevant kinematic values, including knee flexion at initial contact, minimum knee flexion in the stance phase, knee range of motion (ROM), mean pelvic tilt and gait deviation index (GDI) score, were the outcome measures. Changes in knee motion and the GDI score were adjusted for multiple factors, such as sex, the Gross Motor Function Classification System (GMFCS) level, and concomitant surgeries as fixed effects, and follow-up duration, laterality, and each subject as random effects, using a LMM. Results We found significant improvements in knee flexion at initial contact, minimum knee flexion in the stance phase, knee ROM, and GDI score 2 years after DHL. In patients with GMFCS level I and II, improvement in all sagittal knee kinematics was maintained during follow-up. In addition, GDI score, which represents overall gait pathology, consistently improved throughout the follow-up duration (1.2 per year, p = 0.008). Conclusion Medial hamstring lengthening with semitendinosus transfer, as a part of a SEMLS, was effective procedure in treating flexed knee gait with regard to sagittal knee kinematics and GDI score in spastic CP with flexed knee gait.

The aim of this study was to investigate the gender- and body-site-specific factors associated with bone mineral density (BMD) at the femoral neck and lumbar spine in a non-institutionalized population aged ≥50 years characterized by low average calcium intake. The comprehensive data utilized were from the 2010 Fifth Korea National Health and Nutrition Examination Survey, which included health behavior questionnaire, blood and urine tests, dual-energy X-ray absorptiometry, and nutrition intake. The factors associated with BMD at the femoral neck and lumbar spine in both genders were analyzed separately using multiple regression analysis with a stepwise selection. The average daily calcium intake in the male subjects was 565.8 mg and in the female subjects was 443.7 mg. In multiple regression analysis, age, body mass index (BMI), alkaline phosphatase (ALP), lead, daily calcium intake, and cadmium were the significant factors associated with femoral neck BMD in male subjects. BMI, creatinine (Cr), total body fat percentile, lead, ALP, and hypertension were found to be the significant factors associated with lumbar spine BMD in male subjects. In the female subjects, the significant factors associated with femoral neck BMD were age, BMI, ALP, house income, and total body fat percentile, while menopause, Cr, mercury, house income, BMI, and ALP were found to be the significant factors associated with lumbar spine BMD. In conclusion, different factors were associated with BMD depending on gender and the body site tested (femoral neck or lumbar spine). These gender- and body-site-specific factors need to be considered for the prevention and management of osteoporosis.

To investigate the anatomic characteristics of congenital excavated optic disc anomalies by using fundus photography, spectral-domain optical coherence tomography (SD-OCT), and swept-source optical coherence tomography (SS-OCT). Fourteen eyes from 13 patients with congenital excavated optic disc anomalies underwent a complete ophthalmologic examination that included best-corrected visual acuity evaluation, fundus photography, and SD-OCT. SS-OCT was performed in cases of peripapillary staphyloma cases in which the excavation depth could not be detected with SD-OCT. On the basis of the funduscopic and OCT findings, patients were classified as morning glory syndrome, optic disc coloboma, or peripapillary staphyloma. Seven eyes with morning glory syndrome were characterized by the presence of the preretinal tractional membrane in front of the excavated optic disc and could be divided into two groups: three eyes without retinal excavation, and four eyes with retinal excavation. Four eyes with optic disc coloboma showed inferiorly decentered scleral excavations with shallow optic disc excavation detectable by SD-OCT. Three eyes with peripapillary staphyloma showed deep excavation, the depth of which could not be detected by SD-OCT. SS-OCT and enhanced depth imaging SD-OCT images focused on the bottom revealed membranous structure at the bottom of the excavation in two cases with peripapillary staphyloma. SD-OCT and SS-OCT are helpful for differential diagnosis of excavated optic disc anomalies. Morning glory syndrome, optic disc coloboma, and peripapillary staphyloma were respectively characterized by the presence of a preretinal tractional membrane, inferiorly decentered excavation, and an excavation deeper than that observed in morning glory syndrome and optic disc coloboma.

