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OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Background: To compare hospital outcomes of aortic aneurysm surgery, casemix correction for preoperative variables is essential. Most of these variables can be deduced from mortality risk prediction models. Our aim was to identify the optimal set of preoperative variables associated with mortality to establish a relevant and efficient casemix model.Methods: All patients prospectively registered between 2013 and 2016 in the Dutch Surgical Aneurysm Audit (DSAA) were included for the analysis. After multiple imputation for missing variables, predictors for mortality following univariable logistic regression were analyzed in a manual backward multivariable logistic regression model and compared with three standard mortality risk prediction models: Glasgow Aneurysm Score (GAS, mainly clinical parameters), Vascular Biochemical and Haematological Outcome Model (VBHOM, mainly laboratory parameters), and Dutch Aneurysm Score (DAS, both clinical and laboratory parameters). Discrimination and calibration were tested and considered good with a C-statistic > 0.8 and Hosmer-Lemeshow (H-L) P > 0.05.Results: There were 12,401 patients: 9,537 (76.9%) elective patients (EAAA), 913 (7.4%) acute symptomatic patients (SAAA), and 1,951 (15.7%) patients with acute rupture (RAAA). Overall postoperative mortality was 6.5%; 1.8% after EAAA surgery, 6.6% after SAAA, and 29.6% after RAAA surgery. The optimal set of independent variables associated with mortality was a mix of clinical and laboratory parameters: gender, age, pulmonary comorbidity, operative setting, creatinine, aneurysm size, hemoglobin, Glasgow coma scale, electrocardiography, and systolic blood pressure (C-statistic 0.871). External validation overall of VBHOM, DAS, and GAS revealed C-statistics of 0.836, 0.782, and 0.761, with an H-L of 0.028, 0.00, and 0.128, respectively.Conclusions: The optimal set of variables for casemix correction in the DSAA comprises both clinical and laboratory parameters, which can be collected easily from electronic patient files and will lead to an efficient casemix model.

BACKGROUND: Colonic ischemia remains a severe complication after abdominal aortic aneurysm (AAA) repair and is associated with a high mortality. With open repair being one of the main risk factors of colonic ischemia, deciding between endovascular or open aneurysm repair should be based on tailor-made medicine. This study aims to identify high-risk patients of colonic ischemia, a risk that can be taken into account while deciding on AAA treatment strategy.METHODS: A nationwide population-based cohort study of 9,433 patients who underwent an AAA operation between 2014 and 2016 was conducted. Potential risk factors were determined by reviewing prior studies and univariate analysis. With logistic regression analysis, independent predictors of intestinal ischemia were established. These variables were used to form a prediction model.RESULTS: Intestinal ischemia occurred in 267 patients (2.8%). Occurrence of intestinal ischemia was seen significantly more in open repair versus endovascular aneurysm repair (7.6% vs. 0.9%; P < 0.001). This difference remained significant after stratification by urgency of the procedure, in both intact open (4.2% vs. 0.4%; P < 0.001) and ruptured open repair (15.0% vs. 6.2%); P < 0.001). Rupture of the AAA was the most important predictor of developing intestinal ischemia (odds ratio [OR], 5.9, 95% confidence interval [CI] 4.4-8.0), followed by having a suprarenal AAA (OR 3.4; CI 1.1-10.6). Associated procedural factors were open repair (OR 2.8; 95% CI 1.9-4.2), blood loss >1L (OR 3.6; 95% CI 1.7-7.5), and prolonged operating time (OR 2.0; 95% CI 1.4-2.8). Patient characteristics included having peripheral arterial disease (OR 2.4; 95% CI 1.3-4.4), female gender (OR 1.7; 95% CI 1.2-2.4), renal insufficiency (OR 1.7; 1.3-2.2), and pulmonary history (OR 1.6; 95% CI 1.2-2.2). Age CONCLUSIONS: One of the main risk factors is open repair. Several other risk factors can contribute to developing colonic ischemia after AAA repair. The proposed prediction model can be used to identify patients at high risk for developing colonic ischemia. With the current trend in AAA repair leaning toward open repair for better long-term results, our prediction model allows a better informed decision can be made in AAA treatment strategy.

Contains fulltext : 226469.pdf (Publisher’s version ) (Open Access) BACKGROUND: Long-term secondary aortic reinterventions (SARs) can be a sign of (lack of) effectiveness of abdominal aortic aneurysm (AAA) surgery. This study provides insight into the national number of SARs after primary AAA repair by endovascular aneurysm repair (EVAR) or by open surgical repair in the Netherlands. METHODS: Observational study included all patients undergoing SAR between 2016 and 2017, registered in the compulsory Dutch Surgical Aneurysm Audit (DSAA). The DSAA started in 2013, SARs are registered from 2016. Characteristics of SAR and postoperative outcomes (mortality/complications) were analyzed, stratified by urgency of SAR. Data of SARs were merged with data of their preceded primary AAA repair, registered in the DSAA after January 2013. In these patients undergoing SAR, treatment characteristics of the preceded primary AAA repair were additionally described, with focus on differences between stent grafts. RESULTS: Between 2016 and 2017, 691 patients underwent SAR, this concerned 9.3% of all AAA procedures (infrarenal/juxtarenal/suprarenal) in the Netherlands (77% elective/11% acute symptomatic/12% ruptured). Endoleak (60%) was the most frequent indication for SAR. SARs were performed with EVAR in 66%. Postoperative mortalities after SAR were 3.4%, 11%, and 29% in elective, acute symptomatic, and ruptured patients, respectively. In 26% (n = 181) of the patients undergoing SAR their primary AAA repair was performed after January 2013 and data of primary and SAR procedures could be merged. In 93% (n = 136), primary AAA repair was EVAR. Endografts primarily used were nitinol/polyester (62%), nitinol/polytetrafluoroethylene (8%), endovascular sealing (21%), and others (9%), compared with their national market share of 76% (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.38-0.71), 15% (OR, 0.50; CI, 0.29-0.89), 4.9% (OR, 5.04; CI, 3.44-7.38), and 4.1% (OR, 2.81; CI, 1.66-4.74), respectively. CONCLUSIONS: In the Netherlands, about one-tenth of the annual AAA procedures concerns an SAR. A quarter of this cohort had an SAR within 1-5 years after their primary AAA repair. Most SARs followed after primary EVAR procedures, in which an overrepresentation of endovascular sealing grafts was seen. Postoperative mortality after SAR is comparable with primary AAA repair.

