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In anomalous trichromacy, the color signals available from comparing the activities of the two classes of cone sensitive in the medium and long wavelength parts of the spectrum are much reduced from those available in normal trichromacy, and color discrimination thresholds along the red-green axis are correspondingly elevated. Yet there is evidence that suprathreshold color perception is relatively preserved; this has led to the suggestion that anomalous trichromats post-receptorally amplify their impoverished red-green signals. To test this idea, we measured chromatic discrimination from white and from saturated red and green pedestals. If there is no post-receptoral compensation, the anomalous trichromat's loss of chromatic contrast will apply equally to the pedestal and to the test color. Coupled with a compressively nonlinear neural representation of saturation, this means that a given pedestal contrast will cause a smaller than normal modulation of discrimination sensitivity. We examined cases where chromatic pedestals impair the color discrimination of normal trichromatic observers. As predicted, anomalous observers experienced less impairment than normal trichromats, though they remained less sensitive than normal trichromats. Although the effectiveness of chromatic pedestals in impairing color discrimination was less for anomalous than for normal trichromats, the chromatic pedestals were more effective for anomalous observers than would be expected if the anomalous post-receptoral visual system were the same as in normal trichromacy; the hypothesis of zero compensation can be rejected. This might suggest that the effective contrast of the pedestal is post-receptorally amplified. But on closer analysis, the results do not support candidate simple models involving post-receptoral compensation either.

Background We sought to understand barriers and facilitators to implementing distress screening (DS) of cancer patients to inform and promote uptake in cancer treatment facilities. We describe the recruitment and data collection challenges and recommendations for assessing DS in oncology treatment facilities. Methods We recruited CoC-accredited facilities and collected data from each facility’s electronic health record (EHR). Collected data included cancer diagnosis and demographics, details on DS, and other relevant patient health data. Data were collected by external study staff who were given access to the facility’s EHR system, or by facility staff working locally within their own EHR system. Analyses are based on a pilot study of 9 facilities. Results Challenges stemmed from being a multi-facility-based study and local institutional review board (IRB) approval, facility review and approval processes, and issues associated with EHR systems and the lack of DS data standards. Facilities that provided study staff remote-access took longer for recruitment; facilities that performed their own extraction/abstraction took longer to complete data collection. Conclusion Examining DS practices and follow-up among cancer survivors necessitated recruiting and working directly with multiple healthcare systems and facilities. There were a number of lessons learned related to recruitment, enrollment, and data collection. Using the facilitators described in this manuscript offers increased potential for working successfully with various cancer centers and insight into partnering with facilities collecting non-standardized DS clinical data.

The objective of this study was to analyze the effectiveness and cost of patient incentives, together with patient navigation and patient reminders, to increase fecal immunochemical test (FIT) kit return rates and colorectal cancer screening uptake in one federally qualified health center (FQHC) in Appalachia. This FQHC is a designated homeless clinic, as 79.7% of its patient population are homeless. We collected process, outcome, and cost data from the FQHC for two time periods: usual care (September 2016–August 2017) and implementation (September 2017–September 2018). We reported the FIT kit return rate, the increase in return rate, and the additional number of individual screens. We also calculated the incremental cost per additional screen. The patient incentive program, with patient navigation and patient reminders, increased the number of FIT kits returned from the usual care period to the implementation period. The return rate increased by 25.9 percentage points (from 21.7% to 47.6%) with an additional 91 people screened at an incremental cost of $134.61 per screen. A patient incentive program, together with the assistance of patient navigators and supplemented with patient reminders, can help improve CRC screening uptake among vulnerable and homeless populations.

Effectiveness of Kinesiology Tex Tape (KTT) is conflicting, with some clinicians supporting and others refuting its effects. There is limited information on the psychological effects of KTT or whether its increased use has been influenced by professional athletes. The purpose of this study was to assess the physiological, psychological, and use of KTT. A descriptive survey on the use of KTT was performed with athletic trainers and other health care providers. Many reported that KTT benefited patients physiologically and psychologically. Those who thought KTT provided a physiological benefit indicated that they use it. Many indicated KTT benefited patients psychologically, without impacting them physiologically. In addition, clinicians indicated KTT use has been influenced by professional athletes.

Male chimpanzees (Pan troglodytes) defend group territories and sometimes kill members of rival communities — a pattern often compared to human warfare1-3. Male chimpanzees also sometimes kill grown males from their own community4-9. Such within-community killings are puzzling, as they reduce the coalition strength needed to win inter-community contests5,10. Here we examine the contexts of within-community killing using data from two neighboring communities at Gombe National Park, Tanzania, as well as published data from other long-term chimpanzee study sites. At Gombe, more killing occurred within the smaller Mitumba community, where fertile females were more monopolizable. Attackers increased their share of mating and paternity following known and inferred killings. Other factors proposed to explain such killings, including the degree of intercommunity threat, male-biased sex ratios, high population density, or generalized aggression, did not explain the high rates of killing in Mitumba. Comparing across study sites, the best predictor of within-community killing was an index of the degree to which fertile females can be monopolized by the highest ranking male11. Our findings therefore support the hypothesis that within-community killing is a strategy to eliminate reproductive rivals that is more likely to pay off when fertile females are more easily monopolized.

