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The purpose of this study was to consider how the Positive Coaching Alliance (PCA) Triple-Impact Competitor (TIC) workshop could be used to help create a positive climate for recreational sport club participants, and to examine how perceptions of a positive team climate related to indices of psychological well-being among sport club athletes. At the beginning of their season, sport club leaders completed the PCA TIC workshop. Following the conclusion of the spring season, we invited all sport club participants ( N = 109) to complete a survey that examined the motivational climate on their teams, as well as their hope, happiness, and self-kindness. Athletes’ perceptions of a CTI climate were significantly and positively related to their hope, happiness, and self-kindness. Results suggest that the PCA TIC training is an inexpensive strategy that may foster a positive environment within university sport club teams and may assist programs in promoting indices of psychological well-being among club sport athletes.

Space radiation in the form of Solar Energetic Protons (SEPs) and Galactic Cosmic Rays (GCR) poses a substantial risk for long-duration space exploration. Active shielding concepts, i.e. shielding a spacecraft with electric and or magnetic fields, has been a topic of interest for more than 50 years. Mass and power requirements have yet to be fulfilled to enable active shielding technology. We present results for a single electric dipole to show the utility of scale-invariance and universal scaling for advancing active shielding concepts. Scattering patterns downstream from the dipole of 2 MeV to 6 MeV electrons and protons show a semi-circular region devoid of incident particles that increases in size with increasing dipole voltage. In particular, results are presented that show how scale-invariant approaches can be leveraged to enable small-scale shields to be built and tested on the ground and then scaled up for in-space use.

For 20 years, Positive Coaching Alliance (PCA) has trained adults who are currently involved in youth sport as coaches and parents to help young athletes have positive sport experiences. Th...

The continuous growth in 3D-NAND flash storage density has primarily been enabled by 3D stacking and by increasing the number of bits stored per memory cell. Unfortunately, these desirable flash device design choices are adversely affecting reliability and latency characteristics. In particular, increasing the number of bits stored per cell results in having to apply additional voltage thresholds during each read operation, therefore increasing the read latency characteristics. While most NAND flash challenges can be mitigated through appropriate background processing, the flash read latency characteristics cannot be hidden and remains the biggest challenge, especially for the newest flash generations that store four bits per cell. In this paper, we introduce read heat separation (RHS), a new heat-aware data-placement technique that exploits the skew present in real-world workloads to place frequently read user data on low-latency flash pages. Although conceptually simple, such a technique is difficult to integrate in a flash controller, as it introduces a significant amount of complexity, requires more metadata, and is further constrained by other flash-specific peculiarities. To overcome these challenges, we propose a novel flash controller architecture supporting read heat-aware data placement. We first discuss the trade-offs that such a new design entails and analyze the key aspects that influence the efficiency of RHS. Through both, extensive simulations and an implementation we realized in a commercial enterprise-grade solid-state drive controller, we show that our architecture can indeed significantly reduce the average read latency. For certain workloads, it can reverse the system-level read latency trends when using recent multi-bit flash generations and hence outperform SSDs using previous faster flash generations.

Despite its widespread use in consumer devices and enterprise storage systems, NAND flash faces a growing number of challenges. While technology advances have helped to increase the storage density and reduce costs, they have also led to reduced endurance and larger block variations, which cannot be compensated solely by stronger ECC or read-retry schemes but have to be addressed holistically. Our goal is to enable low-cost NAND flash in enterprise storage for cost efficiency. We present novel flash-management approaches that reduce write amplification, achieve better wear leveling, and enhance endurance without sacrificing performance. We introduce block calibration, a technique to determine optimal read-threshold voltage levels that minimize error rates, and novel garbage-collection as well as data-placement schemes that alleviate the effects of block health variability and show how these techniques complement one another and thereby achieve enterprise storage requirements. By combining the proposed schemes, we improve endurance by up to 15× compared to the baseline endurance of NAND flash without using a stronger ECC scheme. The flash-management algorithms presented herein were designed and implemented in simulators, hardware test platforms, and eventually in the flash controllers of production enterprise all-flash arrays. Their effectiveness has been validated across thousands of customer deployments since 2015.

Healthcare is a unique services environment with increasing demand for services coupled with widely diverse patient needs. In addition, hospitals are under increased pressure to provide quality car...

Passive radiation shielding alone cannot provide adequate protection for astronauts on long-term, deep-space missions. High atomic number and energy (HZE) ions, and/or their secondaries, can penetrate any realistic mass shielding for long-term deep-space missions and cause damage to cells via direct energy deposition and/or through the production of secondary particles and fragmented nuclei. Active shielding, or the use of electromagnetic fields to deflect or stop incoming ions before reaching the spacecraft, has gained substantial attention over the last decade as a way to augment passive shielding. Recently, a mathematical relationship between a dimensionless scaling parameter characterizing the active shield and the incoming ion and a protected area formed on a downstream detector due to the deflection of HZE ions by the applied field was validated in Earth-based laboratory conditions. In the present work, the mathematical formulation is extended to relate electrostatic shielding efficacy with the ability to deflect positively charged ions with parameters relevant to space applications. Additionally, a modified scaling parameter is formulated to characterize the shielding efficacy of a “family” of electrostatic active shielding configurations for reducing flux density for a space-relevant isotropic source of energetic protons. The results of this study demonstrate a strong correlation among dimensionless scaling parameters and shielding efficacy metrics for space radiation-relevant HZE ions in beam and isotropic angular distributions. Furthermore, it establishes a framework for optimizing design of three-dimensional electrostatic shielding configurations to improve space radiation protection for astronauts on exploration-class missions.

