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Introduction Like many teaching hospitals in Australia, after-hours computed tomography (CT) reporting at our institution is undertaken by the on-call radiology registrar. The accuracy of these reports is important as management is often initiated based on the interim findings, prior to review by the consultant radiologist. A common exception to this approach is cervical CT (CCT), as many hospital protocols recommend patients to remain in spinal precautions until the report is finalised by a consultant, although there are very few studies to support this practice. Methods The interim registrar reports for all CCTs performed after-hours over a 12-month period were retrospectively reviewed. The final consultant report was used as the gold standard to establish accuracy of the registrar report. The primary outcome was discrepancy between the provisional and final reports. Any discrepancy was classified as either an 'overcall' or 'miss'. Discrepancies were graded by the RADPEER scoring system. Results A total of 1084 after-hours CCT studies were reviewed. The number of cases positive for injury was 37 (3.4%). The total number of discrepancies was 14 (discrepancy rate 1.3%), including 4 overcalls (0.3%) and 10 misses (0.9%). The discrepancy rates for junior and senior registrars were 1.7% and 0.7% respectively. Only 5 misses (0.5%) were considered clinically significant. Conclusion Registrars reporting after-hours CCT have low rates of discrepancy with very few clinically significant misses. However, the reduced registrar sensitivity for detection of cervical injury highlights the ongoing importance of consultant review in the process of cervical spine clearance pathways.

Background. The article describes the application of kinesioteiping as an additional treatment for patients in the rehabilitation period after osteosynthesis of the lower jaw. Aims. To evaluate the effectiveness of kinesiotherapy in patients after osteosynthesis of the lower jaw in the rehabilitation period. Materials and methods. The nociceptive sensitivity and edema size in patients were evaluated after osteosynthesis of the lower jaw, and the durations of the rehabilitation period with and without kinesiotherapy were compared. The study involved 30 patients who were hospitalized (from January 2019 to February 2020) in the Department of Maxillofacial Surgery, Regional Clinical Hospital, Ryazan. A visual analog pain scale and a photographic protocol were used to evaluate the effectiveness of the methodology. Results. On the third day of the study, 46.6% of the patients in the control group expressed an improvement in their health. Subjectively: mouth opening restrictions of 2 cm were observed, spontaneous pain in the lower jaw was preserved, and soft tissue edema was preserved. In the study group, the results were more positive compared with the first day after surgery. On the third day, 66.6% of the patients recovered better and faster. Subjectively: the level of pain in the lower jaw decreased, soft tissue edema reduced, and the mouth opening restriction of 2 cm was preserved. Conclusion. Kinesiotherapy is an effective and well-proven additional non-drug method that allows to reduce the rehabilitation period after osteosynthesis of the lower jaw.

Background To prescribe early trismus therapy, prognostic factors influencing the restricted mouth opening should be identified first. Our aim is to present an overview of these factors in patients with head and neck cancer. Methods PubMed, Cochrane, EMBASE, and CINAHL were searched using terms related to head and neck cancer and mouth opening. Risk of bias was assessed using the “Quality in Prognosis Studies” tool. A best evidence synthesis was performed. Results Of the identified 1418 studies, 53 were included. Three studies contained a prognostic multivariate model for a restricted mouth opening. Conclusions Patients with head and neck cancer will most likely develop a restricted mouth opening when they have a large tumor near the masticatory muscles that requires extensive cancer treatment. A restricted mouth opening most likely occurs within 6 months after cancer treatment. Further research is necessary on factors related to healing tendency or pain intensity.

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema. Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management. Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control). Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV1 from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV1 responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV1 showed statistically significant improvements between the treatment and control groups—between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060–0.141) and 0.099 L (95% BCI, 0.048–0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax. Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile. Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

BACKGROUND AND OBJECTIVES Endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are effective treatments for dysplastic Barrett's esophagus (BE). This study evaluates efficacy, durability and safety in a single high-volume UK tertiary centre with 15-years' experience. METHODS Prospective data were collected from Nottingham University Hospitals 2004-2019 for endotherapy of dysplastic BE or intramucosal adenocarcinoma. Procedural outcome measures include complete resection, complications and surgery rates. Efficacy outcomes include complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), recurrence, treatment failure rates, durability of RFA, median follow up and tumor-associated mortality. RESULTS A total of 319 lesions were resected; 671 RFAs were performed on 239 patients. Median age was 67 (±9.5) years, male:female ratio was 5:1 and median BE length was C3 [interquartile range (IQR): 6] M6 (IQR: 5). The most common lesion was Paris IIa (64%) with a median size of 10 mm (3-70). Final histology was adenocarcinoma in 50%. Complete resection rates were 96%. The multiband mucosectomy technique (91%) was most commonly used. The median number of RFA sessions was 3 (IQR: 2). The rates of CR-D and CR-IM were 90.4%% and 89.8% achieved after a median of 20.1 (IQR: 14) months. The most common complications: EMR was bleeding 2.2% and RFA was stricture (5.4%) requiring a median of 2 (range 1-7) dilatations. Median follow up post CR-IM/CR-D was 38 months (14-60). Metachronous lesions developed in 4.7% after CR-D and tumor-related mortality was 0.8%. Dysplasia and intestinal metaplasia-free survival at 5 years was 95 and 90%, respectively. CONCLUSION BE endotherapy is minimally invasive, effective, safe and deliverable in a day-case setting.

This chapter focuses on spontaneous intestinal perforation (SIP), which is an important disease entity that shares similarities with necrotizing enterocolitis. In fact, SIP is a separate condition entirely from NEC, with a very different pathogenesis, clinical history, and radiographic features. Importantly however, patients with SIP are often found to contaminate NEC datasets, a fact which has had a major, confounding impact on our understanding of NEC, and which has led to much confusion in the care of premature infants with these conditions. This chapter seeks to address this confusion, by highlighting the defining diagnostic and clinical features of NEC versus SIP, and by offering diagnostic insights that can be useful at the bedside.

Objective: Crowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU). Methods: We conducted a retrospective observational study from 2008–2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU. Results: Of 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08). Conclusion: In a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

Background Clinical trials performed in our emergency department at Barnes-Jewish Hospital utilize a centralized infrastructure for alerting, screening, and enrollment with rule-based alerts sent to clinical research coordinators. Previously, all alerts were delivered as text messages via dedicated cellular phones. As the number of ongoing clinical trials increased, the volume of alerts grew to an unmanageable level. Therefore, we have changed our primary notification delivery method to study-specific, shared-task worklists integrated with our pre-existing web-based screening documentation system. Objective To evaluate the effects on screening and recruitment workflow of replacing text-message delivery of clinical trial alerts with study-specific shared-task worklists in a high-volume academic emergency department supporting multiple concurrent clinical trials. Methods We analyzed retrospective data on alerting, screening, and enrollment for 10 active clinical trials pre- and postimplementation of shared-task worklists. Results Notifications signaling the presence of potentially eligible subjects for clinical trials were more likely to result in a screen (p Conclusion Shared-task worklists, with the functionalities we have described, offer a viable alternative to delivery of clinical trial alerts via text message directly to clinical research coordinators recruiting for multiple concurrent clinical trials in a high-volume academic emergency department.