Contains fulltext : 226467.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Composite measures may better objectify hospital performance than individual outcome measures (IOM). Textbook outcome (TO) is an outcome measure achieved for an individual patient when all undesirable outcomes are absent. The aim of this study was to assess TO as an additional outcome measure to evaluate quality of care in symptomatic patients treated by carotid endarterectomy (CEA). METHODS: All symptomatic patients treated by CEA in 2018, registered in the Dutch Audit for Carotid Interventions, were included. TO was defined as a composite of the absence of 30 day mortality, neurological events (any stroke or transient ischaemic attack [TIA]), cranial nerve deficit, haemorrhage, 30 day readmission, prolonged length of stay (LOS; > 5 days) and any other surgical complication. Multivariable logistic regression was used to identify covariables associated with achieving TO, which were used for casemix adjustment for hospital comparison. For each hospital, an observed vs. expected number of events ratio (O/E ratio) was calculated and plotted in a funnel plot with 95% control limits. RESULTS: In total, 70.7% of patients had a desired outcome within 30 days after CEA and therefore achieved TO. Prolonged LOS was the most common parameter (85%) and mortality the least common (1.1%) for not achieving TO. Covariates associated with achieving TO were younger age, the absence of pulmonary comorbidity, higher haemoglobin levels, and TIA as index event. In the case mix adjusted funnel plot, the O/E ratios between hospitals ranged between 0.63 and 1.27, with two hospitals revealing a statistically significantly lower rate of TO (with O/E ratios of 0.63 and 0.66). CONCLUSION: In the Netherlands, most patients treated by CEA achieve TO. Variation between hospitals in achieving TO might imply differences in performance. TO may be used as an additive to the pre-existing IOM, especially in surgical care with low baseline risk such as CEA.

Contains fulltext : 226470.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Mycotic aneurysms of the abdominal aorta (MAAA) can be treated by open repair (OR) or endovascular aneurysm repair (EVAR). This nationwide study provides an overview of the situation of MAAA treatment in The Netherlands in 2016. METHODS: A retrospective cohort study was conducted with all centers that registered aortic abdominal aneurysms in the Dutch Surgical Aneurysm Audit in 2016. Questionnaires on 1-year outcomes were sent to all centers that treated patients with MAAA. The primary aim was to determine 30-day and 1-year mortality and morbidity of OR- and EVAR-treated patients. Morbidity was determined by the need for reoperations and the number of readmissions to the hospital. RESULTS: Twenty-six MAAA were detected in the Dutch Surgical Aneurysm Audit database of 2016, resulting in an incidence of 0.7% of all registered abdominal aortic aneurysms. The 30-day mortality for OR and EVAR treated patients was 1 in 13 and 0 in 13, respectively. Major and minor reinterventions within 30 days were needed for two (one OR and one EVAR) and two (one OR and one EVAR) patients, respectively. Two patients (15.4%) in the OR group and one patient (7.7%) in the EVAR group were readmitted to hospital within 30 days. In total, 1-year outcomes of 23 patients were available. In the OR group, one patient (9.1%) died in the first postoperative year. There was one major reintervention (removal of endoprosthesis and spiralvein reconstruction) in the EVAR group. Two patients (18.2%) treated with OR and two (16.7%) treated with EVAR required a minor reintervention. In both groups, four patients (OR, 36.4%; EVAR, 33.3%) were readmitted to hospital within 1 year postoperatively. CONCLUSIONS: Both OR- and EVAR-treated patients show acceptable clinical outcomes after 30 days and at the 1-year follow-up. Depending on the clinical course of the patient, EVAR may be considered in the management of this disease.

Contains fulltext : 229914.pdf (Publisher’s version ) (Open Access) BACKGROUND: While several observational studies suggested a lower postoperative mortality after minimal invasive endovascular aneurysm repair (EVAR) in patients with a ruptured abdominal aortic aneurysm (RAAA) compared to conventional open surgical repair (OSR), landmark randomized controlled trials have not been able to prove the superiority of EVAR over OSR. Randomized controlled trials contain a selected, homogeneous population, influencing external validity. Observational studies are biased and adjustment of confounders can be incomplete. Instrumental variable (IV) analysis (pseudorandomization) may help to answer the question if patients with an RAAA have lower postoperative mortality when undergoing EVAR compared to OSR. METHODS: This is an observational study including all patients with an RAAA, registered in the Dutch Surgical Aneurysm Audit between 2013 and 2017. The risk difference (RD) in postoperative mortality (30 days/in-hospital) between patients undergoing EVAR and OSR was estimated, in which adjustment for confounding was performed in 3 ways: linear model adjusted for observed confounders, propensity score model (multivariable logistic regression analysis), and IV analysis (two-stage least square regression), adjusting for observed and unobserved confounders, with the variation in percentage of EVAR per hospital as the IV instrument. RESULTS: 2419 patients with an RAAA (1489 OSR and 930 EVAR) were included. Unadjusted postoperative mortality was 34.9% after OSR and 22.6% after EVAR (RD 12.3%, 95% CI 8.5-16%). The RD adjusted for observed confounders using linear regression analysis and propensity score analysis was, respectively, 12.3% (95% CI 9.6-16.7%) and 13.2% (95%CI 9.3-17.1%) in favor of EVAR. Using IV analysis, adjusting for observed and unobserved confounders, RD was 8.9% (95% CI -1.1-18.9%) in favor of EVAR. CONCLUSIONS: Adjusting for observed confounders, patients with an RAAA undergoing EVAR had a significant better survival than OSR in a consecutive large cohort. Adjustment for unobserved confounders resulted in a clinical relevant RD. An "EVAR preference strategy" in patients with an RAAA could result in lower postoperative mortality.

We assessed the effects of (a) stimulus fading, (b) verbal feedback, and (c) superimposition training on college students’ skill acquisition, maintenance, and generalization of accurate pours of a standard serving of beer (12 oz). Participants were 18 college students who failed to pour within 10% o

Ecological memory is central to how ecosystems respond to disturbance and is maintained by two types of legacies – information and material. Species life-history traits represent an adaptive response to disturbance and are an information legacy; in contrast, the abiotic and biotic structures (such as seeds or nutrients) produced by single disturbance events are material legacies. Disturbance characteristics that support or maintain these legacies enhance ecological resilience and maintain a “safe operating space” for ecosystem recovery. However, legacies can be lost or diminished as disturbance regimes and environmental conditions change, generating a “resilience debt” that manifests only after the system is disturbed. Strong effects of ecological memory on post-disturbance dynamics imply that contingencies (effects that cannot be predicted with certainty) of individual disturbances, interactions among disturbances, and climate variability combine to affect ecosystem resilience. We illustrate these concepts and introduce a novel ecosystem resilience framework with examples of forest disturbances, primarily from North America. Identifying legacies that support resilience in a particular ecosystem can help scientists and resource managers anticipate when disturbances may trigger abrupt shifts in forest ecosystems, and when forests are likely to be resilient.

