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To examine the safety and efficiency of balloon-assisted gastrostomy for insertion of large bore feeding tubes compared to conventional techniques using dilators. Retrospective review of all fluoroscopically guided percutaneous gastrostomy tube insertions between July 2017 and September 2019 was performed. Collected data points included patient demographics, initial pathology, type of gastrostomy tube (G tube) inserted [(Avanos standard balloon retained (Mic-G), or low-profile balloon retained (Mic-Key)], type of insertion technique (balloon-assisted or -nested dilator technique), fluoroscopy time, amount of sedation required, technical success, and complications. The focus of the study was method of tract dilatation – either balloon-assisted gastrostomy (BAG group) versus nested or sequential dilators (dilator group). Two hundred patients were included in this study; 100 patients were evaluated in each group. There were no significant differences between the two groups. The overall rate of minor complications (grades 1 and 2, according to the CIRSE classification system) was higher in the dilator group (11%, compared to 7% in the BAG group) but did not reach statistical significance. Males were associated with lower risk of minor complications (OR 0.19, 95% CI (0.07, 0.53)), while age did not present a significant association. Patients in the BAG group received a significantly lower amount of fentanyl (p

Purpose of review Bone metastases are responsible for considerable morbidity, which can significantly limit a patient's quality of life. This article aims to review minimally invasive, image-guided locoregional treatments for symptomatic bone metastases as an adjunct to conventional treatment modalities. Recent findings Conservative therapy and radiation therapy (RT) can be effective at addressing pain, however, they require time to achieve optimal efficacy and do not address the instability and progressive collapse of pathological fractures. Vertebral and pelvic augmentation with cement enhances structural stability and can prevent progressive collapse and deformity. Ablative therapies, including radiofrequency ablation (RFA), cryoablation, and photodynamic therapy (PDT), induce cellular destruction of tumor tissue. RFA and PDT can be combined with cement augmentation in a single sitting. Summary Minimally invasive image-guided treatments can provide rapid pain relief, enhance mechanical stability, and improve quality of life. These treatments are associated with low complication rates and are suitable for frail patients. They can be used as companion procedures to conventional treatments, or function as an alternative for patients with radioresistant biologies or those with dose limitations from prior RT sessions.

Background The purpose of this case series is to assess the safety and efficacy, as well as the overall survival (OS) and progression free survival (PFS) of patients with intrahepatic cholangiocarcinoma (ICC) treated with percutaneous ablation, transarterial arterial chemoembolization (TACE) or a combination of both at our institution. Methods Ten patients with pathological diagnosis of adenocarcinoma treated at out institution between January 1st 2013 and January 1st 2019 were reviewed. Three patients received a combined TACE and ablation treatment, three patients received TACE without ablation and four patients were treated with ablation only. Ablation technical success was determined by absence of residual tumor in the ablation zone on follow-up imaging one-month post-ablation. TACE response was assessed using the Modified Response Evaluation Criteria in Solid Tumors (mRECIST). Technical success was defined as injection of chemoembolic material in the involved liver lobes. PFS and OS were calculated from the date of diagnosis. Results In the TACE and radiofrequency ablation (RFA) group, OS was 12, 55 and 56 months; PFS was 5, 6 and 32 months, one patient died and two others remain alive. In the TACE group, OS was 29, 10 and 5 months; PFS was 15, 10 and 4 months. All three patients remain alive. In the ablation group, OS and PFS were 16, 31, 30 and 40 months. All patients remain alive. Overall, 9 of 10 patients are alive, with a Median OS and PFS of 29.5 and 15.5 months, respectively, with some patients remain alive over four years following initial presentation. Conclusions Our study shows that ablation and TACE in combination with more traditional modalities such as chemoradiation and surgical resection can extend survival in patients with ICC significantly. Locoregional therapy is well tolerated with only minor adverse events. The use of stereotactic body radiation therapy (SBRT) with ablation demonstrated the synergistic nature of using multiple lines of interventions.

Objective: Our aim was to validate the prognostic relevance in NSCLC of potential residual tumor (R) descriptors, including the proposed International Association for the Study of Lung Cancer definition for uncertain resection, referred to as R(un). Methods: A total of 14,712 patients undergoing resection with full R status and survival were analyzed. The following were also evaluated: whether fewer than three N2 stations were explored, lobe-specific nodal dissection, extracapsular extension, highest lymph node station status, carcinoma in situ at the bronchial resection margin, and pleural lavage cytologic examination result. Revised categories of R0, R(un), R1, and R2 were tested for survival impact. Results: In all, 14,293 cases were R0, 263 were R1, and 156 were R2 (median survivals not reached, 33 months, and 29 months, respectively). R status correlated with T and N categories. A total of 9290 cases (63%) had three or more N2 stations explored and 6641 cases (45%) had lobespecific nodal dissection, correlated with increasing pN2. Extracapsular extension was present in 62 of 364 cases with available data (17%). The highest station was positive in 942 cases (6.4%). The pleural lavage cytologic examination result was positive in 59 of 1705 cases (3.5%): 13 had carcinoma in situ at the bronchial resection margin. After reassignment because of inadequate nodal staging in 56% of cases, 6070 cases were R0, 8185 were R(un), 301 were R1, and 156 were R2. In node-positive cases, the median survival times were 70, 50, and 30 months for RO, R(un) (p < 0.0001), and R1 (p < 0.001), respectively, with no significant difference between RO and R(un) in pN0 cases. Conclusions: R descriptors have prognostic relevance, with R(un) survival stratifying between R0 and R1. Therefore, a detailed evaluation of R factor is of particular importance in the design and analyses of clinical trials of adjuvant therapies. (C) 2019 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