Using a wearable electroencephalogram (EEG) device, this paper introduces a novel method of quantifying and understanding the visual acuity of the human eye with the steady-state visually evoked potential (SSVEP) technique. This method gives users easy access to self-track and to monitor their eye health. The study focuses on how varying the SSVEP stimulus frequency and duration affect the overall representation of a person’s visual perception. The study proposes two methods for this visual representation. The first method is a hardware system that utilizes long-exposure photography to augment reality and collocate the visual map onto the plane of interest. The second is a software implementation that captures the visual field at a set distance. A three-dimensional mapping is created by gathering software-defined visual maps at various set distances. Preliminary results show that these methods can gain some insight into the user’s central vision, peripheral vision, and depth perception.

Introduction Dysplasia in Barrett’s oesophagus (BO) is often invisible at white light endoscopy (WLE) and Seattle protocol is labour intensive. There is lack of randomised evidence that advanced imaging improves dysplasia detection. Probe-based confocal endomicroscopy (pCLE) is accurate for high-grade dysplasia (HGD) and intramucosal cancer (IMC) associated to visible lesions, but due to the narrow field requires combination with a red-flag technique for long-segment inconspicuous BO. We aimed to assess the diagnostic accuracy of optical biopsy by pCLE targeted by autofluorescence imaging (AFI) for any grade of dysplasia in patients without visible lesions. Methods In this prospective multi-centre randomised cross-over trial BO patients were randomised to WLE with Seattle protocol (standard arm) https://mail.addenbrookes.nhs.uk/owa/auth/logon.aspx?replaceCurrent=1u (b) overall histology, which included (a) + biopsies within the 12 months of enrolment. Secondary outcomes included procedural time. Results 133 patients completed both arms. 27.8% of patients received a diagnosis of dysplasia (LGD; n=19, HGD/IMC; n=18). In primary analysis (trial histology), pCLE had a sensitivity and specificity for dysplasia of 73.0% and 68.8%, respectively and 72.2% and 61.7% for HGD/IMC. Seattle protocol had a sensitivity of 73.0% for dysplasia and 83.3% for HGD/IMC, with no significant difference between arms. In secondary analysis (overall histology), pCLE had a similar sensitivity to Seattle protocol for dysplasia (61.8% vs. 49.1%; p=0.09) and HGD/IMC (70.0% vs 50.0%; p=0.11). The procedural time in the experimental arm was longer than standard arm (Mean mins 22.3 vs. 16.4; p Conclusions In combination with AFI, pCLE detects inconspicuous dysplasia in approximately three quarters of cases. pCLE has equal diagnostic accuracy for dysplasia compared to Seattle protocol dispensing extensive sampling but at expense of longer procedural time.

The purpose of this work is to harness the creative energy of the subconscious mind, to perform useful work while meditating, daydreaming, lucid dreaming, and the like. One of our ultimate goals is “jobbing on the sleep”, an inverse or reciprocal to “sleeping on the job”. We present, as the first step in this direction, an experimental apparatus for inducing and measuring steady-state visually evoked potentials (SSVEPs), where the subject concentrates on the rotating pattern that is mounted to the shaft of an electric motor. Essentially, we prove that human-in-the-loop meditation and visual attention exercises as a user concentrates on the rotating pattern results in some degree of SSVEP response.

We present an augmented reality (AR) system using the Sequential Wave Imprinting Machine (SWIM) with software-defined radio (SDR) to phase-coherently visualize electromagnetic (EM) radio waves and other periodic wave phenomena in real-time. This allows us to see, understand, learn about, teach, exhibit, display, and photograph the otherwise invisible waves. The SWIM achieves phase-coherent detection by using a lock-in amplifier (LIA) fed from a receive antenna that moves together with a light source (e.g. linear array of LEDs). They both move together with respect to a stationary radio source such as a transmit antenna, and a stationary reference antenna. Thus, the otherwise invisible radio waves become visible to the naked eye, photographic camera, or to a phenomenal augmented or virtual reality system.

BACKGROUND: Trismus occurs frequently in patients with head and neck cancer. Determining the prevalence and associated factors of trismus would enable prediction of the risk of trismus for future patients.METHODS: Based on maximal mouth opening measurements, we determined the prevalence of trismus in 730 patients with head and neck cancer. Associated factors for trismus were analyzed using univariate analyses and multivariate logistic regression analyses. Based on the regression model, a calculation tool to predict trismus was made.RESULTS: Prevalence of trismus was 23.6%. Factors associated with trismus were: advanced age; partial or full dentition; tumors located at the maxilla; mandible; cheek; major salivary glands; oropharynx; an unknown primary; a free soft tissue transfer after surgery; reirradiation; and chemotherapy.CONCLUSION: About one-fourth of patients with head and neck cancer develop trismus. Based on prevalence and associated factors of trismus, a simple calculation tool predicts the risk of trismus in these patients.

Calprotectin is an antimicrobial protein found in stool when released by granulocytes. We sought to create stool calprotectin reference ranges in preterm neonates and to evaluate whether levels exceeding the upper reference interval are diagnostic for necrotizing enterocolitis (NEC). Stool calprotectin was measured in premature neonates without gastrointestinal pathology to create reference intervals. For comparison, levels from infants undergoing “rule out NEC” evaluations were plotted on these reference intervals. Stool calprotectin reference intervals were created according to gestational age at birth and corrected gestational age. Levels during “rule out NEC” evaluations were more often above the upper reference interval with NEC vs. those without NEC. Stools from preterm neonates have a higher range of calprotectin than stools from healthy term neonates. In evaluating preterm neonates for NEC with stool calprotectin, a calprotectin upper reference interval that incorporates corrected gestational age best predicts the diagnosis of NEC.

Better means to diagnose and define necrotizing enterocolitis are needed to guide clinical practice and research. Adequacy of Bell's staging system for clinical practice and clarity of cases used in NEC clinical datasets has been a topic of controversy for some time. This article provides reasons why a better global definition for NEC is needed and offers a simple alternative bedside definition for preterm NEC called the "Two out of Three" rule. Some argue that biomarkers may fill knowledge gaps and provide greater precision in defining relevant features of a clinical disease like NEC. NEC biomarkers include markers of inflammation, intestinal dysfunction, hematologic changes, and clinical features. Development and reporting of NEC biomarkers should be guided by the FDA's BEST Consensus resource, "Biomarkers, EndpointS, & other Tools" and consistently report metrics so that studies can be compared and results pooled. Current practice in the NICU would be enhanced by clinical tools that effectively inform the clinical team that a baby is at increasing risk of NEC. Ideally, these tools will incorporate both clinical information about the baby as well as molecular signals that are indicative of NEC. While meaningful biomarkers for NEC and clinical tools exist, translation into practice is mediocre.