Background: Medication regimen complexity describes multiple characteristics of a patient’s prescribed drug regimen. Heart transplant recipients must comply with a lifelong regimen that consists of numerous medications. However, a systematic assessment of medication regimen complexity over time has not been conducted in this, or any other, transplant population. Objective: The objective of this study was to quantify patient-level medication regimen complexity over time following primary heart transplantation and heart retransplantation, using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool. Methods: Medication lists were reviewed at transplant discharge and years 1, 3, and 5 post–primary heart transplant, and at transplant discharge and years 1 and 3 post–heart retransplantation. Medications were categorized as transplant-specific, other prescription, and over-the-counter (OTC). Results: In primary heart transplant recipients (n = 60), mean total medication count was 14.3 ± 3.4 at transplant discharge and did not change significantly over time ( P = 0.64). Transplant-specific medication count decreased significantly from discharge (2.9 ± 0.4) to year 5 (2.3 ± 0.6); P = 0.02. However, 32% of patients were taking 16 or more total medications at year 5 posttransplant. More than 70% of the pMRCI score was attributed to other prescription and OTC medications, which was largely driven by dosing frequency in this cohort. Medication complexity did not differ significantly between heart retransplant recipients (n = 11) and matched primary heart transplant controls (n = 22). Conclusion: Together, these data highlight the substantial medication burden after heart transplantation and reveal opportunities to address medication regimen complexity in this, and other, transplant populations.

Objectives: Failure to rescue (FTR) is a composite quality indicator, defined as the proportion of deceased patients following major complications. The aims of this study were to compare FTR with mortality for hospital comparisons in abdominal aortic aneurysm (AAA) surgery in The Netherlands and investigate hospital volume and associated factors.Methods: Patients prospectively registered between 2013 and 2015 in the Dutch Surgical Aneurysm Audit (DSAA) were analysed. FTR was analysed for AAA patients and subgroups elective (EAAA) and acute (AAAA; symptomatic or ruptured) aneurysms. Variables and hospital volume were analysed by uni- and multivariable regression analysis. Adjusted hospital comparisons for mortality, major complications, and FTR were presented in funnel plots. Isomortality lines were constructed when presenting FTR and major complication rates.Results: A total of 9258 patients were analysed in 61 hospitals: 7149 EAAA patients (77.2%) and 2109 AAAA patients (22.8%). There were 2785 (30.1%) patients with complications (unadjusted range 5-65% per hospital): 2161 (77.6%) with major and 624 (28.4%) patients with minor complications. Overall mortality was 6.6% (adjusted range 0-16% per hospital) and FTR was 28.4% (n = 613) (adjusted range 0-60% per hospital). Glasgow Coma Scale, age, pulse, creatinine, electrocardiography, and operative setting were independently associated with FTR. Hospital volume was not associated with FTR. In AAAA patients hospital volume was significantly associated with a lower adjusted major complication and mortality rate (OR 0.62, 95% CI 0.49-0.78; and 0.64, 95% CI 0.48-0.87). Four hospitals had a significant lower adjusted FTR with different major complication rates on different isomortality lines.Conclusions: There was more variation in FTR than in mortality between hospitals. FTR identified the same best performing hospitals as for mortality and therefore was of limited additional value in measuring quality of care for AAA surgery. FTR can be used for internal quality improvement with major complications in funnel plots and diagrams with isomortality lines. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Knowledge of the mechanisms by which fish excrete their metabolic nitrogenous waste and insights into nitrogen cycling in aquaculture systems is of utmost importance to improve the sustainable commercial production of fish. In fish, most nitrogenous waste is excreted via the gills as ammonia, a potentially toxic nitrogenous compound. In this study; activity assays, physiological experiments, molecular analysis and microscopy were used to show that the gills of fish harbor a unique combination of hitherto overlooked nitrogen-cycle microorganisms that can theoretically detoxify excreted ammonia by converting it into inert dinitrogen gas. By doing so, these microorganisms may benefit from the ammonia supply by the host and prevent the build-up of this compound to toxic concentrations. This novel relationship between vertebrates and microorganisms may shed new light on nitrogen handling by ammonotelic fish species.

This study assessed the lasting impact of dexamethasone (DEX) exposure during early development on tissue repair capacity at later life stages (5, 14, and 24 days post fertilization [dpf]) in zebrafish larvae. Using the caudal fin amputation model, we show that prior exposure to DEX significantly delays but does not prevent wound healing at all life stages studied. DEX-induced impairments on wound healing were fully restored to normal levels with longer post amputation recovery time. Further analyses revealed that DEX mainly exerted its detrimental effects in the early phase (0-5 hours) of wound-healing process. Specifically, we observed the following events: (1) massive amount of cell death both by necrosis and apoptosis; (2) significant reduction in the number as well as misplacement of macrophages at the wound site; (3) aberrant migration and misplacement of neutrophils and macrophages at the wound site. These events were accompanied by significant (likely compensatory) changes in the expression of genes involved in tissue patterning, including up-regulation of FKBP5 6 hours post DEX exposure and that of Wnt3a and RARγ at 24 hours post amputation. Taken together, this study provides evidence that DEX exposure during early sensitive periods of development appears to cause permanent alterations in the cellular/molecular immune processes that are involved in the early phase of wound healing in zebrafish. These findings are consistent with previous studies showing that antenatal course of DEX is associated with immediate and lasting alterations of the immune system in rodent models and humans. Therefore, the current findings support the use of the larval zebrafish model to study the impact of stress and stress hormone exposure in immature organisms on health risks in later life.