We sought to determine the efficacy of genetically distinct bacillus Calmette-Guérin strains in preventing disease recurrence in patients with nonmuscle invasive bladder cancer.We conducted a systematic review and network meta-analysis of trials evaluating bacillus Calmette-Guérin strains against all possible comparators (different bacillus Calmette-Guérin strains, chemotherapy and nonbacillus Calmette-Guérin biological therapies) with intravesical chemotherapy as the common comparator. MEDLINE® (http://www.ncbi.nlm.nih.gov/pubmed) served as the primary data source, with the search from inception to October 2016 for clinical trials involving patients with nonmuscle invasive bladder cancer receiving bacillus Calmette-Guérin. Primary outcome measure was bladder cancer recurrence, defined as recurrent bladder tumor of any grade or stage. Random effect network meta-analysis provided estimates for outcomes and is presented as odds ratios.Across all possible comparators (65 trials, 12,246 patients, 9 strains) there were 2,177 recurrences in 5,642 treated patients (38.6%) and 2,316 recurrences in 5,441 comparators (42.6%). With chemotherapy as the common comparator (28 trials, 5,757 patients, 5 strains) Tokyo-172 (OR 0.39, 95% CI 0.16-0.93), Pasteur (OR 0.49, 95% CI 0.28-0.86) and TICE® (OR 0.61, 95% CI 0.40-0.93) strains were significantly better than chemotherapy at preventing recurrence. No bacillus Calmette-Guérin strain demonstrated significant superiority when compared to any other strain at preventing recurrence in the network meta-analysis.Bacillus Calmette-Guérin strains exhibited significant differences in efficacy compared to chemotherapy. However, no definitive conclusions could be reached regarding strain superiority, and head-to-head trials are greatly needed to further understand the importance of strain selection in determining bacillus Calmette-Guérin efficacy.

We provide evidence for a causal link between the US economy and the global financial cycle. Using a unique intraday dataset, we show that US macroeconomic news releases have large and significant effects on global risky asset prices. Stock price indexes of 27 countries, the VIX, and commodity prices all jump instantaneously upon news releases. The responses of stock indexes co-move across countries and are large - often comparable in size to the response of the S&P 500. Further, US macroeconomic news frequently explains more than 15% of the quarterly variation in foreign stock markets. The joint behavior of stock prices and long-term bond yields suggests that systematic US monetary policy reactions to news do not drive the estimated effects. Instead, the evidence is consistent with a direct effect on investors' risk-taking capacity. Our findings show that a byproduct of the United States' central position in the global financial system is that news about its business cycle has large effects on global financial conditions.

The human retina contains three classes of cone photoreceptors each sensitive to different portions of the visual spectrum: long (L), medium (M) and short (S) wavelengths. Color information is computed by downstream neurons that compare relative activity across the three cone types. How cone signals are combined at a cellular scale has been more difficult to resolve. This is especially true near the fovea, where spectrally-opponent neurons in the parvocellular pathway draw excitatory input from a single cone and thus even the smallest stimulus will engage multiple color-signaling neurons. We used an adaptive optics microstimulator to target individual and pairs of cones with light. Consistent with prior work, we found that color percepts elicited from individual cones were predicted by their spectral sensitivity, although there was considerable variability even between cones within the same spectral class. The appearance of spots targeted at two cones were predicted by an average of their individual activations. However, two cones of the same subclass elicited percepts that were systematically more saturated than predicted by an average. Together, these observations suggest both spectral opponency and prior experience influence the appearance of small spots.

Tracking SLO systems equipped to perform retinally targeted stimulus delivery typically use near-IR wavelengths for retinal imaging and eye tracking and visible wavelengths for stimulation. The lateral offsets between wavelengths caused by transverse chromatic aberration (TCA) must be carefully corrected in order to deliver targeted stimuli to the correct location on the retina. However, both the magnitude and direction of the TCA offset is dependent on the position of the eye’s pupil relative to the incoming beam, and thus can change dynamically within an experimental session without proper control of the pupil position. The goals of this study were twofold: 1) To assess sources of variability in TCA alignments as a function of pupil displacements in an SLO and 2) To demonstrate a novel method for real-time correction of chromatic offsets. To summarize, we found substantial between- and within-subject variability in TCA in the presence of monochromatic aberrations. When adaptive optics was used to fully correct for monochromatic aberrations, variability both within and between observers was minimized. In a second experiment, we demonstrate that pupil tracking can be used to update stimulus delivery in the SLO in real time to correct for variability in chromatic offsets with pupil displacements.

Organisms are faced with the challenge of making inferences about the physical world from incomplete incoming sensory information. One strategy to combat ambiguity in this process is to combine new information with prior experiences. We investigated the strategy of combining these information sources in color vision. Single cones in human subjects were stimulated and the associated percepts were recorded. Subjects rated each flash for brightness, hue and saturation. Brightness ratings were proportional to stimulus intensity. Saturation was independent of intensity, but varied between cones. Hue, in contrast, was assigned in a stereotyped manner that was predicted by cone type. These experiments revealed that, near the fovea, long (L) and middle (M) wavelength sensitive cones produce sensations that can be reliably distinguished on the basis of hue, but not saturation or brightness. Taken together, these observations implicate the high-resolution, color-opponent parvocellular pathway in this low-level visual task.

The study of fixational eye motion has implications for the neural and computational underpinnings of vision. One component of fixational eye motion is tremor, a high-frequency oscillatory jitter reported to be anywhere from ∼11-60 arcseconds in amplitude. In order to isolate the effects of tremor on the retinal image directly and in the absence of optical blur, high-frequency, high-resolution eye traces were collected in six subjects from videos recorded with an adaptive optics scanning laser ophthalmoscope. Videos were acquired while subjects engaged in an active fixation task where they fixated on a tumbling E stimulus and reported changes in its orientation. Spectral analysis was conducted on periods of ocular drift, with all drifts being concatenated together after removal of saccades from the trace. The resultant amplitude spectra showed a slight deviation from the traditional 1/f nature of optical drift in the frequency range of 50-100 Hz, which is indicative of tremor. However, this deviation rarely exceeded 1 arcsecond and the consequent standard deviation of retinal image motion over the tremor band (50-100 Hz) was just over 5 arcseconds. Given such a small amplitude, it is unlikely tremor will contribute in any meaningful way to the visual percept.