This document represents the first position statement produced by the British Society of Gastroenterology and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, setting out the minimum expected standards in diagnostic upper gastrointestinal endoscopy. The need for this statement has arisen from the recognition that while technical competence can be rapidly acquired, in practice the performance of a high-quality examination is variable, with an unacceptably high rate of failure to diagnose cancer at endoscopy. The importance of detecting early neoplasia has taken on greater significance in this era of minimally invasive, organ-preserving endoscopic therapy. In this position statement we describe 38 recommendations to improve diagnostic endoscopy quality. Our goal is to emphasise practices that encourage mucosal inspection and lesion recognition, with the aim of optimising the early diagnosis of upper gastrointestinal disease and improving patient outcomes.

Purpose Several cut-off points for trismus in head and neck cancer patients have been used. A mouth opening of 35 mm or less is most frequently used as cut-off point. Due to the variation in cut-off points, prevalence, risk factors and treatment outcomes of trismus cannot be studied in a uniform manner. To provide uniformity, we aimed to verify the cut-off point of 35 mm or less. Additionally, we aimed to determine associated covariates with reported difficulties when opening the mouth. Methods In a cross-sectional design, we measured the mouth opening in 671 head and neck cancer patients at the Department of Oral and Maxillofacial Surgery, at the University Medical Center Groningen. The cut-off point was determined using the receiver operating characteristic curve and Youden index, with reported difficulties when opening the mouth as criterion for trismus. Cut-off points for significant covariates were also determined. Results The Youden index was highest at 35 mm, with a sensitivity of 0.71 and a specificity of 0.86. Of the covariates analysed, type of treatment modality was significantly associated with reported difficulties when opening the mouth. The highest Youden index for patients treated with surgery alone was 37 mm and for patients treated with radiotherapy alone 33 mm. Conclusions The cut-off point of 35 mm or less for trismus was confirmed in a head and neck cancer population and is recommended to be used in future studies. Patients receiving different treatment modalities experience difficulty when opening the mouth differently.

There are currently no effective treatments for moderate-to-severe traumatic brain injuries (TBIs). The paracrine functions of undifferentiated neural stem cells (NSCs) are believed to play a significant role in stimulating the repair and regeneration of injured brain tissue. We therefore hypothesized that fibroblast growth factor (FGF2) enriching chondroitin sulfate glycosaminoglycan (CS-GAG) matrices can maintain the undifferentiated state of neural stem cells (NSCs) and facilitate brain tissue repair subacutely post-TBI. Rats subjected to a controlled cortical impactor (CCI) induced TBI were intraparenchymally injected with CS-GAG matrices alone or with CS-GAG matrices containing PKH26GL labeled allogeneic NSCs. Nissl staining of brain tissue 4 weeks post-TBI demonstrated the significantly enhanced (p < 0.05) tissue protection in CS-GAG treated animals when compared to TBI only control, and NSC only treated animals. CS-GAG-NSC treated animals demonstrated significantly enhanced (p < 0.05) FGF2 retention, and maintenance of PKH26GL labeled NSCs as indicated by enhanced Sox1+ and Ki67+ cell presence over other differentiated cell types. Lastly, all treatment groups and sham controls exhibited a significantly (p < 0.05) attenuated GFAP+ reactive astrocyte presence in the lesion site when compared to TBI only controls.

In the last decades the reported incidence of preterm necrotizing enterocolitis (NEC) has been declining in large part due to implementing comprehensive NEC prevention initiatives, including breast milk feeding, standardized feeding protocols, transfusion guidelines, and antibiotic stewardship and improving the rigor with which non-NEC cases are excluded from NEC data. However, after more than 60 years of NEC research in animal models, the promise of a "magic bullet" to prevent NEC has yet to materialize. There are also serious issues involving clinical NEC research. There is a lack of a common, comprehensive definition of NEC. National datasets have their own unique definition and staging definitions. Even within academia, randomized trials and single center studies have widely disparate definitions. This makes NEC metadata of very limited value. The world of neonatology needs a comprehensive, universal, consensus definition of NEC. It also needs a de-identified, international data warehouse.

Hypoxia is a physiological state defined as a reduction in the distribution of oxygen to the tissues of the body. It has been considered a major factor in aviation safety worldwide because of its potential for pilot disorientation. Pilots are able to operate aircrafts up to 3810 m without the use of supplemental oxygen and may exhibit symptoms associated with hypoxia.To determine the effects of 3810 m on physiology, cognition and performance in pilots during a flight simulation.Ten healthy male pilots engaged in a counterbalanced experimental protocol comparing a 0-m normoxic condition (NORM) with a 3810-m hypoxic condition (HYP) on pilot physiology, cognition and flight performance.Repeated-measures analysis of variance demonstrated a significant (p ≤ 0.05) time by condition interaction for physiological and cognitive alterations during HYP. A paired-samples t test demonstrated no differences in pilot performance (p ≥ 0.05) between conditions.Pilots exhibited physiological and cognitive impairments; however, pilot performance was not affected by HYP.

BACKGROUND Neonates with necrotizing enterocolitis (NEC) have higher calprotectin levels in stool than do healthy neonates. However, it is not known whether high stool calprotectin at the onset of bowel symptoms identifies neonates who truly have NEC vs. other bowel disorders. STUDY DESIGN Neonates were eligible for this study when an x-ray was ordered to “rule-out NEC”. Stool calprotectin was quantified at that time and in a follow-up stool. Each episode was later categorized as NEC or not NEC. The location of calprotectin in the bowel was determined by immunohistochemistry. RESULTS Neonates with NEC had higher initial and follow-up stool calprotectin levels than did neonates without NEC. Calprotectin in bowel from neonates with NEC was within neutrophil extracellular traps (NETs). CONCLUSION At the onset of signs concerning for NEC, fecal calprotectin is likely to be higher in neonates with NEC. Calprotectin in their stools is exported from neutrophils via NETs.

