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Precis: Patients can be quite amenable to using eye drop instillation aids. We should consider recommending these devices to patients who otherwise struggle with drop instillation and medication adherence. Purpose: The purpose of this study was to compare patient acceptance of 3 commercially available eye drop instillation aids in a diverse tertiary care population. Methods: In this prospective, randomized controlled study, 39 patients being treated with topical antihypertensives were assigned to Arm A (no intervention) or Arm B (AutoDrop, AutoSqueeze, or SimplyTouch). Subjects in Arm B were instructed to administer their eye drop with the assigned drop aid at every use for ~6 weeks. Satisfaction surveys were administered at 3 and 6 weeks, where patients also reported the number of drops missed. Results: Thirty-two of 39 subjects completed study participation and full data analysis. Within this total group, 24 subjects were randomized to drop aids (AutoDrop N=10, AutoSqueeze N=8, SimplyTouch N=6), and 8 were randomized to no drop aid. At the 3 and 6-week timepoints, patients found instillation easier with AutoDrop (70.0%, 60.0%) followed by the AutoSqueeze (62.5%, 75.0%), and lastly SimplyTouch (33.3%, 33.3%). For the AutoSqueeze, the mean number of drops missed with and without the drop aid were significantly different (P=0.015 at 3 wk, P=0.008 at 6 wk). There was no difference in the mean number of drops missed with the AutoDrop and SimplyTouch at either timepoint. Conclusions: For the AutoDrop and AutoSqueeze groups, over 60% of the patients found the devices helpful and would consider using them long-term. Our results suggest that patients would be amenable to using eye drop instillation aids, although more objective data is needed to determine whether these devices would improve medication compliance and clinical outcomes.

Introduction/Background: A rough, visual estimate of pupil size is used in grading the severity of opioid withdrawal. Few studies have examined the clinical utility of more precise automated pupillometry measurements. Methods: This prospective cohort study enrolled 27 patients receiving opioid agonist therapy (OAT) to treat cravings or withdrawal during an acute hospitalization. Six sets of automated pupillometry measurements were obtained at regular intervals before and after administration of OAT. Clinical Opiate Withdrawal Scale measurements were performed pre and post OAT. Primary outcomes included pupil size in dark and bright illumination (mm). Latency of the pupillary light response (s), constriction and dilation velocity (mm/s), and percent constriction (%) were secondary outcomes. Results: The mean predosing pupil size in dark and bright illumination was 4.33 ± 1.40 mm and 2.96 ± 0.79 mm, respectively. A significantly decreased mean pupil size was first detected at 15 minutes postdosing (4.01 ± 1.34 mm, P = 0.0115 for dark illumination; 2.71 ± 0.72 mm, P = 0.0003 for bright illumination) and this reduction in pupil size persisted at later postdosing timepoints. Those with Clinical Opiate Withdrawal Scale

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee. Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; P =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19–10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 ( P =0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96–40.95]). Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03837574.

Purpose: This work aims to determine whether patient satisfaction with oral sedation is noninferior to intravenous (IV) sedation in vitrectomy surgery. Methods: This prospective, randomized, double-masked, noninferiority clinical trial measured patient satisfaction in 84 participants receiving oral or IV sedation during vitrectomy surgery under monitored anesthesia care. Patients were excluded if they were unable to receive benzodiazepines. Results: The primary outcome was patient satisfaction. Secondary outcomes included surgeon and anesthesia provider satisfaction, need for supplemental anesthesia, and surgical complications. Among the 84 patients (46 [54.8%] men; mean [SD] age, 57.0 [12.7 years]), mean patient satisfaction scores were 5.22 ± 0.81 (range, 3.08-6; scale 1-6) with oral and 5.25 ± 0.63 (range, 3.83-6; scale 1-6) with IV sedation. With an a priori noninferiority margin of 0.5 and a difference in mean scores between the groups of 0.03 (1-tailed 95% CI, infinity to 0.29), our results demonstrated the noninferiority of oral sedation ( P = .002). There were no significant differences in surgeon or anesthesia satisfaction or major intraoperative complications. Five patients receiving oral (11.9%) and 3 receiving IV (7.1%) sedation required supplemental IV sedation (difference, 4.8%; P = .46). Conclusions: Patient satisfaction for oral sedation was noninferior to IV sedation for vitrectomy surgery.

Background: Sars-Cov-2 epidemic in Italy caused one of the greatest 2020 European outbreaks, with suspension of elective bariatric/metabolic surgery (BMS). From May 2020 a significant decline of the epidemic has been observed (phase 2); National Health Service protocols permitted elective BMS’ resumption. A new, more severe COVID-19 surge, the “second wave”, started on October 2020 (phase 3). Aim: The primary end point was to analyze the outcomes of any Sars-Cov-2 infection and related morbidity/mortality within 30 POD after laparoscopic BMS during phase 2–3; secondary end points were readmission and reoperation rates. Methods: Study design prospective, multicenter, observational. Setting: Eight Italian high-volume bariatric centers. All patients undergoing BMS from July 2020 through January 2021 were enrolled according to the following criteria: no Sars-Cov-2 infection; primary procedures; no concomitant procedure; age > 18 < 60 years; compensated comorbidities; informed consent including COVID-19 addendum; adherence to specific admission, in-hospital and follow-up protocols. Data were collected in a prospective database. Patients undergone BMS during July-December 2019 were considered a control group. Results: 1258 patients were enrolled and compared with 1451 operated on in 2019, with no differences for demographics, complications, readmission, and reintervention rates. Eight patients (0·6%) tested positive for Sars-Cov-2 infection after discharge, as well as and 15 healthcare professionals, with no related complications or mortality. Conclusions: Introduction of strict COVID-19 protocols concerning the protection of patients and health-care professionals guaranteed a safe resumption of elective BMS in Italy. The safety profile was, also, maintained during the second wave of outbreak, thus allowing access to a cure for the obese population.

Summary Background COVID-19 has brought significant challenges to society globally, particularly in the area of healthcare provision. A pressing need exists in protecting those tasked with delivering healthcare solutions during the COVID-19 crisis by providing solutions for preserving adequate supplies of effective personal protective equipment (PPE). Aim To evaluate and validate available methods for the decontamination of N95 filtering facepiece respirators (FFRs) while maintaining functionality during re-use. Methods Multiple low temperature steam and vaporized hydrogen peroxide (VHP) technologies were assessed for inactivation of Mycobacterium sp. and Feline calicivirus (employed as representatives of the contamination challenge). Findings Virus (≥ 3log10) and Mycobacterium sp. (≥ 6log10) inactivation on varying types of N95 FFRs using an array of heat (65-71oC), humidity (>50% RH) and VHP without affecting the performance of the PPE. Conclusion Methods have been validated and were authorized by the United States Food and Drug Administration (US FDA) under a temporary Emergency Use Authorization (EUA). Based on findings, opportunities exist for development and deployment of decontamination methods made from simple, general-purpose materials and equipment should a future need arise.