Clinical Scenario: Exertional heat stroke (EHS) is a medical emergency characterized by body core temperatures >40.5°C and central nervous system dysfunction. An EHS diagnosis should be immediately...

This article summarizes strategies being investigated in patients with nonmuscle invasive bladder cancer. Progress has been made toward improving the delivery method of intravesical agents. Intravesical therapy is limited by the amount of time that the agent remains in contact with the bladder. Bladder cancer is considered to be responsive to immune therapy. Thus, many novel approaches are immune-based therapies and include cancer vaccines, use of Bacillus Calmette-Guérin (BCG) subcomponents, and checkpoint inhibitors. Finally, access to bladder mucosa via direct catheterization into the bladder via the urethra has enabled unique strategies for delivery of cancer therapy including viral- or plasmid-based gene therapy.

This article challenges the idea that cancer cannot be prevented among older adults by examining different aspects of the relationship between age and cancer. Although the sequential patterns of aging cannot be changed, several age-related factors that contribute to disease risk can be. For most adults, age is coincidentally associated with preventable chronic conditions, avoidable exposures, and modifiable risk behaviors that are causally associated with cancer. Midlife is a period of life when the prevalence of multiple cancer risk factors is high and incidence rates begin to increase for many types of cancer. However, current evidence suggests that for most adults, cancer does not have to be an inevitable consequence of growing older. Interventions that support healthy environments, help people manage chronic conditions, and promote healthy behaviors may help people make a healthier transition from midlife to older age and reduce the likelihood of developing cancer. Because the number of adults reaching older ages is increasing rapidly, the number of new cancer cases will also increase if current incidence rates remain unchanged. Thus, the need to translate the available research into practice to promote cancer prevention, especially for adults at midlife, has never been greater.

BACKGROUND In 2005 through 2009, the Centers for Disease Control and Prevention (CDC) funded 5 sites to implement a colorectal cancer screening program for uninsured, low-income populations. These 5 sites composed a demonstration project intended to explore the feasibility of establishing a national colorectal cancer screening program through various service delivery models. METHODS A longitudinal, multiple case study was conducted to understand and document program implementation processes. Using metaphor as a qualitative analytic technique, evaluators identified stages of maturation across the programmatic life cycle. RESULTS Analysis rendered a working theory of program development during screening implementation. In early stages, program staff built relationships with CDC and local partners around screening readiness, faced real-world challenges putting program policies into practice, revised initial program designs, and developed new professional skills. Midterm implementation was defined by establishing program cohesiveness and expanding programmatic reach. In later stages of implementation, staff focused on sustainability and formal program closeout, which prompted reflection about personal and programmatic accomplishments. CONCLUSIONS Demonstration sites evolved through common developmental stages during screening implementation. Findings elucidate ways to target technical assistance to more efficiently move programs along their maturation trajectory. In practical terms, the time and cost associated with guiding a program to maturity may be potentially shortened to maximize return on investment for both organizations and clients receiving service benefits. Cancer 2013;119(15 suppl):2926–39. © 2013 American Cancer Society.

BACKGROUND Colorectal cancer remains the second leading cause of cancer-related deaths among US men and women. Screening rates have been slow to increase, and disparities in screening remain. METHODS To address the disparity in screening for this high burden but largely preventable disease, the Centers for Disease Control and Prevention (CDC) designed and established a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 for low-income, under-insured or uninsured men and women aged 50 to 64 years in 5 participating US program sites. In this report, the authors describe the design of the CRCSDP and the overall clinical findings and screening test performance characteristics, including the positive fecal occult blood testing (FOBT) rate; the rates of polyp, adenoma, and cancer detection with FOBTs and colonoscopies; and the positive predicative value for polyps, adenomas, and cancers. RESULTS In total, 5233 individuals at average risk and increased risk were screened for colorectal cancer across all 5 sites, including 44% who underwent screening FOBT and 56% who underwent screening colonoscopy. Overall, 77% of all individuals screened were women. The FOBT positivity rate was 10%. Results from all screening or diagnostic colonoscopies indicated that 75% had negative results and required a repeat screening colonoscopy in 10 years, 16% had low-risk adenomas and required surveillance colonoscopy in 5 to 10 years, 8% had high-risk adenomas and required surveillance colonoscopy in 3 years, and 0.6% had invasive cancers. CONCLUSIONS This report documents the successes and challenges in implementing the CDC's CRCSDP and describes the clinical outcomes of this 4-year initiative, the patterns in program uptake and test choice, and the comparative test performance characteristics of FOBT versus colonoscopy. Patterns in final outcomes from the follow-up of positive screening tests were consistent with national registry data. Cancer 2013;119(15 suppl):2820–33. © 2013 American Cancer Society.