Background: The Dutch Audit for Carotid Interventions (DACI) registers all patients undergoing interventions for carotid artery stenosis in the Netherlands. This study describes the design of the DACI and results of patients with a symptomatic stenosis undergoing carotid endarterectomy (CEA). It aimed to evaluate variation between hospitals in process of care and (adjusted) outcomes, as well as predictors of major stroke/death after CEA.Methods: All patients with a symptomatic stenosis, who underwent CEA and were registered in the DACI between 2014 and 2016 were included in this cohort. Descriptive analyses of patient characteristics, process of care, and outcomes were performed. Casemix adjusted hospital procedural outcomes as (30 day/in hospital) mortality, stroke/death, and major stroke/death, were compared with the national mean. A multivariable logistic regression model (backward elimination at p > 0.10) was used to identify predictors of major stroke/death.Results: A total of 6459 patients, registered by 52 hospitals, were included. The majority (4,832, 75%) were treated Conclusion: CEA in The Netherlands is associated with an overall low mortality and (major) stroke/death rate. Whereas the indicator time to intervention varied between hospitals, mortality and (major) stroke/death were not significantly distinctive enough to identify worse practices and therefore were unsuitable for hospital comparison in the Dutch setting. Additionally, predictors of major stroke/death at population level could be identified. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Die zerebrale Sinusthrombose kann eine vielfaltige Symptomatik mit entsprechend schwieriger Diagnosestellung aufweisen. Es existieren nur wenige evidenzbasierte Daten bezuglich Therapie und Prognose, insbesondere bezuglich tiefer Hirnvenen. Bei der Thrombose der Vena Galeni wird eine schlechtere Prognose angenommen. Unser Fallbericht beschreibt die lokale kombinierte neurointerventionelle Therapie als individueller Heilversuch bei fulminantem Verlauf.

Three-dimensional printing of viscoelastic inks to create porous, elastomeric architectures with mechanical properties governed by the ordered arrangement of their sub-millimeter struts is reported. Two layouts are patterned, one resembling a “simple cubic” (SC)-like structure and another akin to a “face-centered tetragonal” (FCT) configuration. These structures exhibit markedly distinct load response with directionally dependent behavior, including negative stiffness. More broadly, these findings suggest the ability to independently tailor mechanical response in cellular solids via micro-architected design. Such ordered materials may one day replace random foams in mechanical energy absorption applications.

In this paper we describe an ongoing project where the goal is to develop competence and confidence among chemistry faculty so they are able to utilize computational chemistry as an effective teaching tool. Advances in hardware and software have made research-grade tools readily available to the academic community. Training is required so that faculty can take full advantage of this technology, begin to transform the educational landscape, and attract more students to the study of science.

Importance The risk of bleeding and recurrent venous thromboembolism (VTE) among patients receiving long-term warfarin sodium therapy for secondary VTE prevention who require temporary interruption of anticoagulant therapy for surgery or invasive diagnostic procedures has not been adequately described. Objective To describe the rates of clinically relevant bleeding and recurrent VTE among patients in whom warfarin therapy is interrupted for invasive procedures and compare these rates among patients who did and did not receive bridge therapy. Design, Setting, and Participants A retrospective cohort study was conducted at Kaiser Permanente Colorado, an integrated health care delivery system. Patients in whom warfarin therapy was interrupted for invasive diagnostic or surgical procedures between January 1, 2006, and March 31, 2012, were identified via queries of administrative data sets. A total of 1812 procedures in 1178 patients met inclusion criteria. Data on outcomes and exposures were collected between June 1, 2005, and April 30, 2012. Exposures Use of bridge therapy vs no bridge therapy during warfarin interruption. Main Outcomes and Measures Thirty-day clinically relevant bleeding, recurrent VTE, and all-cause mortality. Outcomes were verified via manual review of medical records. Results Among the 1178 patients, the mean (SD) age was 66.1 (12.7) years, 830 procedures (45.8%) were in men, and the most common indication for warfarin therapy was deep vein thrombosis (56.3%). Most patients were considered to be at low risk for VTE recurrence at the time of warfarin interruption (1431 procedures [79.0%]) according to the consensus guidelines of the American College of Chest Physicians. Clinically relevant bleeding within 30 days after the procedure in the bridge therapy and non–bridge therapy groups occurred in 15 patients (2.7%) and 2 patients (0.2%), respectively (hazard ratio, 17.2; 95% CI, 3.9-75.1). There was no significant difference in the rate of recurrent VTE between the bridge and non–bridge therapy groups (0 vs 3; P = .56). No deaths occurred in either group. Conclusions and Relevance Bridge therapy was associated with an increased risk of bleeding during warfarin therapy interruption for invasive procedures in patients receiving treatment for a history of VTE and is likely unnecessary for most of these patients. Further research is needed to identify patient- and procedure-related characteristics associated with a high risk of perioperative VTE recurrence during warfarin therapy interruption.

Fatigue crack nucleation at grain boundaries near the endurance limit was examined combining the results of fatigue tests with local orientation measurements and with finite element calculations. Coarse-grained thin sheets were examined in which the orientation and inclination of each boundary could be measured directly. These results were used as input for FEM calculation in which the stress concentrations near the grain boundaries were calculated. In the fatigue tests, the boundaries, at which the first cracks nucleate, were measured by a replica technique. A comparison between the experimental results and the FE calculation showed that the cracks nucleated and propagated along the boundaries with the largest stress concentration. When a crack hits a boundary with a lower stress concentration, it either stops or propagates transgranularly depending on the local stress concentration given by the microstructure. From these results, it can be concluded that elastic strain incompatibility combined with the microstructure (grain size and orientation) can be used to predict the crack nucleation sites and the scatter in life time for fatigue near the endurance limit.

An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. Rates of neuromusculoskeletal complaints in 9e diagnostic categories were compared between groups with and without chiropractic coverage. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. Expressed in terms of unique patients with neuromusculoskeletal complaints, the cohort with chiropractic coverage experienced a rate of 162.0 complaints per 1000 member years compared with 171.3 complaints in the cohort without chiropractic coverage. These results indicate that patients use chiropractic care as a direct substitution for medical care.

European directives and regulations (Restriction of Hazardous Substances in Electrical and Electronic Equipment (RoHS), Energy-Related Products (ERP), Waste Electrical and Electronic Equipment (WEEE) and Registration, Evaluation and Authorization of Chemicals (REACh)) and International Electrotechnical Commission (IEC) standards in the field of environment are the new driving forces of technological developments for proactive companies. Looking at environmental concerns in the field of electrical distribution network equipment means being interested in the efficiency of the network and medium voltage equipment features. This chapter gives facts on the European and French electrical networks. It describes the state of the art of legislation and standards in the environmental field. An example of the environmental declaration of medium-voltage switchgear according to product environmental profile ecopassport rules is given. It is a fair environmental identity card and a good answer to the market need for ecodesign.