The effect of subthalamic deep brain stimulation (STN DBS) on cognition in Parkinson's disease (PD) remains controversial, and it is unclear which factors are related to cognitive decline and dementia after STN DBS, especially over the long term. To this end, we analyzed the cognitive outcome of 103 non-demented patients with PD who were followed-up for at least 12 months after bilateral STN DBS surgery. Preoperatively, the patients were evaluated with the Unified Parkinson's Disease Rating Scale and neuropsychological tests. The rate of global cognitive decline and the incidence of dementia during follow-up for up to 7 years (mean 42.4 ± 24.5 months) were calculated, and preoperative clinical and neuropsychological factors associated with postoperative global cognitive decline or dementia were analyzed. The prevalence of mild cognitive impairment (MCI) and its relation to later cognitive decline or dementia were also evaluated. The annual decline in the mini-mental state examination score was 0.4 ± 1.7 with impaired attention and executive function and a higher levodopa equivalent dose at baseline being the predictors of a faster global cognitive decline after STN DBS. Dementia developed in 13 patients with an incidence rate of 35.7 per 1,000 person-years. Impaired executive function at baseline predicted dementia. At baseline, 63.1 % of the patients had PD-MCI, and these patients were more likely to develop dementia than those without PD-MCI. This study showed that dysfunctions in the frontostriatal circuitry at baseline were associated with a risk of subsequent global cognitive decline and dementia in patients with PD who underwent STN DBS. In addition, preoperative PD-MCI was a risk factor for dementia after STN DBS.

We report the bone attenuation of ankle joint measured on computed tomography (CT) and the cause of injury in patients with ankle fractures. The results showed age- and gender-dependent low bone attenuation and low-energy trauma in elderly females, which suggest the osteoporotic features of ankle fractures. This study was performed to investigate the osteoporotic features of ankle fracture in terms of bone attenuation and cause of injury. One hundred ninety-four patients (mean age 51.0 years, standard deviation 15.8 years; 98 males and 96 females) with ankle fracture were included. All patients underwent CT examination, and causes of injury (high/low-energy trauma) were recorded. Mean bone attenuations of the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis were measured on CT images. Patients were divided into younger age (

Background Although ankle fracture surgery can affect glycemic control by either trauma-induced stress or a postoperative decrease in physical activity, there is little evidence on this issue. This study aimed to evaluate the influence of ankle fracture surgery on glycemic control and to assess the risk factors for poor glycemic control after surgery in patients with diabetes. Methods We reviewed the medical records of consecutive patients with diabetes who underwent open reduction and internal fixation for the treatment of ankle fracture at our hospital. Patients who underwent blood testing, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), and cholesterol levels, as part of a routine check-up before surgery and again more than 2 times after surgery were included. Changes in blood test results were adjusted by multiple factors using a linear mixed model with sex, age at time of surgery, body mass index (BMI), and type of ankle fracture as the fixed effects and each subject and timing of blood test as the random effects. Results Sixty patients were ultimately included in this study. At 1 month postoperatively, mean FBG and cholesterol levels had increased significantly compared with preoperative levels (p = 0.011 and 0.024, respectively). After surgery, FBG levels showed an estimated monthly decrease of 2.2 mg/dL (p = 0.017). Sex, age at time of surgery, and type of ankle fracture did not significantly affect the monthly change in FBG level. FBG returned to the preoperative level at an estimated period of 8.1 months. BMI significantly affected preoperative FBG level (p = 0.015) but not the postoperative change in FBG level (p = 0.500). Conclusion Ankle fracture surgery increased the FBG level at 1 month postoperatively. FBG levels decreased gradually after surgery at an estimated monthly rate of 2.2 mg/dL. Physicians should be aware of the difficulty in postoperative blood glucose control in patients with diabetes, even several months after surgery.

The authors want to acknowledge the Korea Meteorological Administration research and Development Program under Grant KMI 2018-07910.