Purpose To determine whether patient satisfaction with oral sedation is noninferior to intravenous sedation for cataract surgery. Design Prospective, randomized, double-masked clinical trial. Participants A volunteer sample of patients 18 years or older from diverse backgrounds scheduled for cataract surgery. Patients who were allergic to benzodiazepines, older than 70 years with a failed delirium screening questionnaire, pregnant or nursing, using a medication inhibiting cytochrome 450 3A, or intoxicated on the day of surgery were excluded. Methods Patients were randomized to receive either oral triazolam with intravenous placebo or intravenous midazolam with oral placebo before surgery. Main Outcomes Measures The primary outcome was patient satisfaction, measured by a survey administered on postoperative day 1. Secondary outcomes included surgeon and anesthesia provider satisfaction, need for supplemental anesthesia, and surgical complications. Results Among the 85 patients (42 men [49.4%]; mean age, 65.8 years; standard deviation, 9.5 years) completing the study, the mean satisfaction score was 5.34±0.63 (range, 3.75–6) in the oral sedation group and 5.40±0.52 (range, 4–6) in the intravenous group. With an a priori noninferiority margin of 0.5 and a difference in mean scores between the 2 groups of 0.06 (1-tailed 95% confidence interval [CI], –infinity to 0.27), our results demonstrate noninferiority of oral sedation with a P value of 0.0004. Surgeon and anesthesia provider satisfaction was similar between the 2 groups. Intraoperative complications occurred in 16.7% in the oral group and 9.3% in the intravenous group (difference, 7.4%; 95% CI, –6.9% to 21.6%; P = 0.31). The only major intraoperative complication—a posterior capsular tear—occurred in the intravenous group. Eight patients in the oral group (19.0%) and 3 in the intravenous group (7.0%) received supplemental intravenous sedation (difference, 12.1%; 95% CI, –2.0% to 26.2%; P = 0.097). Conclusions The use of oral sedation in cataract surgery has been suggested as a cost- and space-saving measure, potentially allowing the transition of some patients from an operating to procedure room or office-based setting. We report the noninferiority of oral compared with intravenous sedation for cataract surgery in a diverse patient population in terms of patient satisfaction.

In this study, we compare the vitreous cytokine profile in patients with proliferative diabetic retinopathy (PDR) to that of patients without PDR. The identification of novel cytokines involved in the pathogenesis of PDR provides candidate therapeutic targets that may stand alone or work synergistically with current therapies in the management of diabetic retinopathy. Undiluted vitreous humor specimens were collected from 74 patients undergoing vitrectomy for various vitreoretinal disorders. Quantitative immunoassay was performed for a panel of 36 neuroinflammatory cytokines in each specimen and assessed to identify differences between PDR (n = 35) and non-PDR (n = 39) patients. Levels of interleukin-8 (IL-8), IL-15, IL-16, vascular endothelial growth factor (VEGF), VEGF-D, c-reactive protein (CRP), serum amyloid-A (SAA), and intracellular adhesion molecule-1 (ICAM1) were significantly increased in the vitreous of PDR patients compared to non-PDR patients (p &lt, 0.05). We report novel increases in IL-15 and IL-16, in addition to the expected VEGF, in the human vitreous humor of patients with PDR. Additionally, we confirm the elevation of ICAM-1, VCAM-1, SAA, IL-8 and CRP in the vitreous of patients with PDR, which has previously been described.

To evaluate the clinical utility of Visible and near infrared optical coherence tomography (vnOCT) for glaucoma early detection, A total of 55 eyes from three groups of subjects (normal subjects, glaucoma suspects, glaucoma patients) were scanned by a custom-designed vnOCT device and Zeiss Spectralis OCT. The peripapillary retinal nerve fiber layer reflectivity in visible light OCT and the ratio between visible and NIR channel is more sensitive in separating suspect eyes from normal ones than clinical OCT thickness measurements. It could be a useful metric in early detection of glaucoma upon further longitudinally validation.

Aims There has been an increasing focus on integrated, multidisciplinary, and holistic care in the treatment of atrial fibrillation (AF). The ‘Atrial Fibrillation Better Care’ (ABC) pathway has been proposed to streamline integrated care in AF. We evaluated the impact on outcomes of an ABC adherent management in a contemporary real-life European-wide AF cohort. Methods and results Patients enrolled in the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry with baseline data to evaluate ABC criteria and available follow-up data were considered for this analysis. Among the original 11 096 AF patients enrolled, 6646 (59.9%) were included in this analysis, of which 1996 (30.0%) managed as ABC adherent. Patients adherent to ABC care had lower CHA2DS2-VASc and HAS-BLED scores (mean ± SD, 2.68 ± 1.57 vs. 3.07 ± 1.90 and 1.26 ± 0.93 vs. 1.58 ± 1.12, respectively; P Conclusion In a large contemporary cohort of European AF patients, a clinical management adherent to ABC pathway for integrated care is associated with a significant lower risk for cardiovascular events, CV death, and all-cause death.

The International Energy Agency (IEA) estimates that $24.5 trillion of energy efficiency (EE) investments will be needed through 2040. Debt- and self-financed projects are expected to contribute only one-third of this capital due to multiple barriers. On the one hand, self-financed projects require upfront capital from companies’ budgets to be spent on EE, which most would regard as a noncore activity. On the other hand, multiple parties face hurdles in a debt-financed project: (i) banks deem EE transactions too small and risky, and (ii) most energy service companies (ESCOs) do not have creditworthy balance sheets. Leasing agreements also have unattractive rates and extract too much project value from ESCOs and/or end users. Altogether, these constraints call for nonmainstream, off-balance sheet financial structures that will shift project risks to third parties and facilitate market benefits, such as collateralization of energy savings and engagement of small and medium-sized enterprises. Such structures include ESCO performance contracts, public–private partnership transactions, ESCO guarantee funds, super ESCOs, and other equity channels. These financing modalities require development in both the ESCO and energy performance contracting sector and EE policies, which could effectively mobilize and de-risk significant capital volumes.

European final energy consumption mainly stems from five sectors: transport, households, industry, residential, and agriculture using fossil fuels as dominant energy carriers. In order to achieve the climate targets, emissions in the demand sectors must be drastically reduced. Due to different characteristics and challenges each sector needs its own strategy how to achieve such decarbonization until 2050. In the following chapter, the impacts of an ambitious mitigation scenario on future energy demand and CO2emissions for transport, industry, residential, and tertiary are analyzed discussing sector specific decarbonization strategies and mitigation options. Implications of such strategies for demand-side flexibility and its future need are analyzed.