BACKGROUND: In 2005, the Centers for Disease Control and Prevention (CDC) funded 5 sites as part of the Colorectal Cancer Screening Demonstration Program (CRCSDP) to provide colorectal cancer screening to low-income, uninsured, and underinsured individuals. Funded sites experienced unexpected challenges in recruiting patients for services. METHODS: The authors conducted a longitudinal, qualitative case study of all 5 sites to document program implementation, including recruitment. Data were collected during 3 periods over the 4-year program and included interviews, document review, and observations. After coding and analyzing the data, themes were identified and triangulated across the research team. Patterns were confirmed through member checking, further validating the analytic interpretation. RESULTS: During early implementation, patient enrollment was low at 4 of the 5 CRCSDP sites. Evaluators found 3 primary challenges to patient recruitment: overreliance on in-reach to National Breast and Cervical Cancer Early Detection Program patients, difficulty keeping colorectal cancer screening and the program a priority among staff at partnering primary care clinics responsible for patient recruitment, and a lack of public knowledge about the need for colorectal cancer screening among patients. To address these challenges, site staff expanded partnerships with additional primary care networks for greater reach, enhanced technical support to primary care providers to ensure more consistent patient enrollment, and developed tailored outreach and education. CONCLUSIONS: Removing financial barriers to colorectal cancer screening was necessary but not sufficient to reach the priority population. To optimize colorectal cancer screening, public health practitioners must work closely with the health care sector to implement evidence-based, comprehensive strategies across individual, environmental, and systems levels of society. Cancer 2013;119(15 suppl):2914-25. V C 2013 American Cancer Society.

BACKGROUND Colorectal cancer, as the second leading cause of cancer-related deaths among men and women in the United States, represents an important area for public health intervention. Although colorectal cancer screening can prevent cancer and detect disease early when treatment is most effective, few organized public health screening programs have been implemented and evaluated. From 2005 to 2009, the Centers for Disease Control and Prevention funded 5 sites to participate in the Colorectal Cancer Screening Demonstration Program (CRCSDP), which was designed to reach medically underserved populations. METHODS The authors conducted a longitudinal, multiple case study to analyze program implementation processes. Qualitative methods included interviews with 100 stakeholders, 125 observations, and review of 19 documents. Data were analyzed within and across cases. RESULTS Several themes related to CRCSDP implementation emerged from the cross-case analysis: the complexity of colorectal cancer screening, the need for teamwork and collaboration, integration of the program into existing systems, the ability of programs to use wisdom at the local level, and the influence of social norms. Although these themes were explored independently from 1 another, interaction across themes was evident. CONCLUSIONS Colorectal cancer screening is clinically complex, and its screening methods are not well accepted by the general public; both of these circumstances have implications for program implementation. Using patient navigation, engaging in transdisciplinary teamwork, assimilating new programs into existing clinical settings, and deferring to local-level wisdom together helped to address complexity and enhance program implementation. In addition, public health efforts must confront negative social norms around colorectal cancer screening. Cancer 2013;119(15 suppl):2870–83. © 2013 American Cancer Society.

We provide three new stylized facts that characterize the role of multinationals in the U.S. manufacturing employment decline, using a novel microdata panel from 1993-2011 that augments U.S. Census data with firm ownership information and transaction-level trade. First, over this period, U.S. multinationals accounted for 41% of the aggregate manufacturing decline, disproportionate to their employment share in the sector. Second, U.S. multinational-owned establishments had lower employment growth rates than a narrowly-defined control group. Third, establishments that became part of a multinational experienced job losses, accompanied by increased foreign sourcing of intermediates by the parent firm. To establish whether imported intermediates are substitutes or complements for U.S. employment, we develop a model of input sourcing and show that the employment, impact of foreign sourcing depends on a key elasticity of firm size to production efficiency. Structural estimation of this elasticity finds that imported intermediates substitute for U.S. employment. In general equilibrium, our estimates imply a sizable manufacturing employment decline of 13%.

The April 2016 Kumamoto earthquake in southwest Japan has sent ripple effects through global supply chains. Toyota, Honda and Sony halted most Japanese production following the quake, and more recently General Motors announced production stoppages at four North American plants, citing parts shortages. Such far-reaching consequences of natural disasters are not without precedent.

Although lung cancer is the deadliest type of cancer, survival rates are improving. To address the dearth of literature about the concerns of lung cancer survivors, the authors conducted 21 in-depth interviews with lung cancer survivors that focused on experiences during diagnosis, treatment, and long-term survivorship. Emergent themes included feeling blamed for having caused their cancer, being stigmatized as throwaways, and long-term survivors' experiencing surprise that they are still alive, given poor overall survival rates. Survivors also desired increased public support. It is imperative for healthcare and public health professionals to learn more about needs of this population.

Reference LPI-ARTICLE-2006-009doi:10.1002/fuce.200500093View record in Web of Science Record created on 2006-05-08, modified on 2017-05-12

Using novel firm-level microdata and leveraging a natural experiment, this paper provides causal evidence for the role of trade and multinational firms in the cross-country transmission of shocks. Foreign multinational affiliates in the U.S. exhibit substantial intermediate input linkages with their source country. The scope for these linkages to generate cross-country spillovers in the domestic market depends on the elasticity of substitution with respect to other inputs. Using the 2011 Tohoku earthquake as an exogenous shock, we estimate this elasticity for those firms most reliant on Japanese imported inputs: the U.S. affiliates of Japanese multinationals. These firms suffered large drops in U.S. output in the months following the shock, roughly one-for-one with the drop in imports and consistent with a Leontief relationship between imported and domestic inputs. Structural estimates of the production function for all firms with input linkages to Japan yield disaggreg ated production elasticities that are similarly low. Our results suggest that global supply chains are sufficiently rigid to play an important role in the cross-country transmission of shocks.