Purpose: To identify patient and procedural factors associated with extrusion of the Dacron cuff from the subcutaneous tunnel of tunneled hemodialysis catheters (THDCs). Materials and methods: Single center 5-year retrospective analysis of 625 catheters in 293 adult patients. Patient data included age, gender, body mass index (BMI), and common comorbidities. Procedural details included type of procedure (new insertion vs. exchange), operator seniority, side of insertion, catheter model and presence of catheter wings skin-sutures. Complications were reported as cumulative risk over time and Cox proportional hazards model was used to evaluate risk factors for cuff extrusion (CE). Results: Median patient follow-up was 503 days (188,913 catheter-days) and median catheter survival 163 days. CE occurred in 23.8% of catheters, at a rate of 0.79 per 1,000 catheter-days and a median time of 64 days. It was more common than infection (14.6%) and inadequate flow (15.5%). The 1-month and 12-month risk of CE was 5.9% and 21.3% respectively. A first episode of CE was a strong predictor of future CE episodes. The only patient factor that affected the risk of CE was BMI (Hazard Ratio 2.36 for obese patients). Procedural factors that affected the risk of CE, adjusted for BMI, were catheter model, type of procedure (lower risk for new insertions) and catheter wings skin-sutures; the latter reduced the 30-day CE risk by 76% without increasing catheter-related infections. Conclusion: Cuff extrusion is common in long-term THDCs. The risk increases with obesity, history of previous cuff extrusion, certain catheter models and absence of wing-sutures.

In 2012, the WHO launched its Global Surveillance and Monitoring System (GSMS) for substandard and falsified medicines, with the aim of improving the quality of reporting and using the data to inform post-market surveillance and build regulatory capacity. However, from a regulatory governance perspective, its effectiveness depends on the willingness and ability of actors ‘on the ground’ to identify, report and investigate possible infringements and to enforce penalties. This paper presents findings from 27 interviews with representatives of agencies charged with regulating pharmaceutical markets and 4 interviews with pharmaceutical industry representatives in Tanzania. Their experiences provide important insights into how the theorised mechanism between reporting and a reduction in undesirable behaviours can play out in a low-income context, revealing hidden assumptions about regulator behaviour and motivations. A combination of chronic under-resourcing, information gaps and enforcement challenges conspires to limit the efforts of local regulators to achieve the GSMS goals, shedding new light on the relationship between apparent ‘misconduct’ and structural constraints.

Tomatoes are the most common vegetable crop widely cultivated in the agricultural fields in India. The tropical climate is ideal for its growth, however certain climatic conditions and various other factors affect the normal growth of tomato plants. Apart from these climatic conditions and natural disasters, plant disease is a major crisis in crop production and results in economic loss. The traditional disease detection methods for tomato crops could not produce the expected outcome and the detection period for diseases was slow. The early detection of diseases can give better results than the existing detection models. Thus, computer vision-based technology deep learning techniques could be implemented for earlier disease detection. This paper introduces a comprehensive analysis of the disease classification and detection techniques implied for tomato leaf disease identification. This paper also reviews the merits and drawbacks of the methodologies proposed. This paper finally proposes the early disease detection technique to identify tomato leaf disease using hybrid deep-learning architecture.

The global crisis prevailing in the wake of the spread of COVID-19 has raised several speculations about the impact of the lockdown on the mental health of people. The dataset presented here is the assessment of the psychological distress experienced by people in India following the implementation of lockdown as a measure to curtail the spread of the coronavirus. The data was collected through a survey conducted by employing an online questionnaire assessing the socio-demographic information (9-items) as well as the administration of the short version of the General Health Questionnaire (GHQ-12 items) originally developed by Goldberg (1972). The period of data collection is between 9th April 2020 and 20th April 2020 where a total of 1,894 responses were obtained. The Google forms containing the questionnaire of the study were shared publicly through emails and via the social media forum like WhatsApp and Facebook. Thereby, those who took the initiative to fill-up the responses were included as the survey participants. Thus, the final sample had participants representing 17 states and Union territories of India. The entire dataset is stored in a Microsoft Excel Worksheet (.xls) and the questionnaire is attached as a supplementary file. The data is beneficial for the timely assessment of the nature and degree of the psychological distress experienced by people in India during the COVID-19 crisis. It could further be an assistance to the Government, policymakers as well as health care workers to take the adequate measures to ensure sound mental health among people.

While core to our understanding of corruption in public office, conflicts of interest pose a complex regulatory challenge. Practically, the term relies on a conceptual distinction between public and private duties which – in a world of outsourcing, secondments and New Public Management – has become blurred. Most regulation trusts individuals to recognise their own conflicts and insulate decisions from personal and social obligations, yet we know that humans are prone to situational biases and struggle with ambiguity. Regulation should address the difficulties of avoiding bias, while training should allow individuals to explore risks in safe contexts. Professional groups may be important for creating peer support networks and helping to socialise members into norms of integrity. Such ‘soft’ regulation is not a substitute for rules and sanctions but might enhance the utility of traditional ‘hard’ approaches, by helping individuals become more self-aware and better able to make informed decisions about their conduct.

