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PURPOSE: To determine the interreader agreement for incomplete retinal pigment epithelium (RPE) and outer retinal atrophy (iRORA) and complete RPE and outer retinal atrophy (cRORA) and their related features in age-related macular degeneration (AMD). DESIGN: Interreader agreement study. PARTICIPANTS: Twelve readers from 6 reading centers. METHODS: After formal training, readers qualitatively assessed 60 OCT B-scans from 60 eyes with AMD for 9 individual features associated with early atrophy and performed 7 different annotations to quantify the spatial extent of OCT features within regions of interest. The qualitative and quantitative features were used to derive the presence of iRORA and cRORA and also in an exploratory analysis to examine if agreement could be improved using different combinations of features to define OCT atrophy. MAIN OUTCOME MEASURES: Interreader agreement based on Gwet's first-order agreement coefficient (AC1) for qualitatively graded OCT features and classification of iRORA and cRORA, and smallest real difference (SRD) for quantitatively graded OCT features. RESULTS: Substantial or better interreader agreement was observed for all qualitatively graded OCT features associated with atrophy (AC1 = 0.63-0.87), except for RPE attenuation (AC1 = 0.46) and disruption (AC1 = 0.26). The lowest SRD for the quantitatively graded horizontal features was observed for the zone of choroidal hypertransmission (± 190.8 μm). Moderate agreement was found for a 3-category classification of no atrophy, iRORA, and cRORA (AC1 = 0.53). Exploratory analyses suggested a significantly higher level of agreement for a 3-category classification using (1) no atrophy; (2) presence of inner nuclear layer and outer plexiform layer subsidence, or a hyporeflective wedge-shaped band, as a less severe atrophic grade; and (3) the latter plus an additional requirement of choroidal hypertransmission of 250 μm or more for a more severe atrophic grade (AC1 = 0.68; P = 0.013). CONCLUSIONS: Assessment of iRORA and cRORA, and most of their associated features, can be performed relatively consistently and robustly. A refined combination of features to define early atrophy could further improve interreader agreement.

Background Accelerated idioventricular rhythm (AIVR) is an uncommon and typically benign dysrhythmia with similarities to more malignant forms of ventricular tachycardia (VT). It is often seen in adults after myocardial infarctions, although it also arises in the newborn period, as well as in children with and without congenital heart disease. Case Report We describe a presentation of AIVR in an otherwise healthy 13-year-old girl, discovered on arrival to the pediatric emergency department in the setting of post-tonsillectomy bleeding. The case reviews the diagnostic criteria of AIVR, associated symptoms, the pathophysiologic origin of AIVR, and potential treatment strategies. Why Should an Emergency Physician Be Aware of This? Given its morphologic similarities to life-threatening forms of VT, AIVR can be misdiagnosed in the emergency department or primary care settings. With an understanding of the dysrhythmia's unique features, emergency physicians can avoid unnecessary interventions and provide the correct diagnosis, workup, and management of AIVR for pediatric patients.

Mean sensitivity (MS) derived from a standard test grid using microperimetry is a sensitive outcome measure in clinical trials investigating new treatments for degenerative retinal diseases. This study hypothesizes that the functional decline is faster at the edge of the dense scotoma (eMS) than by using the overall MS.Multicenter, international, prospective cohort study: ProgStar Study.Stargardt disease type 1 patients (carrying at least 1 mutation in the ABCA4 gene) were followed over 12 months using microperimetry with a Humphrey 10-2 test grid. Customized software was developed to automatically define and selectively follow the test points directly adjacent to the dense scotoma points and to calculate their mean sensitivity (eMS).Among 361 eyes (185 patients), the mean age was 32.9 ± 15.1 years old. At baseline, MS was 10.4 ± 5.2 dB (n = 361), and the eMS was 9.3 ± 3.3 dB (n = 335). The yearly progression rate of MS (1.5 ± 2.1 dB/year) was significantly lower (β = -1.33; P.001) than that for eMS (2.9 ± 2.9 dB/year). There were no differences between progression rates using automated grading and those using manual grading (β = .09; P = .461).In Stargardt disease type 1, macular sensitivity declines significantly faster at the edge of the dense scotoma than in the overall test grid. An automated, time-efficient approach for extracting and grading eMS is possible and appears valid. Thus, eMS offers a valuable tool and sensitive outcome parameter with which to follow Stargardt patients in clinical trials, allowing clinical trial designs with shorter duration and/or smaller cohorts.

