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OBJECTIVE: To characterize diabetes care across healthcare facilities in six Peruvian regions. METHODS: Cross-sectional study of patients with type 2 diabetes mellitus (T2DM), ranging from primary care facilities to hospital-based facilities, in six Peruvian regions. Data was collected by health staff trained between 2012 and 2016. We studied six diabetes care outcomes and four adequate diabetes care outcomes considering the healthcare facility as the exposure of interest. We estimated prevalence ratios (PR) and their 95% confidence intervals (95% CI) using Poisson regression with robust variance. RESULTS: Data from 8879 patients with T2DM, mean age 59.1 years (SD ± 12.2), 53.6% males, was analyzed. Of these, 8096 (91.2%) were treated at primary care facilities. The proportions of patients who had HbA1c, LDL-c, and creatinine/microalbumin test performed increased with the setting of the healthcare facility. Overall, 39%-56% of patients had an adequate HbA1c control, being higher in hospital-based facilities with specialists in comparison to primary care facilities. CONCLUSIONS: We observed that the higher the setting of the facility, the higher the rate of the assessed diabetes care outcomes and adequate diabetes care for four of the six targets (fasting glucose, HbA1c, LDL-c and creatinine or microalbumin) and for three of the four targets (glucose≤130 mg/dL, HbA1c ≤7%(53 mmol/mol) and LDL-c

Correlations between postoperative complications and oncological outcomes have been reported in several malignancies, but their impact in retroperitoneal sarcoma (RPS) is unclear. Our study aimed to evaluate the association between postoperative complications and prognosis in patients with RPS. Patients undergoing surgery for primary RPS from 2008 to 2019 at a sarcoma center were evaluated. The cumulative burden of postoperative complications was quantified using the Comprehensive Complication Index (CCI), and associations with local recurrence (LR), distant metastases (DM) and overall survival (OS) were assessed. Data were available for 191 patients, of whom 160 (82.9%) developed at least one postoperative complication, with a median CCI of 20.9 (interquartile range 8.7–33.5). After postoperative deaths were excluded (n = 3, 1.6%), the remaining patients were divided into those with a CCI of 0–20.9 (n = 97) and > 20.9 (n = 91). Patients with a CCI >20.9 had significantly shorter OS than those with a CCI of 0–20.9 (43.3% vs. 69.5% at 5 years; p = 0.005), and this difference remained significant after multivariable adjustment for patient- and treatment-related factors [hazard ratio (HR) 2.31, 95% confidence interval (CI) 1.30–4.09; p = 0.004]. However, CCI > 20.9 was not found to be a significant independent predictor of either LR (HR 1.30, 95% CI 0.76–2.23; p = 0.333) or DM (HR 1.08, 95% CI 0.61–1.93; p = 0.786). Increasing complication burden, as quantified by the CCI, is a significant independent predictor of OS; however, there is no evidence of a significant association with either LR or DM, which may be more related to tumor biological factors.

Aims Tenosynovial giant cell tumour (TGCT) is one of the most common soft-tissue tumours of the foot and ankle and can behave in a locally aggressive manner. Tumour control can be difficult, despite the various methods of treatment available. Since treatment guidelines are lacking, the aim of this study was to review the multidisciplinary management by presenting the largest series of TGCT of the foot and ankle to date from two specialized sarcoma centres. Methods The Oxford Tumour Registry and the Leiden University Medical Centre Sarcoma Registry were retrospectively reviewed for patients with histologically proven foot and ankle TGCT diagnosed between January 2002 and August 2019. Results A total of 84 patients were included. There were 39 men and 45 women with a mean age at primary treatment of 38.3 years (9 to 72). The median follow-up was 46.5 months (interquartile range (IQR) 21.3 to 82.3). Localized-type TGCT (n = 15) predominantly affected forefoot, whereas diffuse-type TGCT (Dt-TGCT) (n = 9) tended to panarticular involvement. TGCT was not included in the radiological differential diagnosis in 20% (n = 15/75). Most patients had open rather than arthroscopic surgery (76 vs 17). The highest recurrence rates were seen with Dt-TGCT (61%; n = 23/38), panarticular involvement (83%; n = 5/8), and after arthroscopy (47%; n = 8/17). Three (4%) fusions were carried out for osteochondral destruction by Dt-TGCT. There were 14 (16%) patients with Dt-TGCT who underwent systemic treatment, mostly in refractory cases (79%; n = 11). TGCT initially decreased or stabilized in 12 patients (86%), but progressed in five (36%) during follow-up; all five underwent subsequent surgery. Side effects were reported in 12 patients (86%). Conclusion We recommend open surgical excision as the primary treatment for TGCT of the foot and ankle, particularly in patients with Dt-TGCT with extra-articular involvement. Severe osteochondral destruction may justify salvage procedures, although these are not often undertaken. Systemic treatment is indicated for unresectable or refractory cases. However, side effects are commonly experienced, and relapses may occur once treatment has ceased. Cite this article: Bone Joint J 2021;103-B(4):788–794.