International audience; Purpose To evaluate the effectiveness of radiofrequency (RF) ablation as measured by change in worst pain score from baseline to 3 mo after RF ablation for the palliative treatment of painful bone metastases. Materials and Methods One hundred patients (mean age, 64.6 y) underwent RF ablation for metastatic bone disease and were followed up to 6 mo. Subjects’ pain and quality of life were measured before RF ablation and postoperatively by using the Brief Pain Index and European Quality of Life questionnaires. Opioid agent use and device-, procedure-, and/or therapy-related adverse events (AEs) were collected. Results Eighty-seven patients were treated for tumors involving the thoracolumbar spine and 13 for tumors located in the pelvis and/or sacrum. All ablations were technically successful, and 97% were followed by cementoplasty. Mean worst pain score decreased from 8.2 ± 1.7 at baseline to 3.5 ± 3.2 at 6 mo (n = 22; P < 0.0001 for all visits). Subjects experienced significant improvement for all visits in average pain (P < .0001), pain interference (P < .0001), and quality of life (P < .003). Four AEs were reported, of which 2 resulted in hospitalization for pneumonia and respiratory failure. All 30 deaths reported during the study were attributed to the underlying malignancy and not related to the study procedure. Conclusions Results from this study show rapid (within 3 d) and statistically significant pain improvement with sustained long-term relief through 6 mo in patients treated with RF ablation for metastatic bone disease.

12086 Background: Patients with bone metastases may experience pain and decreased quality of life. Standard of care therapies such as radiation therapy could take weeks for pain relief and carry a risk of radiation induced fracture. Minimally invasive percutaneous radiofrequency ablation (RFA) have been shown in small observational studies to be an alternative treatment for bone metastases. We report the results of the OPuS One trial evaluating RFA for the palliative treatment of patients with painful bone metastases. Methods: OPuS One (NCT03249584) was a multicenter prospective trial. 218 subjects with painful bone metastases (≥ 4/10 worst pain scores, Brief Pain Inventory [BPI], at target treated site) were enrolled from 15 sites. RFA was performed under image guidance at one or two locations. Vertebral augmentation was followed based on physician’s discretion. Subjects’ pain (BPI) and quality of life (EQ-5D) scores were calculated in subjects at three days, one week, and one, three, six, and 12 months post RFA. Rate of complete (0 pain score at treated site with no concomitant analgesic increase) and partial responders (≥ 2 pain score reduction without analgesic increase or analgesic reduction of ≥ 25% from baseline) were calculated. Device-, procedure-, and/or therapy-related adverse events (AEs) were collected. Results: 206 subjects, 113 (55%) female and 93 (45%) males (mean age was 63.7 years) were treated with RFA. Most common primary cancers were breast (23%), lung (23%), and kidney (10%). 184 (89%) subjects were treated for metastatic lesions involving the thoracolumbar spine and 22 (11%) subjects were treated for iliac crest, periacetabulum, sacrum or mixed vertebral and pelvic location. 99% (262/264) of RFA procedures were technically successful and 97% were followed by vertebral augmentation. Subjects reported significant improvement in worst pain from baseline at 7.8 to 5.5, 4.7, 3.6, 3.2, 2.4, and 2.6 at three days, one week and one, three, six, and 12 months post RFA, respectively (p < 0.0001 for all visits). Significant improvements were also seen in average pain (p < 0.0001 for all visits), pain interference (p < 0.0001 for all visits), and quality of life scores (p < 0.0001 for all visits). Overall response rates were 53%, 58%, 61%, 63%, 70%, and 75% at three days, one week, one month, three months, six months, and twelve months post RFA, respectively. Six AEs were reported with three as serious: intra-abdominal fluid collection, pneumonia and respiratory failure. 82 deaths were reported during the study, none were related to the device, therapy, and/or procedure. No skeletal related events were reported. Conclusions: In a large prospective multicenter trial, OPuS One, RFA provided rapid, significant, and durable improvements in pain relief and quality of life up to 12 months. Clinical trial information: NCT03249584.

Background: To assess the safety and clinical outcomes of bipolar radiofrequency ablation (RFA) assisted vertebroplasty (VP) and osteoplasty (OP) in pathological and insufficiency fractures. The insufficiency fractures were in patients who sustained demineralization secondary to cancer treatment. Methods: Patients referred for symptomatic malignant or insufficiency fractures for VP or OP from January 2011 to May 2015 were retrospectively reviewed. Bipolar RFA was performed (Osteocool RF ablation system, Baylis Medical) reaching a constant temperature of 70 ℃ over 7 to 15 minutes followed by cement injection. Clinical outcomes were evaluated by review of the electronic medical record (EMR). Radiological outcomes were assessed with CT. Pre and post procedural pain scores were also documented for the RFA subset, primarily to see if there were any adverse effects when using RFA on pain relief. Results: Twenty-six patients in the study were treated with the RFA assisted technique. These contributed to 4 OPs and 35 VP levels. Of these four VP levels were insufficiency fractures. All were technically successful without morbidity or mortality. Fifty-six patients were treated with a non RFA assisted technique. All these were VPs and 142 levels were treated in total. Two levels in this subset were insufficiency fractures. All were technically successful without morbidity or mortality. There was a significantly reduced rate of posterior and venous cement leaks when RFA was used prior to VP. There was no difference in the rate of leakage into the disc spaces when comparing RFA assisted to the conventional technique. Pain scores in the RFA assisted group decreased significantly post procedure with no unanticipated neuropathic events. Conclusions: RFA assisted VP and OP using a bipolar device is safe and allows for controlled injection of cement into a preformed thermal cavity with a significant decrease in venous and posterior cement leaks. Rate of cement leakage into the disc spaces was unaffected.