A high cellobiohydrolase (CBH)-producing strain was isolated and identified as Penicillium purpurogenum KJS506 according to the morphology and comparison of internal transcribed spacer rDNA gene sequence. When rice straw and corn steep powder were used as carbon and nitrogen sources, respectively, a maximum CBH activity of 2.6 U mg-protein−1, one of the highest among CBH-producing microorganisms, was obtained. The optimum temperature and pH for CBH production were 30 °C and 4.0, respectively. The increased production of CBH in P. purpurogenum culture at 30 °C was confirmed by two-dimensional electrophoresis followed by MS/MS sequencing of the partial peptide. The internal amino acid sequences of P. purpurogenum CBH showed a significant homology with hydrolases from glycoside hydrolase family 7. The extracellular CBH was purified to homogeneity by sequential chromatography of P. purpurogenum culture supernatants on a DEAE-sepharose column, a gel filtration column, and then on a Mono Q column with fast-protein liquid chromatography. The purified CBH was a monomeric protein with a molecular weight of 60 kDa and showed broad substrate specificity with maximum activity towards p-nitrophenyl β-d-cellobiopyranoside. P. purpurogenum CBH showed t 1/2 value of 4 h at 60 °C and V max value of 11.9 μmol min−1 mg-protein−1 for p-nitrophenyl-d-cellobiopyranoside. Although CBHs have been reported, the high specific activity distinguishes P. purpurogenum CBH.

A highly efficient beta-1,4-glucosidase (BGL) secreting strain, Stereum hirsutum SKU512, was isolated and identified based on morphological features and sequence analysis of internal transcribed spacer rDNA. A BGL containing a carbohydrate moiety was purified to homogeneity from S. hirsutum culture supernatants using only a single chromatography step on a gel filtration column. The relative molecular weight of S. hirsutum BGL was determined as 98 kDa by sodium dodecyl sulfate polyacrylamide gel electrophoresis or 780 kDa by size exclusion chromatography, indicating that the enzyme is an octamer. S. hirsutum BGL showed the highest activity toward p-nitrophenyl-beta-D-glucopyranoside (V (max) = 3,028 U mg-protein(-1), k (cat) = 4,945 s(-1)) ever reported. The enzyme also showed good stability at an acidic pH ranging from 3.0 to 5.5. The BGL was able to promote transglycosylation with an activity of 42.9 U mg-protein(-1) using methanol as an acceptor and glucose as a donor. The internal amino acid sequences of the isolated enzyme showed significant homology with hydrolases from glycoside hydrolase family 1 (GH1), indicating that the S. hirsutum BGL is a member of GH1 family. The characteristics of S. hirsutum BGL could prove to be of interest in several potential applications, especially in enhancing flavor release during the wine fermentation process.

To describe idiopathic maculopathy in eyes with regressed retinopathy of prematurity, which differs from cicatricial changes in retinopathy of prematurity. Setting: institutional. Patients: patients were former preterm infants who had undergone fundus examinations for retinopathy of prematurity between December 1993 and May 2002. Posterior polar cicatricial change was excluded. The medical records of eight eyes (four patients) with photo-documented idiopathic maculopathy were reviewed retrospectively. Main outcome measures: complete ophthalmologic examinations including best corrected visual acuity (BCVA), refractive error, funduscopic examination, fluorescein angiography (FAG), and optical coherence tomography (OCT). Maculopathy was characterized by depigmented geographic atrophy. FAG showed window defects due to atrophy of retinal pigment epithelium. OCT showed depression in the fovea with retained internal architecture. In all cases patients had retinopathy of prematurity, and all except one had been treated with laser photocoagulation. In the case without laser photocoagulation, maculopathy was observed on the first exam. In the other cases, no maculopathy was observed on the first exam, but was detected after laser photocoagulation. No patient had a family history of hereditary retinal dystrophy. In all cases, maculopathy was noted in both eyes with myopia. BCVA was variable (0.0∼0.82, 0.32 ± 0.32 logMAR). No progression was observed over the course of 8 years. Idiopathic maculopathy is a rare posterior polar change that differs from the cicatricial changes seen in retinopathy of prematurity, and is independent of prior laser photocoagulation. No progression was observed, and visual prognosis was fair.

A novel beta-glucosidase (BGL)-producing strain was isolated and identified as Penicillium purpurogenum KJS506 based on its morphology and internal transcribed spacer (ITS) rDNA gene sequence. When rice straw and corn steep powder were used as carbon and nitrogen sources, respectively, the maximal BGL activity of 12.3 U ml(-1), one of the highest levels among BGL-producing microorganisms was observed. The optimum temperature and pH for BGL production were 32 degrees C and 4, respectively. An extracellular BGL was purified to homogeneity by sequential chromatography of P. purpurogenum culture supernatants, and the purified BGL showed higher activity (V (max) = 934 U mg protein(-1)) than most BGLs from other sources. The complete ORF of bgl3 was cloned from P. purpurogenum by a modified thermal asymmetric interlaced polymerase chain reaction. The bgl3 gene consists of a 2,571-bp ORF and encodes a putative protein containing 856 amino acids with a calculated molecular mass of 89,624 Da. The putative gene product was identified as a member of glycoside hydrolase family 3. The present results should contribute to improved industrial production of BGL by P. purpurogenum KJS506.