Background This paper describes the evolutionary changes in morphology and orientation of the PFJ using species present through our ancestry over 340 million years. Methods 37 specimens from the Devonian period to modern day were scanned using a 64-slice CT scanner. 3D geometries were created following routine segmentation and anatomical measurements taken from standardised bony landmarks. Results Findings are described according to gait strategy and age. The adoption of an upright bi-pedal stance caused a dramatic change in the loading of the PFJ which has subsequently led to changes in the arrangement of the PFJ. From Devonian to Miocene periods, our sprawling and climbing ancestors possessed a broad knee with a shallow, centrally located trochlea. A more rounded knee was present from the Paleolithic period onwards in erect and bipedal gait types (aspect ratio 0.93 vs 1.2 in late Devonian), with the PFJ being placed lateral to the midline compared to the medial position in quadrapeds. The depth of the trochlea groove was maximal in the Miocene period of the African ground apes with associated acute sulcus angles in Gorilla (117°) becoming more flattened towards the modern human (138°). Conclusions The evolving bipedal gait lead to anteriorisation of the patellofemoral joint, flattening of the trochlea sulcus, in a more lateral, dislocation prone arrangement. Ancestral developments might help explain the variety of presentations of anterior knee pain and patellofemoral instability.

Background High-sensitivity Troponin T and I (hsTnT/I) concentration is independently associated with coronary artery disease (CAD) severity and cardiovascular outcome. Here we explored whether hsTnT/I blood levels add predictive information irrespective of CAD severity and further confounders in unselected stable patients with angiographically characterized CAD. Methods Between 2015 and 2020, 3,012 patients undergoing coronary angiography were included in the observational Hamburg INTERCATH study. In 2,209 consecutive patients Troponin levels were quantified for hsTnT (Roche Diagnostics Elecsys) and hsTnI (Abbott Diagnostics ARCHITECT STAT). Patients presenting with acute coronary syndromes and heart transplant recipients were excluded, leaving 1,841 patients for analyses. CAD severity was graded according to the Gensini score. Major adverse cardiac events (MACE) as a composite of cardiovascular death, stroke, myocardial infarction, and coronary revascularization were defined as endpoint. Kaplan-Meier analyses stratified by hsTnT/I quartiles were performed. Multivariable Cox models were computed for the association of hsTnT/I with MACE adjusting for age, gender, arterial hypertension, hyperlipoproteinemia, smoking, diabetes mellitus, body-mass index, eGFR and Gensini Score. Results Mean age was 68.5±10.9 years (27.9% female). 81.1% were diagnosed with CAD by coronary angiography. Gensini score was 21.0±30.2. Median follow-up time was 4.42 years. hsTnT quartiles differentiated MACE across all categories (Figure 1A). For hsTnI, cardiovascular risk was differentiated between the lowest and highest quartiles as well as the 1st and 2nd quartile particularly beyond 24 months of follow-up (Figure 1B). However, MACE after 3 years was not associated with hsTnT after adjustment for classical cardiovascular risk factors and CAD severity (Figure 1C), whereas the hazard of MACE was increased in the 3rd and 4th hsTnI quartiles compared to the 1st quartile (HR 1.3, IQR 1.1–1.6 for both categories; Figure 1D). Conclusion Increasing hsTn concentration was related to intermediate term cardiovascular outcome in unselected stable patients. Only hsTnI concentration remained as independent predictor after testing for most possible confounders, including CAD severity. This data underpins the role of hsTnI in outcome prediction. Funding Acknowledgement Type of funding sources: None.

