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Automation in the home is often presented as a value neutral process which makes life easier, more efficient and more productive. As recent research on the introduction of domestic technologies has revealed, these technologies are rarely value neutral and often work to reinforce gender dynamics in the household. This article examines the gendered and generational dimensions of how smart and automated technologies are being integrated into homes. Drawing upon 3 years research conducted between 2015 and 2017 in 11 households in Melbourne, Australia, we examine how households manage the storing and transfer of digital material and digital devices (images, videos and files from smartphones, tablets and laptops). Digital materials move within households and between different family members, and these processes are governed by often unstated rules, including changes in the life course. By examining the relationships between gendered and generational roles and automation in the household, we highlight the importance of smaller scale interpersonal relationships, which influences the negotiation of automation in emotionally laden contexts of families. Automated decision making may both support and challenge gendered norms around technology ownership and management.

The availability and affordability of memory and other services formats to store digital material has proliferated over the past 15 years. Making, sharing and storing digital material is now a mundane practice that is part of a broader ecology of living with different kinds of data. This article examines routines of managing networked technologies in the home: digital housekeeping through three core practices of sharing and storing everyday data. The first, what we will call tidying, involves the everyday routines of cleaning up the mess of data through practices such as syncing material ‘in the cloud’, creating inboxes and manually moving digital data such as pictures and videos to ‘folders’. The second set of practices comprises more periodic, but deeper forms of sorting, spring cleaning. During digital spring cleaning, the focus is upon decluttering digital data by disposing, editing and other forms of curation whereby digital materials can be ‘located’ when desired in the future. The final set of practices, moving house, consists of the shift or relocation of digital data from one device or service to another. Depending upon the age and functioning of the device or service, this often involves changes in format to render digital data useful into the future, the realisation of lost data, as well as an additional assessment of the value of moving such digital material. Through fine-grained attention to the ways in which households live with digital materials, this article considers the engagement with and consequence of everyday data in our lives.

This article examines images circulated through mobile media to emphasise the emotion work invested into familial relationships that are defined by place. Drawing on ethnographic fieldwork conducted in Trinidad, the article contributes a cross-cultural perspective to literature in digital visual communication and digital media in family relationships that has typically focused on peer-to-peer relationships between youth or that has focused on nuclear households in predominantly Western contexts. The consequences of uses of digital media platforms are strongly intertwined with the category of relationship (mother and daughter, or couples for example), their cultural inflections, relationship hierarchies and the life-stages of individuals. Digital visual communication functions to navigate, maintain and acknowledge relationships that varies across different platforms. The more public uses of images over Facebook to the more private circulation of images over WhatsApp provide examples that illustrate positive aspects of intimacy through constant contact as well as ambivalent feelings of obligation to reciprocate communication compelled by the availability afforded by mobile media. This article advances the understanding of the relationship between emotions, intimacy and mobile media by revealing how norms, ideals and expectations of familyhood and digital practices that are often essentialised are context-driven and specific.

Early-onset colorectal cancer has been on the rise in Western populations. Here, we compare patient characteristics between those with early- (&lt, 50 years) vs. late-onset (≥50 years) disease in a large multinational cohort of colorectal cancer patients (n = 2193). We calculated descriptive statistics and assessed associations of clinicodemographic factors with age of onset using mutually-adjusted logistic regression models. Patients were on average 60 years old, with BMI of 29 kg/m2, 52% colon cancers, 21% early-onset, and presented with stage II or III (60%) disease. Early-onset patients presented with more advanced disease (stages III–IV: 63% vs. 51%, respectively), and received more neo and adjuvant treatment compared to late-onset patients, after controlling for stage (odds ratio (OR) (95% confidence interval (CI)) = 2.30 (1.82–3.83) and 2.00 (1.43–2.81), respectively). Early-onset rectal cancer patients across all stages more commonly received neoadjuvant treatment, even when not indicated as the standard of care, e.g., during stage I disease. The odds of early-onset disease were higher among never smokers and lower among overweight patients (1.55 (1.21–1.98) and 0.56 (0.41–0.76), respectively). Patients with early-onset colorectal cancer were more likely to be diagnosed with advanced stage disease, to have received systemic treatments regardless of stage at diagnosis, and were less likely to be ever smokers or overweight.

BACKGROUND In the classic descriptions of the human liver, the common hepatic duct forms at the confluence of left and right hepatic ducts. Many authors have documented variations in the intra-hepatic ductal system, but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations. AIM To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography (MRC) in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean. Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders. METHODS This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean. We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1, 2017 to March 31, 2019. Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang's classification. A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant. The variants in our population were compared to the global population. RESULTS There were 152 MRCs evaluated in this study in 86 males and 66 females. There were 109 (71.7%) persons with "classic" biliary anatomy (type A1) and variants were present in 43 (28.3%) persons. There was no statistical relationship between the presence of anatomic variants and gender or ethnicity. We encountered the following variants: 29 (19.1%) type A2, 7 (4.6%) type A3, 6 (3.95%) type A4, 0 type A5 and a single variant (quadrification) that did not fit the classification system. Compared to the global prevalence, our population had a significantly greater occurrence of A1 anatomy (71.7% vs 62.6%; P = 0.0227) and A2 trifurcations (19.1% vs 11.5%; P = 0.0069), but a significantly lower incidence of A3 variants (4.61% vs 11.5%; P = 0.0047). CONCLUSION There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics. Specifically, persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.