Post-operative hematoma following anterior cervical discectomy and fusion (ACDF) is an uncommon but feared complication. Typically, these complications present in the immediate post-operative period. We present a case of a 51 year-old woman who underwent a C4-5 ACDF for left sided radicular pain. Her immediate post-operative course was uncomplicated, but she presented 6 weeks subsequently to the emergency department with neck swelling, difficulty swallowing, cough, and shortness of breath. She was found to have a 4.5 cm anterior neck hematoma with settling of the instrumentation and a new C4 vertebral fragment protruding anteriorly. She underwent evacuation of hematoma without clear evidence of a bleeding source. After several days of observation, she was discharged home and ultimately had resolution of her presenting symptoms. Most hematomas resulting in airway compromise appear in the immediate post-operative period, but a high index of suspicion must remain high in any patient with a prior anterior cervical surgery presenting with symptoms of pre-vertebral compression or respiratory compromise.

Background & Aims Advancing liver disease results in deleterious changes in a number of critical organs. The ability to measure structure, blood flow and tissue perfusion within multiple organs in a single scan has implications for determining the balance of benefit vs. harm for therapies. Our aim was to establish the feasibility of magnetic resonance imaging (MRI) to assess changes in Compensated Cirrhosis (CC), and relate this to disease severity and future liver-related outcomes (LROs). Methods A total of 60 patients with CC, 40 healthy volunteers and 7 patients with decompensated cirrhosis were recruited. In a single scan session, MRI measures comprised phase-contrast MRI vessel blood flow, arterial spin labelling tissue perfusion, T1 longitudinal relaxation time, heart rate, cardiac index, and volume assessment of the liver, spleen and kidneys. We explored the association between MRI parameters and disease severity, analysing differences in baseline MRI parameters in the 11 (18%) patients with CC who experienced future LROs. Results In the liver, compositional changes were reflected by increased T1 in progressive disease (p Conclusions MRI enables the contemporaneous assessment of organs in liver cirrhosis in a single scan without the requirement for a contrast agent. MRI parameters of liver T1, renal T1, hepatic and splenic perfusion, and superior mesenteric arterial blood flow were related to the risk of LROs. Lay summary This study assesses the changes to structure, blood flow and perfusion that occur in the key organs (liver, spleen and kidney) associated with severe liver disease (Compensated Cirrhosis), using magnetic resonance imaging. The magnetic resonance imaging measures which changed with disease severity and were related to negative liver-related clinical outcomes are described.

Background The true survival benefit of noncurative primary tumor resection in patients with de novo metastatic colorectal cancer (mCRC) remains uncertain. The present study examined the effect of primary tumor resection on systemic inflammation and survival in patients with mCRC. Materials and Methods Consecutive patients with de novo mCRC who had undergone primary tumor resection were identified from a prospective database. Patients were excluded if they had undergone resection of metastases, had undergone delayed primary resection, or if blood samples were unavailable. The neutrophil/lymphocyte ratio (NLR) was used as a biomarker of systemic inflammation. Overall survival (OS) was compared between patient groups according to the pre- and postprimary resection NLR. The associations between the reversal of an elevated NLR and primary tumor bulk or performance status were explored. Results A total of 145 eligible patients were identified from the database, with a median age of 70 years. The baseline NLR was elevated (> 5) in 65 patients, 36 (55%) of whom had a low NLR after surgery. The reversal of an elevated NLR was associated with significantly improved OS (hazard ratio, 0.53; P = .017). A similar benefit was seen after excluding patients undergoing emergency primary resection. NLR reversal was more frequent in patients with larger primary tumors or good performance status. Conclusion The present study is the first to demonstrate a relationship between the reversal of a systemic inflammatory response and the improved survival after primary resection in those with mCRC. A greater effect was seen in patients with large primary tumors. If validated, these observations could guide clinical decision-making in patients with mCRC at presentation.

We show that the MBJLDA exchange and correlation potential proposed by Tran and Blaha for bulk materials [Phys. Rev. Lett. 2009, 102, 226401], combined with spin-orbit interactions and LDA pseudopotentials within the plane wave density functional method, accurately reproduces the electronic structure and photoemission data of the complex Ge(111)c(2 × 8) surface without requiring any energy shifts. The MBJLDA + SO calculations also enable the nature of the states comprising the various photoemission bands to be unambiguously determined. Coupled with earlier studies, these results indicate that this new approach provides an accurate and computationally viable method for investigating semiconductor surfaces.

Objective Little data exist on short-term quality-of-life (QOL) outcomes, specifically sinonasal measures, after endoscopic pituitary surgery. Design Prospective case series assessed sinonasal QOL before and after the transnasal endoscopic approach to the sella with resection of nasal cavity and sinus tissues. Setting/Participants/Main Outcome Measures A total of 39 adults scheduled to undergo resection for a pituitary mass preoperatively completed the Sinonasal Outcome Test-22 (SNOT-22). Rating various QOL issues, testing repeated postoperatively at 1 month by 37 patients and 3 months by 35 patients, was analyzed (paired Student t test). Results SNOT-22 scores (5-point scale; total: 110) averaged 23.4 preoperatively and 27.6 at 1 month but had significantly improved to 16.2 at 3 months (p = 0.03). Emotional well-being parameters (e.g., sadness, frustration, concentration, productivity, fatigue) significantly improved 3 months postoperatively (p

Object Estimating survival time in cancer patients is crucial for clinicians, patients, families, and payers. To provide appropriate and cost-effective care, various data sources are used to provide rational, reliable, and reproducible estimates. The accuracy of such estimates is unknown. Methods The authors prospectively estimated survival in 150 consecutive cancer patients (median age 62 years) with brain metastases undergoing radiosurgery. They recorded cancer type, number of brain metastases, neurological presentation, extracranial disease status, Karnofsky Performance Scale score, Recursive Partitioning Analysis class, prior whole-brain radiotherapy, and synchronous or metachronous presentation. Finally, the authors asked 18 medical, radiation, or surgical oncologists to predict survival from the time of treatment. Results The actual median patient survival was 10.3 months (95% CI 6.4–14). The median physician-predicted survival was 9.7 months (neurosurgeons = 11.8 months, radiation oncologists = 11.0 months, and medical oncologist = 7.2 months). For patients who died before 10 months, both neurosurgeons and radiation oncologists generally predicted survivals that were more optimistic and medical oncologists that were less so, although no group could accurately predict survivors alive at 14 months. All physicians had individual patient survival predictions that were incorrect by as much as 12–18 months, and 14 of 18 physicians had individual predictions that were in error by more than 18 months. Of the 2700 predictions, 1226 (45%) were off by more than 6 months and 488 (18%) were off by more than 12 months. Conclusions Although crucial, predicting the survival of cancer patients is difficult. In this study all physicians were unable to accurately predict longer-term survivors. Despite valuable clinical data and predictive scoring techniques, brain and systemic management often led to patient survivals well beyond estimated survivals.