The objective of this study was to evaluate the clinical and duplex outcome after carotid endarterectomy (CEA) in recently symptomatic patients aged 80 years or older. Information was assembled from a prospective data collection of all CEAs performed from January 1986 to December 1999. Included were all patients with recently symptomatic carotid artery stenosis who were aged 80 years or older at time of operation. Thirty-two patients, with a mean age of 82 years, were included. Outcome events were stroke, death, and restenosis (more than 50% diameter reduction) during routine duplex scan follow-up. Conventional surgical technique was used regarding anesthesia and selective shunting or patching. None of the operated-on patients suffered a stroke at any time during follow-up. One patient (3.1%) died in the early postoperative phase (< 30 days). An additional 8 patients died during follow-up. None of these deaths were of cerebrovascular origin. Survival at 3 years was 73% (life table analysis). Routine duplex scan follow-up showed 2 patients with a diameter reduction of more than 50%, both 3 months after CEA. Restenosis rate on duplex scan was 7.4% after 1 year. The authors conclude that there seems to be no reason to deny the very elderly the benefits of CEA. Stroke-free survival and survival rates show that carotid surgery is a safe procedure in patients aged 80 and over who are in apparently good health. These findings are supported by a low incidence of restenosis on duplex scan follow-up, indicating a durable repair.

Purpose Polypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity. Methods A sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained. Findings The cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7–8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing. Implications As expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient's entire regimen for opportunities to reduce complexity and improve ease of self-care.

Currently in the United States, health care systems are being asked to increase the volume of patients who receive medication therapy management (MTM) services and to improve quality indicators that have a heavy emphasis on appropriate medication use. MTM services include comprehensive assessment and evaluation of a patient's complete medication therapy regimen.1 The Centers for Medicare and Medicaid Services (CMS) 2014 guidelines for MTM programs added requirements for health plan sponsors to have a dedicated MTM information page linked to their website and to actively promote available MTM services to beneficiaries in an effort to increase awareness of MTM service availability and ultimately utilization.2 A similar medication focus can be found in the recent CMS star rating system for health plans that implemented incentive quality-based payments based on number of stars earned, where some star rating criteria are related directly to medication use and could be improved through MTM programs.3 For example, star ratings are earned through direct medication targets, such as medication adherence rates (e.g., diabetes, hypertension), percentage of members receiving medications with a high risk of side effects, or other criteria that depend on appropriate medication use (e.g., percentage of patients with diabetes with controlled levels of blood sugar). A screening tool that reliably identifies patients with greater medication regimen complexity could be useful for health plans (e.g., CMS ratings) and for practicing clinicians. A literature review of measures of medication regimen complexity and associated outcomes found that medication regimen complexity is related to patient nonadherence, caregiver burden, quality of life, and medical resource utilization.4 Many different methods were used to quantify the complexity of medication regimens. The medication regimen complexity index (MRCI) was the most frequently used method. The MRCI is a tool that quantifies medication regimen complexity beyond the number of medications to include weighted scores for types of prescribed dosage forms, dosing frequency, and additional administration directions.5 The MRCI has been used to quantify medication regimen complexity in several studies.6–21 Results of MRCI studies describe medication regimen complexity for general groups of patients8,10–13,15–18 and for defined cohorts based on specific disease management (e.g., diabetes, hypertension).6,7,9,14,19–21 Two studies assessed the relationship of MRCI scores with medication adherence and found that increased MRCI scores were related to lower medication adherence levels.6,12 Earlier MRCI studies included only prescription medications for specific target diseases of interest (e.g., prescribed diabetes medications) and ignored other prescription and over-the-counter (OTC) medications for comorbidities (e.g., hypertension, pain management). In contrast, recent studies broadened the MRCI score to include all prescription and OTC medications used for all comorbidities, thus reporting a patient-level MRCI score.11,18,20,21 Patient-level MRCI scores have been shown to differentiate between high, medium, and low medical complexity as determined by other accepted measures of patient complexity, hospital readmission rates, medication count, comorbidity count, and Charlson comorbidity scores (a method of predicting mortality risk based on presence of comorbidities).11,20,21 The potential for the MRCI to be used as a tool in clinical practice and by health plans to identify patients who may benefit from subsequent interventions (e.g., comprehensive medication review) is limited by the original narrowly defined scope for the tool and the associated validation evidence. Although the MRCI was judged to be a reliable and valid tool from the original expert panel validation, the process was conducted using a single cohort of patients (chronic obstructive pulmonary disease) and only included prescription medications in the assessment of medication regimen complexity.5 Also, concordance of MRCI score ranking versus five expert clinician rankings was conducted by asking five experts from different fields (academic, research nurse, adherence expert, clinical pharmacist, and home medication review expert) to judge “the difficulty in coping with the provided regimens without taking into account any drug-, clinical-, or patient-related factors.”5 Considering the number of studies conducted since this initial validation, there appears to be a desire to use the MRCI as a risk assessment tool, along with other patient data, across disease states to identify patients for subsequent interventions.6–21 Thus, there is a need to validate the MRCI to identify patients for subsequent MTM interventions using commonly available drug- and patient-related data across multiple disease states.

Background: Patients with HIV often have multiple medications besides antiretrovirals (ARV). Medication regimen complexity—formulations, dosing frequencies, and additional directions—expands pill burden by considering self-care demands. Studies show an inverse association between ARV adherence and medication complexity for ARVs only. Patient-level medication regimen complexity beyond ARV complexity is unknown. Objective: To measure and characterize Patient-level Medication Regimen Complexity Index (pMRCI) and Antiretroviral Medication Regimen Complexity Index (ARCI) for patients in 2 HIV clinics. We hypothesized that an all-medication complexity metric will exceed disease-state-defined complexity metrics; for ARVs only, the pMRCI score will be smaller than the ARCI score by capturing fewer features of regimens. Associations between complexity and adherence were not assessed. Method: Electronic records supplied a retrospective, random sample of adult patients with HIV; medication lists were used to code the pMRCI (n=200). A random subsample (n=66) was coded using ARCI for ARV regimens only. Result: Medication counts ranged from 1 to 27; pMRCI scores ranged from 2 to 67.5. ARVs contributed roughly 25% to the pMRCI; other prescriptions contributed about 66%. Dosing frequency made the largest contribution of all components (62%) to the pMRCI. For ARVs, pMRCI and ARCI scores did not differ statistically. Conclusion: Unique dosing frequencies raised complexity and may provide opportunities for intervention. Other prescriptions drove pMRCI scores, suggesting that HIV management programs should review all medications. A patient-level approach added value to understanding the role of medications in patient complexity; future work can assess association of pMRCI with adherence and patient outcomes.