Purpose. There are many known variations in the arterial supply to the liver. We sought to document the incidence and details of anomalies of the extrahepatic arteries in an unselected population in the West Indies. Methods. This study spanned 24 months. All 205 CT scans were evaluated at a hepatobiliary referral center in Trinidad and Tobago. We described the anomalies of the arterial supply to the liver using the conventional classification proposed by Michels. Results. 205 CT scans were evaluated, and 112 persons (54.6%) had conventional Type 1 anatomy. However, compared to the incidence in the existing medical literature, we encountered a greater incidence of replaced right hepatic arteries (18.1% vs 11%; P 0.04 ) and a lower incidence of accessory right hepatic arteries (2.4% vs 7%; P 0.030 ). Conclusion. Although 54.6% of persons in this West Indian population have conventional hepatic arterial supply, the distribution of anatomic variants of the right hepatic artery is quite different to that seen in North American and European centers. We found a higher incidence of replaced right hepatic arteries and a lower incidence of accessory right hepatic arteries.

Usually late in the course of advanced prostate carcinoma, atypical nodal and distant metastases may be encountered. Accurate characterisation of disease spread and assessment of disease response have significant treatment and prognostic implications. Surveillance imaging, therefore, along with clinical and biochemical parameters, is a key factor in directing appropriate management. Atypical metastases may also require histological re-evaluation, as they may indicate differentiation into aggressive histologic subtypes, which can lead to management alteration. We present a pictorial review of the less common patterns of metastatic prostate carcinoma, to aid in timely recognition and diagnosis.

B Field Overview and Background Located in the South China Sea, B oil field was first discovered in 1971 and has been in production since 1982; it is located in offshore of Sarawak, Malaysia, with a water depth of approximately 70 metres. The field has an interval of over 7000 ft. of stacked reservoir sands and thin continuous shale layers, making up approximately 165 individual reservoir units with Late Miocene to Early Pliocene in age, with the stratigraphic intervals reservoir section. With the objective to find a technically and economically viable enhanced oil recovery (EOR) development concept for B oil field, a feasibility study was conducted by taking several EOR strategies into considerations – low-salinity waterflood, chemical EOR, and immiscible water alternating gas (IWAG). By evaluating individual layers of the field, the study concluded with a recommendation to implement EOR via IWAG on EF reservoirs on the basis of value, timeline, and flexibility for future EORs; IWAG would yield the best result from technical and economical point of view, and also with the ability to be implemented as earliest as possible. The theory behind IWAG implementation in the field is that the gas component of IWAG injection will help to sweep oil that is left along the top of reservoir sands due to poor water-oil mobility ratio and gravity effects, and due to the fact that gas moves quickly in the reservoir, the water component of IWAG injection will come into assistance by controlling gas mobility and maintaining reservoir pressure as more drainage points are introduced into the reservoir. Additionally, water injection provides the control to improve the aquifer's sweep, three-phase hysteresis effects and reduced residual oil (in gas) is expected to improve recovery mobilizing more oil in the reservoir, and gas injection may also assist to drain oil that are trapped in attic accumulations. In B field, IWAG injection involves gas and water injections into wells that are located down-dip of the reservoir. Out of four IWAG injector wells in the recent B field drilling campaign, one well was selected to be equipped with a Distributed Temperature Sensing (DTS) system after considering the following benefits that the DTS system would provide: Conformance monitoring specifically for water to qualitatively identify which sand the water is being injected to or any potential internal crossflow Quantitative flow into each reservoir layer derived from warm-back analysis for the short term and hot-slug propagation for the long term instead of running wireline production logging tool (PLT) Hydraulic fracturing profiling to prevent the formation from fracturing unintentionally due to the water hammer effect or cooling of formation with injection water (i.e., thermal fracture); inversely, when zonal fracturing is intentional and required, profiling to gauge effectiveness and fracture spread Real-time injection issues or zonal anomaly identification to eliminate the need to perform well intervention to obtain information which often results in delayed action Injected gas or water fluid front monitoring when combined with existing DTS in producer wells Reduced intervention risks in a highly deviated well that could lead to fish in hole and potential workover

AIM To evaluate the variations in venous drainage from the left liver. MATERIALS AND METHODS A retrospective evaluation was performed of all consecutive abdominal computed tomography (CT) examinations at a tertiary referral facility between 1 January and 30 June 2018. Osirix (Pixmeo SARL, Bernex, Switzerland) was used to examine the major hepatic veins and their tributaries in each scan. The classification of variants as proposed by Nakamura and Tsuzuki was used to describe the findings. The following information was collected: ramification pattern, number, length and diameter of middle (MHV) and left (LHV) hepatic vein tributaries. Two researchers collected data independently, and the average measurements were used as the final dimensions. RESULTS Of 102 examinations evaluated, only 27 demonstrated the conventional venous drainage patterns. The LHV and MHV combined to form a common trunk that emptied into the inferior vena cava (IVC) in 75 (73.5%) cases. The common trunk had a mean length of 8.89 mm and mean diameter of 20.18 mm. Other patterns included Nakamura and Tsuzuki type I (27.5%), type II (29.4%) and type III variants (16.7%). In addition, 4.9% of patients had absent superior middle veins and 80% had supernumerary short hepatic veins (4%). CONCLUSION Only 26.5% of patients in this population had conventional venous drainage from the left liver. Surgeons and radiologists in hepatobiliary practice should be aware of these variants in order to minimise morbidity when performing invasive procedures.