The recorded history of anal fistulas dates back to the Ancient Greeks, but no fistula in history has been as well or interestingly documented as that of Louis XIV, the Sun King of France. His story illustrates not only the state (or lack thereof) of medicine at the time, but also the first recorded use of the fistulotomy. This narrative provides a unique perspective for the role of the surgeon in 17th century France as well as cementing the place of cryptoglandular fistula disease in history.

3D NAND flash memory has entered dynamically into the space of enterprise server and storage systems, offering significantly higher capacity and better endurance than the latest 2D technology node. Moreover, the advancements in vertical stacking, cell design and program/read algorithms, have also enabled TLC 3D NAND flash with enterprise-level reliability, thus achieving further increase in capacity and cost-per-bit reduction. This paper presents an in-depth analysis of the bit-error characteristics of state-of-the-art 64-layer 3D TLC NAND flash with a focus on read-voltage calibration. We provide experimental measurements of the RBER and threshold voltage distributions using typical and mixed-mode test patterns of program/erase cycling, retention and read-disturb. Moreover, we quantify the RBER components attributed to threshold voltage level overlapping and on-chip 2-step program errors. Finally, we characterize how the optimal read voltages change under different device stress and we evaluate calibration schemes with different performance and complexity trade-offs.

It is a delicate task to accurately assess the impact of solar particle events (SPEs) on future long-duration human exploration missions. In the past, researchers have used several functional forms to fit satellite data for radiation exposure estimation. In this work we present a segmental power law interpolating algorithm to stream satellite data and get time series of proton spectra, which can be used to derive dosimetric quantities for any short period during which a single SPE or multiple SPEs occur. Directly using the corrected High Energy Proton and Alpha Detector fluxes of GOES, this method interpolates the intensity spectrum of a typical SPE to hundreds of MeV and extrapolates to the GeV level as long as sufficient particles are recorded in the high-energy sensors. The high-energy branch of the May 2012 SPE is consistent with the Band functional fitting, which is calibrated with ground level measurement. Modeling simulations indicate that the input spectrum of an SPE beyond 100 MeV is the major contributor for dose estimation behind the normal shielding thickness of spacecraft. Applying this method to the three SPEs that occurred in 2012 generates results consistent with two sets of in situ measurements, demonstrating that this approach could be a way to perform real-time dose estimation. This work also indicates that the galactic cosmic ray dose rate is important for accurately modeling the temporal profile of radiation exposure during an SPE.

BACKGROUND: Demand for respiratory care services and staffing levels of respiratory therapists (RTs) is expected to increase over the next several years. Hence, RT job satisfaction will be a critical factor in determining recruitment and retention of RTs. Determinants of RT job satisfaction measures have received little attention in the literature. This study examines the use of respiratory care protocols and associated levels of RT job satisfaction, turnover intentions, and job stress. METHODS: Four-hundred eighty-one RTs at 44 hospitals responded to an online survey regarding job satisfaction, turnover intentions, and job stress. Random coefficient modeling was used for analysis and to account for the nested structure of the data. RESULTS: Higher levels of RT protocol use were associated with higher levels of job satisfaction, lower rates of turnover intentions, and lower levels of job stress. In addition, RTs with greater experience had higher levels of job satisfaction, and RTs working at teaching hospitals had lower rates of turnover intentions. CONCLUSIONS: The study extends prior research by examining how the use of respiratory care protocols favorably affects RTs9 perceptions of job satisfaction, turnover intention, and job stress. In a time of increasing demand for respiratory care services, protocols may enhance retention of RTs.

BACKGROUND: Organizational factors associated with adoption and use of respiratory care protocols have received little attention. This study examines patterns of protocol use and features of a hospital and providers that are associated with respiratory care protocol use. METHODS: Forty-four hospitals and their health-care providers responded to an online survey regarding perceived outcomes of protocol use and their level of support for using protocols. Hospital features (ie, size, teaching status, and use of information systems) were also assessed. Descriptive statistics and multivariate logistic regression were used for analysis. RESULTS: Of the 9 types of respiratory care protocols assessed (ie, asthma, COPD, ARDS, hypoxemia, pneumonia, noninvasive ventilation therapy, supplemental oxygen titration and discontinuation, ventilator weaning, and bronchopulmonary hygiene), the most commonly used were for oxygen titration and ventilator weaning. Large hospitals (> 350 beds) used protocols more widely than smaller hospitals (P = .01). Respondents felt that use of protocols enhanced cost and quality of care. Finally, hospital features that were associated with overall protocol use were stakeholder support for protocol use and use of high-quality hospital information systems. CONCLUSIONS: The study extends prior research by clarifying features of hospitals and providers associated with use of respiratory care protocols. Validation in future hypothesis-testing samples will further advance this knowledge.

Operations management (OM) is a relatively new field of business, having become recognised as a standalone discipline in the mid 1980s. With this in mind, this study analyses the origins, geographical regions, countries, and institutions, of OM research in 11 top level academic journals from 1985 through 2010. Since the field is rather new and is still being developed, an analysis of current and past research constituents offers a unique opportunity to assess how research and education in OM has spread across the globe. We identify those geographic regions and countries that encourage and support OM research and education from the academic institutions within their boundaries. Further, through the research contributions of affiliated authors and PhD graduates, we identify those institutions within each country that are the leaders in terms of OM research and education efforts. We consider the research of faculty affiliated with each institution as well as the research of each institution’s PhD graduates. ...