BACKGROUND: At present, guidelines are lacking on platelet transfusion in patients with a traumatic intracranial bleed and history of antiplatelet therapy. The aspirin and P2Y12 response unit (ARU and PRU, respectively) assays detect the effect of aspirin and P2Y12 inhibitors in the cardiac population. OBJECTIVE: To describe the reversal of platelet inhibition after platelet transfusion using the ARU and PRU assays in patients with traumatic brain injury. METHODS: Between 2010 and 2015, we conducted a prospective comparative cohort study of patients presenting with a positive head computed tomography and a history of antiplatelet therapy. ARU and PRU assays were performed on admission and 6 hours after transfusion, with a primary end point of detection of disinhibition after platelet transfusion. RESULTS: One hundred seven patients were available for analysis. Seven percent of patients taking aspirin and 27% of patients taking clopidogrel were not therapeutic on admission per the ARU and PRU, respectively. After platelet transfusion, 51% of patients on any aspirin and 67% of patients on any clopidogrel failed to be reversed. ARU increased by 71 ± 76 per unit of apheresis platelets for patients taking any aspirin, and PRU increased by 48 ± 46 per unit of apheresis platelets for patients taking any clopidogrel. CONCLUSION: A significant percentage of patients taking aspirin or clopidogrel were not therapeutic and thus would be unlikely to benefit from a platelet transfusion. In patients with measured platelet inhibition, a single platelet transfusion was not sufficient to reverse platelet inhibition in almost half.

Summary Background Barrett's oesophagus predisposes to adenocarcinoma. However, most patients with Barrett's oesophagus will not progress and endoscopic surveillance is invasive, expensive, and fraught by issues of sampling bias and the subjective assessment of dysplasia. We investigated whether a non-endoscopic device, the Cytosponge, could be coupled with clinical and molecular biomarkers to identify a group of patients with low risk of progression suitable for non-endoscopic follow-up. Methods In this multicentre cohort study (BEST2), patients with Barrett's oesophagus underwent the Cytosponge test before their surveillance endoscopy. We collected clinical and demographic data and tested Cytosponge samples for a molecular biomarker panel including three protein biomarkers (P53, c-Myc, and Aurora kinase A), two methylation markers ( MYOD1 and RUNX3 ), glandular atypia, and TP53 mutation status. We used a multivariable logistic regression model to compute the conditional probability of dysplasia status. We selected a simple model with high classification accuracy and applied it to an independent validation cohort. The BEST2 study is registered with ISRCTN, number 12730505. Findings The discovery cohort consisted of 468 patients with Barrett's oesophagus and intestinal metaplasia. Of these, 376 had no dysplasia and 92 had high-grade dysplasia or intramucosal adenocarcinoma. In the discovery cohort, a model with high classification accuracy consisted of glandular atypia, P53 abnormality, and Aurora kinase A positivity, and the interaction of age, waist-to-hip ratio, and length of the Barrett's oesophagus segment. 162 (35%) of 468 of patients fell into the low-risk category and the probability of being a true non-dysplastic patient was 100% (99% CI 96–100) and the probability of having high-grade dysplasia or intramucosal adenocarcinoma was 0% (0–4). 238 (51%) of participants were classified as of moderate risk; the probability of having high-grade dysplasia was 14% (9–21). 58 (12%) of participants were classified as high-risk; the probability of having non-dysplastic endoscopic biopsies was 13% (5–27), whereas the probability of having high-grade dysplasia or intramucosal adenocarcinoma was 87% (73–95). In the validation cohort (65 patients), 51 were non-dysplastic and 14 had high-grade dysplasia. In this cohort, 25 (38%) of 65 patients were classified as being low-risk, and the probability of being non-dysplastic was 96·0% (99% CI 73·80–99·99). The moderate-risk group comprised 27 non-dysplastic and eight high-grade dysplasia cases, whereas the high-risk group (8% of the cohort) had no non-dysplastic cases and five patients with high-grade dysplasia. Interpretation A combination of biomarker assays from a single Cytosponge sample can be used to determine a group of patients at low risk of progression, for whom endoscopy could be avoided. This strategy could help to avoid overdiagnosis and overtreatment in patients with Barrett's oesophagus. Funding Cancer Research UK.

BACKGROUND: As systemic therapies improve and patients live longer, concerns mount about the toxicity of whole-brain radiation therapy (WBRT) for treatment of brain metastases. Development of delayed white matter abnormalities indicative of leukoencephalopathy have been correlated with cognitive dysfunction. This study assesses the risk of imaging-defined leukoencephalopathy in patients whose management included WBRT in addition to stereotactic radiosurgery (SRS). This risk is compared to patients who only underwent SRS. METHODS: We retrospectively compared 37 patients with non–small cell lung cancer who underwent WBRT plus SRS to 31 patients who underwent only SRS. All patients survived at least 1 year after treatment. We graded the development of delayed white matter changes on magnetic resonance imaging using a scale to evaluate T2/FLAIR (fluid attenuated image recovery) images: grade 1 = little or no white matter hyperintensity; grade 2 = limited periventricular hyperintensity; and grade 3 = diffuse white matter hyperintensity. RESULTS: Patients treated with WBRT and SRS had a significantly greater incidence of delayed white matter leukoencephalopathy compared to patients who underwent SRS alone (P < .001). On final imaging, 36 of 37 patients (97.3%) treated by WBRT developed leukoencephalopathy (25% with grade 2; 70.8% with grade 3). Only 1 patient treated with SRS alone developed leukoencephalopathy. CONCLUSIONS: Risk of leukoencephalopathy in patients treated with SRS alone for brain metastases was significantly lower than that for patients treated with WBRT plus SRS. A prospective study is necessary to correlate these findings with neurocognition and quality of life. These data supplement existing reports regarding the differential effects of WBRT and SRS on normal brain structure and function. Cancer 2013. © 2012 American Cancer Society.

Objective: To determine diagnostic performance statistics of extra-labral magnetic resonance (MR) findings for detection of labral tears in a population of patients with clinical suspicion of this diagnosis. Materials and Methods: Seventy-nine patients clinically suspected of having a labral tear (who underwent arthroscopy) had their MR studies retrospectively reviewed to determine the presence of lateral acetabular oedema-like marrow signal, ganglia, dysplastic femoral bumps, synovial herniation pits and geodes. These findings were then correlated with the arthroscopic presence (or absence) of a labral tear. Results: All findings (lateral acetabular oedema-like marrow signal, ganglia, dysplastic femoral bumps, synovial herniation pits and geodes) had a specificity and positive predictive value (PPV) of 100%. Lateral acetabular oedema-like marrow signal had a sensitivity of 35% and 20% negative predictive value (NPV). This was the only statistically significant finding (P 0.05). Conclusion: Lateral acetabular oedema-like marrow signal is a useful sign (100% PPV) in the MR diagnosis of a labral tear, if one is clinically suspected. The other findings (ganglia, dysplastic femoral bumps, synovial herniation pits and geodes) were not statistically significant. Further studies are required to evaluate these.