BACKGROUND Our study aimed to compare the comprehensive complication index (CCI) to the conventional Clavien-Dindo classification (CDC) in patients undergoing surgery for primary retroperitoneal sarcoma (RPS). METHODS Data were collected for patients who underwent surgery from 2008 to 2019 at a tertiary institution. The length of hospital stay (LOS) was used as a surrogate marker for clinical outcomes, and associations with CDC and CCI were assessed. RESULTS Data were available for 191 patients, with the highest CDC Grade of I, II, III, and IV in 18.3%, 41.9%, 17.8%, and 4.2%, respectively; the 30-day postoperative mortality (CDC Grade V) was 1.6% (N = 3). Whilst both classification systems were significantly correlated with LOS, this association was significantly stronger for CCI (Spearman's ρ: 0.768 vs. 0.648, p

Studies reporting outcomes of liver resection for sarcoma metastases (LRSM) typically include gastrointestinal stromal tumours (GIST), or pooled analyses of "non-colorectal liver metastases", which do not reflect the subgroup of patients with sarcomatous liver metastases. This study aimed to perform a systematic review to evaluate oncological and surgical outcomes in patients undergoing LRSM, and to report new data from two tertiary institutions.MEDLINE and the Cochrane Library were searched for studies reporting oncological and surgical outcomes after LRSM, following PRISMA guidelines. Studies reporting liver resection for GIST were excluded. The resulting studies were pooled, with data from two European centres.Six studies of LSRM were included, comprising 212 patients from previously reported series and 24 patients from ours, with median follow-up times of 18-53 months. Postoperative mortality rates ranged from 0 to 9%, and the pooled overall survival (OS) was 89% (95% CI: 83-96%), and 31% (95% CI: 14-47%) at one and five years, respectively (median: 36 months). The presence of synchronous extra-hepatic metastases was found to be a significant risk factor for shorter OS in two cohorts, with hazard ratios of 3.7 (p 0.001) and 9.1 (p = 0.016), respectively. The largest reported series also found larger metastases (≥100 mm), lack of response to chemotherapy and a shorter disease-free interval to be associated with significantly shorter OS after LSRM.Patients undergoing LRSM with negative prognostic factors such as the presence of extra-hepatic metastases are unlikely to benefit from surgery. Acceptable medium- and long-term survival may be achievable in highly selected patients.

Extended surgery remains the mainstay of treatment in retroperitoneal sarcoma, although conflicting data exist on the benefit of neoadjuvant and adjuvant therapies, particularly with regard to tumour grade and histological type. Experience of radiotherapy and chemotherapy in extremity soft tissue sarcoma can inform treatment strategies, however these data cannot be universally extrapolated to the retroperitoneum where disease biology and anatomical considerations are different. The present review sets a historical context before discussing recent evidence and on-going multi-centre trials in retroperitoneal sarcoma. Promising data on histologically- and molecularly-targeted chemotherapy are discussed and the need for centralisation of retroperitoneal sarcoma services in order to facilitate large international collaborative trials is emphasised.

Carcinosarcomas (CS) are uncommon, highly aggressive, biphasic tumours consisting of both sarcomatous and carcinomatous elements. They appear to originate from a common cell of origin, either via transformation from a single premature precursor or conversion of a mature epithelial cell through an epithelial-mesenchymal transition. CS should be considered a unique cancer subtype with cells typically displaying diffuse mitotic activity and widespread atypical mitoses predisposing to early metastasis and a tendency to local recurrence following resection. This review addresses the pathophysiology of CS and discusses its presentation, natural history and management at a variety of sites within the abdominal cavity and retroperitoneum.

Myeloid sarcoma is an extramedullary tumor of immature granulocytic cells. It is a rare condition, most often associated with acute myeloid leukemia (AML), although in some rare cases it may present in nonleukemic patients. It should therefore be considered as a differential diagnosis of any atypical cellular infiltrate. It may occur at any site, leading to very varied clinical presentations. Diagnosis is challenging and relies on a high index of suspicion as well as radiology, histology, immunophenotyping, and molecular analyses, which also are essential for risk stratification and treatment planning. Systemic chemotherapy using AML-like regimens should be commenced early, even in nonleukemic disease. Surgery and/or radiotherapy may be indicated for symptomatic lesions or tumors causing local organ dysfunction or obstruction. Allogeneic hematopoietic stem cell transplantation has demonstrated promising results, particularly in patients who achieved complete remission with AML-induction protocols, and recent advances in genetic profiling may enable the development of novel targeted therapies. Prospective multicenter controlled trials are required to further refine management decisions and investigate the role of novel targeted therapies.