Background: Fluorescence diagnosis (FD) using the photosensitiser 5-aminolaevulinic acid (ALA) was experimentally combined with conventional video assisted thoracic surgery (VATS) to improve tumour staging in advanced lung cancer with pleural tumour spread. Methods: A disseminated pleural carcinosis affecting the entire pleural cavity was induced by inoculation of human adenocarcinoma cells in nude rats. After 5–7 weeks of tumour growth the animals were randomised into six groups with different photosensitisation parameters. Pleural lavage was performed either with 1.5% or 3.0% ALA solution. Photosensitisation times varied were 2, 4, or 6 hours. Conventional white light VATS was first performed to evaluate tumour growth in the pleural cavity. Fluorescence illumination of the light source, the D-light, was then used to examine the site for additional tumours which were previously invisible. The tumour fluorescence intensity was measured spectrometrically and compared with normal tissue. Results: Compared with conventional white light VATS alone, thoracoscopic fluorescence diagnosis (TFD) detected up to 30% additional pleural malignant lesions. The highest diagnostic sensitivity was reached 6 hours after 3.0% ALA pleural lavage. Photosensitiser accumulation in the tumour, measured indirectly by spectrometry, was up to 11 times higher than in normal tissue. Conclusions: TFD increases sensitivity of VATS for tumour staging. It may prevent unnecessary thoracotomies in cancer patients and facilitate surgical planning.

Red, green, blue, yellow, and white have been distinguished from other hues as unique. We present results from two experiments that undermine existing behavioral evidence to separate the unique hues from other colors. In Experiment 1 we used hue scaling, which has often been used to support the existence of unique hues, but has never been attempted with a set of non-unique primaries. Subjects were assigned to one of two experimental conditions. In the "unique" condition, they rated the proportions of red, yellow, blue, and green that they perceived in each of a series of test stimuli. In the "intermediate" condition, they rated the proportions of teal, purple, orange, and lime. We found, surprisingly, that results from the two conditions were largely equivalent. In Experiment 2, we investigated the effect of instruction on subjects' settings of unique hues. We found that altering the color terms given in the instructions to include intermediate hues led to significant shifts in the hue that subjects identified as unique. The results of both experiments question subjects' abilities to identify certain hues as unique.

Our knowledge of the etiologies of syncope and presyncope has been rapidly expanding along with an awareness that syncope, previously considered a universally benign event, does require evaluation. Syncope during adolescence can be caused by a variety of conditions including: neurologic, cardiac (excluding arrhythmias), arrhythmogenic, metabolic, and psychiatric conditions (Table 1) (1–10). The most common cause of syncope (at least 50%) appears to be neurally mediated syncope (11–14). Neurally mediated syncope (NMS), defined as the transient loss of blood flow to the brain secondary to hypotension and bradycardia, is emerging as a significant and potentially disabling condition for many adolescents. This condition may produce a wide variety of symptoms that include, but are not limited to, fatigue, dizziness, abdominal discomfort, muscle or joint pain, decreased mental concentration, and syncope (15). Syncope may occur without warning, thus precipitating trauma or death if the adolescent is engaged in an activity such as driving a vehicle or standing on a ladder. Linzer et al. (16) have shown that people with recurrent syncope have significant impairment, both of psychosocial and physical functioning. Teenagers may miss a great deal of school, work, and social activities owing to incapacitating symptoms, misdiagnosis, or ineffective treatment. Furthermore, lack of preparation of school personnel or employers to feel comfortable in assisting the adolescent with management of their symptoms while at school or work may also keep them from normal adolescent activities. Because these symptoms can be associated with a variety of conditions, an expensive and exhaustive evaluation is generally done. An empiric knowledge base is building to support NMS as an easily diagnosed and treatable condition. This article will focus on the etiologies of syncope and presyncope that can be diagnosed by tilt-table testing and describe an appropriate assessment, evaluation, and intervention in a cost-effective yet inclusive manner.

Because traditional mental health models are inadequate in meeting the needs of adolescents, hotlines have been developed to alleviate this gap in service. National survey results of adolescent hotlines and an indepth study of one program are presented. Although data indicated only 10% of hotlines exclusively use peers to answer phones, the authors' case study suggests that the “self-help” model of volunteering has benefits not only for consumers but also for adolescent volunteers.

Collaboration is used by the US National Security Council as a means to integrate inter-federal government agencies during planning and execution of common goals towards unified, national security. The concept of collaboration has benefits in the healthcare system by building trust, sharing resources, and reducing costs. The current terrorist threats have made collaborative medical training between military and civilian agencies crucial.This review summarizes the long and rich history of collaboration between civilians and the military in various countries and provides support for the continuation and improvement of collaborative efforts. Through collaboration, advances in the treatment of injuries have been realized, deaths have been reduced, and significant strides in the betterment of the Emergency Medical System have been achieved. This review promotes collaborative medical training between military and civilian medical professionals and provides recommendations for the future based on medical collaboration.

This paper describes the software tools, testing activities, and testing methods that were used to port the DPPX/SP operating system from its original implementation on the IBM 8100 Information System to its new implementation on the IBM ES/9370 Information System.

We report on our experience with transhepatic access for catheter interventions in six children (age range 2.5 months-9 years). Three had systemic venous anomalies, and one infant a femoral venous occlusion. In two further patients with bradyarrhythmia after a Fontan operation with an intraatrial Gore-Tex tunnel, transhepatic access was chosen to achieve a perpendicular orientation of the transseptal needle to the atrial baffle, allowing puncture of the Gore-Tex membrane. Two of the patients underwent ablation of an accessory pathway; in one an atrial septal defect was closed. A 2.5 month old baby after Norwood I operation, underwent balloon dilation of the pulmonary arteries. Two patients after prior Fontan surgery underwent DDDR pacemaker implantation. The size of the introducer sheath ranged from 4 F up to two 9 F introducers in the same vein for pacemaker insertion. At the end of the procedure, hemostasis was achieved by external compression.Transhepatic access could be established in all six patients (using a mirror image approach in children with left atrial isomerism) and the interventional procedures could be performed as planned. In one patient with implantation of a permanent pacemaker, a subcutaneous hematoma occurred, requiring blood transfusion.In selected pediatric patients, transhepatic access for catheter intervention can easily be achieved.