Aim: Monosymptomatic enuresis (ME) is a common disorder in children with serious social and psychological consequences. Treatment is usually initiated with desamino-arginine vasopressin (dDAVP) and/or alarm therapy as first-line treatment and imipramine as second-line. All treatments have proven efficacy, but are not successful with all patients. Therefore, a differentiation into subgroups according to treatment efficacy would be beneficial. Methods: A group of patients resistant to first-line treatment was treated with imipramine and compared with matched controls successfully treated with dDAVP and/or alarm therapy. Prepulse inhibition (PPI) to acoustic startle reflexes was measured in all patients. Results: In a group of 23 nonresponders, the median PPI was 72% (range 43–94%) compared with the matched dDAVP/alarm – responders with a median PPI of 26% (range 0–61%) (p

Object The object of this study was to define the long-term outcomes and risks of arteriovenous malformation (AVM) management using 2 or more stages of stereotactic radiosurgery (SRS) for symptomatic large-volume lesions unsuitable for surgery. Methods In 1992, the authors prospectively began to stage the treatment of anatomical components to deliver higher single doses to AVMs with a volume of more than 10 cm3. Forty-seven patients with such AVMs underwent volume-staged SRS. In this series, 18 patients (38%) had a prior hemorrhage and 21 patients (45%) underwent prior embolization. The median interval between the first-stage SRS and the second-stage SRS was 4.9 months (range 2.8–13.8 months). The median target volume was 11.5 cm3 (range 4.0–26 cm3) in the first-stage SRS and 9.5 cm3 in the second-stage SRS. The median margin dose was 16 Gy (range 13–18 Gy) for both stages. Results In 17 patients, AVM obliteration was confirmed after 2–4 SRS procedures at a median follow-up of 87 months (range 0.4–209 months). Five patients had near-total obliteration (volume reduction > 75% but residual AVM). The actuarial rates of total obliteration after 2-stage SRS were 7%, 20%, 28%, and 36% at 3, 4, 5, and 10 years, respectively. The 5-year total obliteration rate after the initial staged volumetric SRS with a margin dose of 17 Gy or more was 62% (p = 0.001). Sixteen patients underwent additional SRS at a median interval of 61 months (range 33–113 months) after the initial 2-stage SRS. The overall rates of total obliteration after staged and repeat SRS were 18%, 45%, and 56% at 5, 7, and 10 years, respectively. Ten patients sustained hemorrhage after staged SRS, and 5 of these patients died. Three of 16 patients who underwent repeat SRS sustained hemorrhage after the procedure and died. Based on Kaplan-Meier analysis (excluding the second hemorrhage in the patient who had 2 hemorrhages), the cumulative rates of AVM hemorrhage after SRS were 4.3%, 8.6%, 13.5%, and 36.0% at 1, 2, 5, and 10 years, respectively. This corresponded to annual hemorrhage risks of 4.3%, 2.3%, and 5.6% for Years 0–1, 1–5, and 5–10 after SRS. Multiple hemorrhages before SRS correlated with a significantly higher risk of hemorrhage after SRS. Symptomatic adverse radiation effects were detected in 13% of patients, but no patient died as a result of an adverse radiation effect. Delayed cyst formation did not occur in any patient after SRS. Conclusions Prospective volume-staged SRS for large AVMs unsuitable for surgery has potential benefit but often requires more than 2 procedures to complete the obliteration process. To have a reasonable chance of benefit, the minimum margin dose should be 17 Gy or greater, depending on the AVM location. In the future, prospective volume-staged SRS followed by embolization (to reduce flow, obliterate fistulas, and occlude associated aneurysms) may improve obliteration results and further reduce the risk of hemorrhage after SRS.

BACKGROUND Nonfunctional pituitary adenomas (NFPAs) represent approximately 50% of all pituitary tumors. OBJECTIVE To evaluate the long-term outcomes of stereotactic radiosurgery for NFPAs. METHODS We evaluated the management outcomes of Gamma Knife radiosurgery in 125 patients with NFPAs over an interval of 22 years. The median patient age was 54 years (range, 16-88 years). One hundred ten patients (88%) had residual or recurrent tumors after ≥ 1 surgical procedures, and 17 (14%) had undergone prior fractionated radiation therapy. The median target volume was 3.5 cm3 (range, 0.4-28.1 cm3), and the median tumor margin dose was 13.0 Gy (range, 10-25 Gy). RESULTS Tumor volume decreased in 66 patients (53%), remained stable in 46 (37%), and increased in 13 (10.4%) during a median of 62 months (maximum, 19 years) of imaging follow-up. The actuarial tumor control rates at 1, 5, and 10 years were 99%, 94%, and 76%, respectively. Factors associated with a reduced progression-free survival included larger tumor volume (≥ 4.5 cm3) and ≥ 2 prior recurrences. Of 88 patients with residual pituitary function, 21 (24%) suffered new hormonal deficits at a median of 24 months (range, 3-114 months). Prior radiation therapy increased the risk of developing new pituitary hormonal deficits. One patient (0.8%) had a decline in visual function, and 2 (1.6%) developed new cranial neuropathies without tumor progression. CONCLUSION Stereotactic radiosurgery can provide effective management for patients with newly diagnosed NFPAs and for those after prior resection and/or radiation therapy.

Objective Vilazodone was recently approved by the US Food and Drug Administration (FDA) for the treatment of major depressive disorder (MDD). The purpose of this review is to summarize the FDA's approach to its review of the clinical pharmacology and the clinical efficacy and safety data for this new drug application, important issues in its decision-making, and its conclusions. Data sources The data sources for this review were the original raw data sets for all clinical trials included in the development program for vilazodone, as well as the sponsor's original analyses of these data. Study selection Data were available from 24 human trials involving vilazodone, and included a total of 2,898 human subjects exposed to 1 or more doses of this drug. Data extraction The FDA had access to original raw data sets for these trials. Results Vilazodone is effective in treating MDD at a dose of 40 mg/d, but it needs to be incrementally adjusted to this dose to minimize gastrointestinal symptoms. It needs to be taken with food to ensure adequate plasma concentrations. Vilazodone's profile of adverse events is similar to that seen with selective serotonin reuptake inhibitors. No dose adjustment is needed based on age, gender, or renal or hepatic impairment. It is recommended that the vilazodone dose be reduced to 20 mg when it is taken with strong cytochrome P450 (CYP) 3A4 inhibitors, eg, ketoconazole. Vilazodone is not expected to have important effects on the clearance of other drugs that are cytochrome P450 substrates. Conclusions Vilazodone is a new treatment for MDD, but it is unknown whether it has any advantages compared to other drugs in the antidepressant class.

