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Objectives To review medical malpractice trends and to identify the most common claims filed against medical providers for the management of patients with priapism. Methods Using the Westlaw legal database, a search was done for the keyword “priapism” between July 1, 1980 and July 1, 2020. Cases were evaluated for plaintiff demographics, reasons for filing claims, management outcomes, legal verdicts and awards and further categorized based upon the timing of the alleged malpractice. Results Alleged negligence during the pre-management period was cited in 30 cases. Administration of psychotropic medications was the most common reasons for filing pre-management claims 22/56 (39.3%). Delay in care accounted for 18/56 (32.1%) and complications of surgery were 5/56 (8.9%) of claims. The majority of the completed cases were in favor of the defendants (39/47; 83.0%). There was no association between type of health care provider or timing of alleged malpractice and ultimate verdict. Conclusions Prescribing psychoactive medications without warning of the adverse effect profile is the most common reason for claims filed against providers with trazodone as the leading medication. Medical providers should ensure that patients are well informed of this adverse effect prior to prescription. Regardless, the majority of medical malpractice cases carry a verdict in favor of the defendant.

We present a unique, extensive, and open synaptic physiology analysis platform and dataset. Through its application, we reveal principles that relate cell type to synaptic properties and intralaminar circuit organization in the mouse and human cortex. The dynamics of excitatory synapses align with the postsynaptic cell subclass, whereas inhibitory synapse dynamics partly align with presynaptic cell subclass but with considerable overlap. Synaptic properties are heterogeneous in most subclass-to-subclass connections. The two main axes of heterogeneity are strength and variability. Cell subclasses divide along the variability axis, whereas the strength axis accounts for substantial heterogeneity within the subclass. In the human cortex, excitatory-to-excitatory synaptic dynamics are distinct from those in the mouse cortex and vary with depth across layers 2 and 3.

While multiple studies have demonstrated that minimally invasive surgical (MIS) techniques are a safe and efficacious approach to adrenalectomy for pheochromocytomas (PC), these studies have only been small comparative studies. The aim of this multi-institutional study is to compare perioperative outcomes between open and MIS, stratified by robotic and conventional laparoscopic, techniques in the surgical management of PC. We retrospectively evaluated patients who underwent adrenalectomy for PCs from 2000 to 2017 at three different institutions. Clinical, perioperative, and pathologic parameters were analyzed using t test, Chi square, and Fisher exact statistical measures. Of the 156 adrenalectomy cases performed, 26 (16.7%) were with an open approach and 130 (83.3%) using MIS techniques. Of the MIS procedures, 41 (31.5%) were performed robotically and 89 (68.5%) performed laparoscopically without robotic assistance. Demographic and clinical parameters were similar between the open and MIS groups. Patients, who underwent MIS procedure had a lower complication rate (p = 0.04), shorter hospitalization (p = 0.02), shorter operative time (p < 0.001), and less blood loss (p = 0.002) than those who underwent open surgical resection. Conventional laparoscopic and robotic operative approaches resulted in similar complication rates, length of hospitalization, and blood loss. Our study is one of the largest cohorts comparing the perioperative outcomes between conventional laparoscopic and robotic adrenalectomies in patients with PC. Our results support that MIS techniques have potentially lower morbidity compared to open techniques, while laparoscopic and robotic approaches have similar perioperative outcomes.

Congenital hemangiomas comprise a subset of vascular tumors with clinicopathologic features that are distinct from the more common infantile hemangioma. The authors present a patient with a large congenital hemangioma involving the forehead and brow which obstructed the visual axis and created significant risk for deprivational amblyopia. Management of the congenital hemangioma involved customized headgear to clear the visual axis and early vascular embolization of feeder vessels with the subsequent successful surgical resection at 23 days of life.A large amblyogenic congenital hemangioma required a multidisciplinary approach involving early vascular embolization of feeder vessels and subsequent surgical resection at 23 days of life.

OBJECTIVE Rezūm vapor ablation is a minimally invasive treatment for benign prostatic hyperplasia (BPH) that uses injections of sterile water vapor directly into the prostate for tissue ablation. Although Rezūm is currently indicated for use in men with prostate sizes ≥30 and ≤80 ml, it is unclear how effective Rezūm is for men in urinary retention. We sought to determine whether Rezūm is effective in the treatment of catheter-dependent urinary retention secondary to BPH. METHODS A retrospective chart review was conducted on consecutive patients who presented for urinary retention and subsequently treated with Rezūm. We evaluated procedural details and examined variables pre- and post-Rezūm (at 6 months) including International Prostate Symptom Score (IPSS), IPSS quality of life (IPSS-QOL), maximum flow (Qmax ), post void residual volume (PVR), prostate specific antigen, rate of retention, and use of alpha blockers and 5-alpha reductase inhibitor (5ARI). RESULTS Of the 49 patients included in this study, median age of was 73 years, median prostate volume was 73cc (Interquartile range [IQR]: 50, 103) and a median lobe was present in 80% of patients. All patients were in urinary retention before treatment with a median PVR of 900 ml (IQR: 566, 1146). Following Rezum, IPSS (17 pre-Rezūm, 4 post-Rezūm) and IPSS-QOL (4 pre-Rezūm, 1 post-Rezūm) both improved at 6 months (p

Introduction: The widespread use of diagnostic and therapeutic ionizing radiation raises concerns regarding excessive occupational and patient exposure. In this study, we test a novel fluo...