The purpose of this study was to examine the association between members' perceptions of staffs behaviors, motivational climate, their own behaviors, commitment to future exercise, and life satisfaction in a group-fitness setting. The theory-driven hypothesized mediating role of perceptions of the climate was also tested.Members (N = 5,541) of a national group-fitness studio franchise completed a survey regarding their class experiences. The survey included questions that measured participants' perceptions of the motivational climate (caring, task-involving, ego-involving), perceptions of staff's behaviors, their own behaviors, commitment to exercise, and life satisfaction. Structural equation modeling was used to assess both the association between variables and the theoretically driven predictive relationships.The participants perceived the environment as highly caring and task-involving and low ego-involving. They reported high exercise commitment and moderately high life satisfaction and perceived that the staffs and their own behaviors reflected caring, task-involving characteristics. Structural equation modeling demonstrated that those who perceived a higher caring, task-involving climate and lower ego-involving climate were more likely to report more task-involving, caring behaviors among the staff and themselves as well as greater commitment to exercise. In addition, a theory-driven mediational model suggested that staff behaviors may be an antecedent to members' exercise experiences by impacting their perceptions of the climate.The results of this study give direction to specific behaviors in which staff of group-fitness programs might engage to positively influence members' exercise experiences.

The Author Affiliation Index (AAI) for ranking a set of academic journals was first presented by Gorman and Kanet (Manuf Serv Oper Manag 7:3---19, 2005). Since that time, it has become a popular method for assessing journal quality in a myriad of academic disciplines. However, a recent paper published by Agrawal et al. (Prod Oper Manag 20:280---300, 2011) pointed out several potential problems with the AAI. In this paper, we present a modified AAI that incorporates several improvements to the original AAI and addresses the three concerns expressed by Agrawal. The modified AAI allows for international institutions, introduces a weighting factor to allow for a greatly expanded set of prestigious institutions, considers the entire population of articles published in a journal during a specified time period, and utilizes a batch means approach to data collection to allow for proper statistical inference. We illustrate the modified AAI using a set of ten well-known journals that publish Operations Research and Operations Management research. The primary intent of this paper, however, is not to rank these ten journals; rather these ten journals are simply used to illustrate the use of the newly developed modified AAI.

This paper evaluates the origins of the research that has been published in the International Journal of Production Research (IJPR) for the time period 1985–2010, which includes approximately 77% of all articles that have been published in IJPR since its inception. We assess the productivity of individual authors, the author’s affiliation at the time each article was published, the country the author’s affiliation is located, and the institution where the author was granted a Ph.D. degree. By analysing the countries in which author affiliations are located, we can determine which countries are having the greatest impact on defining the research published in IJPR. For international journals, it is important to publish research from an international constituency, thus maintaining one of its purposes. By analysing the affiliations of the authors as well as where the authors received their Ph.D. training, we can determine which institutions are having the greatest contributions to the research published in IJ...

Images observed by the twin spacecraft Solar TErrestrial RElations Observatory (STEREO) A and B appear as complex structures for two coronal mass ejections (CMEs) on 1 August 2010. Therefore, a series of sky maps of Thomson-scattered white light by interplanetary coronal mass ejections (ICMEs) on 1 August 2010 are simulated using the Hakamada–Akasofu–Fry (HAF) three-dimensional solar-wind model. A comparison between the simulated images and observations of STEREO-A and -B clarifies the structure and evolution of ICMEs (including shocks) in the observed images. The results demonstrate that the simulated images from the HAF model are very useful in the interpretation of the observed images when the ICMEs overlap within the fields of view of the instruments onboard STEREO-A and -B.

Determining the quality of research outlets is important for Operations Management (OM) for reasons well documented in the published literature. Over the past few decades, utilising several different methodologies from a variety of perspectives, 15 studies have assessed the quality of journals that publish OM research. The published results are inconsistent in that the relative quality of journals varies from one study to the next and no single set of OM journals is unanimously recognised as being the top set. Historically, OM researchers have published in a wide variety of journals, utilised a variety of research methodologies and studied a broad range of topics. Given that each of the 15 studies assessed journal quality from a different perspective and utilised different methodologies, they represent a diversity of opinions regarding the OM field and add to the knowledge base regarding the quality of OM research outlets. In this paper, we combine the published results in a data envelopment analysis (DEA...

The People's Republic of China's National People's Congress amended the 1997 Criminal Law in February 2011 in order to cover bribery of foreign government officials or officials of international public organisations, with the Amendment coming into effect on 1 May 2011. Known as the Eighth Amendment to the Criminal Law, this Amendment, inter alia, brought the PRC into line with Article 16(1) of the UN Convention against Corruption.

The field of international law often is taught and thought of as a group of disconnected substantive subfields, each with its own epistemic community. These specialized subfields range from international human rights law to the law of the sea, from international trade law to collective security law. Examples where subfields conflict with each other and separate examples where subfields complement each other have led two camps of commentators over the past decade to comprehensively define international law’s nature as either united or fragmented in a binary fashion. Even the United Nations’ International Law Commission established a study group to explore this topic, which concluded in 2006 after over four years of study that international law is fragmented due, in part, to the collision of various branches of international law.