Aims To investigate the link between benign prostatic hypertrophy, BMI and type 2 diabetes mellitus. Materials and methods This was the retrospective study conducted at the urology clinic of NCRHA and SWRHA, in Trinidad. Data was obtained from 85 patients with high PSA values (>4.0 ng/mL). The data collected were age, ethnicity, weight, height, lifestyle and their most recent blood sugar levels were recorded. Ultrasound reports of patients diagnosed with BPH were also analyzed to gather data on whether their hyperplasia was benign or malignant. Results The majority of the sample population was of Afro-Trinidadian descent (41) followed by East Indian descent (26) and then of mixed ethnicity (18). Individuals in the sample population with a normal BMI had a mean PSA value of 23.66 ng/mL, while those with a BMI in the overweight range had a mean PSA value of 28.1 ng/mL, and those with a BMI in the obese range had a mean PSA value of 18.5 ng/mL. There were no statistically significant differences in the mean values of PSA levels between diabetics and non-diabetics, between the 3 major ethnic groups in our sample population and between the 3 different groupings based on BMI ranges. However it was found that the average mean age of patients of East Indian descent (62.96 ± 2.23) was significantly lower than that of patients of African descent (70.15 ± 2.02). Conclusions This study did not show any significant differences in the mean values of PSA levels between diabetics and non-diabetics, between the 3 different groupings based on BMI ranges.

Background: Plasma microRNAs (miRNAs) are promising non-invasive biomarkers for colorectal cancer (CRC) prognosis. However, the published studies to date have yielded conflicting and inconsistent results for specific plasma miRNAs. Methods: We have conducted a study using robust assays to assess a panel of nine miRNAs for CRC prognosis and early detection of recurrence. Plasma samples from 144 patients in a prospective CRC cohort study were collected at diagnosis, 6, 12, and 24 months after diagnosis. miRNAs were assayed by Taqman qRT–PCR to generate miRNA normalised copy numbers. Results: Preoperative high plasma miRNA levels were associated with increased recurrence risk for miR-200b (HR [95% CI]=2.04 [1.00, 4.16], P=0.05), miR-203 (HR=4.2 [1.48, 11.93], P=0.007), miR-29a (HR=2.61 [1.34,5.07], P=0.005), and miR-31 (HR=4.03 [1.76, 9.24], P=0.001). Both plasma miR-31 (AUC: 0.717) and miR-29a (AUC: 0.703) could discriminate recurrence from these patients without recurrence. In addition, high levels of miR-31 during surveillance was associated with a three-fold increased risk of recurrence across all time points. Dynamic postoperative plasma miR-141 and 16 levels correlated with recurrence in the surveillance samples. Conclusions: Pre-operative plasma miR-29a, 200b, 203, and 31 are potential CRC prognosis biomarkers. In addition, dynamic postoperative miR-31, 141 and 16 levels are potential biomarkers for the early detection of recurrence during CRC surveillance.

Book review: A history of the convergence of ethnography, cultural studies and digital media

In this panel we consider how social actors situate uses of technologies within systems of moral norms and values while at the same time compelling the creation of new ones. Popular discourse tends to present dualistic thinking of the positive and negative impacts of technologies. Scholars have engaged with the internet and digital media, emphasising emancipatory subcultures (Coleman 2014; Gehl 2016, 2018) or presenting a critical view of the constraining aspects of networked technologies (Fish & Follis 2019; Fuchs 2014; Lovink 2016). These approaches are complimented by scholarship that considers technological practices and how they are embedded in social and cultural cosmologies (Burrell 2012; Horst & Foster 2018; Miller et. al. 2016). We argue for a closer integration of these bodies of scholarship through an examination of the contentious moral economies operating in emergent social spaces. The panel interrogates the relationship that social, political and economic actors have between their own ideas about what is good, appropriate and right and the diversity of orientations towards trust in techno-bureaucratic systems. We draw attention to immaterial systems and consider the social relationships and individual and collective imaginations that shape the production and experience of networked technologies. Through the papers, we articulate the forms of negotiation, resistance and refusal that occur when diverse moral universes, techno-regulating systems, and the conditions in which people find themselves collide.

Objective The use of text messaging in clinical care has become ubiquitous. Due to security and privacy concerns, many hospital systems are evaluating secure text messaging applications. This paper highlights our evaluation process, and offers an overview of secure messaging functionalities, as well as a framework for how to evaluate such applications. Methods Application functionalities were gathered through literature review, Web sites, speaking with representatives, demonstrations, and use cases. Based on similar levels of functionalities, vendors were grouped into three tiers. Essential and secondary functionalities for our health system were defined to help narrow our vendor choices. Results We stratified 19 secure messaging vendors into three tiers: basic secure communication, secure communication within an existing clinical application, and dedicated communication and collaboration systems. Our essential requirements revolved around functionalities to enhance security and communication, while advanced functionalities were mostly considered secondary. We then narrowed our list of 19 vendors to four, then created clinical use cases to rank the final vendors. Discussion When evaluating a secure messaging application, numerous factors must be considered in parallel. These include: what clinical processes to improve, archiving text messages, mobile device management, bring your own device policy, and Wi-Fi architecture. Conclusion Secure messaging applications provide a Health Insurance Portability and Accountability Act (HIPAA) compliant communication platform, and also include functionality to improve clinical collaboration and workflow. We hope that our evaluation framework can be used by other health systems to find a secure messaging application that meets their needs.