Vasovagal or neurocardiogenic syncope usually occurs in the upright position as a result of an inappropriate vasomotor response allowing venous pooling. This decrease in venous return is thought to result in vigorous ventricular contractions and activation of cardiac mechanoreceptors. This results in a paradoxic bradycardia and peripheral vascular dilation, further augmenting hypotension. This in turn may lead to cerebral hypoxia and syncope.1,2 Upright tilt table testing has been determined to be a useful provocative tool for evaluating patients with recurrent unexplained syncope.1-20 Although tilt table responses may indicate neurocardiogenic syncope of the classic or dysautonomic pattern or postural orthostatic tachycardia, treatment has been similar. Traditional treatment includes volume expansion, cardioselective β-1 adrenergic blocking agents, anticholinergic agents, methylxanthines, and serotonin reuptake inhibitors.8,20 We retrospectively reviewed a select group of patients with positive tilt table responses who were particularly resistant to traditional therapy. These patients also had coexistent menstrual irregularities. We describe their improvement in symptoms related to neurocardiogenic syncope during treatment with ovarian hormone therapy prescribed to treat their menstrual irregularities. This is a case series of 15 women, seen between 1993 and 1996 at the Medical College of Ohio, who …

Objective: To examine mutual support of inner-city parents and how it relates to the father's expected role as a parent. Design: Cross-sectional study. Setting: An urban teaching hospital in inner-city Baltimore, Md. Patients or Other Participants: Inner-city—dwelling parents whose neonates were born at an urban teaching hospital between March and May 1992. Intervention: Data were collected through structured independent interviews with each parent during the neonate's hospitalization. Main Outcome Measures: General social support was assessed by Sarason's Social Support Questionnaire. Paternal involvement was defined as the father's expected accessibility, engagement in child-rearing tasks, and decision-making responsibility during infancy. Results: Most mothers and fathers cited the other parent as a source of general support. Most believed that the other parent would help and would not hinder them in their role as parent. For mothers, the father's expected accessibility, engagement, and decision-making responsibility was positively correlated with his general support. For the fathers, expected accessibility was positively related to general support from the mother. As parents' mutual support increased, so did concordance in their expectations of the father's role. Conclusions: Many inner-city parents do rely on each other. Pediatricians can promote shared parenting by recognizing and building on this mutual support. (Arch Pediatr Adolesc Med. 1995;149:868-872)

Abstract 2419 Poster Board II-396 Syncope is generally defined as a state of temporary, partial or complete, loss of consciousness (fainting) with spontaneous recovery. The basis for the phenomenon is complex and includes a variety of orthostatic intolerance conditions including neurocardiogenic syncope (NCS), postural orthostatic tachycardia syndrome (POTS), and other disorders affecting the autonomic nervous system. NCS patients and POTS patients can be differentiated with an upright tilt test because either bradycardia or tachycardia will occur with hypotension, respectively. Both are induced by the inability to maintain adequate systemic blood pressure. Though the two primary types of syncope are different in origin, both conditions are treated similarly. Recent reports suggest that syncope is a low serotonin (5HT) disorder and selective serotonin reuptake inhibitors (SSRIs) are a commonly prescribed treatment for both NCS and POTS patients. The major storage pool of serotonin, independent of the central nervous system, is contained in platelet dense granules (DG). Peripheral serotonin aids in vasoconstriction and blood clotting. Individuals prone to syncope may be deficient in serotonin. Insufficient peripheral serotonin may create conditions that lead to hypotension and excessive bleeding in an individual. We previously reported that patients having episodes of syncope (Blood, 112(11):451, 2008) had statistically significant decreases of DG/PL, consistent with DG storage pool deficiency (δSPD), and PL 5HT concentrations when compared to control subjects. Our test subjects were screened by questionnaire to determine syncope and distinction between NCS and POTS was not considered. These patients had an average of 3.08 ± 0.52 DG/PL and a mean 5HT concentration of 248.40 ± 37.94 ng/109 PL (PL 5HT normal range = 215-850 ng/109 PL). Control subjects (n=24) had an average of 4.22 ± 0.12 DG/PL and a 5HT concentration of 666.54 ± 56.25; both values having a significant difference (p=.003 and p Patients for this study were obtained from our cardiology clinic and all were positive for POTS; they were not currently taking or were recently prescribed a SSRI for therapeutic management of their condition. Control subjects did not have syncope or history of bleeding. Peripheral blood was collected and PLs obtained via centrifugation to determine the mean DG/PL by electron microscopy and the mean 5HT concentration extracted from PLs using an ELISA technique. POTS patients (n=14) had a mean serotonin level of 326.6 ± 76.7 ng/109 PL compared to 589.6 ± 56.3 ng/109PL (p Disclosures: No relevant conflicts of interest to declare.