Throughout history, oral administration has been regarded as the most convenient mode of drug delivery, as it requires minimal expertise and invasiveness. Although oral delivery works well for small-molecule drugs, oral delivery of macromolecules (particularly proteins and peptides) has been limited by acidic conditions in the stomach and low permeability across the intestinal epithelium. Accordingly, the large numbers of biologic drugs that have become available in the past 10 years typically require administration by injection or infusion. As such, a renewed emphasis has been placed on the development of novel materials that overcome the physiological challenges of oral delivery for macromolecular agents. This Review provides an overview of physiological barriers to the oral delivery of biologics and highlights the advances made in materials across various length scales, from small molecules to macroscopic devices. This Review also describes the current status of materials for oral delivery of protein and peptide drugs. New materials, beyond those that have already obtained regulatory approval, are needed to improve the bioavailability of orally administered proteins. In this Review, barriers to the oral delivery of protein-based therapies are discussed, along with the current translational landscape and state of the art of materials for oral protein delivery.

Background Although adolescents and young adults may be particularly prone to mental health symptoms after heart transplant, screening practices are variable. Objective To assess the feasibility of using patient-reported outcome (PRO) measures to assess mental health, functional status, and resiliency in posttransplant adolescents and young adult patients. Methods Patients transplanted between ages 15 and 25 years at 3 centers completed 6 PRO instruments via web-based platforms: PROMIS instruments for anxiety, depression, satisfaction with social roles, and physical functioning; the Posttraumatic Stress Diagnostic Scale for Diagnostic and Statistical Manual of Mental Disorders, version 5; and the Connor-Davidson Resilience Scale-10. Feasibility (completion, time to completion, and measure missingness) and PRO results were described and compared between patients with congenital heart disease and cardiomyopathy. Results Nineteen patients (median age at transplant 17.7 y [interquartile range 16.3, 19.2 y], 84% male) were enrolled at an average of 3 ± 1.8 years after transplant. Enrollment was 90% among eligible patients. Measure missingness was zero. The average completion time was 12 ± 15 minutes for all instruments. Timely PRO completion was facilitated by in-clinic application. The PRO results indicated that 9 patients (47%) had at least mild posttraumatic stress disorder symptoms (≥11 points on Posttraumatic Stress Diagnostic Scale for Diagnostic and Statistical Manual of Mental Disorders, version 5). Among them, 4 patients had scores >28 suggestive of probable posttraumatic stress disorder. Two (11%) and 6 (32%) patients had anxious and depressive symptoms, respectively. The cardiomyopathy cohort had a higher median Posttraumatic Stress Diagnostic Scale for Diagnostic and Statistical Manual of Mental Disorders, version 5 score than that of the congenital heart disease subgroup (11.0 vs 6.0; P = 0.015). Twelve (63%) had resiliency scores that were lower than the population average. No significant differences were found in PRO results between patients with cardiomyopathy and congenital heart disease apart from the posttraumatic stress disorder assessment. Conclusions This novel PRO-based approach to psychiatric screening of adolescents and young adult patients after transplant appears feasible for assessing mental health, functional status, and resiliency, with excellent enrollment and completion rates. These instruments characterized the burden of mental health symptoms within this adolescents and young adult heart transplant cohort, with a high prevalence of posttraumatic stress disorder symptoms. Resiliency scores were lower than in a comparison population. Electronically-administered PRO administration could facilitate more consistent mental health screening in this at-risk group.

A new deep-learning approach based on dimensionality reduction techniques for the design and knowledge discovery in nanophotonic structures will be presented. It is shown that reducing the dimensionality of the response and design spaces in a class of nanophotonic structures can provide new insight into the physics of light-matter interaction in such nanostructures while facilitating their inverse design. These unique features are achieved while considerably reducing the computation complexity through dimensionality reduction. It is also shown that this approach can enable an evolutionary design method in which the initial design can be evolved intelligently into an alternative with favorable specification like less complexity, more robustness, less power consumption, etc. In addition to providing the details about the fundamental aspects of the latent learning approach, its application to design of reconfigurable metasurfaces will be demonstrated.

Solar photovoltaic power generation capacity is growing rapidly, increasing the need for dynamic load balancing when solar production dips. This balancing might be delivered using energy storage and/or advanced power generation cycles, that are compact, dynamic, and highly efficient, such as supercritical carbon dioxide (sCO2) cycles. Here, the load balancing capability of a sCO2 combined cycle plant was compared to open cycle and steam combined cycle gas turbines. A characteristic-based transient model was developed to evaluate the impact of machinery ramp rates, minimum part loads, and cycle efficiencies. High resolution demand and solar irradiance data from the University of Virginia campus, before and after installation of a major solar project, was used to represent low and high levels of solar deployment in the grid. The results suggest that under high deployment of solar power, sCO2 cycles and steam combined cycle systems with ramp rates greater than 5.75%/minute can balance load and provide comparable levelized costs of electricity ($0.057/kWh). Solar curtailment was driven by the minimum part load capabilities. A sCO2 cycle with a minimum part load of 30% was predicted to have a curtailment of 15% in the high solar scenario without a battery, and 4% with a 30 MWh battery.