Objectives: Evaluation of an aggressive policy for the treatment of phrenic nerve palsy (PNP), following cardiac operations, with emphasis on early diaphragmatic plication. Attention was given to the incidence and predisposing factors for PNP and the potential for recovery following plication. Methods: From 1 June 1991 to 1 January 1996 we prospectively screened patients for PNP following cardiac surgery. The diagnosis was suspected if difficulty was experienced in weaning the child from the ventilator. If abnormal elevation of the hemidiaphragm was present diaphragmatic plication was performed. Echocardiography was used to assess subsequent return of diaphragmatic function. Results: Seventeen children (nine boys, eight girls), out of 867 (1.9%) children younger than 16 years of age, undergoing cardiac operations were found to have PNP. The mean age was 66 days (range 1‐17 months) with 16 patients below 1 year out of a total of 285 patients (incidence 5.6%) and one patient 17 months old. The incidence following open procedures was 11/190, following closed procedures 2/95 and following reoperation 4/83. PNP was diagnosed from 2 to 44 days (mean 14 days) following surgery. It was present on the right side in seven cases, the left in nine and was bilateral in one patient. Two patients were extubated at the time of diagnosis, one patient could be extubated shortly thereafter. Fourteen children underwent diaphragmatic plication, at a median 5 days post diagnosis. Extubation was possible 1‐60 days (mean 4 days) after plication. Mean follow-up was 19 ∠ 5 months. Subsequent recovery of diaphragmatic movement was documented in seven (41%) children. Time to recovery following plication was 16 months, without plication 38 months. Conclusion: Prospective screening for PNP revealed an incidence in children younger than 1 year of 6%. Early plication substantially reduces the duration of ventilation, with its associated reduced morbidity and ICU stay. © 1998 Elsevier Science B.V. All rights reserved

Item does not contain fulltext We demonstrate that glucocorticoids induce an osteoporotic phenotype in regenerating scales of zebrafish. Exposure to prednisolone results in altered mineral content, enhanced matrix breakdown, and an osteoporotic gene-expression profile in osteoblasts and osteoclasts. This highlights that the zebrafish scale provides a powerful tool for preclinical osteoporosis research. INTRODUCTION: This study aims to evaluate whether glucocorticoid (prednisolone) treatment of zebrafish induces an osteoporotic phenotype in regenerating scales. Scales, a readily accessible dermal bone tissue, may provide a tool to study direct osteogenesis and its disturbance by glucocorticoids. METHODS: In adult zebrafish, treated with 25 muM prednisolone phosphate via the water, scales were removed and allowed to regenerate. During regeneration scale morphology and the molar calcium/phosphorus ratio in scales were assessed and osteoblast and osteoclast activities were monitored by time profiling of cell-specific genes; mineralization was visualized by Von Kossa staining, osteoclast activity by tartrate-resistant acid phosphatase histochemistry. RESULTS: Prednisolone (compared to controls) enhances osteoclast activity and matrix resorption and slows down the build up of the calcium/phosphorus molar ratio indicative of altered crystal maturation. Prednisolone treatment further impedes regeneration through a shift in the time profiles of osteoblast and osteoclast genes that commensurates with an osteoporosis-like imbalance in bone formation. CONCLUSIONS: A glucocorticoid-induced osteoporosis phenotype as seen in mammals was induced in regenerating scalar bone of zebrafish treated with prednisolone. An unsurpassed convenience and low cost then make the zebrafish scale a superior model for preclinical studies in osteoporosis research. 01 februari 2014

PURPOSE To determine the long-term impact on disease-free survival (DFS) and overall survival (OS) of adjuvant anthracycline-based chemotherapy, when prospectively compared by random allocation with standard cyclophosphamide, methotrexate, and fluorouracil (CMF) in node-positive (N+) breast cancer patients. PATIENTS AND METHODS Two hundred forty-nine patients with N+ breast cancer, recruited from eight French cancer centers, were randomized to receive 12 monthly cycles of adjuvant chemotherapy, either CMF (n = 112) or doxorubicin, vincristine, cyclophosphamide, and fluorouracil (AVCF) (n = 136). All had a negative metastatic work-up before inclusion, which was stratified by accrual center, tumor stage (International Union Against Cancer [UICC]), and menopausal status. RESULTS No severe adverse effect related to grade 4 (World Health Organization [WHO]) toxicity was observed. There was no difference in second primary tumor incidence between the two arms. The treatment given was 88% of planned for AVCF and 75% for CMF in both premenopausal and menopausal patients. With a median follow-up time of 16 years (range, 13 to 17), the OS and DFS rates are significantly longer in the AVCF arm (56% v 41% [P = .01] for OS, and 53% v 36% [P = .006] for DFS). These differences are significant, irrespective of tumor stage (T1 to T2 v T3 to T4), and remain positive in patients with or without postoperative locoregional radiotherapy (55% of cohort). When analyzed according to menopausal status, the differences remain significant only for premenopausal patients. CONCLUSION This set of mature controlled data confirms the added value of anthracycline-based combination adjuvant therapy for N+ breast cancer patients when compared with CMF, with both regimens given for 1 year.

BackgroundExpected treatment effectiveness from medications can be diminished due to suboptimal adherence. Medication nonadherence has been linked to pill burden from the quantity of medications; however, medication regimens with similar quantities of medications vary in complexity due to multiple dosage forms, frequency of dosing, and additional usage directions. Thus, a simple medication count ignores medication regimen complexity, especially as it pertains to a patient-level perspective that includes prescription and over-the-counter medications. A gap exists in the study of a patient-level medication regimen complexity metric across disease-specific populations.ObjectiveThe goal of this study was to implement the quantitative Medication Regimen Complexity Index (MRCI) at the patient level in defined populations with chronic disease (geriatric depression, HIV, diabetes mellitus, and hypertension). Patient-level medication regimen complexity included all prescribed medications and over-the-counter medications documented in the electronic medication list.MethodsUsing electronic medical records at the University of Colorado Hospital ambulatory clinics, we sampled 4 retrospective cohorts of adult patients in active care in 2011 with a qualifying medical diagnosis and prescribed disease-specific medication. Samples were randomly selected from all qualifying patients; de-identified information was coded using the MRCI.ResultsCohort-defining disease-specific prescription medications (eg, antidepressants for the depression-defined cohort) contributed

Objectives Sac growth after endovascular aneurysm repair (EVAR) is an important finding, which may influence prognosis. In case of a type II endoleak or endotension, clipping of side branches and subsequent sac fenestration has been presented as a therapeutic alternative. The long-term clinical efficacy of this procedure is unknown. Methods The study included eight patients who underwent laparoscopic aortic collateral clipping and sac fenestration for enlarging aneurysms following EVAR. Secondary interventions and clinical outcome were retrieved from hospital records. Sac behaviour was evaluated measuring volumes on periodical computed tomography angiography (CTA) imaging using dedicated software. Results Follow-up had a median length of 6.6 (range 0.6–8.6) years. During this time, only three patients successfully achieved durable aneurysm shrinkage ( n = 2) or stability ( n = 1). The remaining patients suffered persistent ( n = 2) or recurrent sac growth ( n = 3), all regarded as failure of fenestration. A total of six additional interventions were performed, comprising open conversion ( n = 2), relining ( n = 1) and implantation of iliac extensions ( n = 3). All additional interventions were successful at arresting further sac growth during the remainder of follow-up. Conclusions Despite being a less invasive alternative to conversion and open repair, the long-term outcome of sac fenestration is unpredictable and additional major procedures were often necessary to arrest sac growth.