Biopsy sensitivity in retroperitoneal dedifferentiated liposarcoma (DDLPS) is variable. Patients with grade 3 DDLPS face a significant risk of metastatic disease and may potentially benefit from neoadjuvant therapy, making highly accurate pretherapy diagnosis essential. Our study aimed to establish whether diagnostic sensitivity could be improved by targeting solid areas of tumor on percutaneous biopsy. Between 2016 and 2019, data on patients with suspected primary retroperitoneal sarcoma who underwent a biopsy were collected, and diagnostic accuracy was calculated. These data were compared with our previously reported series from 2005 to 2016. For DDLPS tumors, comparisons were then made between biopsies that targeted the solid component and those that did not. Data were available for 121 patients in the current series and 238 from the previous study. The proportion of biopsies returning a histological subtype concordant with postoperative pathology was 83% in the current series, marking a significant improvement over our previous study (67%, p = 0.001). For diagnosis of DDLPS, biopsy sensitivity improved from 40 to 74% (p

The incidence of oesophageal adenocarcinoma has increased by 500% over the past 30 years [1]. Improved understanding of the mechanisms of neoplastic progression provides an opportunity to reverse this trend. A thorough review of emerging strategies aiming to prevent the formation of oesophageal malignancy is presented. These include dietary modification, chemoprevention, early endoscopic identification and treatment of premalignant disease, and the potential for a non-endoscopic screening test. Oesophageal adenocarcinoma has become a major public health problem in the West and it is essential that clinicians are fully informed of risk reduction strategies so that they can be actively promoted in the community.

Background Early detection and targeted endoscopic resection of Barrett's esophagus–associated high-grade dysplasia (HGD) can prevent progression to invasive esophageal malignancy. Raman spectroscopy, a highly sophisticated analytical technique, has been translated into an endoscopic tool to facilitate rapid, objective diagnosis of dysplasia in the esophagus. Objective To evaluate the ability of endoscopic Raman spectroscopy (ERS) to objectively detect esophageal HGD and adenocarcinoma. Design A total of 798 one-second spectra were measured from 673 ex vivo esophageal tissue samples, collected from patients with Barrett's esophagus by using a novel endoscopic Raman probe. Spectra were correlated with consensus histopathology. Multivariate analysis was used to evaluate the classification accuracy of ERS ex vivo. Setting Probe measurements were conducted in the laboratory. Tissue specimens were collected from the operating theatre and endoscopy unit. Patients Tissue from 62 patients was included in the study. Interventions Endoscopic biopsy/resection or esophagectomy was performed where indicated clinically. Main Outcome Measurement Diagnostic performance of ERS for detection of HGD and esophageal adenocarcinoma. Results ERS demonstrated a sensitivity of 86% and a specificity of 88% for detecting HGD and adenocarcinoma. The ability to grade dysplasia and differentiate intestinal metaplasia from nonintestinal metaplasia columnar-lined esophagus was also demonstrated. Diagnostic classification was based on objective measurement of the biochemical profile of different tissue types. The potential for combination ERS and narrow-band imaging was also demonstrated. Limitations Measurements were taken from ex vivo tissue. Conclusion ERS enables rapid, accurate, objective diagnosis of superficial esophageal disease (metaplasia, dysplasia, intramucosal cancer) in clinically applicable time scales.