Neurocardiogenic, or vasovagal syncope as it is also known, is a condition that may lead to a temporary loss of consciousness. It is thought to be caused primarily by a lack of blood flow to the brain. The condition, commonly referred to as “fainting” or “passing out”, is reported to be the basis for 3% of emergency room visits and 6% of hospital admissions. The pathogenesis of syncope is yet to be completely understood but it has been postulated that a sudden failure of the autonomic nervous system’s ability to maintain blood pressure and heart rate leads to insufficient cerebral perfusion. A “hyper-contractile” cardiac state is created due to excessive venous pooling and a diminished peripheral venous return is thought to activate afferent mechanoreceptors, subsequently causing a paradoxical reflex of bradycardia, that results in a drop of peripheral vascular resistance. It has been postulated that an increase in serotonin (5HT) activity in the central nervous system acts as an inhibitor of sympathetic stimulation, preventing the symptoms of syncope. One of a number of pharmacologic approaches to the management of neurocardiogenic syncope is the use of selective serotonin reuptake inhibitors (SSRIs). We commonly evaluate patients having undiagnosed bleeding symptoms for PL DG SPD, many of which have been diagnosed with neurocardiogenic syncope; we have previously reported laboratory results from a total of 358 subjects having neurocardiogenic syncope (Blood110(11):945A, 2007). In that study, eighty-two percent (293/358) of the patients had DG SPD, with an average of 2.27 ± 0.06 DG/PL (normal: 4–6 DG/PL). 98% (351/358) of the patients were female. Common bleeding symptoms included 53.8% with menorrhagia (189/351), 43.9% (157/358) with easy bruising, and 15.6% with epistaxsis (56/358). Neurocardiogenic syncope has been reported to be a low 5HT disorder. The major storage pool of 5HT in the circulation is known to exist in platelet (PL) dense granules (DGs) and therefore it is possible that a PL dense granule storage pool deficiency (DG SPD) could be an important mediator of neurocardiogenic syncope. Our ongoing study of neuocardiogenic syncope patients now includes the ELISA results for 5HT concentration extracted from PLs of 38 subjects. These patients had an average of 3.08 ± 0.52 DG/PL and a mean 5HT concentration of 248.40 ± 37.94 ng/109 PL (PL 5HT normal range = 215– 850 ng/109 PL). Control subjects (n=24) had an average of 4.22 ± 0.12 DG/PL and a 5HT concentration of 666.54 ± 56.25. Both DG/PL and 5HT values are significantly different (p=.003 and p Our results suggest that a significant number of patients having neurocardiogenic syncope have DG SPD and low concentrations of 5HT stored in these granules. These results may be related to the fact that most subjects included in our study have a history or symptom of bleeding. The mechanism of 5HT uptake by the platelet is independent of adenine nucleotide and calcium storage within DGs, thus the low 5HT levels found in the 38 cases described here may/may not be related to pathophysiology of neurocardiogenic syncope.

From July 1986 to July 1989, 40 patients (92% pretreated) with deep-seated, advanced soft tissue sarcomas (STS, 25 patients), Ewing's sarcomas (ES, eight patients), osteosarcomas (OS, three patients) and chondrosarcomas (ChS, four patients) were treated at the University of Munich in a protocol involving regional hyperthermia (RHT) combined with ifosfamide plus etoposide. A total of 265 RHT treatments (mean, 6.6 RHT per patient) were applied including 33 pelvic, four extremity, and three abdominal sites. The mean tumor volume was 537 cc (range, 50 to 2,980 cc). For systemic chemotherapy, all patients received ifosfamide (1.5 g/m2, days 1 to 5), etoposide (100 mg/m2, days 1, 3, and 5), and mesna (300 mg/m2 x 4, days 1 to 5) with RHT given only on days 1 and 5 in repeated cycles every 4 weeks. Acute toxicity consisted primarily of pain (57%) combined with local discomfort within the annular phased array applicator (AA) of the BSD hyperthermia system (BSD Medical Corp, Salt Lake City, UT). The average maximum systemic temperature was 37.4 +/- 0.5 degrees C, and there was no indication of enhanced bone marrow toxicity due to the addition of RHT to the systemic chemotherapy. Detailed thermal mapping by invasive thermometry was performed in all patients. In 38 assessable patients, the overall objective response rate was 37%: six complete responses (CRs), four partial responses (PRs), and four favorable histologic responses (FHRs) (95% confidence limits, 22% to 54%). Complete responders are alive and disease-free at 40, 35, 23, 19, 19, and 8 months. Of patients with PR and FHR, two died from metastatic disease after 4 and 17 months and one died from other disease after 27 months. The remaining five patients are stable at 37, 25, 21, 13, and 8 months. Eleven patients showed no change (NC), and 13 patients showed local tumor progression (PD). The mean observation time for all patients was 11.6 months. The time-averaged temperatures (Ts) of all RHT treatments calculated as 20% (T20), 50% (T50), or 90% (T90) of measured tumor sites differed significantly between responders and nonresponders (T20, P = .003; T50, P = .006; and T90, P = .004; respectively). These data support activity for ifosfamide-etoposide combined with RHT in pretreated patients with advanced sarcomas.