Purpose: Use of a pediatric airway exchange catheter (PAEC) has been advocated as a potentially useful adjunct for difficult extubations. We evaluated the laryngeal passing ability of a tracheal tube over a PAEC and compared its success rate between adult patients in the sniffing position and adult patients with simulated cervical spine immobilization created using a manual in-line axial stabilization (MIAS) technique. Methods: A total of 100 adult patients were randomized into two groups of equal size with respect to position during the simulated reintubation trial: the MIAS position (Group M) and the sniffing position (Group S). After induction of anesthesia, an 11-F PAEC was placed in the trachea under direct laryngoscopic view, and a wire-reinforced tube (with its bevel facing to the left) was gently railroaded over the PAEC and into the trachea. If insertion was impeded, a second attempt was made after rotating the tube 90° counterclockwise. If this also failed, one additional attempt was made using external laryngeal pressure before changing to conventional laryngoscopic intubation. Results: After the second attempt, the cumulative success rates in Groups M and S were 41.3% and 72.3%, respectively (P = 0.003). After three attempts, the overall success rate was significantly lower in Group M (52.2%) than in Group S (76.6%) (P = 0.018). Conclusion: Owing to the high failure rate of PAEC-guided intubation in patients with simulated cervical spine immobilization, use of a PAEC is not recommended for maintaining continuous airway access after extubation in adult patients with cervical immobility or instability.

Since Hick's original description, many subsequent studies have confirmed the logarithmic relationship that exists between response time and the number of alternatives (NA) for a choice response. In the present study a novel paradigm was used to quantify saccade response time as a function of NA. Normal subjects were required to make a saccade to the remembered location of a visual target whose color was specified by a centrally located cue. The paradigm thus required a stimulus-response transformation similar to that used by Hick. The results show that, when such a transformation was required, a logarithmic relationship was found for saccadic response time. The use of a color-to-location paradigm to study saccade choice response time produced an unexpected additional result that may provide insight into the neural organization of the saccadic system. When the number of alternative choice responses was large (4 or 8), subjects frequently made a two-saccade response instead of a single saccade to the correct location. The first movement in such a sequence was in the correct direction, but was hypometric. A second movement then followed which moved the eyes onto the correct location. These results suggest dynamic dissociations in the mechanisms underlying the triggering of saccades and the specification of their metrics.

Background: Codman's paradox reveals a misunderstanding of geometry in orthopedic practice. Physicians often encounter situations that cannot be understood intuitively during orthopedic interventions such as corrective osteotomy. Occasionally, unexpected angular or rotational deformity occurs during surgery. This study aimed to draw the attention of orthopedic surgeons toward the concepts of orientation and rotation and demonstrate the potential for unexpected deformity after orthopedic interventions. This study focused on three situations: shoulder arthrodesis, femoral varization derotational osteotomy, and femoral derotation osteotomy. Methods: First, a shoulder model was generated to calculate unexpected rotational deformity to demonstrate Codman's paradox. Second, femoral varization derotational osteotomy was simulated using a cylinder model. Third, a reconstructed femoral model was used to calculate unexpected angular or rotational deformity during femoral derotation osteotomy. Results: Unexpected external rotation was found after forward elevation and abduction of the shoulder joint. In the varization and derotation model, closed-wedge osteotomy and additional derotation resulted in an unexpected extension and valgus deformity, namely, under-correction of coxa valga. After femoral derotational osteotomy, varization and extension of the distal fragment occurred, although the extension was negligible. Conclusions: Surgeons should be aware of unexpected angular deformity after surgical procedure involving bony areas. The degree of deformity differs depending on the context of the surgical procedure. However, this study reveals that notable deformities can be expected during orthopedic procedures such as femoral varization derotational osteotomy.