There is a strong demand for small foot-print high-flux hard X-rays machines in order to enable a large variety of science activities and serve a multidisciplinary user community. For this purpose, two compact Inverse Compton Sources (ICSs) are currently being developed in Italy. The most recent one is the Bright and Compact X-ray Source (BriXS) which has recently been proposed to produce very energetic X-rays (up to 180 keV) and high photon flux (up to 1013 photons/s with expected bandwidth of 1-10%). BriXS will be installed in Milan and it will enable advanced large area radiological imaging applications to be conducted with mono-chromatic X-rays, as well as allowing basic fundamental science of matter and health sciences at both pre- and clinical levels. Based on an energy-recovery linac (ERL) scheme and superconducting technology, BriXS will operate in CW regime with an unprecedented electron beam repetition rate of 100 MHz. The second Italian ICS light source is the Southern Europe Thomson back-scattering source for Applied Research (STAR) which is currently installed at the University of Calabria (UniCal). STAR is a compact machine that has been designed to produce monochromatic and tunable, ps-long, polarized X-ray beams in the range 40-140 keV with a photon flux up to 1010 photons/s and energy bandwidth below 10%. The electron beam injector is based on normal-conducting technology in S-Band with a repetition rate up to 100 Hz.

Objective. To investigate CT morphologic and densitometric features and 18-FDG PET findings of surgically excised lung adenocarcinomas “mixed subtype” with predominant lepidic component, appearing as solid solitary pulmonary nodules (SPNs) on CT scan. Materials and Methods. Approval for this study was given from each local institutional review board according to its retrospective nature. Nodules pathologically classified as lung adenocarcinoma mixed subtype with bronchioloalveolar otherwise lepidic predominant component, in three different Italian institutions (Napoli; Varese; Parma), were retrospectively selected. Results. 22 patients were identified. The number of SPNs with smooth margins was significantly lower with respect to the number of SPNs with spiculated margins (p: 0.033), radiating spiculations (p: 0.019), and notch sign (p: 0.011). Mean contrast enhancement (CE) was 53.34 HU (min 5.5 HU, max 112 HU); considering 15 HU as cut-off value, CE was positive in 20/22 cases. No significant correlation was found between size and CE. Mean SUVmax was 2.21, ranging from 0.2 up to 7.5 units; considering 2.5 units as cut-off, SUVmax was positive in 7/22 cases. The number of SPNs with positive CE was significantly higher than the number of SPNs with positive SUVmax (p: 0.0005). Conclusion. CT generally helps in identifying solid SPN suspicious for malignancy but 18-FDG PET may result in false-negative evaluation; when 18-FDG PET findings of a solid SPN are negative even though CT morphology and CE suggest malignancy, radiologist should consider that lepidic component may be present inside the invasive tumor, despite the absence of ground glass.

It has been 10 years since the publication of the first article looking at plants as a biomechatronic system and as model for robotics. Now, roboticists have started to look at plants differently and consider them as a model in the field of bioinspired robotics. Despite plants have been seen traditionally as passive entities, in reality they are able to grow, move, sense, and communicate. These features make plants an exceptional example of morphological computation - with probably the highest level of adaptability among all living beings. They are a unique model to design robots that can act in- and adapt to- unstructured, extreme, and dynamically changing environments exposed to sudden or long-term events. Although plant-inspired robotics is still a relatively new field, it has triggered the concept of growing robotics: an emerging area in which systems are designed to create their own body, adapt their morphology, and explore different environments. There is a reciprocal interest between biology and robotics: plants represent an excellent source of inspiration for achieving new robotic abilities, and engineering tools can be used to reveal new biological information. This way, a bidirectional biology-robotics strategy provides mutual benefits for both disciplines. This mini-review offers a brief overview of the fundamental aspects related to abioengineering approach in plant-inspired robotics. It analyses the works in which both biological and engineering aspects have been investigated, and highlights the key elements of plants that have been milestones in the pioneering field of growing robots.

BackgroundNeurofilament light chain (NfL) is a promising biomarker of neurodegeneration in the cerebrospinal fluid and blood. This study investigated the presence of NfL in the vitreous humor and its associations with amyloid beta, tau, inflammatory cytokines and vascular proteins, apolipoprotein E (APOE) genotypes, Mini-Mental State Examination (MMSE) scores, systemic disease, and ophthalmic diseases.MethodsThis is a single-site, prospective, cross-sectional cohort study. Undiluted vitreous fluid (0.5–1.0 mL) was aspirated during vitrectomy, and whole blood was drawn for APOE genotyping. NfL, amyloid beta (Aβ), total Tau (t-Tau), phosphorylated Tau (p-Tau181), inflammatory cytokines, chemokines, and vascular proteins in the vitreous were quantitatively measured by immunoassay. The main outcome measures were the detection of NfL levels in the vitreous humor and its associations with the aforementioned proteins. Linear regression was used to test the associations of NfL with other proteins,APOEgenotypes, MMSE scores, and ophthalmic and systemic diseases after adjustment for age, sex, education level, and other eye diseases.ResultsNfL was detected in all 77 vitreous samples. NfL was not found to be associated with ophthalmic conditions, APOE genotypes, MMSE scores, or systemic disease (p > 0.05). NfL levels were positively associated with increased vitreous levels of Aβ40(p = 7.7 × 10−5), Aβ42(p = 2.8 × 10−4), and t-tau (p = 5.5 × 10−7), but not with p-tau181 (p = 0.53). NfL also had significant associations with inflammatory cytokines such as interleukin-15 (IL-15,p = 5.3 × 10−4), IL-16 (p = 2.2 × 10−4), monocyte chemoattractant protein-1 (MCP1,p = 4.1 × 10−4), and vascular proteins such as vascular endothelial growth factor receptor-1 (VEGFR1,p = 2.9 × 10−6), Vegf-C (p = 8.6 × 10−6), vascular cell adhesion molecule-1 (VCAM-1,p = 5.0 × 10−4), Tie-2 (p = 6.3 × 10−4), and intracellular adhesion molecular-1 (ICAM-1,p = 1.6 × 10−4).ConclusionNfL is detectable in the vitreous humor of the eye and significantly associated with amyloid beta, t-tau, and select inflammatory and vascular proteins in the vitreous. Additionally, NfL was not associated with patients’ clinical eye condition. Our results serve as a foundation for further investigation of NfL in the ocular fluids to inform us about the potential utility of its presence in the eye.

BackgroundPatients with cardiovascular disease are at increased risk of critical illness and mortality from Covid-19 disease. Conflicting findings have raised concerns regarding the association of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) use with likelihood or severity of infection during this pandemic.ObjectiveTo study the cumulative evidence for association of ACEI/ARB use with outcomes among patients with confirmed Covid-19.MethodsThe MEDLINE and EMBASE databases were thoroughly searched from November 01, 2019 to May 15, 2020 for studies reporting on outcomes based on ACEI/ARB use in patients with confirmed Covid-19. Preferred reporting items for systematic review and meta-analysis guidelines were used for the present study. Relevant data was collected and pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using random-effects model.Main Outcome measuresIn-hospital mortality was the primary end of interest. Second end-point was severe or critical illness defined as either need for intensive care unit, invasive mechanical ventilation, or mortality.ResultsFifteen studies with total of 23,822 patients (N ACEI/ARB=6,650) were included in the present analysis. Overall, prevalence of ACEI/ARB use ranged from 7.7% to 46.2% across studies. Among 10 studies, patients using ACEI/ARB had similar odds of mortality [OR 1.03 (0.69-1.55)] and severe or critical illness [1.18 (0.91-1.54)] compared to those not on ACEI/ARB. In an analysis restricted to patients with hypertension, ACEI/ARB use was associated with significantly lower mortality [0.64 (0.45-0.89)], while the odds of severe/critical illness [0.76(0.52-1.12); p=0.16] remained non-significant compared with non-ACEI/ARB users.ConclusionThere is no evidence for increased risk of severe illness or mortality in patients using ACEI/ARB compared with non-users. In patients with hypertension, ACE/ARB use might be associated with reduced mortality, however these findings need to be confirmed in prospective randomized controlled trials.