The method of localized harmonic motion (LHM) monitoring has been proposed as an ultrasound-based monitoring technique for in vivo real-time ultrasound-guidance during thermal surgery. Objective: The focus of this paper is to study the performance of LHM monitoring in vivo in order to assess the tissue coagulation during ultrasound surgery of bone metastases. This is done through a pre-clinical study on large scale animals (pigs) as well as a first-in-human pilot study, using a hand held ultrasound-guided HIFU phased array. Methods: A flat, fully steerable HIFU phased array system (1024 elements, 100 mm diameter, 516 kHz), in combination with a co-aligned 64 element imaging system, is used to perform thermal surgery and monitor tissue coagulation using the LHM technique. The in vivo experiments are conducted using thirteen animals, followed by a first-in-human pilot study in which nine patients are enrolled. Results: The pre-clinical results show that the LHM monitoring method is able to detect about 80% of the observed coagulated tissue volumes visible in dissection. In the pilot study, six out of nine patients have durable pain reduction with good correlation observed from LHM detections. Conclusion: In general, the results suggest that the LHM monitoring performance is promising in detecting thermal tissue coagulation during focused ultrasound surgery in tissues close to the bone. Significance: The LHM technique can offer a very accessible and cost-efficient monitoring solution during ultrasound surgery within a clinical setting.

Upon completion of this chapter, the reader should be able to • Discuss issues, implications, diagnosis, and treatment of substance abuse in HIV-positive individuals. The prevalence of substance use in HIV-positive individuals is high, with rates of abuse/dependence much greater than those in the normal population. These substances include alcohol, opioids, cocaine/crack, methamphetamine, MDMA (“ecstasy” or “molly”), benzodiazepines, marijuana, ketamine, ...

Upon completion of this chapter, the reader should be able to • Discuss the psychiatric concomitants of HIV illness and the role of psychiatric care in the overall treatment of HIV populations. From the earliest recognized AIDS deaths in 1981 to the commencement of highly active antiretroviral therapy (HAART) in the mid-1990s and the simpler combination ART regimens now available, HIV has remained a disease and an epidemic in constant evolution. For many years a near-certain death sentence, it has become a treatable chronic condition, with issues of HIV-associated dementia and rapid death by opportunistic infection generally replaced by treatment of “premature” aging and slow neurological decline and questions of maximizing adherence to treatment. Issues that have not changed include the tremendous psychosocial burden to the individual and family and the economic cost to the patient and society, as well as factors of stigmatization and marginalization of HIV populations. Many HIV-positive individuals were already stigmatized before contracting this illness. The prevalence of HIV infection is much higher in gay/bi/transsexual populations, in people of color, in substance abusers, in prison populations, in the homeless, in individuals with histories of physical and emotional trauma, and in people with mental illness (...

Focused ultrasound (FUS) for palliation of bone metastases has typically been performed under magnetic resonance guidance. To address limitations of this approach, this pilot study evaluated a stand-alone, portable FUS device guided by diagnostic ultrasound alone (ultrasound [US]-guided FUS). Nine patients were treated; safety and efficacy were assessed for 10 d after the procedure, and medical charts were evaluated to assess durability of pain response. The procedure was safe and tolerable, with four patients reporting minor skin-related irritations. Average pain score decreased from 6.9 at baseline to 3.2 at day 10; analgesic use on average also decreased from baseline to day 10. Six patients had durable pain relief as assessed after the follow-up period. Our study provides evidence that US-guided FUS is a safe, tolerable and versatile procedure. It appears to be effective in achieving durable pain response in patients with painful bone metastases. Further research is required to refine the technology and optimize its efficacy.

Purpose: Vertebroplasty (VP) and balloon kyphoplasty (KP) are minimally invasive stabilization procedures for pathologic vertebral compression fractures (VCF). Concurrent administration of photodynamic therapy (PDT) as a tumor-ablative modality has yet to be studied in humans as a potential complement to improved mechanical stability that is afforded by vertebral cement augmentation (VCA). Patients and Methods: This first-in-human trial used a single 6 mg/m2 dose of the clinical photosensitizer Visudyne with escalating laser light doses. Following a cohort of light-only controls (n = 6), the drug and light treatment groups (n = 6 each) were 50, 100, 150, and 200 J/cm. VCA was performed within 15 minutes following PDT. Patients were clinically reviewed at 1 and 6 weeks. The primary outcome measure was safety from a neurologic perspective. Results: Thirty patients comprising a variety of primary tumors were treated with PDT and either KP or VP. Vertebral PDT was technically feasible and delivered in all study patients. No dose groups showed significant increases in pain as defined by the generic SF-36 as well as disease-specific EORTC-QLQ-BM22 and EORTC-QLQ-C15-PAL questionnaires. The 50 and 100 J/cm groups showed the most significant pain reduction (P < 0.05). Twelve (40%) patients experienced complications during the study including 3 patients with further vertebral fracture progression by 6 weeks despite VCA. No complications were directly attributed to PDT. Conclusions: Using the parameters described, vertebral PDT as an adjunct to VCA is safe from a pharmaceutical and neurologic perspective. The results of this trial motivate scale-up study evaluating potential PDT efficacy in vertebral metastatic treatment.