Digoxin has been associated with lower interstage mortality (ISM) following stage 1 palliation (S1P). Despite a substantial increase in digoxin use nationally, ISM has not declined. We aimed to determine the impact of digoxin on ISM in the current era. This study analyzed data from the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry. All patients who survived to hospital discharge following S1P were included. Comparisons were made between pre-specified eras (1: 2010-2015, 2: 2016-2019) based on digoxin use. ISM risk was estimated using the previously published NEONATE score (excluding digoxin). Multivariable Cox proportional hazard models assessed the impact of digoxin on ISM and freedom from unplanned readmission in era 2. A total of 1400 (46.8%) patients were included from era 1 and 1589 (53.2%) from era 2. Digoxin use (22.4% vs 61.7%, p0.001) and the proportion of high-risk patients (9.1% vs 20.3%, p0.001) increased across eras. There was no difference in predicted ISM risk between those who did vs did not receive digoxin in era 2 (p = 0.82). In era 2, digoxin use was independently associated with lower ISM (AHR 0.60, 95%CI 0.36 to 0.98, p = 0.043) and greater freedom from unplanned readmission (AHR 0.44, 95%CI 0.32 - 0.59, p0.001). In conclusion, digoxin is independently associated with lower ISM and greater freedom from interstage readmission. The lack of improvement in overall ISM in the current era may be secondary to a greater proportion of high-risk patients and/or disproportionately higher digoxin use in lower risk patients, who may not derive the same benefit.

We present a new approach based on manifold learning for breaking the geometrical complexity of the photonic nanostructures during solving the inverse design problem. By encoding the high-dimensional spectral responses of a class of nanostructures into the latent space, we provide intuitive information about the underlying physics of these structures. We discuss the relations between the non-Euclidean distances in the latent space and changes in the optical responses and relate the movements in the latent space to the modifications of the optical responses for a class of nanostructures. Finally, we provide a new approach to use the insight about the role of design parameters to design nanostructures with minimal design complexity for a given functionality.

Here, we leverage Mie scattering resonances supported by an all-dielectric metasurface made of phase-change material GeSe3 nanopillars to demonstrate nanoscale high-saturation color switching.

We present a new manifold-learning-based approach to reduce the geometric complexity of the inverse design of photonic nanostructures and show how this approach can provide valuable insight about the underlying physics of their operation.

Purpose Pterygium is characterized by the development of wing-shaped fibrovascular tissue from the bulbar conjunctiva across the limbus onto the cornea. The purpose of this study was to quantify the discrepancy of the pterygium size between the fibrous area and the vascularized area. Methods Color photographs of 146 eyes with pterygia obtained with a single-lens reflex camera system were analyzed by 2 independent graders for width (vertical dimension), length (horizontal dimension), and surface area of the pterygium head using 2 methods: the fibrous method, which measures any fibrovascular tissue crossing the corneal limbus, and the vascular method, which measures only tissue with discernible active blood flow, without any avascular tissue or opacity. Statistics of intraclass correlation coefficients for intergrader and intragrader reproducibility were calculated, and the paired t test between methods was used. Results Both intergrader and intragrader intraclass correlation coefficients for both methods were above 0.85. The vascular measurement was significantly larger in width (vertical dimension, fibrous 3.97 ± 1.02 mm vs. vascular 4.49 ± 1.33 mm, P = 0.01), whereas the fibrous measurement was significantly larger in length (horizontal dimension, fibrous 2.41 ± 1.16 mm vs. vascular 2.23 ± 1.05 mm, P = 0.04). No significant difference was found in the surface area (fibrous 7.27 ± 4.65 mm vs. vascular 7.40 ± 5.13 mm, P = 0.67). Conclusions With both methods, reproducibility of the size of the pterygium head was high. Significant differences were shown between the two methods in quantification of the width and length but not in the surface area. Such methods can be used to standardize the evaluation of pterygia in clinical research and clinical trials.

Improving change of direction (COD) with the use of strength training has led to mixed results. To date, the modified single leg squat (MSLS) and the bilateral squat (BS) have been successfully used to improve COD, with equal improvement. COD is primarily performed at a 45-75° frontal plane angle; however, the MSLS and BS are performed at a 90° frontal plane angle. Based on the force vector theory, it is proposed that a more mechanically similar strength training exercise, the Laterally Resisted Split Squat (LRSS), be used. The purpose of this study is to compare COD with the LRSS, MSLS, and the BS via kinetic measurements. Ten healthy and recreationally active female individuals volunteered for this study. Participants were pre-screened using a COD test to verify proper mechanics. Participant's weight was measured and 1RM (using Bryzcki formula/technique) for the LRSS, MSLS, and BS calculated. Peak ground reaction force (GRF) of participant's dominant leg in the frontal plane for COD and the three exercises at 70% 1RM was collected and used to calculate peak magnitude and vector angle. Peak GRF magnitude was significantly larger in COD (2.13 ± 0.52 bodyweight: BW) than the LRSS (0.85 ± 0.07 BW; p < 0.001), MSLS (0.99 ± 0.10 BW; p = 0.001), and BS (0.52 ± 0.07 BW; p < 0.001). COD (66.70° ± 4.98°) vector angle was not significantly difference than the LRSS (74.94° ± 4.11°; p = 0.057) as compared to the MSLS (89.04° ± 0.48°; p < 0.001) and BS (82.69° ± 4.30°; p < 0.001). In an application of the force vector theory, the LRSS more closely matches COD than the MSLS or BS.