Plants are getting increasing interest from scientists for the development of novel biomimetic products. Especially, the stems of climbing plants possess impressively high-adaptable materials, which can be relevant in robotics for the development of new machines able to work in unpredictable environments. In this work, we present a study on the mechanical properties of the stem of the hook-climber Galium aparine. Three different stem regions (basal, middle and apical parts) were analyzed in order to investigate how the mechanical properties vary along the stem. Tensile tests were performed on the different stem parts. Results demonstrated a significant decrease of Young’s modulus, the breaking strain and the tensile strength values from the basal to the upper parts. In contrast, we observed a decrease only in the tensile strength between the middle and apical parts. The collected data on the mechanical response of natural plant stems will be used as benchmarks for the design of novel soft robots that can act and move in real unstructured scenarios for exploration and monitoring tasks.

Some recent studies evaluated the introduction of Diffusion Weighted Magnetic Resonance Imaging (DW-MRI) in the diagnosis of Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC). Objective- To evaluate whether DW-MRI can contribute to non-invasive diagnosis of BPS/IC. The agreement between two raters (two radiologists involved in the study) was also evaluated, the relevance of the "operator-dependent" factor defined; Patients and methods- Twenty-two female patients with a diagnosis of BPS-IC were recruited and performed DW-MRI. The same investigation was also performed in 20 patients with pelvic gynecological diseases and no BPS-IC. Results- A significant difference was found between BPS-IC and no-BPS-IC since 17 out of 22 subjects of the first group were positive, compared to 3 out of 20 no-IC subjects, with a P value of 0.001 to highlight the statistical significance. The sensitivity of the exam was 77%, while the specificity was 85%. There was good agreement between the 2 raters in the evaluation of MRI results. Conclusion DW-MRI helps to obtain a non invasive diagnosis of BPS/IC, by providing useful information on the choice of which patients may be more appropriately submitted to cystoscopy and bladder biopsy.

One of the major challenges in robotics and engineering is to develop efficient technological solutions that are able to cope with complex environments and unpredictable constraints. Taking inspiration from natural organisms is a well-known approach to tackling these issues. Climbing plants are an important, yet innovative, source of inspiration due to their ability to adapt to diverse habitats, and can be used as a model for developing robots and smart devices for exploration and monitoring, as well as for search and rescue operations. This review reports the main methodologies and approaches used by scientists to investigate and extract the features of climbing plants that are relevant to the artificial world in terms of adaptation, movement, and behaviour, and it summarizes the current available climbing plant-inspired engineering solutions.

Background Mental stress is one of the main risk factors for cardiovascular disease. Meditation and music listening are two techniques that are able to counteract it through the activation of specific brain areas, eliciting the so-called Relaxing Response (RR). Epidemiological evidence reveals that the RR practice has a beneficial prognostic impact on patients after myocardial infarction. We aimed to study the possible molecular mechanisms of RR underlying these findings. Methods We enrolled 30 consecutive patients after myocardial infarction and 10 healthy controls. 10 patients were taught to meditate, 10 to appreciate music and 10 did not carry out any intervention and served as controls. After training, and after 60 days of RR practice, we studied the individual variations, before and after the relaxation sessions, of the vital signs, the electrocardiographic and echocardiographic parameters along with coronary flow reserve (CFR) and the carotid's intima media thickness (IMT). Neuro-endocrine-immune (NEI) messengers and the expression of inflammatory genes (p53, Nuclear factor Kappa B (NfKB), and toll like receptor 4 (TLR4)) in circulating peripheral blood mononuclear cells were also all observed. Results The RR results in a reduction of NEI molecules (p, Graphical abstract Image 1

This paper presents the TRIMODE integrated model for Europe that combines the simulation of transport, economy and energy systems for the assessment of major transport infrastructure projects and policies. Within a single software platform, the TRIMODE model components include a full four stage transport model of passenger and freight movements across Europe, an energy model with dynamic vehicle fleets for all transport modes and an economy model representing the complete macroeconomic system of European countries. Covering the whole European Union and it neighbouring countries, the model has a very detailed spatial resolution of the transport system, whose multimodal network and zoning systems are based on the NUTS III level and below, coupled with a very detailed disaggregation of transport demand by socio-economic groups and trip purposes for passengers and by commodity groups and modes of appearance for freight. From the energy point of view the model incorporates complete vehicle fleet models for cars, trucks, trains, vessels and planes, including all types of energy sources and technologies. The economic impacts of transport are dealt with by a two layers General Equilibrium model that works at regional basis. The main focus of the paper is on the passenger modelling in the specific context of a EU wide scale model, considering generation, distribution, mode sequence choice and assignment within long distance intermodal passenger trips. The passenger demand model is embedded within the PTV Visum software plus several appended modules developed as Python scripts to manage in a consistent and transparent form some tasks that are not part of standard software functions.

Item does not contain fulltext Aspergillosis is a fungal infection that primarily affects the respiratory tract. Amphotericin B has broad antifungal activity and is commonly used to treat aspergillosis, a fungal pneumonia that is a common sequela in oiled waterfowl as well as other birds in wildlife rehabilitation. Pharmacokinetic parameters of nebulized amphotericin B in an avian model have been reported, but those of direct intratracheal delivery have yet to be established. The objective of this study was to evaluate if a single 3 mg/kg dose of liposomal amphotericin B delivered intratracheally using a commercial atomizer would achieve plasma and lung tissue concentrations exceeding targeted minimum inhibitory concentrations (MIC) for Aspergillus species in adult mallard ducks (Anas platyrhynchos). Following intratracheal delivery, amphotericin B was present in lung parenchyma at concentrations above the targeted MIC of 1 mug/g for up to 9 days post-administration; however, distribution of the drug was uneven, with the majority of the drug concentrated in one lung lobe. Concentrations in the contralateral lung lobe and the kidneys were above the targeted MIC 1 day after administration but declined exponentially with a half-life of approximately 2 days. Plasma concentrations were never above the targeted MIC. Histological examination of the trachea, bronchi, lungs, heart, liver, and kidneys did not reveal any toxic changes. Using a commercial atomizer, intratracheal delivery of amphotericin B at 3 mg/kg resulted in lung parenchyma concentrations above 1 mug/ml with no discernable systemic effects. Further studies to establish a system of drug delivery to both sides of the pulmonary parenchyma need to be performed, and the efficacy of this treatment for disease prevention remains to be determined.