This article is the first to analyze the 2010 guidelines established by Mercosur’s Common Market Council for drafting an Agreement on Investment for Mercosur, which up until now has lacked any regulations for the promotion and protection of investment. This agreement is important not only because it potentially would fill a large gap in Mercosur law and strengthen Mercosur’s emergent common market, but also because it ostensibly represents the first time that Brazil has shown a real willingness to create an international system for investment protection, which represents a monumental breakthrough for Brazil. However, the guidelines (provided at the end of this article in an appendix) appear to have been created using the Protocol of Montevideo on Trade in Services as the model, as opposed to the more directly relevant norms from the realm of international investment law. This article explores whether this approach will lead to an international investment agreement that adequately promotes and protects investment in Mercosur. This article asserts that a better approach would be to use models from the realm of international investment law because these types of protections are needed in order to reassure investors. The sub-working group charged with drafting this agreement still is working on the draft agreement. Therefore, this article aims to influence that drafting process and subsequent debates over this draft agreement prior to its conclusion.

The recorded history of anal fistulas dates back to the Ancient Greeks, but no fistula in history has been as well or interestingly documented as that of Louis XIV, the Sun King of France. His story illustrates not only the state (or lack thereof) of medicine at the time, but also the first recorded use of the fistulotomy. This narrative provides a unique perspective for the role of the surgeon in 17th century France as well as cementing the place of cryptoglandular fistula disease in history.

Preclinical data suggested that bryostatin-1 (bryo) could potentiate the cytotoxicity of cisplatin when given prior to this drug. We designed a phase I study to achieve tolerable doses and schedules of bryo and cisplatin in combination and in this sequence.Patients with non-hematologic malignancies received bryo followed by cisplatin in several schedules. Bryo was given as an 1 and a 24 h continuous infusion, while cisplatin was always given over 1 h at 50 and 75 mg/m(2); the combined regimen was repeated on an every 3-week and later on an every 2-week schedule. Bryo doses were escalated until recommended phase II doses were defined for each schedule. Patients were evaluated with computerized tomography every 2 cycles.Fifty-three patients were entered. In an every 2-week schedule, the 1-h infusion of bryo became limited by myalgia that was clearly cumulative. With cisplatin 50 mg/m(2) its recommended phase II dose was 30 microg/m(2). In the 3-week schedule, dose-limiting toxicities were mostly related to cisplatin effects while myalgias were tolerable. Pharmacokinetics unfortunately proved to be unreliable due to bryo's erratic extraction. Consistent inhibition of PKC isoform eta (eta) in peripheral blood mononuclear cells was observed following bryo.Bryo can be safely administered with cisplatin with minimal toxicity; however, only four patients achieved an objective response. Modulation of cisplatin cytotoxicity by bryo awaits further insight into the molecular pathways involved.

During the 19805 much attention, both pro and con, was directed toward optimized production technology (OPT). Criticism was directed at the proprietary nature of the scheduling algorithms within the software. Despite these criticisms, many large companies installed OPT. Little has been written on how the software is constructed and operates. This article introduces the software, provides a discussion of how it interfaces with management, and how various algorithms are imbedded in the software function. Last, a survey of companies that had implemented the software revealed that the major users are in the automotive industry.

As manufacturers evolve from make-to-stock to make-to-order strategies, they are forced to rely less on inventory to meet demands and more on the effective usage of existing capacity as they determine which orders to accept and schedule. Several accounting-based heuristics are used to identify and accept those jobs that maximize plant throughput. Accounting heuristics have been suggested as surrogates for approximating the opportunity costs of manufacturing one order instead of another order. Research results suggest that the best heuristic is dependent on the balance of the manufacturing resources. Moreover, these tendencies are affected by product mix and load.

Postoperative ileus after gastrointestinal surgery results from many factors, including the effects of surgical trauma, anesthetic agents, hyperactivity of the sympathetic nervous system, local inflammatory reactions, and the use of opioids in the postoperative period. Postoperative ileus can lead to potential complications and may prolong patients' hospitalization, thereby leading to an increase in healthcare costs. There have been recent efforts to improve the understanding of the pathogenesis of postoperative ileus and to develop new treatments to prevent or minimize its occurrence. Here, we present a review of the factors related to the development of postoperative ileus and new therapies directed at its prevention.

While the standard of care for patients with rectal cancer who sustain a complete clinical response (cCR) to chemoradiotherapy (CRT) remains proctectomy with total mesorectal excision, data suggests that non-operative management may be a safe alternative. The purpose of this study is to compare outcomes between patients treated with CRT that attained a cCR and opted for a vigilant surveillance to those of the patients who had a complete pathologic response (cPR) following proctectomy. This is a retrospective review of patients treated for adenocarcinoma of the rectum who achieved either a cCR or a cPR following CRT. Patients with a cCR were enrolled in an active surveillance program which included regularly scheduled exams, proctoscopy, serum carcinoembryonic antigen (CEA), endorectal ultrasound, and cross-sectional imaging. Outcomes were compared to those patients who underwent proctectomy with a cPR. Our primary outcome measures were post-treatment complications, recurrence, and survival. We reviewed 18 patients who opted for surveillance after cCR and 30 patients who underwent proctectomy after a cPR. No non-operative patients had a documented treatment complication, while 17 patients with cPR suffered significant morbidity. There were two recurrences in the active surveillance group, one local and once distant, both treated by salvage resection with no associated mortality at 54 and 62 months. In the cPR group, one patient had a distant recurrence 24 months after surgery which was managed non-operatively. This patient died of unrelated causes 35 months after surgery. Active surveillance can be a safe option that avoids the morbidity associated with proctectomy and preserves oncologic outcomes.