Leveraging sharp toroidal resonances supported by an all-dielectric metasurface (MS) made of high-index phase-change material Sb2S3 nanopillars (NPs), we demonstrate tunable ultrahighly saturated structural color with unprecendted large color gamut.

Herein, for the first time to our knowledge, we experimentally demonstrate Fano resonant all-dielectric metasurfaces comprising of high- and median-index nanopillars (HfO2, TiO2 and ZrO2) with zero loss in visible range for polarization-sensitive structural coloration.

Purpose To investigate the natural history of Stargardt disease (STGD1) using fixation location and fixation stability. Design Multicenter, international, prospective cohort study. Methods Fixation testing was performed using the Nidek MP-1 microperimeter as part of the prospective, multicenter, natural history study on the Prog ression of Star gardt disease (ProgStar). A total of 238 patients with ABCA4-related STGD1 were enrolled at baseline (bilateral enrollment in 86.6%) and underwent repeat testing at months 6 and 12. Results Outcome measures included the distance of the preferred retinal locus from the fovea (PRL) and the bivariate contour ellipse area (BCEA). After 12 months of follow-up, the change in the eccentricity of the PRL from the anatomic fovea was −0.0014 degrees (95% confidence interval [CI], −0.27 degrees, 0.27 degrees; P = .99). The deterioration in the stability of fixation as expressed by a larger BCEA encompassing 1 standard deviation of all fixation points was 1.21 degrees squared (deg2) (95% CI, −1.23 deg2, 3.65 deg2; P = .33). Eyes with increases and decreases in PRL eccentricity and/or BCEA values were observed. Conclusions Our observations point to the complexity of fixation parameters. The association of increasingly eccentric and unstable fixation with longer disease duration that is typically found in cross-sectional studies may be countered within individual patients by poorly understood processes like neuronal adaptation. Nevertheless, fixation parameters may serve as useful secondary outcome parameters in selected cases and for counseling patients to explain changes to their visual functionality.

Traumatic brain injury (TBI) is a leading cause of death and disability, with injuries classified as mild in severity being the most frequently sustained. While the majority of patients recover within 3 months post-injury, many individuals continue to experience debilitating emotional sequelae several months after the injury. While spiritual well-being has been shown to carry protective benefits against both depression and anxiety in the general population, it has not been investigated as a protective factor in this population. The aim of this study was to investigate whether spiritual well-being leads to a reduction in anxious and depressive symptomatology following mild TBI (mTBI). The Beck Anxiety Inventory, Beck Depression Inventory-II, and Spiritual Well-Being Scale were administered to a sample of 83 litigating examinees who had undergone neuropsychological testing to assess their present functioning secondary to mTBI. The existential well-being (EWB) subscale significantly predicted depressive symptomatology. These findings support the role of EWB as contributory factor related to depressive symptomatology following mTBI. Rehabilitation practitioners should consider treatment paradigms that address EWB as a primary contributor to reduce depressive symptomatology, which may ultimately lead to improved functional ability.

Diabetes mellitus has become a major public health issue that has almost reached epidemic proportions worldwide. Injectable insulin has been typically utilized for the management of this chronic disease. However, lack of patient compliance with injectable formulations has spurred the development of oral insulin formulations, which although appealing, face several delivery challenges. We have developed novel mucoadhesive intestinal patches, several hundred micrometers in dimension (micropatches) that address the challenges of oral insulin delivery. The micropatches adhere to the intestinal mucosa, release their drug load rapidly within 30 min and are effective in lowering blood glucose levels in vivo. When insulin-loaded micropatches were administered with a permeation enhancer and protease inhibitor, a peak efficacy of 34% drop in blood glucose levels was observed within 3 h. Efficacy further improved to 41% when micropatches were administered in multiple doses. Here, we describe the design of micropatches as an oral insulin formulation and report their in vivo efficacy.