Background: Several 3D multi-segment foot models (MFMs) have been introduced for the in vivo analysis of dynamic foot kinematics. However, reproducibility of a model should be checked and ascertained before clinical utilization of a MFM. The purpose of this study was to determine the reliability of recently introduced MFM with a 15-marker set by assessing the participant's stride-to-stride (intra-session) and visit-to-revisit (inter-session) repeatability. Methods: Twenty healthy adults with a mean age of 28.9 years (10 males and 10 females) were tested. Three representative strides from five separate trials were used for analysis from each session. Kinematic data of foot segmental motion was collected and tracked using the Foot3D Multi-Segment Software (Motion Analysis Co., Santa Rosa. CA). A retest was performed in the same manner at an interval of 4 weeks. Coefficients of multiple correlation (CMC) and intra-class correlation coefficient (ICC) were calculated in order to assess the intra-session and inter-session repeatability. Results: Inter-segment foot angles from healthy adults from a MFM with 15-marker set showed a narrow range of variability during the gait cycle. The mean intra-session ICC was 0.981 (+/- 0.010), which was interpreted as excellent. The mean intra-session CMC was 0.948 (+/- 0.027), which was interpreted as very good repeatability. The mean inter-session ICC was 0.886 (+/- 0.047) and the mean inter-session CMC was 0.801 (+/- 0.077), which were interpreted as excellent and good repeatability, respectively. Conclusion: We demonstrated a MFM with a 15-marker set had high intra-session and inter-session repeatability, especially in sagittal plane motion. We thought this MFM would be applicable to evaluation of the segmental foot motion during gait.

in female than in male. The stride length, the step width, and the step time were significantly longer in male. The speed and the proportion of stance phase were not significantly different (Table 1). The range of segmental motion (hallux, forefoot, hindfoot) and arch data were recorded during the gait and compared between male and female. The both genders had similar patterns of segmental foot motions. The range of sagittal motion and coronal angulation of the hallux was greater during gait in females. The range of motion on the hindfoot was also greater in females. The male had higher adjusted arch height and arch index. However, the range of adjusted arch height was larger in females (Figure 1). We demonstrated that there was a substantial temporal pattern of the foot segmental motion in normal adults. We also presented that

Several 3D multi-segment foot models (MFMs) have been introduced for the in vivo analysis of dynamic foot kinematics [1,2]. However, there is scanty evidence available to support their clinical use. Considering the potential of MFM to assess the function in foot pathology, there is a need for simple, reproducible and reliable multi-segment foot models. The purpose of this study was to assess the reliability of a simple MFM with 15-marker set. Twenty healthy adults mean aged 28.9 years (10 males and 10 females) were tested. Eight markers of 15-marker set were placed in foot to evaluate segmental foot motion. Three representative strides from five separate trials were used for analysis from each session. Kinematic data of foot segmental motion was collected and tracked using the Foot3D Multi-Segment Software (Motion Analysis Co., Santa Rosa. CA). Retests were performed in the same manner with an interval of 4 weeks. Coefficients of multiple correlation (CMC) and intra-class correlation (ICC) were calculated in order to assess the inter-trial and inter-session repeatability. Inter-segment foot angles from healthy adults from a MFM with 15-marker set showed a narrow range of variability during the whole gait cycle. The mean inter-trial ICC (± Standard deviation) was 0.981 (± 0.010), which was interpreted as excellent. The mean inter-trial CMC (± Standard deviation ) was 0.948 (± 0.027), which was interpreted as excellent or very good repeatability. The mean inter-session ICC (±SD) was 0.886 (± 0.047) and the mean inter-session CMC (±SD) was 0.801 (± 0.077), which were interpreted as excellent or very good repeatability. The lowest repeatability was in the transverse plane at the forefoot and the most consistent finding was observed at the sagittal plane of the hallux and hindfoot (Table ​(Table1,1, Figure ​Figure11). Table 1 Repeatability of foot kinematics Figure 1 Walking kinematics for the 1st and 2nd visit (average with a range representing 2 standard deviations). Each row shows the motion of each segment: hallux, hindfoot, arch, forefoot, medial forefoot, lateral forefoot motion. Each column represents motion ... We demonstrated a MFM with 15-marker set had high inter-trial and inter-session repeatability, especially in sagittal plane motion. We thought this MFM would be applicable to evaluation of the motion of the foot segment during gait.