The purpose of this study was to evaluate platelet dysfunction as a mitigating factor of neurocardiogenic syncope. Neurocardiogenic, or vasovagal syncope as it is also known, is a condition that may lead to temporary loss of consciousness and posture. Commonly referred to as, “fainting,” or, “passing out”, it is the basis for 3% of emergency room visits and 6% of hospital admissions; it is thought to be caused primarily by a lack of blood flow to the brain. However, the pathogenesis of syncope is yet to be completely understood. Vasovagal syncope has been postulated to occur due to a sudden failure of the autonomic nervous system’s ability to maintain blood pressure and heart rate leading to insufficient cerebral perfusion. Subsequently, a cardiac “hyper-contractile” state is created, due to excessive venous pooling and diminished peripheral venous return that is thought to activate afferent mechanoreceptors, interpreted by the brain as hypertension causing a paradoxical reflex of bradycardia, resulting in a drop of peripheral vascular resistance. It has been postulated that an increase in serotonin (5HT) activity in the central nervous system acts as an inhibitor of sympathetic stimulation, preventing the symptoms of syncope. One of a number of pharmacologic approaches to the management of neurocardiogenic syncope is the use of selective serotonin reuptake inhibitors (SSRIs). Neurocardiogenic syncope has also been reported to be a low 5HT disorder. As the major storage pool of 5HT in the circulation is known to exist in platelet (PL)dense granules (DGs), it is possible that a PL dense granule storage pool deficiency (DG SPD) could be an important mediator of neurocardiogenic syncope. We commonly evaluate patients having undiagnosed bleeding symptoms for PL DG SPD. A total of 358 subjects having neurocardiogenic syncope have been evaluated because of a significant bleeding history. Eighty-two percent (293/358) of these patients have DG SPD, with an average of 2.27 ± 0.06 DG/PL (normal: 4–6 DG/PL). Interestingly, 98% (351/358) of these patients are female. Common bleeding symptoms included 53.8% with menorrhagia (189/351), 43.9% (157/358) with easy bruising, and 15.6% with epistaxsis (56/358). It has been reported in a study of 15 patients, that the PL 5HT concentration, determined by HPLC methodology, did not alter during episodes of syncope, suggesting that the serotonergic system does not play a role in the pathophysiology of vasovagal syncope. We are currently evaluating the 5HT concentration extracted from PLs of syncope patients by ELISA. To date, 10 such patients have been studied, having an average of 2.32 ± 0.26 DG/PL; their mean 5HT concentration is 202.13 ± 29.12 ng/109 PL (normal range = 215–850 ng/109 PL). Our preliminary results suggest that a significant number of patients having neurocardiogenic syncope have DG SPD and low concentrations of 5HT stored in these granules. These results may be attributed to the fact that all subjects included in our study presented with a history or symptom of bleeding. The mechanism of 5HT uptake by the platelet is independent of adenine nucleotide and calcium storage within DGs, thus the low 5HT levels found in the few cases described here may/may not be related to pathophysiology of neurocardiogenic syncope. A prospective study of neurocardiogenic syncope patients with/without bleeding histories or symptoms is planned to further evaluate the PL DG storage pool.

We describe the response to hormonal therapy of a cohort of women with known neurocardiogenic syncope and dysfunctional uterine bleeding. This is a retrospective evaluation of 17 women aged 14 - 55 years of age (12 patients were less than 22 years old) seen in a tertiary care medical center. All had tilt-table tests which were consistent with neurocardiogenic syncope of the classic or dysautonomic pattern, and symptoms which did not completely resolve until the addition of hormonal therapy. All 17 patients were initially treated with at least “standard” therapy which may have included: Florinef, beta-blockers, and methylphenidate. Many were also treated with serotonin re-uptake inhibitors. None experienced full resolution of symptoms on this regimen. All reported disturbances of their menstrual cycle ranging from oligomenorrhea to metromenorrhagia and/or worsening of syncopal symptoms at the time of menses. Their syncopal/presyncopal symptoms improved significantly with the introduction of hormonal therapy either in the form of oral contraceptive pills, Depo Provera, or estrogen replacement. Hormonal therapy may be important not only for the menstrual irregularities associated with dysautonomia but also for management of the syncopal symptoms.

All the possible arrangements of closed-cycle helium turbines for combined power and steam generation can be reduced to three variations of one single arrangement. A method for the optimum layout of this arrangement is described. Optimum data are determined for the expansion ratio and the regenerative heat exchange as functions of general parameters—electric power output and quantity and quality of the steam produced—and as functions of special parameters of the gas turbine cycle—number of intercoolers, cooling and feedwater temperatures, turbine inlet temperature and pressure drop—to obtain the best possible efficiencies.

Many methods have been described for diagnostic procedures in sarcoidosis with different rates of success. Complications depend upon the skill and experience of the examiner. Since in sarcoidosis usually there are no great consequences therapeutically, those diagnostic procedures are prefered with minimal discomfort and risc for the patients. One of these methods is the transmural lymphnode aspiration biopsy of the carina. This is possible with a long needle which is pushed forward by the guidance of the rigid bronchoscope into the lymphnode of the carina (Fig. 1). By forced aspiration material for cytologic examination can be obtained. This material is ejected and smeared on a preparation slide. The macroscopic appearance of the aspirate already showes its effectivity. In case of aspiration of blood or aspiration of aquous material the biopsy has to be repeated. A sample of opaque and pink material demonstrates that lymphatic material is obtained.

VARIOUS studies have been performed on a group of patients unde. going section of the vagus nerves for peptic ulceration1on the Thin (New York University) Surgical Division, Bellevue Hospital. Moreover, Dr. Frank B. Berry, Director of the First (College of Physicians and Surgeons) Surgical Division, has permitted us to make observations on a small group of patients undergoing similar procedures on that service. We have outlined a plan of investigation devoting attention not only to alterations in gastric physiology but to other visceral functions proved or suggested by animal experimentation to be mediated through the vagus nerves. All of these studies require further pursuit and analysis. However, certain findings which seem to us to be of some significance are presented at this time. They are as follows: (1) the effect of alcohol intragastrically and intravenously on secretion of gastric acid, and its relation to the effect of histamine