Background: Retrocaval ureter is a rare entity with a reported incidence of ∼1 in 1100 and a 2.8-fold male predominance. The course of the ureter could be classified, using an intravenous urography, as type 1 having S-shaped, fish-hook, or J-shaped retrocaval course or type 2 having sickle-shaped course. No case report describing retrograde endoscopic management of ureteral calculi in the presence of retrocaval ureter could be found in existing literature. We are presenting a case of type I retrocaval ureter with ureteral calculi and nonobstructive drainage, which was effectively managed by flexible ureteroscopy. Case Presentation: A 62-year-old Caucasian man presented with complaints of a renal colic. The patient was positive for a history of noninsulin-dependent diabetes and hypertension. A direct abdomen CT scan showed an 8 mm ureteral stone with suspected retrocaval course of right proximal ureter with no hydronephrosis. After informed consent, ureteroscopy was performed on the patient's right proximal ureter. No complications occurred intraoperatively and postoperatively. On follow-up of up to 3 months, patient was asymptomatic and direct abdomen CT scan showed normal kidney without hydronephrosis. Conclusion: In the presence of retrocaval ureter and associated ureteral calculi with a condition of nonobstructive drainage, retrograde ureteroscopy is a safe and optimal procedure.

A great deal of effort and resources is expended on the cleaning and rehabilitation of oiled wildlife, but the ultimate fate of these animals is often unknown. Post-release monitoring is essential for improving methodology and directing resources to those animals most likely to survive after release. The Refugio oil spill occurred in May 2015, spilling approximately 100,000 gallons of oil on the California coast near Santa Barbara. Brown pelicans were the most common avian species affected. We instrumented 12 oiled pelicans with solar-powered satellite GPS tags at the time of their release following cleaning and rehabilitation. An additional 8 control (unoiled) pelicans from a nearby area were similarly instrumented and released immediately. All birds survived for at least 12 weeks. In the first 6 months after release, distance traveled and movements were similar between rehabilitated and control pelicans. Several individuals traveled >5000 km, migrating to northern California or central Oregon in the late summer and early fall. In the spring, most birds traveled south, some as far as southern Baja California. Mortality was documented among both rehabilitated and control birds; however, the majority of birds that stopped transmitting were never found. Lack of transmission could represent mortality, tag or battery failure, or tag loss. After at least 40 weeks of tracking, 5 birds (3 rehabilitated and 2 control) were still transmitting. Based on presence in breeding colonies, none of the birds appeared to breed. These results demonstrate that brown pelicans can survive and travel long distances following oiling and rehabilitation.

Nicaragua's Bosawás Biosphere Reserve is a vast forested area inhabited largely by indigenous Mayangna and Miskitu people. Most Bosawás residents rely on subsistence hunting and swidden agriculture, and hunting dogs are important for finding and securing wild game. We investigated the health of hunting dogs in three communities differing in location, size, and economy. Dogs in all communities were nutritionally compromised and experienced a heavy burden of disease. Seroprevalence of canine distemper, canine parvovirus, Rickettsia rickettsii, and Leptospira spp. exceeded 50% of dogs. At least one dog was actively shedding leptospires in urine, and many dogs were anemic and/or dehydrated. These dogs interact with wildlife in the forest and humans and domestic livestock in the communities, and may therefore serve as sources of zoonotic and wildlife diseases. Bosawás represents one of the largest intact tracts of habitat for jaguars (Panthera onca) in Central America, and given that these communities are located within the forest, jaguars may be at risk from disease spillover from hunting dogs. Dog owners reported that four of 49 dogs had been attacked and killed by jaguars in the past year, and that retaliatory killing of jaguars was sometimes practiced. Disease spillover from dogs to wildlife could occur both in the course of dogs' hunting activities as well as during jaguar attacks. A better understanding of dog depredation by jaguars, pathogen exposure in jaguars, and a management strategy for the hunting dog population, are urgently needed to mitigate these dual threats to jaguars, improve the lives of hunting dogs, and safeguard the health of their owners.

Animal studies have shown diabetes-induced lysyl oxidase (LOX) upregulation promotes blood-retinal-barrier breakdown and retinal vascular cell loss associated with diabetic retinopathy (DR). However, it is unclear whether changes in LOX expression contribute to the development and progression of DR. To determine if vitreous LOX levels are altered in patients with DR, 31 vitreous specimens from subjects with advanced proliferative DR (PDR), and 27 from non-diabetics were examined. The two groups were age- and gender-matched (57 ± 12 yrs vs. 53 ± 18 yrs; 19 males and 12 females vs. 17 males and 10 females). Vitreous samples obtained during vitrectomy were assessed for LOX levels using ELISA. LOX was detected in a larger number of PDR subjects (58%) than in non-diabetic subjects (15%). Additionally, ELISA measurements showed a significant increase in LOX levels in the diabetic subjects with PDR, compared to those of non-diabetic subjects (68.3 ± 112 ng/mL vs. 2.1 ± 8.2 ng/mL; p < 0.01). No gender difference in vitreous LOX levels was observed in either the diabetic or non-diabetic groups. Findings support previous reports of increased LOX levels in retinas of diabetic animals and in retinal vascular cells in high glucose condition, raising the prospect of targeting LOX overexpression as a potential target for PDR treatment.

Cardiovascular disease (CVD) is the primary cause of morbidity and mortality in patients with diabetes. Endothelial cell dysfunction is a factor in the atherosclerotic process that underpins CVD, but the link between diabetes and endothelial dysfunction is not fully understood. In this study, the effects of glucose exposure on a human-derived endothelial cell line, EA.Hy926, was examined. EA.hy926 cells were grown in two distinctive pre-treatment glucose conditions during the cell growth phase: 5.5 mM (‘normal glucose’; NG) or 25 mM glucose (‘high glucose’; HG). Cells were subsequently exposed to three different test glucose concentrations for 48 hours (5.5, 12.5 and 25 mM). The effect of the glucose exposure on cell viability, growth rate, metabolism, and cell functionality were assessed. The study showed that the glucose exposure in the growth phase (HG and NG conditions) does not affect EA.hy926 cell viability, membrane integrity or growth rate. However, EA.hy926 metabolism and mitochondrial activity were modulated by the glucose concentration in the growth phase; cells cultured in NG medium showed a more energetic profile, a greater NAD/NADH ratio and ADP/ATP ratio. Increasing the test glucose concentration was also found to reduce endothelial nitric oxide (NO) synthase-derived NO generation from NG cells, as indicated by an increase in the surrogate NO marker, nitrite, in the supernatant. In conclusion, the present study found that exposure of EA.hy926 endothelial cells to hyperglycaemic conditions induced a rapid, reversible change in metabolism. In addition, acute exposure of cells to hyperglycaemic conditions had a substantial impact on mediators that are key to endothelial modulation of vascular tone and the atherosclerotic process. The results lend weight to the hypothesis that modulation of endothelial cell metabolism and function by glucose mediates the dysfunction that underpins atherogenesis.