The ability to acquire and use several languages selectively is a unique and essential human capacity. Here we investigate the fundamental question of how multiple languages are represented in a human brain. We applied functional magnetic resonance imaging (fMRI) to determine the spatial relationship between native and second languages in the human cortex, and show that within the frontal-lobe language-sensitive regions (Broca's area)1,2,3, second languages acquired in adulthood (‘late’ bilingual subjects) are spatially separated from native languages. However, when acquired during the early language acquisition stage of development (‘early’ bilingual subjects), native and second languages tend to be represented in common frontal cortical areas. In both late and early bilingual subjects, the temporal-lobe language-sensitive regions (Wernicke's area)1,2,3 also show effectively little or no separation of activity based on the age of language acquisition. This discovery of language-specific regions in Broca's area advances our understanding of the cortical representation that underlies multiple language functions.

Background This study was performed to investigate the usefulness of clinical pathway (CP) using an electronic medical record (EMR) in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus, by analyzing the length of hospital stay, hospital cost and satisfaction of the medical teams. Methods This before and after comparative study included consecutive children who underwent closed pinning for supracondylar fracture of the humerus since 2009. The pre-CP group consists of 90 patients with the mean age of 5.7 years, and the post-CP group consists of 32 patients with the mean age of 6.2 years. Multidisciplinary work-team developed CP using an EMR system in March 2011. The length of hospital stay was the primary outcome variable, and hospital cost and medical team’s satisfaction score were secondary outcome variables. The non-inferiority test was used to demonstrate the efficiency of the pathway. Results The length of hospital stay decreased from 2.9 ± 0.7 days to 2.4 ± 0.7 days by 15.0%, after the implementation of CP, and the lower bound of the 95% CI of the difference (0.14 day) was within the non-inferiority margin of −0.3 days. The hospital cost decreased from 1162.2 ± 236.7 US$ to 1139.8 ± 291.1 US$ by 1.9% and the lower bound of the 95% CI of the difference was −81.3 US$, which did not exceed the non-inferiority margin of −116.2 US$. Therefore, the post-CP group was not inferior compared with the pre-CP group in term of the length of hospital stay and total hospital cost. There was significant increase in the satisfaction score for doctors after implementation of CP (p Conclusions The development and implementation of CP, using an EMR, in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus enhances the treatment efficiency by streamlining the treatment process with no increases of the length of the hospital stay and total hospital costs.

Background The purpose of this study was to analyze kinematic trunk motion data in normal adults and to investigate gender effect. Methods Kinematic trunk motion data were obtained for 20 healthy subjects (11 men and 9 women; age from 21 to 40 years) during walking a 9 m long lane at a self selected speed, namely, motions in the sagittal (tilt), coronal (obliquity), and transverse (rotation) planes, which were all expressed as motions in global (relative to the ground) and those in pelvic reference frame (relative to pelvis), i.e., tilt (G), obliquity (G), rotation (G), tilt (P), obliquity (P), rotation (P). Results Range of tilt (G), obliquity (G) and rotation (G) showed smaller motion than that of tilt (P), obliquity (P) and rotation (P), respectively. When genders were compared, female trunks showed a 5 degree more extended posture during gait than male trunks (p = 0.002), which appeared to be caused by different lumbar lordosis. Ranges of coronal and transverse plane motion appeared to be correlated. In gait cycle, the trunk motion appeared to counterbalance the lower extremity during swing phase in sagittal plane, and to reduce the angular velocity toward the contralateral side immediate before the contralateral heel strike in the coronal plane. Conclusions Men and women showed different lumbar lordosis during normal gait, which might be partly responsible for the different prevalence of lumbar diseases between genders. However, this needs further investigation.