Collective action initiatives in which governments and companies make anti-corruption commitments have proliferated in recent years. This apparently prosocial behavior defies the logic of collective action and, given that bribery often goes undetected and unpunished, is not easily explained by principal-agent theory. Club theory suggests that the answer lies in the institutional design of anti-corruption clubs: collective action can work as long as membership has high entry costs, members receive selective benefits, and compliance is adequately policed. This article contributes to the debate by examining how these conditions manifest in the case of anti-corruption clubs in the realm of international business, with particular focus on the international dimension of many initiatives. This vertical aspect of institutional design creates a richer, more complex set of reputational and material benefits for members, as well as allowing for more credible and consistent monitoring and enforcement.

Insufficiency fractures are stress fractures that occur from normal weight-bearing on weakened bone. Radiation treatment to malignancies in the prostate, rectum, anus, or cervix may increase the risk of insufficiency fractures in the pelvic region by damaging osteoblasts that are essential to bone formation. In elderly women with cancer, this risk is greater due to their susceptibility to developing osteoporosis. These fractures may be confused with pathological fractures resulting from bone metastases on imaging and should be identified for proper management. We report two cases in which two women developed painful insufficiency fractures in the pelvic region after receiving radiation treatment to the rectum. After consulting an orthopedic surgeon, one patient underwent a cementoplasty, while the other patient was encouraged to take bone strengthening medications.

Anthropogenic inputs nowadays are the major source of nutrients to the coastal area. While a wealth of data exists from high latitude regions, little is known on the amount and composition of nutrient fluxes from densely populated tropical catchments. The South Indian Pamba River is a prime example in this respect because of its manifold human interventions such as the Sabarimala pilgrimage, the largest pilgrim centre in the world and agricultural practices. In order (i) to identify direct cause-effect relationships, (ii) to quantify land use specific nutrient inputs and (iii) to assess the respective impacts water was sampled along the river course during the pre monsoon, south west monsoon and north east monsoon periods in 2010 to 2012. Sampling segments were chosen according to prevailing land use. A socioeconomic survey on agricultural practices was conducted to collect information on the type, time and quantity of fertilizer application. Our results indicate (i) little human activities in the forest segment resulted in a low nutrient yield; (ii) pilgrim activities led to high ammonium and phosphate yields in the temple segment; (iii) specific fertilizer management resulted in moderate and maximum nitrate yields in the respective agriculture segments. Annual NPK fertilizer inputs to the catchment were 95 kg ha(-1) yr(-1).The average yield for the Pamba River catchment amounted to 3.5 kg ha(-1) yr(-1) of DIN and 0.2 kg ha(-1) yr(-1) of phosphate-P. As opposing predictions for densely-populated regions the N and P yields of the Pamba River are moderate to low on a global scale. It highlights the need for land use specific quantitative estimates from tropical regions in order to improve the global database and local water quality management.

Cultural eutrophication of coastal aquatic systems is a major undesired phenomenon of today, which is mainly ascribed to the application of inorganic fertilizers in agriculture. Consequently, dissolved inorganic nitrogen (DIN) is considered the major problem and widely studied. However, human interventions also strongly influence the riverine dissolved organic nitrogen (DON) concentrations and fluxes. Studies of nutrient inputs from tropical river catchments are biased towards DIN, even though they account for only a portion of the total dissolved nitrogen (TDN) pool, whereas the rest is comprised of DON and has been largely ignored. The tropical Pamba River was studied because of its manifold human activities in the catchment and was sampled during the south west monsoon (SWM), north east monsoon (NEM) and the pre monsoon (PM) months during 2010 to 2013. The largest pilgrim center on earth, the Sabarimala temple, located in the upstream forest is a unique feature of the catchment. Fertilizer application, livestock farming and inadequate sewage treatment are the prevailing land use practices. The goals of this study were to (i) define cause-effect relationships by assessing the effect of various human interventions such as the pilgrims, agriculture and sewage disposal in combination with the seasonal variations in hydrology on the DON concentrations and fluxes and to (ii) quantify the inputs from respective land use segments. The global maximum DON concentration (29 302 μM) was measured for the Pamba River. Pilgrim activities, high population density, agricultural and livestock farming as well as the lack of infrastructure for sanitation facilities were the cause for extremely high DON concentrations and fluxes in the plantation and settlement with mixed tree crop (SMT) segments. A DON yield of 745 kg ha−1 yr−1 was calculated for the Pamba catchment. The total DON inputs from all quantifiable sources amounted to 514 kg ha−1 yr−1 comprising of 69% of the total Pamba DON yield. In the Pamba River, sewage is the major source of DON and the unique Sabarimala pilgrim event accounts for most of it. Nevertheless, sewage input from the rest of the densely-populated catchment is high, which is a common feature of developing countries that lack adequate sanitation and water technology, i.e. in South and Southeast Asia and tropical Africa. Our study shows that DON makes up a significant portion of anthropogenic nitrogen in rivers, in particular in those regions, which are, however, scarce in respective data. It underscores the need for more quantitative studies from densely-populated tropical river catchments in order to improve global nitrogen budgets and the assessment of the consequences of anthropogenic nitrogen inputs into coastal aquatic systems.