Digoxin use has been associated with lower interstage mortality in infants with HLHS and variants. The NEONATE score was developed to risk stratify patients for interstage mortality or transplantation; risk factors included type of stage 1 palliation (S1P)—Norwood with BT or Sano shunt vs. Hybrid

With the rise in diabetes mellitus cases worldwide and lack of patient adherence to glycemia management using injectable insulin, there is an urgent need for the development of efficient oral insulin formulations. However, the gastrointestinal tract presents a formidable barrier to oral delivery of biologics. Here we report the development of a highly effective oral insulin formulation using choline and geranate (CAGE) ionic liquid. CAGE significantly enhanced paracellular transport of insulin, while protecting it from enzymatic degradation and by interacting with the mucus layer resulting in its thinning. In vivo, insulin-CAGE demonstrated exceptional pharmacokinetic and pharmacodynamic outcome after jejunal administration in rats. Low insulin doses (3–10 U/kg) brought about a significant decrease in blood glucose levels, which were sustained for longer periods (up to 12 hours), unlike s.c. injected insulin. When 10 U/kg insulin-CAGE was orally delivered in enterically coated capsules using an oral gavage, a sustained decrease in blood glucose of up to 45% was observed. The formulation exhibited high biocompatibility and was stable for 2 months at room temperature and for at least 4 months under refrigeration. Taken together, the results indicate that CAGE is a promising oral delivery vehicle and should be further explored for oral delivery of insulin and other biologics that are currently marketed as injectables.

Background Patients presenting with mild stroke symptoms are excluded inconsistently from intravenous (IV) thrombolysis. We aimed to compare acute magnetic resonance imaging findings in patients with mild symptoms to those with more severe deficits to identify clinically mild patients who might benefit from IV thrombolysis. Methods We retrospectively studied consecutive stroke patients presenting with perfusion deficit who underwent time-of-flight magnetic resonance angiography within 24 hours of time last seen normal. Two raters measured the lesion volumes on diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) with mismatch (MM) calculated as PWI minus DWI. Occlusion site was categorized as "proximal," "distal," or "magnetic resonance angiography-negative" by consensus review. Stroke with mild symptoms was defined as admit National Institutes of Health Stroke Scale score of 4 or less. Values were reported as n (%). Results Ninety-one patients were included; 56 (61.5%) with nonmild and 35 (38.5%) with mild symptoms. After stratifying for occlusion site, there were no differences in PWI and MM lesion volumes for the nonmild versus mild patients ( P = .34-.98 and P = .54-1, respectively). Furthermore, there was a trend for thrombolyzed mild stroke patients (88%, n = 7 of 8) to more likely have a favorable clinical outcome (discharge modified Rankin score ≤ 2) versus untreated patients (70%, n = 16 of 23). Conclusions When present, conspicuous vessel occlusions in clinically mild stroke patients are concomitant with similar perfusion deficit and MM volumes in more clinically severe stroke patients. Coupled with a trend toward better outcomes in mild stroke patients who were treated with IV tissue plasminogen activator (t-PA), this could indicate that advanced imaging may be used in standardizing the way these patients are selected for IV t-PA therapy.

Objective: Since April 2010, our institution has repaired complete atrioventricular septal defects (CAVSDs) with a two-patch technique utilizing CorMatrix extracellular material. This material is potentially an attractive patch because of its theorized eventual integration with the host tissue. We sought to analyze initial outcomes of CAVSD repair with CorMatrix. Methods: Data were collected on consecutive pediatric (age Results: Fifteen patients were identified. The average age at operation was 205 days, with mean follow-up time at 1,364 days. Echocardiograms revealed the following: 12 (80%) patients showed either improved or stable left AV valve performance remaining at “mild” or less insufficiency, while two (13%) declined from “none” to mild and one (7%) from mild to “severe,” which required reoperation. There was no residual shunting or LVOT obstruction at follow-up. The single (7%) reoperation was performed after three years due to left AV valve zone of apposition dehiscence. No permanent pacemakers were needed, and no deaths were reported. Conclusion: Our initial experience with CorMatrix in the repair of CAVSD in children has resulted in good initial and midterm outcomes. The CorMatrix patch remained stable through midterm follow-up, thus may be efficacious for use in CAVSD repair.

Purpose For adolescents and young adults, receiving a heart transplant is a profoundly challenging experience. This pilot study examined the burden of psychiatric co-morbidities and resiliency factors in post-transplant patients using patient-reported outcomes (PRO). Methods Patients transplanted between ages 15-25 years at one of three tertiary care centers were asked to complete six PRO measures—PROMIS® measures to assess depression, anxiety, satisfaction with social roles (SSR), and physical functioning (PF); Posttraumatic Stress Diagnostic Scale for DSM-5 (PDS-5) for Posttraumatic Stress Disorder (PTSD); and the Connor-Davidson Resilience Scale-10 for resiliency. Formal psychiatric diagnoses and demographics were collected retrospectively from chart review. Comparisons were made between PRO measures and formal diagnoses, with further comparison between those transplanted for congenital heart disease (CHD) and cardiomyopathy (CM). PROMIS® scores were dichotomized at their literature-reported cutoffs for depression and anxiety. Fisher's exact test, McNemar's test for paired samples, and Wilcoxon rank-sum test were used as appropriate. Results We enrolled 14 patients (median age at transplant 17.9 years [IQR 16.5, 20.7 yr]; 86% male and 64% with CM). Of 13 with complete data, 8/13 patients (62%) had at least mild PTSD symptoms and 3/13 (23%) had PDS-5 scores indicating probable PTSD diagnosis. Only one patient carried a formal diagnosis of PTSD. 5/13 (39%) patients had probable depression by PROMIS®. Compared to CM patients, CHD patients had more severe PTSD symptoms (p = 0.035), higher depression scores (p = 0.018) and lower PF and SSR PROMIS® scores (p = 0.017 and 0.003, respectively). Conversely, CM patients had higher resiliency scores (p = 0.021). Conclusion In this pilot study, we found high prevalence of PTSD and depression symptoms with discordant formal psychiatric diagnoses. This suggests that these disorders may be underrecognized in the adolescent and young adult heart transplant population. The routine use of PRO measures should be tested in an expanded prospective study to further evaluate their screening utility for psychiatric co-morbidities among members of this vulnerable population.