Objective: This paper examines the availability of basic and comprehensive emergency obstetric care (EmOC), interventions used to treat direct obstetric complications. Determining what interventions are provided in health facilities is the first priority in analyzing a country's capabilities to treat obstetric emergencies. There are eight key interventions, six constitute basic EmOC and all eight comprehensive EmOC. Methods and results: Based on data from 24 needs assessments, the following global patterns emerge: comprehensive EmOC facilities are usually available to meet the recommended minimum number for the size of the population, basic EmOC facilities are consistently not available in sufficient numbers, both in countries with high and moderate levels of maternal mortality, and the majority of facilities offering maternity services provide only some interventions indicating an unrealized potential. Conclusion: Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource-poor countries.

Drum–Buffer–Rope (DBR) is an alternative approach to manufacturing planning and control that is not as formally tested as Material Requirements Planning (MRP) systems which have traditionally been around for years. Yet, some reports indicate very good performance for DBR and the associated use of synchronous manufacturing principles. But how do these systems compare and relate to one another? Based on our experiences of studying a Bearing Manufacturing Company that actually made the transition from an MRP system to a DBR system, we conduct simulation-based experiments in this paper with the objective of providing a more formal comparison between these two systems than what has been offered in prior literature. To our knowledge, this is the only study of its kind that uses a real-world setting to evaluate key differences and convergence points between comprehensive MRP and DBR systems. Our results show that even though the MRP and DBR systems position inventory differently and provide different dynamic res...

A growing body of literature has examined Nicholls' Theory of Achievement Motivation and revealed a number of positive benefits for athletes when they perceive a highly task- rather than a highly e...

The United Nations Process Indicators for emergency obstetric care (EmOC) have been used extensively in countries with high maternal mortality ratios (MMR) to assess the availability, utilization and quality of EmOC services. To compare the situation in high MMR countries to that of a low MMR country, data from the United States were used to determine EmOC service availability, utilization and quality. As was expected, the United States was found to have an adequate amount of good-quality EmOC services that are used by the majority of women with life-threatening obstetric complications.

The ability to predict the arrival of interplanetary shocks near earth is of great interest in space weather because of their relationship to sudden impulses and geomagnetic storms. A number of models have been developed for this purpose. For models to be used in forecasting, it is important to provide verification in the operational environment using standard statistical techniques because this enables the intercomparison of different models. A verification method is described here, comparing the prediction capabilities of four models that use solar observations for input. Three of the models are based on metric Type II radio burst observations, and one uses halo/partial-halo coronal mass ejections. A method of associating solar events with interplanetary shocks is described. The predictions are compared to associated shocks observed at L1 by the Advanced Composition Explorer (ACE) spacecraft. The time period of this study is January 2002-May 2002. Although the data sample is small, the statistical intercomparison of the results of these models is presented as a demonstration of the verification method.

The aim of this retrospective, case-matched controlled study was to determine the benefit of laparoscopic-assisted colectomy (LC) for the elderly (75 years of age) and the young (75 years of age) compared to an open colectomy (OC) control group.A retrospective review of 39 patients older than 75 years of age and 38 patients younger than 75 years of age who underwent LC for colorectal cancer between 1991 and 1999 was performed. LC patients were matched with an open control group for procedure, age, gender, year of procedure, and surgeon. Procedures included right and left colectomy, anterior resection of the rectosigmoid, and abdominoperineal resection. Measured intraoperative variables included anesthesia time, operative time, and estimated blood loss. Postoperative parameters consisted of duration of intravenous or epidural narcotic usage, return of bowel function (RBF), length of stay, and independence at discharge. These variables were compared in the entire group of 154 patients.Mean ages were 81.4 and 81.8 years for LC and OC age75 and 62.9 and 62.7 for LC and OC age75. Mean anesthesia time and operative time were significantly longer (p0.05) for LC compared to OC (46.8 vs 39.3 and 159.3 vs 111.7 min, respectively) for age75 and for age75 (47.1 vs 40.3 and 182.8 vs 135.5 min, respectively). LC achieved faster recovery in both age groups: RBF (3.9 vs 4.9 days for age75; 6.7 vs 7.7 days for age75) (p0.05). Narcotic usage was shorter for the LC group age75 (3.3 vs 4.4 days; p0.05). There was no significant difference in independence at discharge between LC and OC in either age group. Faster recovery was seen with left LC in age75 and right LC in age75 compared to OC.The advantages of LC over OC are the same for the elderly and the young. There may be a selective benefit of laparoscopic left colectomy in the elderly and laparoscopic right colectomy in the young.