Background Preoperative immunosuppressive use among patients with Crohn's disease or ulcerative colitis may lead to an increased risk of postoperative complications. There is limited information on the preoperative safety profile of methotrexate (MTX) in inflammatory bowel disease (IBD). Methods A retrospective study of patients who underwent abdominal surgery for IBD between 1993 and 2012 was performed and records abstracted, including preoperative use of MTX, azathioprine/6-mercaptopurine, antitumor necrosis factor, and corticosteroids. Early postoperative complications, including death, septic, and nonseptic complications were identified. A meta-analysis was also performed on the use of preoperative MTX in patients with IBD or rheumatoid arthritis. Results A total of 180 patients with IBD underwent abdominal surgery. A total of 15 patients received MTX either monotherapy or in combination therapy. Total early postoperative complications were identified in 71 (39%) patients, specifically 5 patients on oral MTX. A total of 51 cases (28%) of septic complications and 20 (11%) nonseptic. No significant association between the use of MTX and early postoperative complications was found. The odds ratio (OR) of complications versus no complications associated with MTX was 0.75 (95% CI, 0.25-2.29) and with azathioprine/6-mercaptopurine, OR 1.48 (95% CI, 0.77-2.84). The odds of a septic complication associated with MTX were 0.58 (95% CI, 0.09-3.73), and higher in azathioprine/6-mercaptopurine, OR 3.97 (95% CI, 1.03-15.3). Our meta-analysis also did not reveal an increased risk of postoperative complications in IBD or rheumatoid arthritis on preoperative MTX (OR 0.62, 95% CI, 0.34-1.15). Conclusions Preoperative MTX use does not seem to be associated with early postoperative complications in IBD.

PURPOSE: The ColoCare Study is an international cohort of men and women (>18 years age) newly diagnosed with stage I-IV colorectal cancer from seven centers in the United States and Germany. Study enrollment is currently ongoing. Here, we describe the clinical and demographic characteristics of this large cohort of prospectively followed colorectal cancer patients and describe differences in demographic, lifestyle, and clinical characteristics by age of onset and tumor site. METHODS: Data on demographics (sex, age, race, ethnicity) and lifestyle factors (smoking, body mass index) collected at baseline are included in this analysis, in addition to information on tumor characteristics (tumor stage and site), treatment (neoadjuvant and adjuvant therapy), and clinical outcomes (vital status, recurrence). Patients were categorized into early- ( RESULTS: Data on 1,933 stage I-IV colorectal cancer cases were included in this study, 19% of which were deceased at the time of this analysis. On average, patients were 60 years old, had a BMI of 29 kg/m2, and were predominantly diagnosed with stage II (25%) and stage III (33%) colorectal cancer. Fifty three percent of cases were diagnosed with colon cancer, while 47% were rectal cancer cases. Twenty percent (n=364) of patients were diagnosed before age 50 (i.e. early-onset cases). The early-onset group presented with a higher percentage of rectal cancer (52%) and more advanced disease (64% stage III-IV cancer) compared to late-onset cases (46% and 48%, respectively). Percentages of ever smokers were higher among late-onset compared to early-onset patients (51% vs. 38%), independent of tumor site. Early-onset cancers were more likely to originate in the rectum compared to colon, particularly among women (61% vs. 51%). Early-onset rectal cancer cases were more likely to be female as compared to late-onset rectal cancer cases (61% vs. 36%). Corresponding with national trends, early-onset cases received more aggressive adjuvant therapy after surgical resection compared to late-onset patients (54% vs. 40%). DISCUSSION: Within this large international multi-center cohort, patients with early-onset colorectal cancer were more likely to be diagnosed with rectal cancer and advanced stage disease. The majority of early-onset cases in the ColoCare Study were non-smokers. As expected, more aggressive treatment modalities were used in patients with early-onset disease. Citation Format: Caroline Himbert, Jane Figueiredo, Lyen Huang, Biljana Gigic, Courtney L. Scaife, Bartley Pickron, Laura Lambert, Jessica Cohan, Mary Bronner, Jolanta Jedrzkiewicz, Esther Herpel, Matthias Kloor, Johanna Nattenmueller, Hans-Ulrich Kauczor, Alexis Ulrich, Seth Felder, Julian Sanchez, Sophie Dessureault, Nathan Hinkle, Justin Monroe, Matthew Mutch, Cory Bernadt, Deyali Chatterjee, Mika Sinanan, Stacey Cohen, Ulrik Wallin, Deepti Reddi, Mukta Krane, Afshin E. Gabayan, David M. Hoffman, Yosef Y. Nasseri, Robert W. Decker, Karen Zaghiyan, Zuri A. Murrell, Andrew E. Hendifar, Jun Gong, Eiman Firoozmand, Alexandra Gangi, Beth A. Moore, Kyle G. Cologne, Maryliza El-Masry, William Grady, Martin Schneider, Stephanie L. Schmit, Erin Siegel, David Shibata, Adetunji Toriola, Christopher Li, Cornelia Ulrich, Sheetal Hardikar. Clinical characteristics and outcomes of colorectal cancer in the ColoCare Study: Differences by age of onset [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2364.