Severe (massive and sub-massive) pulmonary embolism (PE) is associated with significant rates of morbidity and mortality. We sought to assess severe PE before and after the inception of a multidisciplinary PE Response Team (PERT). Acute PE patients in the pre-PERT and early-PERT years (2013-2016)

Awake craniotomy (AC) has seen an expanded role in brain tumor surgery over the past few decades. AC allows intraoperative cortical mapping and the continuous assessment of neurophysiological parameters, which are otherwise unattainable under general anesthesia (GA). The ability of AC to analyze eloquent brain areas makes it a powerful method for reducing the risks associated with tumor resection, especially in motor and language cortex. We present a review of the literature to examine the benefits and limits of using AC over GA.A literature search was performed using the Medline and PubMed databases from 1970 and 2012 that compared craniotomy for tumor resection under GA and AC. Data of interest included length of hospital stay, operating time, extent of resection, and neurological sequelae.A total of 8 studies with 951 patients (411 utilizing AC and 540 utilizing GA) were included in this review. Our interpretation of the literature suggests that AC (4 d, n=110) results in a shorter hospital stay than GA (9 d, n=116). Mean extent of resection was slightly less under awake conditions (41%, n=321) versus GA (44%, n=444), and postoperative deficits were less frequent under awake conditions (7%, n=411) versus GA (23%, n=520). Surgery time was slightly less in the AC group (165 min, n=324) versus GA (168 min, n=477).Given the effectiveness of AC for resection of eloquent tumors, the data suggests an expanded role for AC in brain tumor surgery regardless of tumor location.

The purpose of our study was to compare the agreement of emergency physician diagnoses relative to the 1991 American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) and 2001 ACCP/SCCM/European Society of Intensive Care Medicine/American Thoracic Society/Surgical Infection Society internationally accepted definitions of sepsis, severe sepsis, and septic shock.This study was an observational cohort study of adult patients presenting to the emergency department (ED) with a chief complaint suggestive of infection over a 6-week period, during a daily enrollment schedule from 7:00 am to 10:00 pm. Patients were categorized as having "no sepsis," "sepsis," "severe sepsis," or "septic shock" based on ED physician diagnosis, the 1991 definitions, or 2001 definitions. Agreement statistics were performed.A total of 1275 patients were enrolled with age 50.1 ± 21.7 years and 59.1% were female. Among the enrolled patients, 228 were identified as having a source of infection. Temperature, heart rate, and white blood cell count were significantly higher in patients with infection, compared with those without (P.001). The odds ratio for disagreement between a physician-designated no sepsis diagnosis and the 1991 definitions was 4.47 (95% confidence interval, 3.01-7.53) and 5.96 (3.78-9.46) between the same physician-designated diagnosis and the 2001 definitions. The odds ratios for disagreement of a severe sepsis physician diagnosis in relation to the 1991 and 2001 definitions were 0.06 (0.01-0.19) and 0.06 (0.01-0.20), respectively. The 1991 and 2001 consensus definitions had strong agreement, with κ = 0.86 and 91.2% agreement. No agreement was found between the physician diagnosis and 1991 consensus sepsis definitions (κ = 0.11 and 52.2% agreement) or between the physician diagnosis and the 2001 consensus sepsis definitions (κ = 0.13 and 50.0% agreement).Our study showed that ED physician diagnosis of sepsis may disagree with the international definitions such that severe sepsis is underrecognized by clinical judgment alone. Although these results are limited to a single center, we raise concern that early treatments for these high-risk patients may be delayed due to inaccurate clinical diagnosis. Efforts are needed to increase the application of sepsis guideline definitions to better identify ED patients with this potentially deadly condition.