The management of Barrett's oesophagus and associated neoplasia has evolved considerably in recent years. Modern endoscopic strategies including endoscopic resection and mucosal ablation can eradicate dysplastic Barrett's and prevent progression to invasive oesophageal cancer. However, several aspects of Barrett's management remain controversial including the stage in the disease process at which to intervene, and the choice of endoscopic or surgical therapy. A review of articles pertaining to the management of Barrett's oesophagus with or without associated neoplasia, was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, Embase and Cochrane databases were searched to identify literature relevant to eight pre-defined areas of clinical controversy. The following search terms were used: Barrett's oesophagus; dysplasia; intramucosal carcinoma; endotherapy; endoscopic resection; ablation; oesophagectomy. A significant body of evidence exists to support early endoscopic therapy for high-grade dysplasia (HGD). Although not supported by randomised controlled trial evidence, endoscopic therapy is now favoured ahead of oesophagectomy for most patients with HGD. Focal intramucosal (T1a) carcinomas can be managed effectively using endoscopic and surgical therapy, however surgery should be considered the first line therapy where there is submucosal invasion (T1b). Treatment of low grade dysplasia is not supported at present due to widespread over-reporting of the disease. The role of surveillance endoscopy in non-dysplastic Barrett's remains controversial.

Giant cell tumors deriving from synovium are classified into a localized (GCT of tendon sheath; GCT-TS) and diffuse form (diffuse-type GCT, Dt-GCT). We propose a multidisciplinary management based upon a systematic review and authors' opinion. Open excision for GCT-TS and open synovectomy (plus excision) for Dt-GCT is advised to reduce the relatively high recurrence risk. External beam radiotherapy should be considered in severe cases, as Dt-GCT commonly extends extra-articular. J. Surg. Oncol. 2013;107:433–445. © 2012 Wiley Periodicals, Inc.

Barrett's oesophagus is a metaplastic condition with an inherent risk of progression to adenocarcinoma. It is essential to identify dysplastic changes within Barrett's oesophagus in order to individualise surveillance strategies and establish which patients warrant endoscopic treatment. There is a trend towards endoscopic resection of focal high-grade dysplasia followed by whole segment ablation. However, endoscopic identification of dysplastic lesions is unreliable and subjective making targeted therapy extremely difficult. In addition, the current practice of taking random quadrantic biopsies may miss dysplastic disease and intramucosal adenocarcinoma. Several advanced endoscopic imaging techniques have been described and tested in clinical trials in an effort to improve the detection of early lesions, although none are routinely used in clinical practice. In this article we will review these techniques and discuss their potential for clinical implementation. We will also discuss the potential benefits of multimodal imaging and highlight several newer techniques which have shown early promise for in vivo diagnosis.

There is a profound clinical need for a diagnostic tool that will enable clinicians to identify early neoplastic change in the oesophagus. Raman Spectroscopy (RS) has demonstrated the potential to provide non-invasive, rapid, objective diagnosis of endoscopically invisible precancerous oesophageal dysplasia in vitro. RS analyses biological material to identify highly specific biochemical information that can be used to influence clinical care. Raman spectroscopic mapping could provide automated assessment of tissue biopsies to aid histopathological diagnosis in vitro. Furthermore, the recent development of fibre-optic Raman probes has enabled endoscopic assessment of oesophageal mucosa in vivo. Accurate identification of dysplasia will enable targeted endoscopic resection of early lesions preventing the development of oesophageal cancer. This review summarises the development of Raman systems for use as laboratory based analytical adjuncts and endoscopic diagnostic tools in the distal oesophagus.

Pigmented villonodular synovitis (PVNS) is a synovial tumour-like lesion that frequently causes osteolysis. PVNS contains numerous macrophages and osteoclast-like giant cells. In this study, we have analysed the cytochemical and functional characteristics of mononuclear and multinucleated cells in PVNS and determined the cellular and humoral mechanisms underlying giant cell formation and resorption in PVNS. Giant cells and CD14+ and CD14− mononuclear cell populations were isolated from PVNS synovial tissue and cultured alone or in the presence and absence of the osteoclastogenic factors, RANKL and M-CSF. Osteoclast formation and activity was assessed by expression of TRAP and evidence of lacunar resorption. Giant cells in PVNS expressed an osteoclast-phenotype (CD51+, TRAP+, CD14−, HLA-DR−) and were formed only in cultures of mononuclear cells that expressed the macrophage marker CD14. Osteoclast formation required RANKL and occurred in both the presence and absence of exogenous M-CSF. CD14− cells in PVNS expressed RANKL. Lacunar resorption by PVNS-derived giant cells was abolished by the addition of the bisphosphonate, zoledronate. Our findings indicate that osteoclasts form by a RANKL-dependent mechanism from CD14+ mononuclear phagocytes in PVNS. Osteoclast formation occurred even in the absence of exogenous M-CSF, a finding which is in keeping with over-expression of M-CSF playing a pathogenic role in this condition. Anti-osteoclast resorptive treatment may be useful to control osteolysis in PVNS. Copyright © 2011 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Prevention is the most desirable strategy for nearly all disease processes, but this is especially true for a malignancy with a tendency for metastasis and a correspondingly poor prognosis. Chemoprevention through appropriate drug treatment is a potentially powerful means of radically reducing the incidence of esophageal cancer, and the search for clinically effective agents has now led to large multicenter randomized controlled trials.