PURPOSE: An interval of six to eight weeks between completion of preoperative chemoradiation therapy and surgical resection of advanced rectal cancer has been described. Our purpose was to determine whether a longer time interval between completion of therapy and resection increases tumor downstaging and affects perioperative morbidity. METHODS: Forty patients with advanced adenocarcinoma of the rectum underwent preoperative chemoradiation on a prospective trial with irinotecan (50 mg/m 2 ), 5-fluorouracil (225 mg/m 2 ), and concomitant external-beam radiation (45-54 Gy) followed by complete surgical resection of the tumor with total mesorectal excision. The time interval between completion of chemoradiation and surgical resection ranged from 28 to 97 days. The patients were divided into two groups with 33 eligible patients: Group A (4-week to 8-week time interval; 28-56 days) and Group B (10-week to 14-week interval; 67-97 days). Tumor downstaging was compared between these two groups. The number of patients downstaged by at least one T stage, those downstaged by at least one N stage, those with pathologic complete responses, and those with only residual microscopic tumor foci were compared. Postoperative length of stay, estimated blood loss, perioperative morbidity, and sphincter-sparing procedures were also compared. Chi-squared tests and Student's t-test were calculated. RESULTS: Group A had 19 patients, and Group B had 14 patients. Patient demographics were comparable. Mean age was 52 years, and 70 percent of patients were male. There were no deaths. There were no statistical differences in perioperative morbidity, with three anastomotic leaks in Group A. Tumors were downstaged in 58 percent of patients in Group A and 43 percent of those in Group B (P = 0.61). Nodal downstaging occurred in 78 percent of Group A and 67 percent of Group B (P = 0.9). The pathologic complete response rate was 21 percent in Group A and 14 percent in Group B (P = 0.97), and a residual microfocus of tumor was found in 33 percent of patients in Group A and 42 percent of those in Group B (P = 0.90). These differences were not statistically significant. CONCLUSIONS: Perioperative morbidity is not affected by longer intervals. A longer interval between completion of neoadjuvant chemoradiationand surgical resection may not increase the tumor response rate of advanced rectal cancer in this cohort.

I would like to express my humble and most profound gratitude for the honor of serving this Society as president for the past year. I’ve approached this presidential address with some trepidation. What can I say that will be of interest that hasn’t already been said? I’ve sat through 22 previous presidential addresses, and reviewed several more in preparation for my own talk. I’m sad to say that I had forgotten the pertinent message of many of these speeches, a fact that I am prepared to accept that most of you will accord to mine today. A couple of addresses I distinctly remember because of their length; sitting through these talks I passed through all of the classic stages described by Elisabeth Kubler-Ross—denial, anger, bargaining with God, depression, and finally reluctant acceptance. I hope not to follow in this mold, and I’m going to attempt to finish at about the anger stage, or at least before the stage of depression that seems to characterize so many of today’s surgical meetings. The title of my talk is “A Picture from Philadelphia,” and the picture I would like to use as a starting reference is the Thomas Eakins’ painting, The Gross Clinic. This work was completed in 1875, in anticipation of the American Centennial Celebration held in Philadelphia the following year. It now hangs in Alumni Hall at Thomas Jefferson University. Thomas Hoving, the former director of the Metropolitan Museum of Art, has called this the most powerful painting ever produced by an American artist. The focal point of the picture is Dr. Samuel Gross, the most famous American surgeon of his day. Gross is caught in a momentary pause after making an incision in the thigh of an adolescent boy to remove a segment of tuberculous bone. He is operating in an amphitheater filled with students. The patient is a Presidential Address at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, June 3 to 8, 2002. No reprints are available. Robert D. Fry, M.D. Volume 46 Diseases of the

BACKGROUND: There is wide variability in reported locoregional recurrence rates after curative resection of adenocarcinoma of the intraperitoneal colon, and there is no universally accepted surgical technique regarding length of the resected specimen or extent of lymphadenectomy. The aim of this study was to determine the disease-free survival, locoregional failure, and perioperative morbidity of patients undergoing curative resection of colon adenocarcinoma. STUDY DESIGN: The records of 316 consecutive patients undergoing curative resection for primary adenocarcinoma of the intraperitoneal colon between 1990 and 1995 were reviewed. Locoregional recurrence was defined as disease at the anastomosis or in the adjacent mesentery, peritoneum, retroperitoneum, or carcinomatosis. The product-limit method (Kaplan-Meier) was used to analyze survival and tumor recurrence. RESULTS: The study population comprised 167 men and 149 women, mean age 70 ± 12 years (range 22 to 95 years). Median followup was 63 ± 25 months. Five-year disease-free survival was 84% overall. Disease-free survival paralleled tumor stage: stage I, 99% (n = 73); stage II, 87% (n = 151); stage III, 72% (n = 92). The predominant pattern of tumor recurrence was distant failure only. Overall locoregional recurrence (locoregional and locoregional plus distant) at 5 years was 4%. Locoregional recurrence paralleled tumor stage: stage I, 0%; stage II, 2%; stage III, 10%. Of the 12 patients who suffered locoregional recurrence, 9 (75%) had T4 primary tumors, N2 nodal disease, or both. Major and minor complications occurred in 93 patients (29%) including: anastomotic leak or intraabdominal abscess (n = 4, 1%); hemorrhage (n = 8, 3%); cardiac complications (n = 17, 5%); pulmonary embolism (n = 4, 1%); death (n = 2, 1%). Multivariate analysis (Cox proportional hazards) revealed that the only independent predictor of disease-free survival and locoregional control was tumor stage. CONCLUSION: Longterm survival and locoregional control can be achieved for patients with colon cancer, with low morbidity. In the absence of adjacent organ invasion and N2 nodal disease, locoregional recurrence should be a rare event. Just as for rectal cancer, the technical aspects of colectomy for colon cancer deserve renewed attention.