Objective To describe long-term quality of life (QOL) outcomes after rectourethral fistula (RUF) repair. RUF is a debilitating diagnosis and complex surgical dilemma with limited data regarding QOL after repair. Methods Patients at a tertiary referral center undergoing transperineal RUF repair 1/2009-5/2016 were analyzed. Patients were contacted by telephone to assess QOL following repair. Descriptive analysis performed of short-term surgical data (success and complications) and long-term QOL data (novel questionnaire). Results Twenty one men underwent RUF surgery with 95% success after initial repair. Fifty two percent had a history of radiation and/or ablation. Four individuals (19%) experienced a Clavien-Dindo complication within 30 days, with 3 of those being grade III+. Fifteen had postoperative urinary incontinence, of whom 73% underwent artificial urinary sphincter placement. Three previously radiated individuals underwent subsequent urethral stricture surgery. At long-term follow-up (mean 45.6 ± 27.1 months), 53% reported perineal pain, 43% reported problems related to the gracilis flap, and 80% reported urinary incontinence (primarily occasional mild leakage). Twenty one percent were unable to do the things they wanted in their daily lives, while 80% reported that surgery positively impacted their life. None would have opted for complete urinary diversion. Conclusion RUF repair leads to patient satisfaction and improved QOL, despite possible residual issues such as perineal pain and urinary incontinence. Definitive RUF repair should be offered to suitable radiated and nonradiated patients.

Background Guideline-concordant delay in elective laparoscopic colectomy for diverticulitis may result in repeated bouts of inflammation. We aimed to determine whether conversion rates from elective laparoscopic colectomy are higher after multiple episodes of diverticulitis. Methods Prospective cohort study evaluating laparoscopic colectomy conversion rates for diverticulitis from 42 hospitals was conducted. Results Between 2010 and 2013, 1,790 laparoscopic colectomies for diverticulitis (mean age 57.8 ± 13; 47% male) resulted in 295 (16.5%) conversions. Conversion occurred more frequently in nonelective operations ( P P = .012). Conversion rates decreased with surgeon case volume ( P = .028). Elective colectomy exclusively for episode-based indications (n = 784) had a conversion rate of 12.9%. Increasing episodes of diverticulitis were not associated with higher conversion rates, even among surgeons with similar experience levels. Conclusions Conversion from laparoscopic colectomy for diverticulitis did not increase after multiple episodes of diverticulitis. Delaying elective resection appears to not prevent patients from the benefits of laparoscopy.

Chilaiditi’s syndrome describes a symptomatic patient with radiographic findings of interposed colon between the diaphragm and right lobe of liver. It may mimic a pneumoperitoneum on plain radiographs. We present a case in which Chilaiditis’ syndrome was entertained, delaying a decision for laparotomy. This case reinforces the diagnostic difficulty associated with Chilaiditi’s syndrome, and it increases awareness of an uncommon variation in the liver surface anatomy.

In No Fond Return of Love (1961), Aylwin Forbes is surprised to find himself behaving like Edmund from Mansfield Park (1814) and falling in love with a woman whom he previously did not desire. Ironically, Forbes’ compliance with a famous Austen romance plot highlights the ambivalent status of desire and sexuality as driving forces in his own plot. Does he really want Dulcie? In this article, the author discusses Pym's representation of desire through her use (or misuse) of the romance plot, to argue that she modifies this powerful ideological structure to satisfy her own particular sense of realism. Considering the importance of Austen to Pym, the author examines, first, the ways in which the domestic woman, as defined by Nancy Armstrong in Desire and Domestic Fiction (1987), persists and is modified as an object of desire in Pym's novels. Second, considering Patricia Meyer Spacks's argument that eighteenth-century romance plots redefine the myths they reflect, the author considers how Pym's work ...

This article highlights the range of osseous findings that can be encountered as well as the imaging features of extramedullary haematopoiesis. As iron overload remains a major cause of morbidity and mortality in these disorders, we also discuss the MRI evaluation of hepatic and cardiac hemosiderosis, to aid in the optimization of iron chelation therapy. Future imaging use will be dictated by evolving clinical needs, such as in screening for emerging morbidities, including hepatic fibrosis and hepatocellular carcinoma.

Background Obesity is an emerging problem in the care of inflammatory bowel disease (IBD) patients and has been associated with a diminished response to adalimumab. Whether obesity influences the response to infliximab (IFX) is not known. Methods A retrospective cohort of 124 subjects with IBD initiating IFX, naive to biologic therapy, was identified. Subjects were stratified according to their weight and body mass index (BMI). The primary outcome was the first occurrence of an IBD flare defined as dose escalation of IFX, corticosteroid use, discontinuation of IFX, hospitalization, or surgery. Multivariable logistic regression was performed considering body mass and BMI as categorical and continuous variables. Results Obese (BMI > 30 kg/m) patients with Crohn's disease were more likely to have an IBD flare than nonobese patients (adjusted hazard ratio [HR]: 3.03, P 25 kg/m) patients with ulcerative colitis trended toward a similar observation (HR: 9.68, P = 0.06). When considered as continuous variables, increasing mass and BMI were associated with earlier IBD flare in both Crohn's disease (adjusted HR: 1.06 per unit increase in BMI [P = 0.02] and 1.02 per kg increase in body mass [P = 0.02]) and ulcerative colitis (adjusted HR: 1.3 per unit increase in BMI [P = 0.01] and 1.11 per kg increase in body mass [P = 0.004]). Conclusions Increased body weight is associated with an earlier time to loss of response to IFX in Crohn's disease and ulcerative colitis, a novel finding given that IFX is the only antitumor necrosis factor agent whose dosing reflects increased body weight.