A new technique was developed for measuring the thickness of can coatings applied to a metal substrate. A metal disc with a known radius creates a small indent in the coating, stopping exactly when the coating thickness is cut through. The indent length is employed to calculate the coating thickness. Accurate measurement of thin films is achieved as the indent is much larger than the respective film thickness. The thickness of epoxy phenolic coatings on tinplate were measured and the results were validated by micrographic cross section analysis and by confocal laser scanning microscopy (CLSM). The coating thicknesses measured using the indentation method coincide with the film thicknesses measured by CLSM, whereas discrepancies were observed using the micrographic cross section analysis. The new technique, presented in this paper, uses simple equipment, is inexpensive, fast and easy to use, and is suitable for film thickness measurements in laboratories and production plants.

Objective: Necrotizing enterocolitis (NEC) is associated with high morbidity and mortality among infants admitted for intensive care. The factors associated with mortality and catastrophic presentation remain poorly understood. Our objective was to describe the factors associated with mortality in infants with NEC and to quantify the degree to which catastrophic presentation contributes to mortality in infants with NEC. Catastrophic NEC was defined before data analysis as NEC that led to death within 7 days of diagnosis. Study Design: We performed a retrospective review of the Pediatrix's Clinical Data Warehouse (1997 to 2009, n=560,227) to compare the demographic, therapeutic and outcome characteristics of infants who survived NEC vs those who died. Associations were tested by bivariate and multivariate analysis. Result: We compared the 5594 infants diagnosed with NEC and who were discharged home with 1505 infants diagnosed with NEC who died. In multivariate analysis, the factors associated with death (P

Object Image-guided frameless stereotactic techniques provide an alternative to traditional head-frame fixation in the performance of fine-needle biopsies. However, these techniques still require rigid head fixation, usually in the form of a head holder. The authors report on a series of fine-needle biopsies and brain abscess aspirations in which a frameless technique was used with a patient's head supported on a horseshoe headholder. To validate this technique, they performed an in vitro accuracy study. Methods Forty-eight patients underwent fine-needle biopsy of intracranial lesions that ranged in size from 0.9 to more than 107.7 ml; a fiducial-less, frameless, image-guided technique was used without rigid head fixation. In 1 of the 48 patients a cerebral abscess was drained. The accuracy study was performed with a skull phantom that was imaged with a CT scanner and tracked with a registration mask containing light-emitting diodes. The objective was a skin fiducial marker with a 4-mm circular target to accommodate the 2.5-mm biopsy needle. A series of 50 trials was conducted. Results Diagnostic tissue was obtained on the first attempt in 47 of 48 brain biopsy cases. In 2 cases small hemorrhages at the biopsy site were noted as a complication on the postoperative CT scan. One of these hemorrhages resulted in hand and arm weakness. The accuracy study demonstrated a 98% success rate of the biopsy needle passing through the 4-mm circular target using the registration mask as the registration and tracking device. This demonstrates a ± 0.75-mm tolerance on the targeting method. Conclusions The accuracy study demonstrated the ability of the mask to actively track the target and allow navigation to a 4-mm-diameter circular target with a 98% success rate. The frameless, pinless, fiducial-less technique described herein will likely be another safe, fast alternative to frame-based stereotactic techniques for fine-needle biopsy that avoids the potential morbidity of rigid head-pin fixation. Furthermore, it should lend itself to other image-guided applications such as the placement of ventricular catheters for shunting or Ommaya reservoirs.

The 7th cervical vertebrae of 240 cadavers of South African Zulu, White, and Colored population groups were examined to determine morphometric variation. White and Colored females had statistically significant narrower cervical anteroposterior diameters than their male counterparts, whereas no statistically significant difference between sexes of the Zulu population group was observed in this variable. In addition, although Zulu and Colored females had statistically significant narrower cervical transverse diameters than their male counterparts, there was no statistically significant variation between South African white males and females in this respect. The findings indicate that sexual dimorphism is more apparent in the vertebral centrum, across the three population groups, where males had significantly larger dimensions in centrum anteroposterior diameter, height, and width than their female counterparts. The study further reveals that sexual dimorphism is more apparent when one compares aspects of the 7th cervical vertebra between sexes within the same population group. Overall, the dimensions of the various variates of the vertebra are substantially smaller in women than in men. The smaller dimensions, particularly of the centrum, may be the result of lower skeletal mass in women and render them more vulnerable to fractures resulting from compression forces. Clin. Anat. 23:399–406, 2010. © 2010 Wiley-Liss, Inc.

OBJECTIVE: We measured the variability in the size of the anterior tubercle of C1 and the optimal depth and angle of placement of C1 lateral mass screws using axial and sagittal reconstructed computed tomographic scans to determine the utility of these parameters for preoperative planning and intraoperative guidance. METHODS: One hundred consecutive cervical spine computed tomographic scans were reviewed (mean patient age, 44.6 years; age range, 7-96 years). The size of the anterior tubercle of C1, bilateral depths of optimal screw placement in the axial and sagittal planes, and optimal angles of placement in the axial and sagittal planes were measured in a standardized manner using the measuring tool included in our radiology server software. These measurements were correlated with age and sex. RESULTS: The mean depth of the C1 tubercle was 6.9 mm (range, 2.7―11.2 mm; standard deviation, 1.7 mm). The depth of the C1 tubercle tended to increase with age, but the relationship was not significant. The optimal screw depth in the sagittal plane was significantly greater than in the axial plane (right 2.09 versus 1.93 cm; left 2.07 versus 1.91 cm). The depth of the right lateral mass increased significantly with age. No other relationships reached significance. CONCLUSION: The depth of the anterior tubercle of C1 varies considerably and should be studied carefully before using lateral fluoroscopy of this structure to guide depth of C1 lateral mass screw placement. Optimal angles and depths of placement of C1 lateral mass screws vary widely and should be examined preoperatively to plan appropriate depth and trajectory.