Dear Editor, We have read about the anti-herpetic synergistic effect of combined treatment with mycophenolate mofetil (MMF) and acyclovir in patients with herpetic eye disease [1]. However, we encountered unexpected neuronal toxicity with this combination. A 55-year-old man was brought to the emergency department on the day of his discharge after he experienced a generalized tonic–clonic seizure. Two days before, he had undergone penetrating keratoplasty on his left eye. Fortunately, he had the seizure just in front of the hospital while he was on his way home. His vital signs were stable except mild hypertension; 157/82 mmHg. He had two additional generalized tonic–clonic seizures with loss of consciousness, as documented by a neurologist at the emergency department. The first documented seizure spontaneously subsided, but the second documented attack lasted for 1 min, and subsided after the neurologist ordered intravenous administration of lorazepam 5 mg. A computed tomography scan of the head showed no evidence of acute intracranial involvement. An electroencephalogram did not show epileptiform discharge in his brain. He denied history of seizure or general medical illness, except his eye problem. He had had recurrent herpetic keratitis in both eyes and subsequent opacity in his left eye. Three years before, he had undergone penetrating keratoplasty, but had experienced graft rejection after 6 months. One year before, he had undergone a second penetrating keratoplasty, but had experienced graft rejection again after 3 months. This operation was his third penetrating keratoplasty. Before the first penetrating keratoplasty, he had been treated with oral acyclovir (400 mg b.i.d.) for 2 months. After the first penetrating keratoplasty, he had continued with oral acyclovir and started an oral steroid (30 mg q.d.) for 1 month. After tapering of the oral steroid therapy, he continued oral acyclovir until rejection. After the second penetrating keratoplasty, he had been treated with oral acyclovir and an oral steroid, and the oral steroid was replaced with oral cyclosporine (100 mg b.i.d.). In the intervening period, he was treated with both oral steroid and cyclosporine with acyclovir. After the third penetrating keratoplasty, he had been treated with oral acyclovir (400 mg b.i.d.) and oral steroid (30mg q.d.), andMMF 1000mg (b.i.d.). On the second day after initiation of this combination, he had three sequential generalized tonic–clonic seizures with loss of consciousness. The patient had not experienced seizure attacks with any of the other previous combinations. After discontinuation ofMMF, he did not suffer anymore seizures, and did not require any anti-epileptic medication. However, he experienced graft rejection in his left eye again. In this patient, MMF or combination ofMMF and acyclovir or oral steroid must have caused the seizures, because he did not suffer from seizures before initiation or after discontinuation of MMF combined with oral acyclovir and steroid or even cyclosporine. The neurotoxicity of immunosuppressant drugs has been reported, especially in anti-metabolites [2] such as methotrexate [3]. No study has reported neurotoxicity of MMF [4, 5]; in fact there was a report of improvement of K. M. Lee :M. K. Kim :W. R. Wee : J.-h. Lee Department of Ophthalmology, Seoul National University College of Medicine, Seoul, South Korea

Fever is frequently observed in critically ill patients. An independent association of fever with increased mortality has been observed in non-neurological critically ill patients with mixed febrile etiology. The association of fever and antipyretics with mortality, however, may be different between infective and non-infective illness. We designed a prospective observational study to investigate the independent association of fever and the use of antipyretic treatments with mortality in critically ill patients with and without sepsis. We included 1,425 consecutive adult critically ill patients (without neurological injury) requiring > 48 hours intensive care admitted in 25 ICUs. We recorded four-hourly body temperature and all antipyretic treatments until ICU discharge or 28 days after ICU admission, whichever occurred first. For septic and non-septic patients, we separately assessed the association of maximum body temperature during ICU stay (MAXICU) and the use of antipyretic treatments with 28-day mortality. We recorded body temperature 63,441 times. Antipyretic treatment was given 4,863 times to 737 patients (51.7%). We found that treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen independently increased 28-day mortality for septic patients (adjusted odds ratio: NSAIDs: 2.61, P = 0.028, acetaminophen: 2.05, P = 0.01), but not for non-septic patients (adjusted odds ratio: NSAIDs: 0.22, P = 0.15, acetaminophen: 0.58, P = 0.63). Application of physical cooling did not associate with mortality in either group. Relative to the reference range (MAXICU 36.5°C to 37.4°C), MAXICU ≥ 39.5°C increased risk of 28-day mortality in septic patients (adjusted odds ratio 8.14, P = 0.01), but not in non-septic patients (adjusted odds ratio 0.47, P = 0.11). In non-septic patients, high fever (≥ 39.5°C) independently associated with mortality, without association of administration of NSAIDs or acetaminophen with mortality. In contrast, in septic patients, administration of NSAIDs or acetaminophen independently associated with 28-day mortality, without association of fever with mortality. These findings suggest that fever and antipyretics may have different biological or clinical or both implications for patients with and without sepsis. ClinicalTrials.gov: NCT00940654