Trinidad and Tobago has been an oil producer for over a hundred years. The land based production has historically been the spine of the energy sector. Many changes in reservoir management philosophies, with respect to improved oil recovery techniques (IOR), in the past, can be pegged to economic ramifications, global market issues and technological practicality. What is for certain is that these issues will always have a cyclical presence, but should not be a deterrent in planning the role-out of IOR projects when the market conditions are right. During periods of low oil prices, when capital spending is usually at its lowest, is an opportune time to reassess how to treat with IOR projects. This paper provides an insight into the planning process which can be used as an instigating tool to create an IOR master plan for the land based acreage of Trinidad. Adding reserves is the ultimate objective but this can be only realized with fit-for-purpose planning and a multidisciplinary coordination of data. The first phase, which this paper addresses, will consider a local historical IOR review, candidate selection with reservoir and technology commentary. These activities would form the basis to drive the first phase action items and spur a second phase of study which would address costs, procurement, execution, KPI monitoring, safety and environment, logistics, risks, contracts, success definitions, approvals, fiscal allowances, technology providers and team building requirements. Conceptualizing the first phase of a master plan was conducted through data mining, report reviews, interviews and simulation modeling. This paper answers, in brief explanations, the experiences of the past and the methods of the future. Technology identification and application seems to be the principle guide that the reservoir management process needs to consider in developing an IOR master plan for Trinidad's onshore oil fields. An onshore IOR master plan would eventually serve as a manual that strives for an effective and structured manner of exploiting mature fields, regardless of changes in management or management philosophies. The guidance offered within should form the basis or foundation of an eventual master plan.

Aliment Pharmacol Ther 2012; 35: 126–132 Summary Background The prevalence of diabetes is increasing rapidly. Given its pro-inflammatory nature, comorbid diabetes may affect the course of Crohn’s disease (CD). Aim To determine whether comorbid diabetes influences the natural history of CD. Methods We compared a cohort with CD and comorbid diabetes to a nondiabetic control population and calculated the period prevalence of surgical intervention over a 5-year period. Unadjusted and adjusted odds-ratios were calculated regarding the need for surgical intervention using univariate and multivariate logistic regression. Results A total of 240 patients were identified, 16 of whom were diabetics (6.7%). The period prevalence of CD-specific surgery in the diabetic cases was 75.0% and in the nondiabetic controls, 31.7%. The diabetic patients were more obese than the controls (44% vs. 10%; P

This study identified selected child factors (e.g., age, gender, race/ethnicity, disabilities, prior victimization, and relationship to perpetrator of abuse), family risk factors (e.g., substance abuse, domestic violence, inadequate housing, and financial problems), and services provided by child protective services that likely increased reports of child sexual abuse recurrence by type of reporter. Survival analysis was conducted using the National Child Abuse and Neglect Data System data set of 2002-2004. Child disability, being a prior victim, having a perpetrator as a caregiver, family financial problems, and receiving family supportive services increased the likelihood for reports of child sexual abuse by mandated reporters. Being Hispanic, having a disability, having a perpetrator as a caregiver, financial problems, and receiving family preservation services statistically decreased the likelihood for reports of child sexual abuse recurrence.

The objective of this study was to design a reliable, valid and culturally appropriate risk questionnaire and determine its effectiveness as a tool for the early detection of type 2 diabetes mellitus in Trinidad. Initially, a questionnaire with 21 close-ended questions on known risk factors for diabetes was administered to 456 patients, and a series of logistic regressions extracted the most significant factors (p

The collaborative effort between fundamental science, engineering and medicine provides physicians with improved tools and techniques for delivering effective health care. Minimally invasive surgery (MIS) techniques have revolutionized the way a number of surgical procedures are performed. Recent advances in surgical robotics are once again revolutionizing MIS interventions and open surgery. In an earlier research endeavor, 30 surgeons performed 7 different MIS tasks using the Blue Dragon system to collect measurements of position, force, and torque on a porcine model. This data served as the foundation for a kinematic optimization of a spherical surgical robotic manipulator. Following the optimization, a seven-degree-of-freedom cable-actuated surgical manipulator was designed and integrated, providing all degrees of freedom present in manual MIS as well as wrist joints located at the surgical end-effector. The RAVEN surgical robot system has the ability to teleoperate utilizing a single bi-directional UDP socket via a remote master device. Preliminary telesurgery experiments were conducted using the RAVEN. The experiments illustrated the system’s ability to operate in extreme conditions using a variety of network settings.

Simulation-based training is becoming integral to the training of surgical residents. The authors describe the use of simulation-based training to address a specific clinical problem. Cognitive and procedural training in central venous catheter (CVC) placement are used to achieve the goal of decreasing CVC-related complications. Training goals and outcome measures—both educational and clinical—are described. This model of using simulation-based training as a tool to address a specific clinically applicable training need should be extended to additional procedures where a specific educational goal can be targeted.