Introduction:Total hip arthroplasty (THA) is 1 of the most common procedures in orthopaedic surgery. Different options and implants are currently available. Uncemented hip cups need primary stability for bone ingrowth, the use of screws is required when the desired stability is not achieved. Another option is the use of a hemispherical threaded cup with enhanced primary stability. The purpose of our study was to compare the results of a 3rd-generation threaded cup versus a press-fit cup with a long track record.Materials and methods:A consecutive series of 300 THAs performed by 2 surgeons was retrospectively reviewed, 150 press-fit cups and 150 screwed cups. Minimum follow-up 27 months; maximum 78 months (mean 52.5 months). The primary endpoint was a stable and painless THA, secondary endpoints included Hip disability and Osteoarthritis Outcome Score, Junior and radiographic evaluation.Results:Preliminary results showed no statistically significant differences between the 2 groups for all the evaluated parameters, the number of early mechanical loosening was higher for press-fit cups, but this value was not statistically significant. At a mean follow-up of 52.5 months 1 cup revision (0.3%) was seen in the screwed cup group and 2 (0.6%) in the press-fit cup; these results were not statistically significant.Discussion and conclusion:The main concern for screwed cups is the greater bone loss and possible removal difficulties during revision surgery. This study has some limitations, in particular regarding follow-up, but is still ongoing. Our results showed no difference between the 2 systems.

Ludwig’s Angina is a rare but life-threatening condition. Managing high airways to provide adequate ventilation and oxygenation, tracheostomy, broad spectrum antibiotics, and surgery are the principle treatments.

Introduction The objectives of this study were to determine if a multimodular introductory ultrasound course improved emergency medicine intern confidence in performing a point-of-care ultrasound and if our educational objectives could be met with our chosen structure. Methods This is a prospective, observational study evaluating three consecutive incoming emergency medicine residency classes from three residency programs. A one-day introductory ultrasound course was delivered. The course consisted of 1) flipped classroom didactics, 2) in-person, case-based interactive teaching sessions, and 3) check-listed, goal-driven, hands-on instruction. Results Over three years, 73 residents participated in this study. There was no significant difference in performance on the written test (p = 0.54) or the skills assessment (p = 0.16) between years. Performance on the written pre-test was not a predictor of performance on the skills test (R2 = 0.028; p = 0.19). Prior to training, residents were most confident in performing a focused assessment with sonography for trauma examination (median confidence 5.5 (interquartile range (IQR): 3 - 7) on a 10-point Likert scale where 1 represents low confidence and 10 represents high confidence). They reported the lowest confidence in performing a cardiac ultrasound (3 (IQR: 2 - 6)). Following training, residents reported increased confidence with all applications (p < 0.001). Eighty-five percent (confidence interval (CI): 73, 92) of residents agreed that the online ultrasound lectures effectively teach point-of-care ultrasound applications and 98% (CI: 88, 100) agreed that case-based interactive sessions helped them understand how ultrasound changes the management of acutely ill patients. Conclusions A written test of knowledge regarding the use of point-of-care ultrasound does not correlate with procedural skills at the start of residency, suggesting that teaching and evaluation of both types of skills are necessary. Following a multimodular introductory ultrasound course, residents showed increased confidence in performing the seven basic ultrasound applications. Residents reported that an asynchronous curriculum and case-based interactive sessions met the learning objectives and effectively taught point-of-care ultrasound applications.

The principles of surgical asepsis apply to field surgeries with few exceptions. The minimum level for performance of surgeries in the field on free-ranging animals should be the same as for domestic animals undergoing surgery in animal hospitals. Surgeries in the field are typically done as part of research and management projects and usually involve a combination of biologists and veterinarians with the possibility of conflicts in scientific cultures. This article outlines a minimum standard of care for field surgeries and will serve as a resource for Institutional Animal Care and Use Committees and biologists and veterinarians planning projects that involve surgeries on free-ranging wildlife in field conditions.

Purpose : Emergency medicine residency programs have evaluated the use of Multiple Mini Interviews (MMIs) for applicants. The authors developed an MMI-style method called the Fast Interview Track (FIT) to predict an applicant’s ‘fit’ within an individual residency program. Methods : Applicants meet with up to five residents and are asked one question by each. Residents score the applicant using a Likert scale from 1 to 5 on two questions: ‘How well does the applicant think on his/her feet?’ and ‘How well do you think the applicant will fit in here?’. To assess how well these questions predicted a resident’s ‘fit’, current residents scored fellow residents on these same questions. These scores were compared with the residents’ interview FIT scores. A postmatch survey of applicants who did not match at this program solicited applicants’ attitudes toward the FIT sessions. Results : Among the junior class, the correlation between interview and current scores was significant for question 1 (rho=0.5192 [ p= 0.03]) and question 2 (rho=0.5753 [ p= 0.01]). Among seniors, Spearman’s rho was statistically significant for question 2, though not statistically significant for question 1. The chi-square measure of high scores (4–5) versus low scores (1–3) found a statistically significant association between interview and current scores for interns and juniors. Of the 29 responses to the postmatch survey, 16 (55%) felt FIT sessions provided a good sense of the program’s personality and only 6 (21%) disagreed. Nine (31%) felt FIT sessions positively impacted our program’s ranking and 11 (38%) were ‘Neutral’. Only two (7%) reported that FIT sessions negatively impacted their ranking of our program. Conclusions : FIT provided program leadership with a sense of an applicant’s ‘fit’ within this program. Interview day scores correlated with scores received during residency. Most applicants report a positive experience with FIT sessions. FIT provides a useful tool to recruit applicants who fit with the residency program. Keywords: MMI; emergency medicine; residency interview (Published: 2 February 2016) Citation: Med Educ Online 2016, 21: 29587 - http://dx.doi.org/10.3402/meo.v21.29587

European cities face increasing challenges to their citizens’ mobility. Urban transport systems are integral elements of the European transport system and are therefore of concern for the Common Transport Policy. Thus, the 2011 Transport White Paper calls for cities to implement a range of strategies to face these challenges - strategies include: land-use planning, pricing schemes, efficient public transport services, infrastructure for non-motorised modes and charging/refuelling of clean vehicles to reduce emissions – and encourage to develop Urban Mobility Plans (SUMPs) that bring all of these elements together. Tools and guidance documents are key instruments for the development of these strategies in order to help city authorities understanding the range of possible actions and steps to successful implementation. This paper presents an overview of the web based policy support tool developed in the European Urban Roadmaps study, supported by DG Move and underpinned by a range of stakeholders’ engagement activities. The aim of the web based tool is to support authorities of small and medium sized cities in Europe who may not have the resource to major policy assessment and modelling work. The tool provide the local transport policy maker with the ability to readily identify, develop, screen and assess different measures and policies scenarios, thereby enabling city authorities to quickly gather a sense of the scale of impacts that could be expected. It is adaptable to different city circumstances, covers all the transport/travel modes that are used in urban areas and provides quantitative outputs covering a range of different metrics, including costs and cost effectiveness, covering the time period until 2030. The development of the tool is complemented by the preparation of different road maps, designed to provide examples of policy selections that could be implemented by a city to work towards the European Commission goals for sustainable urban transport until the year 2030.