The rotating-frame imaging (RFI) method has proven useful for measuring the spatial distributions of NMR-visible nuclides without the aid of static magnetic field gradients. However, traditional RFI has several disadvantages, including relatively poor time efficiency and high RF power deposition in the sample. A B1-gradient imaging technique, rapid rotating-frame imaging using an RF pulse train (RIPT), is discussed which can reduce both the image data-acquisition time and the RF power deposition by several orders of magnitude compared to RFI. The method is most readily applied to samples having only one resonance line, but a chemical-shift-selective version is also described which permits imaging of arbitrary lines in multipeak spectra. It is shown that RIPT images can be produced even when sample relaxation times are only a few milliseconds. Furthermore, by adding a suitable preparation period to the sequence, the RIPT signal intensity can be weighted by the relaxation time constant. Finally, postprocessing techniques are described which correct some of the image distortions common to most B1-gradient imaging techniques.

From 1986 to 1990, a multicentric phase II study was conducted with pirarubicin, a new semi-synthetic anthracyclin [4′- O -tetrahydropyranyl-adriamycin (THP)]. 87 patients with advanced gynaecological cancers were treated: epidermoid cervical carcinoma ( n = 31), adenocarcinoma of the endometrium ( n = 28) and ovarian adenocarcinoma ( n = 28). THP was administered by short intravenous infusion, for 3 consecutive days, every 3 weeks. The initial dose of THP was 25 mg/m 2 day (25% of patients) which was then reduced to 20 mg/m 2 day. The average number of courses was 3.7 (range 1–10). The cumulative THP dose was 180 mg/m 2 (range 56–594) in cervix and endometrial tumours and 121 mg/m 2 (range 58–425) in ovarian tumours. Myelosuppression was the major observed toxicity with grade 3–4 leukopenia and thrombocytopenia in 62 and 19% of the patients, respectively. Severe general complications occurred in 6% of the patients with three fatalities due to infections. Gastro-intestinal side-effects were frequent and usually mild (7% of grade 3 vomiting). 48% of the patients showed alopecia, which was complete in 9 cases (10%). 3 patients experienced cardiac events. No significant antitumoral activity was observed in patients who had failed to respod to previous chemotherapy. Promising antitumoral activity was noticed in untreated cervico-uterine carcinomas with 19% partial responses and 12% complete responses (CR). THP activity was lower in endometrial carcinomas (9.5% CR). Results were found to be negligible in ovarian cancer patients, most of them being refractory to previous chemotherapy containing an anthracyclin compound. On the basis of these results, the definite role of THP in gynaecological cancers deserves to be studied in more favourable programmes (e.g. in combined protocols as first-line chemotherapy).

The following points should be observed: 1. 1. Prompt transportation of the injured to a hospital or station where definite treatment may be executed. 2. 2. Careful history as to mechanism and severity of injury. 3. 3. Examination of the injured with making of records and prompt laboratory procedures. Repeated examinations at frequent intervals until a surgical opinion has been reached. 4. 4. Prompt use of measures to combat shock and control hemorrhage; operation when indicated within the first six hours if possible. It is better to operate in cases which present indefinite and obscure findings with a possibility of serious abdominal injury, than to consider conservative observation too long. 5. 5. Chemotherapy with the use of sulfa drugs and penicillin to combat infection. 6. 6. Judicious use of methods to maintain a proper fluid balance and to combat distention postoperatively.

In order to evaluate the efficacy of two different sequences of second and third line hormonotherapy in advanced post-menopausal breast cancer, 257 women aged 36-91 years (mean age: 63.6 years) who had become resistant to tamoxifen (TAM), entered into a multicenter randomized trial comparing two different regimens: 1) Aminoglutethimide (Ag) 500 mg/day with hydrocortisone supplementation from 30 to 60 mg/day; and 2) oral medroxyprogesterone acetate (MPA) 500 mg twice a day. 250 patients were evaluated following second line hormone therapy and, after cross-over, 128 following third line hormonotherapy. No significant difference was observed, during either second or third line therapies, for toxicity, survival, or response rate; however, in both second and third line therapies the median time to progression was significantly longer with Ag therapy.

The reconstruction of two-dimensional spatial images with 0.5-mm resolution using radio frequency gradients generated by an NMR coil system rotated about the sample is demonstrated for 23Na. The method retains chemical shift, should be capable of mapping T1 and T2 information, and might offer sensitivity advantages for nuclides with short T2. © 1990 Academic Press, Inc.

Seventy-five breast cancer patients scheduled to receive a first course (in a new cycle) of cyclophosphamide, fluorouracil, and doxorubicin (FAC) or epirubicin (FEC) participated in a double-blind crossover study to compare the antiemetic efficacy and safety of ondansetron (GR38032), a 5-hydroxytryptamine3 (5-HT3) receptor antagonist, and metoclopramide. Ondansetron was given as an 8 mg loading dose (4 mg intravenously [IV] plus 4 mg orally) before chemotherapy followed by 8 mg every 8 hours orally for 3 to 5 days. Metoclopramide was given as an 80 mg loading dose (60 mg IV plus 20 mg orally) before chemotherapy followed by 20 mg every 8 hours orally for 3 to 5 days. A "period" interaction in the analysis of emetic response in the first 24 hours necessitated a parallel group analysis of first treatments only, 68 patients being assessable for this parameter. In the first 24 hours, complete or major control (zero to two emetic episodes) of emesis was achieved in 30 of 35 (86%) patients receiving ondansetron and in 14 of 33 (42%) patients receiving metoclopramide (P less than .001). Ondansetron was also more effective in reducing acute nausea. On days 2 to 3, the complete or major responses were significantly better with ondansetron (81% v 65%; P = .033), but there was no statistical difference in the control of nausea. There was a significant patient preference for ondansetron (63% v 26%; P = .001). Extrapyramidal reactions were observed in two metoclopramide treatments; both treatments were otherwise well tolerated. These results are consistent with serotonin (5-HT), being a significant neurotransmitter of cyclophosphamide/doxorubicin- or epirubicin/fluorouracil-induced emesis.