Endoscopic ultrasound-guided trucut biopsy (EUS-TCB) technique has the advantage of obtaining tissue for histological examination rather than for cytology alone. However, the diagnostic yield may depend on factors related to both technical aspects and the lesions sampled. Safety of EUS-TCB is yet to be established in a large number of procedures. The aim of the study was to determine factors predicting a positive diagnostic yield, and safety for EUS-TCB in a large tertiary referral center-based service.All patients were referred for EUS-guided tissue sampling as a part of their diagnostic workup. Linear-array echoendoscope (GF-2000-OL5, KeyMed) with a 19-gauge trucut needle (Quick-Core, Wilson-Cook) was used by two operators to obtain tissue samples. Clinical data, details of the EUS-TCB, post-procedure complications, and histology were prospectively collected between May 2002 and February 2008.In total, 247 patients (143 men) aged 57-73 (median 66) had EUS-TCB performed. Lesions sampled were in the pancreas (113), esophagogastric wall (34), and extra-pancreatic areas (100) (lymph nodes: 52). The maximum diameter of the lesion/wall thickness ranged from 0.6 to 5.4 cm (median 3). One to five passes were made (median 3) to obtain tissue cores 2-18 mm (median 10) in length. The procedure failed in 6% of cases. The overall diagnostic accuracy was 75%. The overall complication rate was 2% (bronchopneumonia, minor hemoptysis, minor hematemesis, mucosal tear, retropharyngeal abscess) with no procedure-related deaths. Site of lesion (pancreatic vs. extra-pancreatic, P0.032), site of biopsy (stomach vs. duodenum vs. esophagus, P0.001), and number of passes (or =2 vs.2, P0.013) were predictors of a positive diagnostic yield in univariate analysis. However, only the site of biopsy (P0.001, 95% CI: 0.58-2.32) and number of passes (P=0.05) were independent predictors in multinominal logistic regression.Diagnostic yield of EUS-TCB is higher when lesion is approached through the stomach and better when more than two passes were made. In this large series, the complication rate of 2% associated with EUS-TCB was similar to that reported with EUS-fine needle aspiration technique.

Spontaneous intestinal perforation (SIP) has emerged as a disease of extremely low-birth-weight (ELBW) infants over the last two decades. Several risk factors have been associated with this disease including early postnatal steroids (EPS; use within the first week of life), early use of indomethacin (EUI; use within the first 3 postnatal days), and the synergistic combination of the two. These two risk factors are thought to play a causal role in the etiology of SIP through their effects on ileal trophism and motility. Two infectious agents ( Candida and Staphylococcus epidermidis) are commonly grown from peritoneal cultures of patients with SIP. It is less clear whether these infections play a causal role or if they represent comorbidities of perforation. Chorioamnionitis is thought to be a risk factor for SIP, as is the stress and elevated cortisol that accompanies it. Recent analyses suggest that antenatal indomethacin may also be a risk factor for SIP, particularly when given close to birth. These latter variables are more challenging to rank in importance compared with EPS and EUI, which have been repeatedly associated with SIP in both retrospective cohorts and randomized controlled trials. Because neonatal care of the ELBW infant is commonly standardized, the habitual combination of any of these risk factors potentially amplifies the risk of SIP. Many of these factors are medicines, thus SIP risk is exacerbated by select forms of polypharmacy. Our challenge lies in understanding how these drug interactions lead to harm.

Objectives: The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time-sensitive therapy. Methods: The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time-sensitive care. Results: There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. Conclusions: Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time-sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored. ACADEMIC EMERGENCY MEDICINE 2008; 15:916‐922 a 2008 by the Society for Academic Emergency

Necrotizing enterocolitis (NEC) is rare during the first week of life; most cases occur after 2 to 4 weeks. We hypothesized that when NEC develops in the first week, certain predisposing factors and feeding practices are identifiable. To test this, we sought to identify every case of NEC diagnosed during the first week within the Intermountain Healthcare system during the most recent 6-year period. Data were collected from neonates admitted to any Intermountain Healthcare neonatal intensive care unit (NICU) with a date of birth from 1 January 2001 through 31 December 2006. Electronic and paper records were obtained for all with a diagnosis of NEC (Bell stage ⩾II) within the first 168 h. X-rays, physician notes, nursing records, laboratory reports and operative reports were subjected to critical review to reexamine the diagnosis of NEC. Among those with confirmed NEC, we recorded underlying conditions and every feeding given prior to the diagnosis of NEC. Comparisons were made with patients that did not develop NEC, yet were cared for in the same NICUs, during the same period of time, and of the same gestational ages. A total of 28 neonates were identified electronically as having NEC during the first week. Critical review confirmed this in 21, but 5 were determined at laparotomy to have had spontaneous intestinal perforation, and 2 others were found on surgical reports to have had a congenital infarction of the colon. Total 20 of the 21 confirmed cases developed NEC while in a NICU being treated for another condition. The exception was a small-for-gestational-age neonate in a well baby nursery. Compared to 6100 controls, the 21 with early NEC were more likely to have had a meconium-positive test for illicit drug exposure (P

The ability to covalently attach organic molecules to semiconductor surfaces in a controllable and selective manner is currently receiving much attention due to the potential for creating hybrid silicon-organic molecular-electronic devices. Here we use scanning tunneling microscopy (STM) and density functional theory calculations to study the adsorption of a simple ketone [acetone; (CH(3))(2)CO] to the silicon (001) surface. We show both bias and time-dependent STM images and their agreement with total energy DFT calculations, simulated STM images, and published spectroscopic data. We investigate the stability of the resulting adsorbate structures with respect to temperature and applied STM tip bias and current. We demonstrate the ability to convert from the kinetically favored single-dimer alpha-H cleavage adsorbate structure to thermodynamically favored bridge-bonded adsorbate structures. This can be performed for the entire surface using a thermal anneal or, for individual molecules, using the highly confined electron beam of the STM tip. We propose the use of the carbonyl functional group to tether organic molecules to silicon may lead to increased stability of the adsorbates with respect to current-voltage characterization. This has important implications for the creation of robust single-molecule devices.

PurposeTo construct, from Bateson's social ideas ranging from Naven to the 1979 Mind and Nature, a Batesonian sociocybernetics.Design/methodology/approachThe paper considers Bateson's ideas about the delineation of systems by the observer, as they were taught to his classes in the 1970s and as they were expressed in the so‐called first, 1936 Epilogue to Naven, and shows how these ideas led Bateson to a skeptical, anti‐reificationist social cybernetics.FindingsBateson de‐emphasized system boundaries, instead seeing systems as creations of the observer and as arbitrary cuttings of a continuous web of cybernetic processes.Research limitations/implicationsBateson's argument in Naven, a work originally published in 1936 and partially based in a sociological tradition which also forms some of the roots of Luhmann's thought, is surprisingly relevant to contemporary issues in second‐order cybernetics and sociocybernetics.Practical implicationsBateson's skepticism about reification, and emphasis on the observer's role in the construction of system boundaries, can point a way for sociocybernetics to address those cybernetic systems which do not fit Luhmann's or Maturana's strict criteria for autopoiesis.Originality/valueThis paper attempts to show the sophistication and relevance of Bateson's social thinking to the field of sociocybernetics.

In the last decade, it has become increasingly clear that necrotizing enterocolitis (NEC) is neither a uniform nor a well-defined disease entity. There are many factors that are forcing this unwelcome realization upon the neonatal and pediatric surgery communities. In the course of this manuscript we will review the history and the physical findings of the disparate etiologies of acquired neonatal intestinal diseases (ANIDs), some which do lead to the common final pathology of NEC and some which do not. New guidelines for distinguishing between ANIDs will also be suggested.