Author(s): Stoneking, Lisa R.; Winkler, John P.; DeLuca, Lawrence A.; Stolz, Uwe; Stutz, Aaron; Luman, Jenifer C.; Gaub, Michael; Wolk, Donna M.; Fiorello, Albert B.; Denninghoff, Kurt R. | Abstract: Introduction: Timely recognition and treatment of sepsis improves survival. The objective is to examine the association between recognition of sepsis and timeliness of treatments.Methods: We identified a retrospective cohort of emergency department (ED) patients with positive blood cultures from May 2007 to January 2009, and reviewed vital signs, imaging, laboratory data, and physician/nursing charts. Patients who met systemic inflammatory response syndrome (SIRS) criteria and had evidence of infection available to the treating clinician at the time of the encounter were classified as having sepsis. Patients were dichotomized as RECOGNIZED if sepsis was explicitly articulated in the patient record or if a sepsis order set was launched, or as UNRECOGNIZED if neither of these two criteria were met. We used median regression to compare time to antibiotic administration and total volume of fluid resuscitation between groups, controlling for age, sex, and sepsis severity.Results: SIRS criteria were present in 228/315 (72.4%) cases. Our record review identified sepsis syndromes in 214 (67.9%) cases of which 118 (55.1%) had sepsis, 64 (29.9%) had severe sepsis, and 32 (15.0%) had septic shock. The treating team contemplated sepsis (RECOGNIZED) in 123 (57.6%) patients. Compared to the UNRECOGNIZED group, the RECOGNIZED group had a higher use of antibiotics in the ED (91.9 vs.75.8%, p=0.002), more patients aged 60 years or older (56.9 vs. 33.0%, p=0.001), and more severe cases (septic shock: 18.7 vs. 9.9%, severe sepsis: 39.0 vs.17.6%, sepsis: 42.3 vs.72.5%; pl0.001). The median time to antibiotic (minutes) was lower in the RECOGNIZED (142) versus UNRECOGNIZED (229) group, with an adjusted median difference of -74 minutes (95% CI [-128 to -19]). The median total volume of fluid resuscitation (mL) was higher in the RECOGNIZED (1,600 mL) compared to the UNRECOGNIZED (1,000 mL) group. However, the adjusted median difference was not statistically significant: 262 mL (95% CI [ -171 to 694 mL]).Conclusion: Patients whose emergency physicians articulated sepsis syndrome in their documentation or who launched the sepsis order set received antibiotics sooner and received more total volume of fluid. Age l60 and absence of fever are factors associated with lack of recognition of sepsis cases. [West J Emerg Med. 2015;16(3):401–407.]

OBJECTIVES To describe our experience with implementation of a novel team-based emergency ultrasound (EUS) fellowship training program. METHODS We conducted a retrospective review at an academic medical center. All emergency department (ED) faculty and residents were divided into 3 teams, and a fellow was assigned to each team. Each fellow was responsible for ultrasound (US) education of their team members and faculty credentialing. Additionally, each fellow was assigned to one of these specific responsibilities every month: (1) education, (2) quality assurance/billing, and (3) equipment. The fellows also received a checklist at the beginning of the fellowship training, which outlined research, reading, teaching, and scanning requirements. RESULTS With a team-based approach, all US examinations were reviewed for quality control within 1 week after the scans were performed. The number of US examinations billed by faculty increased by 180%. The US billing revenue increased by 60% during the study period. Fifteen additional faculty members were credentialed to use US in the ED. Compliance with bedside documentation of US findings increased from 30% to 90%. There was increased resident engagement, and the number of scans performed by residents increased by 130%. There was also a substantial decrease in the funds required to replace damaged transducers. CONCLUSIONS A team-based EUS fellowship training program had a substantial impact on US use in the ED, quality control review, faculty credentialing, US billing revenue, compliance with documentation, and resident US education.

Projections show that CO2 emissions from road transport will continue to rise in the future if adequate policy measures are not implemented. Electrically driven vehicle (EDV) deployment is one way to reduce the CO2 emissions. EDV drive and charge patterns determine the resulting electricity demand, emission reductions, future infrastructure requirements and the integration of non-dispatchable renewable electricity. In order to analyse the impact of EDVs on European energy and infrastructure needs, the driving patterns of potential EDV users should be analysed. Due to the lack of sufficient historical representative data on driving patterns with EDVs, this study analyses whether European national travel surveys (NTS) can be a potential data source to derive usage patterns for EDVs. We perform a meta-analysis of NTS from 9 European countries to assess their adequacy for analysing the impacts of EDVs on the European electricity system. Several gaps in data availability and comparability are identified. Except for the UK, European NTS are not detailed enough to assess EDV charging profiles, which is also due to the methodological differences used for NTS data collection in the various countries. We conclude that a dedicated survey needs to be developed to reliably estimate EDV charging profiles., JRC.F.6-Energy Technology Policy Outlook

Objectives The aim of this study was to determine the fiscal impact of implementation of a novel emergency department (ED) point-of-care (POC) ultrasound billing and reimbursement program. Methods This was a single-center retrospective study at an academic medical center. A novel POC ultrasound billing protocol was implemented using the Q-path Web-based image archival system. Patient care ultrasound examination reports were completed and signed electronically online by faculty using Q-path. A notification was automatically sent to ED coders from Q-path to bill the scans. ED coders billed the professional fees for scans on a daily basis and also notified hospital coders to bill for facility fees. A fiscal analysis was performed at the end of the year after implementing the new billing protocol, and a before-and-after comparison was conducted. Results After implementation of the new billing program, there was a 45% increase in the ED faculty participation in billing for patient care examinations (30%-75%). The number of ultrasound examinations billed increased 5.1-fold (4449 vs 857) during the post implementation period. The total units billed increased from previous year for professional services to 4157 from 649 and facility services to 3266 from 516. During the post implementation period, the facility fees revenue increased 7-fold and professional fees revenue increased 6.34-fold. After deducting the capital costs and ongoing operational costs from approximate collections, the net profits gained by our ED ultrasound program was approximately $350 000. Conclusions Within 1 year of inception, our novel POC ultrasound billing and reimbursement program generated significant revenue through ultrasound billing.