Multiple new options are available in the palliation of bone metastases. Most of these techniques can be used in conjunction with radiation therapy either before or after and are now giving patients who have reached dose limitations new options. These techniques can also be used with vertebroplasty (VP) to increase structural stability post tumor ablation. Localized percutaneous treatment in the bone such as thermal [radiofrequency ablation (RFA)] and light [photodynamic therapy (PDT)] have been used to destroy tumor prior to injection with cement. This educational review will discuss the safety profile, technique and indications for emerging technology in the area of locoregional treatment of bone metastases in conjunction with vertebral augmentation. It will not delve comprehensively into conventional lines of treatment where indications and outcomes have already been well established.

Following scandals about corruption in foreign aid, and in a political climate that increasingly questions the legitimacy of development assistance, donors are under pressure to control how their funds are spent. At the same time, they also face pressure to trust recipient governments to disburse project funds themselves, so as to build capacity in developing countries. This paper assesses under which conditions donor regulations are successful in controlling corruption in aid spent by national governments through procurement tenders. By mining procurement contracts funded by the World Bank in 100 countries over the period 1998-2008 for corruption “red flags”, we create a dataset that provides an unprecedentedly accurate picture of corruption risks in the spending of aid across the developing world. Through propensity score matching and regression analysis, we find that the 2003 World Bank regulatory reform aiming to control corruption was effective in reducing corruption risks: lowering single bidding on competitive markets by 3.8-4.3 percentage points. This effect is greater in countries with low state capacity.

Transparency in the extractives sector is widely seen as a key tool for improving accountability and deterring corruption. Yet for those very reasons, it is a puzzle that so many governments in corruption-prone countries have voluntarily signed up to greater scrutiny in this area, by joining the Extractive Industries Transparency Initiative (EITI). We argue that EITI serves as a reputational intermediary, whereby reformers can signal good intentions and international actors can reward achievement. International and domestic actors thus utilize EITI to diffuse the norm of resource transparency and to advance reformist aims in a highly problematic policy area.

We investigate why top-down directives aimed at eradicating corruption are ineffective at altering on-the-ground practices for organizations that have adopted industry-wide “gold standards” to prevent bribery and corruption. Using interview and focus group data collected from leading multinational pharmaceutical firms, we unearth antecedents contributing to organizations’ systemic failure to embed their anticorruption policies in business practice. We identify two tensions that contribute to this disconnect: a culture clash between global and local norms, especially in emerging markets and a similar disconnect between the compliance and commercial functions. To overcome these tensions, we suggest that organizations are likely to find it easier to implement a no gifts policy if they cease to rely on local agents embedded in local norms and that there needs to be strong evidence of board-level commitment to antibribery programs, innovative ways of incentivizing compliant behavior, and a fundamental rethinking of organizations’ business model and remuneration practices.

Background: Bone metastases clinic (BMC) is a multidisciplinary clinic where patients with bony metastases are assessed in conjunction by orthopedic surgery, radiation oncology, interventional radiology, and palliative medicine teams. The objective of the study was to determine the number of older adult (OA) referrals made to BMC and to examine their case dispositions. Methods: Patients who were referred to the BMC from 2007 to 2015 were included in the study. Demographic information including gender, age, Karnofsky Performance Status (KPS), primary cancer site and reason for referral, as well as case dispositions were recorded for each patient. The proportion of OA attendance was calculated for each year from the total number of patient visits. OA attendance was defined as individuals ≥65 years of age who attended the BMC, and non-OA patients were those Results: A total of 551 patients were included with a median age of 64 years. The median KPS was 70 for OA and 80 for non-OA patients. OA attendance ranged per year from 42.5% to 58.7%. 14.1% of non-OA and 10.9% of OA patients were offered surgery. 62 patients in both cohorts (22.6% of OA and 22.4% of non-OA patients) were offered palliative radiation. Conclusions: From 2007 to 2015, OA patients comprised a significant proportion of referrals to the BMC. Younger patients were offered surgery slightly more often when compared to OA patients. Age did not appear to be a precluding factor for BMC referral or a deterrent in treatments offered.

Purpose The purpose of this study was to compare the effectiveness of portal vein embolization (PVE) with different embolic agents used at our centre. Specifically, the effectiveness of N-butyl cyanoacrylate (NBCA) glue is compared with that of polyvinyl alcohol (PVA) particles. Methods We performed a retrospective chart review of all patients (N = 77) who underwent PVE at our institution over a 5-year period. Pre- and postprocedural computed tomography or magnetic resonance imaging, when available, were used to measure the volume of total liver volume and future liver remnant (FLR). The absolute values obtained were used to calculate percentage of FLR. The growth in FLR was determined 4–6 weeks after PVE. Technical details of the procedure including the type and amount of embolic agent used were obtained from the chart reviews, electronic patient records, and radiology reports. Statistical analysis was performed using Kruskal-Wallis test, Wilcoxon rank sum test, and the Spearman correlation coefficient with post hoc analysis. Results are expressed as mean ± SD ( P < .05 considered statistically significant). Results NBCA (n = 29) produced a mean change in FLR of 14.8% compared with 9.3% for PVA particles (n = 24; P = .007). Mean change in FLR was 10.1% in the group where a combination of NBCA and PVA particles was used (n = 24). The effect of glue volume and glue-to-lipiodol ratio on the outcome was not found to be statistically significant ( P = .5 and .7, respectively). Conclusions We conclude that NBCA glue is a better embolic agent than PVA particles in inducing liver hypertrophy.