Surgical intervention in patients with infected necrotizing pancreatitis generally consists of laparotomy and necrosectomy. This is an invasive procedure that is associated with high morbidity and mortality rates. In this report, we present an alternative minimally invasive technique: videoscopic assisted retroperitoneal debridement (VARD). This technique can be considered a hybrid between endoscopic and open retroperitoneal necrosectomy. A detailed technical description is provided and the advantages over various other minimally invasive retroperitoneal techniques are discussed.

The British Orthodontic Society invites outstanding contributors from the field of Orthodontics to give the guest lecture in memory of George Northcroft. In 2005 the guest lecturer was Professor Nigel Hunt. The article that follows was presented as the Northcroft Memorial Lecture 2005 at the World Orthodontic Congress, Paris.

We hypothesized that the use of muscle flaps, known as tissue transfer (TT), at the time of abdominoperineal resection (APR) reduces perineal wound complications. A restrospective review of patients undergoing an APR at the University of Washington (1984–2003) was conducted. Perineal wound complications and eventual wound healing were compared in patients with and without TT. Ninety-two patients (mean age, 56.6 years) underwent APR; 23.9 per cent (n = 22) had concurrent TT. Patients undergoing TT were more likely to have cancer (91% vs. 77%, P = 0.05) and radiation therapy (86% vs. 52%, P < 0.01). Operative times were nearly 2 hours longer in patients having TT (7.4 hours ± 2.5 hours vs. 5.6 hours ± 1.8 hours, P = 0.03), but lengths of stay were similar (13 ± 5.9 days vs. 12 ± 7.6 days, P = 0.5). Patients undergoing TT had a higher rate of all wound-healing complications (59% vs. 40%, P = 0.1) and major wound-healing complications (32% vs. 26%, P = 0.6). However, these differences were not statistically significant. No differences in major complications were identified in patients with and without preoperative radiation therapy (26% vs. 28%, P = 0.8). Fifteen per cent (n = 14) of all patients failed to heal wounds at 6 months, but only 9 per cent (n = 2) of patients undergoing TT failed to heal their wounds at 6 months compared with 17 per cent (n = 12) in the non-TT group ( P = 0.3). After controlling for important covariates, patients undergoing TT during an APR did not have a significantly lower rate of wound complications. The impact of TT on wound healing in patients with recurrent cancer and preoperative radiation therapy is suggestive of a benefit but requires prospective investigation.

This editorial introduces the Special Issue on Post-Traumatic Stress Disorder. This issue examines difference presenting problems that can lead to PSTD and reviews and critiques some of the different treatment modalities that exist.

Children who are victims of sexual abuse not only endure trauma, but also are likely to experience negative symptomatology as a result of this horrific ordeal. This article reviews the literature on child sexual abuse and examines the most effective treatment modalities that deal with the associated trauma. This review is not comprehensive but rather provides some highlights of the current treatment outcome literature for treating childhood trauma associated with child sexual abuse.

Background: Percutaneous drainage of infected pancreatic fluid collections is often unsuccessful. Alternatively, open necrosectomy techniques are very morbid. We hypothesized that in selected cases, laparoscopic techniques could be used to facilitate percutaneous drainage of the residual particulate necrosectum and avoid a laparotomy. We report our experience with laparoscopic assisted retroperitoneal debridement as an adjunct to percutaneous drainage for patients with infected pancreatic necrosis. Methods: Case studies were reviewed retrospectively. We analyzed the course of six patients undergoing laparoscopic assisted debridement of infected pancreatic necrosis after failure of percutaneous drainage. With the drains and computed tomography (CT) scan used as a guide, laparoscopic debridement of the necrosectum was performed. Results: Between November 1995 and December 1999, six patients were treated with this method. In four patients, laparoscopic assisted percutaneous drainage was successful. Two patients required open laparotomy. Complications included a self-limited enterocutaneous fistula and a small flank hernia. No deaths occurred. Conclusions: This early, limited experience has demonstrated the feasibility of laparoscopic assisted percutaneous drainage for infected pancreatic necrosis. With this technique, two-thirds of our patients avoided the morbidity of a laparotomy.

Neurolytic celiac plexus block (CPB) under radiological guidance is often performed to manage pain associated with pancreatic cancer. Serious complications related to the block are rare. Computed Tomography (CT)-guided neurolytic CPB is advocated to improve the efficacy of the block and to reduce the incidence of associated complications. We describe a case of superior mesenteric vein thrombosis associated with neurolytic CPB performed under CT guidance.

Electronic communication and social networking sites form an increasingly central part of young people's lives today. In bereavement work, counsellors and bereavement support workers need to adjust their approaches to the needs of adolescents, if they are successfully to engage them in the work. Incorporating online social networking sites, such as MySpace.com, in bereavement support sessions with adolescents may be helpful: in establishing trust, in providing insight into the young person's feelings and thoughts, in enabling support to be tailored to the young person's needs and in assessment of progress. This article draws on a number of case studies to illustrate its argument for the benefits of working with these new technologies, while keeping mindful of important safety concerns.