The application of semi-supervised methodology to improve the classification performance of a Raman spectroscopic probe for the diagnosis of oesophageal cancer is described. It is well known that gold standard histopathology diagnosis can be highly subjective, particularly for diseases which have several stages, such as cancer. A ‘consensus’ pathology decision can be obtained to ensure a robust gold standard by obtaining a diagnosis from several experts and samples are then only included in standard classification models if they have been assigned the same pathology by all experts. This can result in a significant number of samples that are excluded from the analysis as no consensus was reached. In this work semi-supervised methodology was used to extend Principal Component Analysis followed by Linear Discriminant Analysis (PCA-LDA) to incorporate samples without consensus pathology when discriminating between benign and oesophageal cancer specimens measured using a Raman endoscopic probe ex vivo. We demonstrate that a fully semi-supervised approach improved sensitivity and specificity from 73% and 78% (PCA-LDA) to 78% and 84% (semi-supervised) for discriminating between intestinal metaplasia and dysplasia and from 44% and 66% (PCA-LDA) to 63% and 72% (semi-supervised) when discriminating between intestinal metaplasia and low grade dysplasia.

We evaluate the potential of a custom-built fiber-optic Raman probe, suitable for in vivo use, to differ- entiate between benign, metaplastic (Barrett's oesophagus), and neoplastic (dysplastic and malignant) oesophageal tissue ex vivo on short timescales. We measured 337 Raman spectra (λex ¼ 830 nm; Pex ¼ 60 mW; t ¼ 1 s) using a confocal probe from fresh (298) and snap-frozen (39) oesophageal tissue collected during surgery or endoscopy from 28 patients. Spectra were correlated with histopathology and used to construct a multivariate classification model which was tested using leave one tissue site out cross-validation in order to evaluate the diagnostic accuracy of the probe system. The Raman probe system was able to differentiate, when tested with leave one site out cross- validation, between normal squamous oesophagus, Barrett's oesophagus and neoplasia with sensitivities of (838% to 6%) and specificities of (89% to 99%). Analysis of a two group model to differentiate Barrett's oesophagus and neoplasia demonstrated a sensitivity of 88% and a specificity of 87% for classification of neoplastic disease. This fiber-optic Raman system can provide rapid, objective, and accurate diagnosis of oesophageal pathology ex vivo. The confocal design of this probe enables superficial mucosal abnormalities (metaplasia and dysplasia) to be clas- sified in clinically applicable timescales paving the way for an in vivo trial. © 2012 Society of Photo-Optical Instrumentation

Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture.We therefore determined: (1) local recurrence rates after curettage with adjuvants or en bloc resection; (2) complication rates after both surgical techniques and whether fracture healing occurred after curettage with adjuvants; and (3) function after both treatment modalities for giant cell tumor of bone with a pathologic fracture.We retrospectively reviewed 48 patients with fracture from among 422 patients treated between 1981 and 2009. The primary treatment was resection in 25 and curettage with adjuvants in 23 patients. Minimum followup was 27 months (mean, 101 months; range, 27-293 months).Recurrence rate was higher after curettage with adjuvants when compared with resection (30% versus 0%). Recurrence risk appears higher with soft tissue extension. The complication rate was lower after curettage with adjuvants when compared with resection (4% versus 16%) and included aseptic loosening of prosthesis, allograft failure, and pseudoarthrosis. Tumor and fracture characteristics did not increase complication risk. Fracture healing occurred in 24 of 25 patients. Mean Musculoskeletal Tumor Society score was higher after curettage with adjuvants (mean, 28; range, 23-30; n = 18) when compared with resection (mean, 25; range, 13-30; n = 25).Our observations suggest curettage with adjuvants is a reasonable option for giant cell tumor of bone with pathologic fractures. Resection should be considered with soft tissue extension, fracture through a local recurrence, or when structural integrity cannot be regained after reconstruction.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Over the past four decades the incidence of oesophageal cancer has increased more rapidly than that of any other solid tumour in the Western World. This rise reflects the emergence of oesophageal adenocarcinoma as the most common pathological type. Despite this growing incidence, progress towards early detection and treatment has been slow and mortality figures have remained dismal – Cancer Research UK quotes overall one and five year survival rates of just 28% and 8% respectively.(CrUK, 2010) As a result, oesophageal cancer repreasents a real and growing public health problem and urgent action is required to improve detection and facilitate early intervention, ideally at a pre-malignant stage. Most oesophageal adenocarcinoma develops following a well recognised series of cellular changes secondary to a multifactorial aetiology. In the classically described pathway there is initially a metaplastic change in the epithelial lining of the oesophagus (Barrett’s oesophagus) which then progresses to ‘low-grade‘ and then ‘high-grade‘ dysplasia. As many as 30% of patients newly diagnosed with high-grade dysplasia may already have a coexistent invasive cancer, and between 5-60% of patients will develop cancer during surveillance over 1-7 years. To date there is no early diagnostic test which can enable instantaneous accurate diagnosis of dysplasia. Clinicians are advised to take random biopsies from areas of Barrett’s oesophagus in order to identify dysplasia, but even histological assessment of dysplasia is subjective and can be unreliable. As a result, significant dysplastic change (or even intramucosal cancer) may be missed. In addition, as dysplasia (the premalignant lesion) is difficult to identify, screening for early oesophageal cancer / high-grade dysplasia cannot currently be recommended, and as a consequence, oesophageal tumours present late and so have a poor prognosis. The early recognition of high-grade dysplasia is paramount to enabling a successful treatment strategy. Surgery is one option for patients with confimred HGD, however the emergence of multiple endotherapies over the past 20 years have demonstrated the ability to cure focal high-grade dysplasia, thus preventing progression to invasive malignancy. In this chapter we will discuss the accuracy of endoscopic and histological diagnosis of dysplasia and will consider novel endoscopic adjuncts which may improve endoscopic sensitivity. We will then discuss the endoscopic therapeutic options that are available for management of dysplastic Barrett’s oesophagus and will propose a endotherapy algorithm for use in specialist Barrett’s surveillance centres.

As part of a program to visit formerly licensed sites to determine if they meet current uncontrolled release conditions, a United States Nuclear Regulatory Commission (USNRC) inspection was conducted in the fall of 1993 at a site that had possessed a radioactive material license from about 1955 to 1970. While the license was in force, the plant processed magnesium scrap containing up to 4 percent thorium. The source of the scrap is believed to be the aircraft manufacturing industry. The scrap was placed in furnaces and heated to the melting point of magnesium, and the molten magnesium was drawn off, leaving the thorium with the residue (dross). Under the regulation in existence at that time, the thorium dross was buried on site in an approximate 14 acre field. In 1993 the inspector found readings up to 900uR/h. Early in 1994 an informal grid survey of most of the 14 acre site was conducted. Based on that survey, it was concluded that the thorium was widespread and extended beyond the property lines. The preliminary findings were reported to the USNRC, and in 1994 the site was designated as a Site Decommissioning Management Plan (SMPD) site. A remediation team was formed which included the following disciplines: remediation health physics, geology, hydrology, engineering, law, public relations, and project management. This remediation team planned, participated in selecting vendors, and provided project over site for all activities from site characterization through the final status survey. In 2006 the site was released for uncontrolled access. A chronology of activities with lessons learned will be presented.Copyright © 2009 by ASME

Due to up-regulation of the parathyroid gland calcium-sensing receptor (CaR), burned children have hypocalcemic hypoparathyroidism, and decreased myocardial contractility. Our aim was to localize the CaR in the heart and measure receptor density changes due to burns. Heart and aorta samples from sheep subjected to 40% burn or sham conditions were probed for CaR via fluorescence microscopy. CaR was localized to endocardial endothelium, myocardial microvasculature, and fibroblasts and vessels of the aortic adventitia. CaR was not found in cardiomyocytes or smooth muscle cells. No differences in density of CaR or beta-adrenergic receptors were noted. No differences in CaR distribution were seen in the myocardium or aorta, in contrast to the parathyroid where burn injury up-regulates CaR. We suggest that CaR has a local, tissue-specific role, and functions in vascular calcium sensing for intravascular calcium deposition or regulation of other calcium channels after trauma or burn.