Objectives To determine the ability of emergency physicians to detect complex abnormalities on point-of-care (POC) echocardiograms. Methods Single-blinded, nonrandomized, cross-sectional study. Twenty-five different emergency medicine clinical scenarios (video clips and digital images) covering a variety of echocardiographic abnormalities were presented to a group of emergency physician sonologists. The echocardiographic abnormalities included right ventricular dysfunction, left ventricular systolic dysfunction, diastolic dysfunction, regional wall motion abnormalities, Doppler abnormalities of pericardial tamponade physiology, left ventricular hypertrophy, hypertrophic cardiomyopathy, and aortic abnormalities. All emergency physician sonologists were blinded to the study hypothesis. They reviewed echocardiography video clips and images individually, and their interpretations were compared with the criterion standard (expert echocardiographer interpretations). Results A total of 200 echocardiography studies (video clips and images) were independently reviewed by 8 emergency physician sonologists with varying POC echocardiography experiences. Emergency physicians accurately identified left ventricular systolic dysfunction 94% of the time, diastolic dysfunction (100%), and right ventricular dysfunction 80% of the time. Regional wall motion abnormalities were detected only 50% of the time. Doppler echocardiographic abnormalities of pericardial tamponade physiology were accurately identified 57% of the time. Emergency physicians who performed more than 250 POC echocardiograms were found to be more accurate in identifying complex echocardiographic abnormalities. Conclusions Our study results suggest that with increased experience, emergency physicians can accurately identify most of complex echocardiographic abnormalities.

Purpose: Ultrasound use by emergency medicine and critical care physicians in the evaluation of the critically ill patient has increased in recent years. Several protocols exist to aid in diagnosing the etiology of shock and identifying rapidly reversible conditions in the undifferentiated hypotension patient. Currently, no protocol provides hemodynamic data or is designed to guide ongoing resuscitation of the critically ill patient with hypotension. Methods: An evidence-based protocol was developed based on the components of echocardiography that have been supported in the literature for bedside evaluation of the critically ill patient. Results: The RECES protocol provides diagnostic and hemodynamic information regarding volume responsiveness , presence of pericardial effusion with tamponade physiology (right ventricular diastolic collapse), systolic failure (poor contractility, decreased stroke volume and cardiac output), diastolic dysfunction (mitral valve inflow velocities and tissue Doppler), Right ventricular systolic failure, acute valvular rupture, obvious wall motion abnormalities, and signs of pressure or volume overload (septal flattening on parasternal short axis). Conclusion: The RECES protocol is a proposed instrument for rapidly and repeatedly assessing the etiology and initial hemodynamic parameters of the patient in shock. Additionally, repeated exams will allow monitoring interventions and guide ongoing resuscitation.

Objective—To evaluate the efficacy and safety of a combination of dexmedetomidine, butorphanol, and midazolam administered IM for anesthesia in captive Asian small-clawed otters (Aonyx cinereus) and to compare this combination with a combination of ketamine and midazolam. Design—Prospective crossover study. Animals—10 captive Asian small-clawed otters. Procedures—A combination of either dexmedetomidine (0.03 mg/kg [0.014 mg/lb]), butorphanol (0.2 mg/kg [0.091 mg/lb]), and midazolam (0.15 mg/kg [0.068 mg/lb]) or ketamine (10.1 mg/kg [4.59 mg/lb]) and midazolam (0.3 mg/kg [0.14 mg/lb]) was administered IM to otters for immobilization to allow scheduled wellness examinations. Otters were intubated and administered 100% oxygen during the examination. Anesthesia was supplemented with isoflurane in oxygen if necessary. Routine medical procedures, including blood collection, radiography, echocardiography, dental scaling, vaccinations, and contraception administration, were performed as indicated during the immobilization. Physiologic, clinicopathologic, and anesthetic variables were recorded and compared. Otters given dexmedetomidine-butorphanol-midazolam were administered atipamezole (0.2 mg/kg [0.091 mg/lb]), naltrexone (0.6 mg/kg [0.27 mg/lb]), and flumazenil (0.05 mg/kg [0.023 mg/lb]) IM at the completion of the examination. Results—The need for and duration of isoflurane administration were greater for ketamine-midazolam anesthesia, compared with dexmedetomidine-butorphanol-midazolam anesthesia. Recoveries were shorter and subjectively smoother with dexmedetomidine-butorphanol-midazolam. Heart rates were significantly higher during ketamine-midazolam anesthesia. Regardless of protocol, all otters developed hypothermia and hypercapnia during anesthesia. Conclusions and Clinical Relevance—Both protocols were safe and effective for this species, but the reversible nature of dexmedetomidine-butorphanol-midazolam resulted in more rapid recoveries than did ketamine-midazolam. Otters anesthetized with ketamine-midazolam may require additional anesthetic medications for routine examinations, and assisted ventilation and thermal support may be of benefit with either protocol.

Background Split liver transplantation increases the number of grafts available for transplantation. Pre-recovery assessment of liver graft volume is essential for selecting suitable recipients. The purpose of this study was to determine the ability and feasibility of constructing a 3-D model to aid in surgical planning and to predict graft weight prior to an in situ division of the donor liver. Methods Over 11 months, 3-D volumetric reconstruction of 4 deceased donors was performed using Pathfinder Scout© liver volumetric software. Demographic, laboratory, operative, perioperative and survival data for these patients along with donor demographic data were collected prospectively and analyzed retrospectively. Results The average predicted weight of the grafts from the adult donors obtained from an in situ split procedure were 1130 g (930-1458 g) for the extended right lobe donors and 312 g (222-396 g) for left lateral segment grafts. Actual adult graft weight was 92% of the predicted weight for both the extended right grafts and the left lateral segment grafts. The predicted and actual graft weights for the pediatric donors were 176 g and 210 g for the left lateral segment grafts and 308 g and 280 g for the extended right lobe grafts, respectively. All grafts were transplanted except for the right lobe from the pediatric donors due to the small graft weight. Conclusions On-site volumetric assessment of donors provides useful information for the planning of an in situ split and for selection of recipients. This information may expand the donor pool to recipients previously felt to be unsuitable due to donor and/or recipient weight.

Background To evaluate time course and predictors of progression of paroxysmal or persistent atrial fibrillation (AF) to permanent AF. Methods and Results We included 460 patients referred for paroxysmal (n = 337) or persistent (n = 123) AF between 1994 and 2012. Mean follow-up was 13.2 ± 6.5 years. AF progression rate was 3.7% per year, 19.7% at 5 years, and 38.1% at 10 years. Lone AF was diagnosed in 217 patients (47%). Predictors of permanent AF were: age, persistent AF, left atrial (LA) size, left ventricular-fractional shortening (LV-FS), lack of antiarrhythmic (AA) drugs, VVI pacing (P 75 years remained highly significant (P 50 mm was highly significant at univariate model (P < 0.001) but to a lesser extent when adjusted (P < 0.05). In patients with paroxysmal AF—with age

full-scale mechanical prototype line was deployed to a depth of 2500 m to test the leak tightness of the electronics containers and the pressure-resistant properties of an electromechanical cable under evaluation for use in the ANTARES deep-sea neutrino telescope. During a month-long immersion study, line parameter data were taken using miniature autonomous data loggers and shore-based optical time domain reflectometry. Details of the mechanical prototype line, the electromechanical cable and data acquisition are presented. Data taken during the immersion study revealed deficiencies in the pressure resistance of the electromechanical cable terminations at the entry points to the electronics containers. The improvements to the termination, which have been integrated into subsequent detection lines, are discussed. The line also allowed deep-sea acoustic measurements with a prototype hydrophone system. The technical setup of this system is described, and the first results of the data analysis are presented. (c) 2007 Elsevier B.V. All rights reserved.