Background: Managing patient referrals for surgical consultation in an academic practice has traditionally emphasized clinical rather than service expertise. However, assuring both efficiency and accuracy in the initial consultation have become critical early measures of quality care. Methods: In partnership with the academic medical center administration, current practice was analyzed. Performance and communication standards were established around an ideal patient experience. A new ambulatory consultation process was developed; and flowcharting methods for resource allocation, statistical process control, and pre-visit data collection were used to reduce patient administrative time. Automated referral reports engaged referring physicians throughout the consultation. Results: Accurate insurance and referral authorization have been provided for all patients, including the 4% who are underinsured. Patient, provider, and referring physician satisfaction has increased significantly. Staff time investment has progressively declined from 52 ± 11 (95% confidence) minutes to 34 ± 10 minutes for most patients. Realignment of tasks has reduced the administrative time spent by the patient by 32% without compromising clinical time. New patient volume increased by 29% per year, maintaining regional market share. Conclusions: Expertise in the process of consultation delivery is feasible and will be increasingly critical to the survival of academic surgical practice in a competitive market.

Rectosigmoid endometriosis is a relatively rare condition and may commonly mimic carcinoma. We report a case presenting with frozen pelvis that was unresectable during an emergency laparotomy. Clinically and radiologically it was suspected to be carcinoma and the patient was subjected to radio- and chemotherapy. The lesion was resected during a second laparotomy and was found to be endometriotic mass. A high index of suspicion is necessary to diagnose this condition.

The age of minimally invasive surgery has brought forth astounding changes in the health care field. Less pain and quicker patient recovery have been demonstrated with several types of operations that were once performed by an open technique. With these changes have come reports of complications. The decreased sense of touch is just one of several limitations inherent to current techniques of minimally invasive surgery that limit detection of subtle or unapparent lesions on palpation, such as common duct stones and liver lesions. The purpose of this study is to demonstrate the ability of a force-feedback-equipped grasper to restore some of the sense of touch that is lost in minimally invasive surgery. To demonstrate this ability, we created six silicone phantoms of identical dimensions but graded compliance, and asked 10 subjects to place them in increasing/decreasing order of compliance. They used three tools (their dominant gloved hand, a standard laparoscopic Babcock grasper, and our force-feedback device fitted with the identical Babcock grasper) to rate the compliance of the samples in a blinded fashion. These conditions thus approximated the conditions of open surgery, minimally invasive surgery, and minimally invasive surgery fitted with a force-sensing device, in terms of palpating tissues. Five surgeons skilled in minimally invasive surgery and five nonsurgeons participated in the study. The results indicate that the force-feedback device is significantly (P

This paper is a sequel to reference [1]. In that paper, the dynamics of the steelpan notes were developed as systems of non-linear mode-localized oscillators. The present paper examines the coupled note-note and note-skirt systems on the steelpan modelled as a plexus of non-linear oscillators interconnected by linear mechanical filters. The tonal qualities of a note depend on the degree of coupling and the closeness in frequency of the excited modes on the interacting subsystems. Modes above the fundamental (the partials) are produced by internal and combination resonances.

SummaryAlthough the procedures of endoscopic surgery are in many ways, simply a new way of approaching old, familiar problems, certain technical aspects are sufficiently different enough from the common experience of the general surgeon so as to require special training and certification for competency. The introduction of laparoscopic cholecystectomy worldwide showed that many aspects of endoscopic surgery deserved emphasis in training. These include the unique instruments, equipment, and techniques associated with videoendoscopic procedures and, perhaps of even greater importance, the differences in anatomic exposure and perspective afforded by the laparoscope [1–4]. Surgeons used to working in a three-dimensional environment with extensive tactile sensation were forced to learn to operate at a distance from the target tissue using instruments that provided much less feel for the tissues. Direct visualization of the operative field was replaced by a narrow field of view and a magnified, two-dimensional ...

Cell loss immediately adjacent to an intracerebral hemorrhage may be mediated in part by the toxicities of extracellular hemoglobin (Hb) and thrombin. However, at low concentrations, these proteins induce tolerance to hemin and iron that may limit further peri-hematomal injury as erythrocyte lysis progresses. The mechanisms mediating these preconditioning effects have not been completely defined, but increased expression of both heme oxygenase (HO)-1 and iron binding proteins likely contributes. In the present study, we hypothesized that iron chelator therapy would attenuate this protective response. Pretreatment of cortical glial cultures (> 90 % GFAP+) with 3 μM methemoglobin (metHb) or 5 units/ml thrombin for 24 h was nontoxic per se, and increased HO-1 and ferritin expression. When challenged with a toxic concentration of hemin, the increase in cellular redox-active iron was attenuated in preconditioned cultures and cell survival was increased. However, if cultures were pretreated with metHb or thrombin plus deferoxamine or 2,2'-bipyridyl, ferritin induction was prevented and cellular redox-active iron increased with hemin treatment. Preconditioning-mediated cytoprotection was consistently reduced by deferoxamine, while 2,2'-bipyridyl had a variable effect. Neither chelator altered HO-1 expression. A cytoprotective response was preserved when chelator therapy was limited to 11 hours of the 24 h preconditioning interval. These results suggest a potentially deleterious effect of continuous iron chelator therapy after ICH. Intermittent therapy may remove peri-hematomal iron without negating the benefits of exposure to low concentrations of Hb or thrombin.