The radiated performance of a multiple-input-multiple-output (MIMO) antenna system is commonly evaluated based on a set of antenna-centric figures of merit (FoM). These generally include the antenna's total efficiency, branch imbalance, and magnitude of the complex (or envelope) correlation coefficient. On the other hand, to validate the over-the-air (OTA) performance of the MIMO system, including both antennas and other parts of the real transceivers, test methodologies were created based on a single FoM: the absolute data throughput. While an antenna-centric FoM provides a preliminary overall insights into the radiated performance of the MIMO antenna system, these FoMs are limited in their overall applicability. Each of these FoMs is based on far-field antenna measurements and assuming a uniform distribution of the incoming power, meaning that passive antenna measurements are made in single-input-single-output (SISO) anechoic chambers. Furthermore, without the implementation of channel models with controllable spatial characteristics, it is impossible to isolate the effect of polarization changes on MIMO performance. In this letter, the radiated performance of MIMO antenna systems will be compared in terms of data throughput using different channel models both with and without controllable cross-polarization ratio and other spatial characteristics.

Recently, 5-aminolevulinic acid (5-ALA) has been utilized as an adjuvant to the surgical resection of primary brain tumors and metastases. We conducted a systematic review of the literature to further understand the role of 5-ALA in neurosurgery. Our goal was to identify the utility of 5-ALA during resection by evaluating its sensitivity and specificity for different tumor types, as well as the extent of tumor resection achieved while using 5-ALA. A search of the literature was conducted using the PubMed database for the period January 1990 through May 2014. Surgical series in which 5-ALA was used for brain neoplasm resections were evaluated for tumor histology, sensitivity, specificity, extent of resection, complications, and outcomes. Twenty-two series, involving 1163 patients, were included in our review. 5-ALA sensitivity was highest in high-grade gliomas (85 %) and meningiomas (81 %). 5-ALA specificity was high in meningiomas (100 %), as well as metastases (84 %) and high-grade gliomas (82 %). Gross total resection (GTR) was achieved using 5-ALA in 66.2 % of all gliomas and 69.6 % of meningiomas, regardless of histological subtype. 5-ALA may be a useful tool in increasing the extent of resection and achieving GTR in intracranial tumors. The resection of tumors for which 5-ALA has high sensitivity and specificity, such as high-grade gliomas, may lead to an increase in extent of resection when compared to operations using only standard white light. Further evidence for the use of 5-ALA in meningiomas and certain subtypes of metastases may be needed to qualify its efficacy.

A spatial light modulator design consisting of cascaded or sandwiched layers of ferroelectric liquid crystals (FLC's) is investigated. The interrelation between the FLC material, the polarization of the incident illumination, and the achievable modulation states is characterized. Magnitude modulation is accomplished by standard methods by addressing the FLC layer with linearly polarized light and following it with a properly oriented analyzer. When the FLC is addressed with circularly polarized light, lossless phase modulation results with the phase states separated by twice the angle of rotation of the optical axes. A continuum of elliptical polarization states ties together the lossless phase states achievable by using circular polarization with the more well-known 0 degrees -180 degrees phase states obtainable with linearly polarized light. Layers of various bistable FLC materials can be cascaded, possibly with polarization control layers between some of the layers, to yield a spatial light modulator that produces multip e quantized bits of complex-valued modulation and with independent control of magnitude and phase states. Four-state phase modulation, ternary amplitude-phase modulation, and four-state magnitude modulation are demonstrated experimentally by using two layers of FLC.

We describe a CRC-based optimal blind transport format determination algorithm for UMTS uplink.

The paper addresses the problem of synchronous CDMA communications when, due to bandwidth limitations, signature waveforms have relatively large correlations. A receiver which uses the multiple received signals available from an antenna array is proposed and its performance analyzed. This receiver may be interpreted as a multichannel extension of the decorrelating detector and therefore shares its immunity to near-far effects. The receiver uses the discrimination afforded by the antenna array to effectively reduce the correlation between users' transmitted signals thereby avoiding the reduction in performance which occurs in the single channel decorrelator when signature correlations become significant. >

The authors present a general methodology for achieving any amount of pure phase modulation between 0 and 180 degrees by controlling the polarization of light used to address a given ferro-electric liquid crystal (FLC) material. Using this technique, an eight-state phase modulator made by cascading three FLC layers is demonstrated. Motivated by the need for predictable behavior within spatial light modulators (SLMs), experimental data characterizing the point by point spatial uniformity of an FLC device used for 0/90 degree phase modulation also is presented.