Noninvasive vascular laboratory findings remain impor- tant in the diagnosis of peripheral arterial disease (PAD). In many circumstances they are as accurate as invasive imaging and have the advantage of being quick and in- expensive. The two basic modalities of evaluation are the indirect methods (ankle brachial pressure index, Doppler wave forms, treadmill exercise) that provide location and functional severity of disease, and the direct method of evaluation, colour duplex imaging (CDI), which provides more specific anatomical and physiological information.

The case of a patient with an aortoesophageal fistula is presented, which was caused by ingestion of a chicken bone and was treated by endovascular stent-graft placement and esophagectomy with early reconstruction. The diagnostic and therapeutic options and challenges encountered in treating an aortoesophageal fistula are discussed.

An Autonomous Pathogen Detection System (APDS) unit is an automated, podium-sized system that monitors the air for all three biological threat agents (bacteria, viruses, and toxins). The system has been developed under the auspices of the U. S. Department of Energy and Department of Homeland Security by the University of California, Lawrence Livermore National Laboratory (LLNL) to protect people in critical or high-traffic facilities and at special events. The system performs continuous aerosol collection, sample preparation, and multiplexed biological tests using advanced immunoassays as the primary screen. Over ten agents are assayed at once, and results are reported hourly. RD this is one of the focuses of the upcoming year's work.« less

The effect of recombinant human tumor necrosis factor alpha (TNF-alpha) on tumor growth and tumor cell proliferation of a human renal cell carcinoma transplanted into nude mice as well as on the body weight of the tumor-bearing animals has been studied. Due to differences of the effect of TNF-alpha after intravenous and intraperitoneal injection reported in the literature the influence of the two routes of application was presently studied. There was no effect on tumor growth with either route of application. Only the mode of growth showed a tendency to an increased rate of growth at the beginning of the treatment and a following increased growth deceleration. A slight change of the 3H-thymidine labeling index and the mitotic index was observed only after intraperitoneal injection of TNF-alpha indicative of a more cytostatic than cytotoxic effect of the drug. This is supported by the lack of an increase of necrotic cells. Although a rather high dose of TNF-alpha was applied, no effect on the body weight of the animals, i.e. no toxic effect of the treatment, has been found. Oncology

Most soils of sewage fields have been contaminated with organic and inorganic pollutants after decades of waste water irrigation. Without irrigation the sites show low adsorption capacities and low yields. The aim of our investigation was to study the agricultural utilization of contaminated land without producing food or feedstuff including the control of harvested crops and plant residues. As most plants used in the test showed a high biomass production we studied their suitability for the decontamination of sewage field soils. Four different plants (Miscanthus sinensis, Polygonum sachalinense, Secale cerale, Zea mays) were tested in a pot experiment using six soils of different degree of pollution (Table 1). The test soils were prepared by mixing material from an extremely contaminated sewage field soil (extr.contam.) with an uncontaminated Ap-horizon of a podzolic brown earth (=Control).

For the chemistry educator wanting to locate reviewed digital materials quickly, the Computational Science Education Reference Desk is an important NSDL pathway. CSERD not only includes resources for chemistry education, it also encompasses computational science education materials for more than forty closely related disciplines.

We describe a 33-year-old man with giant hypertrophic gastropathy (Menetrier's disease), which, on operative biopsy of the stomach, showed a significant inflammatory component. The patient was treated with prednisone and quickly responded. Although a review of the literature revealed only two cases similarly treated, with equivocal results, spontaneous remission, does occur. Symptoms associated with this disease may respond to corticosteroids, which may offer effective therapy while awaiting involution of the gastropathy. Thus total gastrectomy may be avoided.

0.5 mg tetracosactrin is considered to be equivalent to 40 mg methylprednisolone with regard to the induced cortisol secretion. 97 female breast cancer patients who received their first two FEC courses (epirubicin 50–75 mg/m 2 , 5-fluorouracil 500 mg/m 2 , cyclophosphamide 500 mg/m 2 ) entered this randomised crossover study (76 had previously received an adjuvant treatment); tetracosactrin was administered intramuscularly and methylprednisolone intravenously immediately before chemotherapy administration. The tolerability was evaluated using a diary card during 5 days and patients were asked for their preference at the end of the two cycles. There was no difference either for vomiting (dry heaves were included) or nausea between the two treatments (the analysis was performed on day 1, the worse day of days 2 and 3 and the worse day of days 4 and 5). At day 1, 49% of the patients experienced no or mild nausea after tetracosactrin and 62% after methylprednisolone (not significant) (first period analysis); a complete control of vomiting (including dry heaves) was observed in 49% of the patients after tetracosactrin and 53% after methylprednisolone (not significant). No difference was observed between patients with or without previous chemotherapy. However, slightly more patients preferred tetracosactrin ( P = 0.048).

Thirty-one elderly patients with measurable advanced breast cancer entered this phase II study. A dose of 15 mg/m2/day of Idarubicin (IDA) for 3 consecutive days every 3 weeks was given orally. Mean total cumulative dose of IDA received was 175 mg/m2 (range: 45-475 mg/m2). Mean number of cycles given was four (range: 1-15). Out of 27 evaluable patients, three achieved a complete response (CR), four had a partial response (PR) (CR + PR = 26 +/- 17%), nine showed no change, and 11 had a progressive disease. Median time to progression was 83 days (range: 19-728 days). Out of 26 patients evaluable for toxicity, hematologic toxicity at day 21 was moderate: neutropenia grades 3 and 4 = 16% of cycles: two patients had grade 1 thrombopenia; and three patients, grade 3. No cumulative hematologic toxicity was detected. Nonhematologic toxicities consisted of nausea and vomiting in 72% of patients [World Health Organization (WHO) grades 3 and 4 = 8%)] and alopecia in 76% (WHO grades 2-3 = 38%). Grade 1 stomatitis occurred in 4% of cycles. Chemotherapy was discontinued in one patient because of drop of left ventricular ejection fraction (LVEF) from 0.62 to 0.44 at a cumulative IDA dosage of 322 mg/m2. The results of this study show that IDA is an active drug in elderly patients with advanced breast cancer. Due to its simplicity of administration IDA deserves further investigations in combination with other drugs.