A patient presented with iliofemoral deep vein thrombosis, a small pulmonary embolism, and a paradoxic embolus to the axillary artery resulting from a patent foramen ovale (PFO). As prophylaxis against further paradoxic emboli while awaiting percutaneous PFO closure, a Günther Tulip inferior vena cava (IVC) filter was implanted. To prevent incorporation of the IVC filter into the caval wall, it was repositioned twice with use of a filter retrieval set from a transjugular approach. In this way, the implantation time of the filter was extended beyond the recommended period of 10 days. The filter was successfully retrieved 19 days later during percutaneous closure of the PFO.

INTRODUCTION: It is often stated that patients with colorectal carcinoid tumors have an increased risk of developing other malignancies. However, this risk has not been conclusively documented. A comprehensive evaluation is needed to more thoroughly assess the risk of second cancers in patients with colorectal carcinoids. METHODS: A search of the National Cancer Institute Surveillance, Epidemiology, and End Result database from 1973 to 1996 revealed 2,086 patients with colorectal carcinoids. This subset of patients was examined for occurrence of second cancers. The observed incidence of cancer for each site was compared with the expected incidence based on the gender-adjusted and age-adjusted cancer rates in the remaining Surveillance, Epidemiology, and End Result file. A Poisson distribution probability was used to determine the significance of these comparisons. RESULTS: Patients with colorectal carcinoids had an increased rate of cancer in the colon and rectum (P < 0.001), small bowel (P < 0.001), esophagus/stomach (P = 0.02), lung/bronchus (P < 0.001), urinary tract (P = 0.005), and prostate (P < 0.001), when compared with a control population. Most of the gastrointestinal tract cancers were synchronous cancers, whereas lesions outside the gastrointestinal tract were most commonly metachronous tumors. CONCLUSIONS: A significantly increased risk of synchronous colorectal, small-bowel, gastric, and esophageal cancers and metachronous lung, prostate, and urinary tract neoplasms is clearly demonstrated. After the diagnosis of colorectal carcinoid tumors, patients should undergo appropriate screening and surveillance for cancer at these sites.

We previously reported that single cells from a human colorectal cancer (CRC) cell line (HCA-7) formed either hollow single-layered polarized cysts or solid spiky masses when plated within type-I collagen in 3D. To begin in-depth analyses into whether clonal cysts and spiky masses possessed divergent malignant properties, individual colonies of each morphology were isolated and expanded. The lines thus derived faithfully retained the parental cystic and spiky morphologies and were termed CC (cystic) and SC (spiky), respectively. Although both CC and SC expressed EGF receptor (EGFR), cetuximab strongly inhibited growth of CC, whereas SC was resistant to growth inhibition and this was coupled to increased tyrosine phosphorylation of MET and RON. Addition of the dual MET/RON tyrosine kinase inhibitor, crizotinib, to cetuximab in SC restored cetuximab sensitivity. To characterize genome-wide divergence between CC and SC, we performed comprehensive genomic and transcriptomic analysis of CC and SC in 3D. One of the most upregulated genes in CC was the tumor suppressor 15-PGDH/HPGD and the most upregulated gene in SC was versican (VCAN) in 3D and xenografts. Analysis of a human CRC tissue microarray showed that epithelial, but not stromal, VCAN staining strongly correlated with reduced survival, and combined epithelial VCAN and absent HPGD staining portended a poorer prognosis. Thus, with this 3D system, we have identified a new mode of cetuximab resistance and a potential prognostic marker in CRC. As such, this represents a potentially powerful system to identify additional therapeutic sensitivities and disease-relevant genes for CRC. Citation Format: Bhuminder Singh, Cunxi Li, Ramona Graves-Deal, Haiting Ma, Alina Starchenko, William H. Fry, Yuanyuan Lu, Yang Wang, Galina Bogatcheva, Mohseen P. Khan, Ginger L. Milne, Shilin Zhao, Gregory D. Ayers, Nenggan Li, Mary K. Washington, Timothy J. Yeatman, Oliver G. McDonald, Qi Liu, Robert J. Coffey. A 3D culture system identifies a new mode of cetuximab resistance and disease-relevant genes in colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5013. doi:10.1158/1538-7445.AM2017-5013

Purpose Endocavitary radiation (RT) provides a conservative alternative to proctectomy. Although most suitable for small, mobile lesions, patients with less favorable tumors are often referred if they are poor surgical candidates. Knowing the extent to which radiation can control such tumors can be an important factor in making clinical decisions. Methods and materials One hundred ninety-nine patients, who received endocavitary RT with or without external beam RT (EBRT) during 1981 through 1995, were followed for disease status for a median of 70 months, including deaths from intercurrent causes. In the early years of the study, 21 patients were treated with endocavitary RT alone, the remainder of the patients received pelvic EBRT (usually 45 Gy in 25 fractions) 5-7 weeks before endocavitary RT. Results Overall, 141 patients (71%) had local control with RT alone. Salvage surgery rendered an additional 20 patients disease free, for an ultimate local control rate of 81%. On multivariate analysis for local control (excluding surgical salvage), the most significant factors were mobility to palpation, use of EBRT, and whether pretreatment debulking of all macroscopic disease had been done (generally a piecemeal, nontransmural procedure). Of 77 cases staged by transrectal ultrasonography, the local control rate with RT alone was 100% for uT1 lesions, 85% (90% with no evidence of disease after salvage) for freely mobile uT2 lesions, and 56% (67% with no evidence of disease after salvage) for uT3 lesions and uT2 lesions that were not freely mobile. Conclusions Patients with small mobile tumors that are either uT1 or have only a scar after debulking achieve excellent local control with endocavitary RT. About 15% of mobile uT2 tumors fail RT; therefore, careful follow-up is critical. Small uT3 tumors are appropriate for this treatment only if substantial contraindications to proctectomy are present.