A review is presented of the response by emergency personnel, including radiation safety staff, to a fire incident in an academic radiation facility. The handling of the incident during the incident itself as well as during post-fire cleanup and recovery efforts are described. The preparation of a variety of written notification reports and the physical and procedural corrective actions taken as a result of the fire are also discussed.

Summary of ADC Measurements for Fetuses with and without Placental Insuffi ciency ParameterRegion 1 * Region 2 † Fetuses with Placental Insuffi ciency ( n = 33)Fetuses without Placental Insuffi ciency ( n = 69)Fetuses with Placental Insuffi ciency ( n = 33)Fetuses without Placental Insuffi ciency ( n = 69) Mean 1.454 1.771 1.415 1.752 Median 1.461 1.773 1.397 1.767 Standard deviation 0.106 0.208 0.132 0.181 Confidence interval 1.428, 1.498 1.705, 1.805 1.358, 1.455 1.686, 1.818 Note.— All measurements are given in 10 2 9 m 2 /sec. The average measurements of both readers are given. * Region 1 is located 2 cm from the insertion of the umbilical cord. † Region 2 is loca ted 5 cm from the insertion of the umbilical cord. “Reduction in False-Positive Results after Introduction of Digital Mammography: Analysis from Four Population-based Breast Cancer Screening Programs in Spain.” Radiology 2011;258(2):388–395 Page 388, the affi liations at the bot-tom left should read as follows: From the

This report describes a volume rendering system for unstructured data, especially finite element data, that creates images with very high accuracy. The system will currently handle meshes whose cells are either linear or quadratic tetrahedra, or meshes with mixed cell types: tetrahedra, bricks, prisms, and pyramids. The cells may have nonplanar facets. Whenever possible, exact mathematical solutions for the radiance integrals and for interpolation are used. Accurate semitransparent shaded isosurfaces may be embedded in the volume rendering. For very small cells, subpixel accumulation by splatting is used to avoid sampling error. A new exact and efficient visibility ordering algorithm is described. The most accurate images are generated in software, however, more efficient algorithms utilizing graphics hardware may also be selected. The report describes the parallelization of the system for a distributed-shared memory multiprocessor machine, and concludes by discussing the system's limits, desirable future work, and ways to extend the system so as to be compatible with projected ASCI/VIEWS architectures.

A temporary Th2 skewed immunity is essential for a successful outcome of pregnancy. It is also a hallmark of atopic disease. We recorded the number of siblings to 3667 children in relation to maternal atopy. In all, 65% of the allergic and 56% of the non-allergic mothers had more than one child (p < 0.001). These data support a hypothesis that the atopic genotype may be associated with an increased likelihood for a successful outcome of pregnancy and thus from an evolutionary point of view compensate for the less efficient host defence against microbial infections associated with this type of immunity.

The effect of a combined pediatric preparation of brompheniramine maleate and phenylpropanolaminehydrochloride (Lunerin mite) was studied in 17 children (aged 4-14 years) with allergic rhinitis. A double-blind cross-over technique was used, and a score system was used for evaluation of symptoms and signs. The results show that the drug had a good effect with statistical differences on the 1 per cent level between the active preparation and the placebo. The effect was less pronounced in children aged more than 10 years, for whom a higher dose of the drug is recommended. The frequency of side-effects was negligible.

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes., R.A.I.B. was supported by a British Academy Postdoctoral fellowship and by the Autism Research Trust. J. Seidlitz was supported by NIMH T32MH019112-29 and K08MH120564. S.R.W. was funded by UKRI Medical Research Council MC_UU_00002/2 and was supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014). E.T.B. was supported by an NIHR Senior Investigator award and the Wellcome Trust collaborative award for the Neuroscience in Psychiatry Network. A.F.A.-B. was supported by NIMH K08MH120564. Data were curated and analysed using a computational facility funded by an MRC research infrastructure award (MR/M009041/1) to the School of Clinical Medicine, University of Cambridge and supported by the mental health theme of the NIHR Cambridge Biomedical Research Centre.