This paper reports the influence of number of layers and length of GFRP sheets wrapped onto RCC beams for strengthening. Twelve beams of size 700mm x 150mm x 150mm were cast and tested. Two beams without GFRP and ten beams wrapped in different lay-up patterns with one and two layers of GFRP sheets was subjected to three point loading test and ultrasonic pulse velocity test. Initial crack load, ultimate failure load and types of failure have been observed and noted. Experimental results indicate a significant increase in initial and ultimate load carrying capacity of GFRP wrapped beams compared to unwrapped beams. The failed control specimen was retrofitted using U wrap scheme and tested under three point loading.

Psychiatric disturbance has been shown to result from stress associated with events related to being a refugee. Children of refugees also experience significant stress but little is known about the prevalence of psychiatric disorders in this group. This survey explores the prevalence of psychiatric disorders in a Tibetan refugee enclave in rural North India.A prevalence survey was conducted using the Beck Anxiety Inventory (BAI) to determine the prevalence of anxiety amongst the Tibetan community. Three hundred fifty forms were distributed amongst the students; 335 were completed of which 300 were considered suitable to be collated and analysed.The results revealed that 21% of the study population had significant levels of anxiety classed as moderate or severe using the BAI. Late adolescents had higher levels of significant moderate and severe anxiety than early and middle adolescents x(2) = 92.95 (P0.0001). Female participants had higher levels of moderate and severe anxiety but this was not statistically significant (x(2) = 1.286, P = 0.2568).There were high rates of anxiety in this study of Tibetan school aged children. School based anxiety prevention programmes and other interventions should be considered in such vulnerable populations especially amongst females and late adolescents who are disproportionately affected. These findings indicate a need for further evaluation of young Tibetan refugees for definitive diagnosis of anxiety disorders, specific phobias, social anxiety, post traumatic stress disorders and other anxiety disorders.

Background: Depression is a common disease, yet it is not commonly studied in the Emergency Medicine literature. Study Objectives: To evaluate the prevalence of emergency department (ED) patients who have the symptoms of depression. Design: This was a prospective observational study performed at two EDs over a 9-month period. Adult patients were screened for depression symptoms by Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria. Results: There were 505 patients screened from April through December, 2004. Of the 505 patients, 109 (21.6%) screened positive for the symptoms of depression. The prevalence of positive screens was similar at each ED. Conclusion: About 1 in 5 ED patients may be suffering with depression.

Fibrotic central venous occlusions in patients with thoracic malignancy and prior radiotherapy can be impassable with standard catheters and wires, including the trailing or stiff end of a hydrophilic wire. We report two patients with superior vena cava syndrome in whom we successfully utilized a radiofrequency guide wire (PowerWire, Baylis Medical, Montreal, Quebec, Canada) to perforate through the occlusion and recanalize the occluded segment to alleviate symptoms.

In this work we will present our plan for an (MR)-guided, high-intensity focused ultrasound (FUS) uterine fibroid registry, with the goal of providing large-scale evidence on the safety and long-term efficacy of FUS for the treatment of symptomatic uterine fibroids.

The success rate of endovascular therapy for iliac occlusions is often limited by failure to traverse the lesion. A single institution's experience with the use of radiofrequency-assisted recanalization of occlusions in 10 iliac arteries is described. The median length of occlusion was 43 mm (range, 14–64 mm; mean, 42 mm). Revascularization was achieved in all cases. One case was complicated by vessel perforation with no adverse sequelae after stent insertion. All patients reported symptom resolution, and no target lesion reintervention or surgery was required. The median follow-up was 42 months (range, 11–63 mo; mean, 35 mo).

Purpose To present our experience in transcatheter arterial embolization (TAE) for hemorrhage following blunt or penetrating chest wall trauma. We provide the reader with a pictorial summary of the full range of angiographic findings and embolization techniques utilized. Material and Methods We performed a retrospective review of all patients treated with TAE for this indication from August 2004 to August 2014 in our institution, a level I trauma center. Data were obtained from the electronic records, pre- and post-procedural imaging, procedure reports, and laboratory results. Results A total of 13 patients were treated during this period. Seven patients had blunt trauma to the chest wall. Four patients had penetrating injury (2 stabbings and 2 gunshot wounds). In 4 cases the injuries were iatrogenic (3 due to chest tube insertion and 1 blunt injury from cardiopulmonary resuscitation). Two patients were previously treated with thoracotomy, which failed to control the bleeding. Embolization of intercostal artery, internal mammary artery and branches of the lateral thoracic and axillary arteries were performed. In all cases, embolization was effective in controlling the hemorrhage. There were no complications related to the procedure. We discuss the spectrum of imaging findings in these cases. Technical aspects such as catheter and embolic material selection are also discussed with pictorial examples. Conclusions In our experience TAE is a safe and effective treatment option in the management of chest wall hemorrhage after blunt and penetrating trauma. This minimally invasive procedure is particularly valuable in patients with significant comorbidities and persistent hemorrhage. Interventionists working in a trauma setting must have a thorough knowledge of the anatomical features and collateral pathways of the chest wall vasculature.

A consecutive case series was conducted evaluating proximal splenic artery embolization (SAE) with the AMPLATZER Vascular Plug 4 (AVP4) (St. Jude Medical, Inc, St. Paul, Minnesota) in eight patients with high-grade splenic trauma. Three proximal and five combined proximal and distal subselective coiling procedures were successfully performed. Mean time from device deployment to splenic artery occlusion was 4.5 minutes (range, 2.1–10.0 min; standard deviation, 2.8 min). There were no immediate complications. One patient developed a perisplenic abscess requiring percutaneous drainage and antibiotics. Results of this initial study show the suitability of the AVP4, with its ease of deployment without a guiding sheath and accurate placement, as a viable adjunct to nonoperative management of blunt splenic injury.