The term "hay fever" is a misnomer, as the symptoms are not due to hay, and instead of fever, there is usually a subnormal temperature. This name was first applied to the disease by the laity, and as it has survived a century of usage, will probably never be discarded. Hay fever is of two types: (1) the seasonal, which is limited to some particular season of the year, and (2) the nonseasonal or perennial, with symptoms occurring more or less irregularly throughout the year. Perennial hay fever has many different names, such as vasomotor rhinitis, hyperesthetic rhinitis and nasal hydrorrhea, and when known to be due to sensitization is spoken of as allergic rhinitis or atopic coryza. Although perennial hay fever is frequently encountered by the medical profession, it is usually poorly handled, and, as a matter of fact, is looked on by most rhinologists as a more

Traditional teaching-and-learning environments often do not address the learning needs of today's “millennial” generation of students who prefer team work, experiential activities, structure and the use of technology. In fact, millennial students view technology as a necessity, both in life and in learning and highly regard “doing rather than knowing”, making interactive, experiential learning, a necessity for their educational success. Recently, there has been a push on the development of interactive simulations for educational and training purposes and such simulations are being incorporated into a large number of curriculums. To develop effective simulations that meet the needs of both millennial students, and educators, end users’ views and perceptions of simulation use in the classroom must be assessed and accounted for. We must develop an understanding of the sentiments and demand for simulations in teaching and learning. Such information provides valuable input into the development of simulations and ensures their use and integration within the classroom. In order to assess this, a single institution, survey study consisting of a two part survey (one geared towards students and the other to faculty) was developed and conducted at the University of Ontario Institute of Technology (UOIT), a laptop-based university, that prides itself on the use of technology in the classroom, to gauge users perceptions of virtual simulations. Results indicate that students and faculty alike do appreciate the use of virtual simulations but care should be taken to ensure that the simulations are relevant to the course material and that educators are familiar with the use of the simulations to assist students should any problems arise.

Excerpt There are three distinct types of seasonal hay-fever in the District of Columbia and vicinity, namely: early spring, due to tree pollens; late spring or summer, the type under consideration...

History. —Mr. F. R., aged 30, consulted me, Sept. 23, 1924, for the relief of perennial hay-fever, with which he had been troubled during the preceding nine months. The symptoms started in January, 1924, with a running nose, pronounced irritation of the eyes and nose, and a feeling of fulness in the head. These symptoms became progressively worse until the patient had an almost constant, clear watery discharge from both nostrils. He felt much better while outdoors. He was treated by his family physician, and also by a competent nose and throat specialist, without relief. He then went to New York and took some sort of light treatments, which he felt helped him a great deal, but only temporarily. The only real relief that he had experienced since the disorder started was during the month of July, which he spent in Atlantic City, where he was entirely free from the disease. He had never

Excerpt Micro-organisms may be divided into four distinct groups, namely, the Schizomycetes or bacteria, the Hyphomycetes or molds, the Blastomycetes or yeasts, and the protozoa. The bacteria, mold...

Very little attention has been paid to cottonseed or kapok sensitization in the extensive literature on allergy, and, to my knowledge, no article has been previously written on this subject. Although Balyeat 1 devotes an entire chapter of the second edition of his book on hay-fever and asthma to kapok as a good substitute for feathers in feather-sensitive patients, he makes no mention of the possibility of sensitization to kapok, nor does he mention cottonseed sensitization. Furthermore, he does not refer to cottonseed or kapok hypersensitiveness in any of his numerous articles on allergy. While talking to Dr. Balyeat less than six months ago, I brought up the question of cottonseed sensitization, and he stated that he had not paid any attention to it as he did not consider it of any importance. Coke, 2 in his book on asthma, also recommends kapok pillows whenever there is sensitization to feathers

Excerpt Although much has been written about local and focal reactions, little or no attention has been paid to constitutional reactions from bacterial vaccine injections. These systemic bacterial ...

Bronchial asthma may be due to many different causes and an exhaustive history is of fundamental importance in the specific diagnosis of this disease. I will endeavor to outline the method of taking such a history, indicating, as I go along, the significance of the various factors. AGE The first point to be considered is that of age, although the actual age of the patient is nothing like as important as the age of onset of the asthma. Naturally, the prognosis is not as good in an asthmatic patient past middle life as it is in a younger one, as in the older patient there is much more likelihood of organic changes in the lungs and heart, such as emphysema, bronchiectasis and myocarditis. The age of onset, on the other hand, is of importance in that the earlier in life the asthma starts, the more likely it is to be

Excerpt Urticaria and angioneurotic edema are commonly spoken of by the laity as hives and giant hives respectively. They are of frequent occurrence, and present to the physician one of his most di...

Excerpt Although occasional references to flaxseed or linseed sensitization are scattered through the vast literature on allergy, it seems to me that hypersensitiveness to this substance is deservi...

At the age of 6 years, my parents noticed that I had considerable difficulty in breathing. This was thought to be due to a pair of very large tonsils, which almost entirely closed the aperture in my throat. Tonsillectomy and adenectomy were performed at this time, but my dyspnea persisted and was then recognized as bronchial asthma. From this time, I suffered with frequently recurring attacks of more or less severity. I scarcely knew the meaning of a good night's sleep and, at times, I was unable to go to bed at all, but was forced to spend the night in a chair. Whenever I had a cold, which was very often, I was completely incapacitated. The inhalation of various asthma powders and cigarets gave me temporary relief, but no hope for a cure was held other than that I might possibly outgrow it. My first real relief was obtained