This study evaluates operating policies for offering a near-perfect delivery performance for vital customers in dual resource-constrained (DRC) job shop environments. Prior studies have considered this problem in machine-limited settings, and shown that dispatching rules that help realise a near-perfect delivery performance for vital customers necessarily deteriorate delivery performance for other customers served by the shop. This study extends prior work, and considers additional tools that can be used by managers in DRC shops such as labour flexibility, and assignment rules that incorporate customer-based information to deploy workers to departments containing high-priority jobs. Results show that labour flexibility in conjunction with appropriate decision rules allows for enhanced delivery performance for both vital and normal priority customers. These results hold even under conditions where 80% of the shop's workload is compromised of high-priority orders.

The majority of research on labour flexibility in a DRC job-shop has focused on the situation where all workers are equally trained. In practice, it is likely that workers would not be trained equally and would possess different skills. In this paper, the situation where workers receive different levels of training across the various departments as well as possessing different levels of proficiency at each task is studied. Research results suggest that, even at the same level of shop flexibility, the mixture of cross training can have a significant impact on shop performance. Indeed, results suggest that it is better to have a mix of workers with no flexibility and some workers with very high flexibility rather than all workers with equal flexibility.

Although the need for adjuvant therapy in high-risk rectal cancer is widely accepted, controversies continue regarding timing, mode, and agents employed. The current recommended practice and its scientific basis are reviewed. Studies of induction therapy are discussed. Evidence of efficacy of new anticancer agents and modes of drug delivery are presented.

PURPOSE: The objective of this study was to analyze patient outcome after strictureplasty for management of intestinal stricture caused by Crohn's disease based on differences in surgical procedures. METHODS: A MEDLINE search was performed using a medical subject heading analysis for strictureplasty in Crohn's disease. Meta-analysis of multiple variables for outcome was performed using random-effects models. RESULTS: Five hundred six patients underwent 1,825 strictureplasties for Crohn's disease with minimal morbidity and zero mortality. Ninety percent of strictures were less than 10 cm in length. Approximately 85 percent of these procedures used the Heineke-Mikulicz technique and 13 percent used Finney strictureplasty. Forty-four percent of procedures included concurrent bowel resection. Recurrence rate of Crohn's disease after strictureplasty was increased in patients with longer study duration after surgery (P=0.04), who showed symptoms of active disease (P=0.02), who experienced preoperative weight loss (P=0.02), or who received the Heineke-Mikulicz procedure (P=0.008). The proportion of patients requiring additional surgery was increased with longer study duration (P=0.006), with properative weight loss (P=0.001), or with the Heineke-Mikulicz procedure (P=0.005). The proportion of patients requiring additional surgery was decreased when a Finney strictureplasty was used (P=0.008) as compared with those treated by the Heineke-Mikulicz procedure. CONCLUSION: Although the Heineke-Mikulicz technique is most often used for Crohn's strictureplasty, outcome analysis revealed the Finney strictureplasty may reduce the reoperation rate.

We have developed a miniature radio receiver designed to operate as a relative ionospheric opacity meter (riometer). This project was funded by NASA as an enabling technology for future planetary radio science missions. We sought to reduce the instrument's size, mass, and power so that it would be practical for a Mars lander or rover mission. A recent study by our group indicates that a riometer might work well on Mars and offers a potentially rich science return. The technology also has immediate terrestrial applications. For example, the University of Maryland operates a chain of imaging riometers at the Automatic Geophysical Observatories (AGOs) in Antarctica. Our riometer includes features that are desirable for extended autonomous operation such as those with AGOs: low power consumption, wide dynamic range and linearity, computer command and data interface, and the ability to be remotely reconfigured. The receiver design provides significant improvements over previous implementations used in riometers. The high degree of system linearity, combined with a digital feedback loop (including a low-duty calibration cycle), allows more time for viewing the radio sky. We implemented several of the receiver subsystems in a field-programmable gate array, including the receiver detector, the control logic, and the data acquisition and processing blocks. Considerable efforts were made to eliminate or minimize RF noise and spurious emissions generated by the receiver's digital circuitry. Results of laboratory and field tests are presented and discussed.

PURPOSE: This is a case of hepatic vein thrombosis presenting in a delayed fashion after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Search for a causative thrombotic condition resulted in the diagnosis of polycythemia vera, a myeloproliferative disorder associated with hypercoagulability. The polycythemia was masked by an iron deficiency associated with the ulcerative colitis. METHODS: The history, physical, diagnostic modalities, and treatment for this patient are described, and the literature of Budd-Chiari syndrome associated with ulcerative colitis is reviewed. RESULTS: Six cases of Budd-Chiari syndrome in the setting of ulcerative colitis are reported in the literature from 1945 to 1997. CONCLUSIONS: Hepatic vein thrombosis is a rare complication of ulcerative colitis. The diagnosis of Budd-Chiari syndrome demands a thorough search for a hematologic condition predisposing to thrombosis. Our patient had a myeloproliferative disorder, polycythemia vera, that is associated with a hypercoagulable state. The disorder was masked by an iron deficiency associated with the ulcerative colitis. Recognition of the entity will permit successful treatment.