Our aim in this study was to report our single-center experience with direct percutaneous jejunostomy over a 4-year period with regard to technical success rate, immediate and late complications, and patient tolerance of the procedure. Institutional records of 22 consecutive patients who underwent radiological insertion of a percutaneous jejunostomy for a variety of indications were reviewed. The proximal jejunum was punctured under either fluoroscopic or ultrasonic guidance, and following placement of retention sutures, a 10- to 12-Fr catheter inserted. There was a 100% technical success rate in placement involving a total of seven operators. The indications for placement were prior gastric resection, newly diagnosed resectable esophageal or gastric carcinoma, unresectable gastric carcinoma with outlet obstruction, and palliative drainage of bowel obstruction. Mean duration of follow-up was 100 days, and catheter placement 57.7 days. There were six minor early complications, consisting of loss of two retention anchors requiring repuncture, three cases of localized excessive postprocedural pain, and one failed relief of symptoms of small bowel obstruction. Four tubes developed late complications (two blocked, one catheter cracked, and one inadvertently pulled out). Three of the four were successfully replaced through the existing tracts. One patient subsequently developed a minor skin infection, while another developed late pericatheter leakage from ascites. We conclude that direct percutaneous jejunostomy is a valuable treatment modality applicable to a number of clinical scenarios, with a high technical success rate and low serious complication rate.

We describe a case of reperfusion of an aneurysm of the pancreaticoduodenal artery following transcatheter coil embolotherapy. The lesion was successfully treated by direct puncture of the aneurysm under computed tomographic guidance, followed by injection of thrombin. This technique is useful when an endovascular approach is not feasible.

Background : Solitary hyperfunctioning nodules of the thyroid gland are usually viewed as benign. They may present with autonomous euthyroidism but are of concern for potential progression to hyperthyroidism. Various methods of treatment are worthy of consideration. Patients and methods : Forty-five patients with solitary hot thyroid nodules verified by radioisotope scintiscanning were selected for treatment. Thirty-one underwent surgery, usually partial thyroidectomy. Eight euthyroid patients received no treatment, 5 underwent therapy with radioactive iodine (RAI), and 1 received thyroid suppression treatment. The cases were assessed retrospectively. Results : Thyroidectomy patients had no morbidity, were well, and showed 1 Hurthle cell tumor and 5 coincidental small malignancies associated with benign hot nodules, including a contralateral cancer. Untreated patients showed continuance of good health, but nodules persisted and 1 Graves' orbititis occurred. The RAI-treated patients had persistent nodularity, improved function, and 1 case of hyperparathyroidism. Thyroid feeding only caused iatrogenic toxicity and was discontinued. Conclusions : There are various techniques for managing the hot nodule. Nonsurgical methods may be effective, but can result in persistent nodularity and iatrogenic sequelae. Excision had no morbidity in this series and was effective in providing immediate relief of problems present and potential.

In 1992, Brazil adopted the goal of measles elimination by the year 2000; however, in 1997, after a 4-year period of good control, there was a resurgence of measles in Brazil. In 1999, to achieve the elimination goal, Brazil implemented the Supplementary Emergency Measles Action plan, with one measles surveillance technician designated to each state. Of 10,007 suspected measles cases reported during 1999, 908 (9.1%) were confirmed, and of them 378 (42%) were confirmed by laboratory analysis. Of 8358 suspected measles cases reported in 2000, 36 (0.4%) were confirmed (30 [83%] by laboratory); 92% of the discarded cases were classified on the basis of laboratory testing. In 2001, only 1 of 5599 suspected measles cases was confirmed, and it was an imported case from Japan. The last outbreak occurred in February 2000, with 15 cases. Current data suggest interruption of indigenous measles transmission in Brazil.

Seventeen newborns in a general hospital had a successful atrial septostomy when indicated. Mostly done at the bedside under echocardiographical guidance, the successful introduction of this procedure enabled the infants to remain with mother to facilitate feeding and bonding prior to elective transfer to a children's hospital for corrective surgery. Background : Atrial septostomy is a well-recognised intervention in the newborn to facilitate atrial mixing in transposition of the great arteries (TGA) or to decompress an atrium where the connecting AV valve is absent or stenosed, e.g. tricuspid atresia (TA). Aims : To review the outcome of this procedure in a general hospital with appropriate neonatal and cardiological facilities. Methods : Retrospective review over an 11-year period. Results : Seventeen inborn infants had successful atrial septostomies, 11 with TGA and 6 with TA. All done under general anaesthesia, 15 were performed in the newborn nurseries, under echocardiographic guidance, and 2 in the catheter laboratory. No complications occurred. Eleven had a prenatal diagnosis made. All infants were able to be subsequently nursed by their mothers, affording prime time facilitating feeding and bonding. They were electively transferred to a children's hospital for corrective surgery. Conclusions : Atrial septostomy can be safely performed in a general hospital with appropriate neonatal and cardiological expertise. Such intervention allows for elective transfer of the infant for corrective surgery, allowing the infant and mother to be initially cared for at the one hospital, thereby facilitating maternal contact, feeding and bonding, doing away with the added stress of emergency transfer.