Cranial index is a widely used 2-dimensional measure of skull form. It has traditionally been calculated as a ratio of the maximal cranial width divided by the maximal skull length. Nevertheless, the points of maximal skull length change dramatically in sagittal craniosynostosis due to variable degrees of frontal and occipital bossing. Therefore, such anatomical changes influence the calculated cranial index. Method This is a retrospective comparative study of 2 methods of measuring cranial index; the traditional method that measures the skull length from glabella to opithcranion versus a modified method that measures the maximal skull length from the most anterior point of the frontal bossing to opithcranion. Cranial indices for 115 patients of radiologically and clinically diagnosed nonsyndromic sagittal craniosynostosis were calculated using both methods. Correlation and Agreements Limits were calculated for comparison between the 2 methods. Results Males constituted 74.8% (n = 86) of the total sample size with the remaining 29 participants identified as female. The mean age of the study participants was 4.8 months (range 8 days-12 months). The 2 methods were strongly correlated (r = 0.94). The Agreement Limits were calculated to be between 4.02% and 0.18%. Conclusion Typical anatomical changes such as variable degrees of frontal and occipital bossing influence the accuracy of cranial index measurement in sagittal craniosynostosis. Traditional method of cephalic index measurement could underestimate the severity of scaphocephaly.

OBJECTIVE To assess interviewing applicant perceptions of a virtual urology residency interview in the setting of changes mandated by COVID-19 and to determine applicant preference for virtual or in person interviews. Applicant perceptions of multiple interview components were queried to identify program specific and interview modality specific strengths or weaknesses in the 2020 to 2021 Urology Match. METHODS A 12 question multiple choice and free text survey was emailed to 66 virtually interviewed applicants for open residency positions at a metropolitan training program after conclusion of interviews. Items of interest included interview type preference, overall interview impression, and recommendations for improvement. RESULTS A total of 50 of 66 (76%) applicants completed the survey corresponding to approximately 11% of the 2020 national urology applicant pool. A total of 49 of 50 (96%) respondents assessed faculty interaction and the virtual platform positively. A total of 38 of 50 (76%) was satisfied with their resident interaction and 32 of 50 (64%) applicants stated they were able to satisfactorily evaluate the site and program. Ultimately, 39 of 50 (78%) respondents would have preferred an in person interview to our virtual interview. Respondents cited challenges in assessing program culture and program physical site virtually. CONCLUSION The majority of survey respondents indicated a preference for in person interviews. A smaller proportion of applicants preferred virtual interviews citing their convenience and lower cost. Efforts to improve the virtual interview experience may focus on improving applicant-resident interaction and remote site assessment.

Atropine eye drops and myopic retinal defocus each slow progression of myopia (short-sight). They also cause thickening of the choroid, and it has been suggested that the thickening is a precursor for reduced eye growth and slowed myopia progression. We investigated whether choroidal thickening due to optical defocus would add to thickening due to atropine when both were applied simultaneously. Addition would suggest that combining the two clinical treatments may improve efficacy of myopia control. We studied 20 children receiving 0.3% atropine daily for myopia control, over a period of 6 months. We imposed short periods of retinal defocus (1 h of myopic or hyperopic defocus (± 2.00D)) both before, and after 1 week and 3 and 6 months of atropine treatment. Prior to atropine, myopic or hyperopic defocus caused significantly thicker or thinner choroids respectively (± 12 µm, p

Background Endovenous revascularization is the standard in the management of acute thrombotic, chronic post-thrombotic iliocaval or iliofemoral obstruction, and nonthrombotic iliac vein lesions. The purpose of this study is to describe our single-center experience of postprocedure anticoagulation and antiplatelet regimens used after endovenous revascularization for a variety of venous occlusive conditions. Methods We conducted a retrospective analysis of 100 consecutive patients who underwent endovenous stenting for iliocaval or iliofemoral obstruction from January 1, 2014, to April 30, 2018. Patients treated with direct oral anticoagulants, warfarin, or low-molecular-weight heparin (LMWH) with or without antiplatelet therapy were identified. Demographic, procedural, patency, and follow-up data were collected. Stent patency was evaluated using duplex Doppler ultrasound examination or contrast venography. Results Seventy-one of 100 patients were treated with direct oral anticoagulant therapy (DOAC). Sixteen (23%) were lost to follow-up, leaving 55 (77%) available for analysis. The mean follow-up was 14 months (range, 1-43 months) with 32 patients (58%) followed for 12 months or longer. Primary, primary-assisted, and secondary-assisted patency rates were 87%, 97%, and 98%, respectively, at 12 months. In the non-DOAC group (patients treated with warfarin or LMWH), these rates were 87%, 93%, and 95%, respectively, at 12 months. Antiplatelet therapy, including clopidogrel, aspirin, or both, was used in 53 of 55 patients in the DOAC cohort and 18 of 19 patients in the non-DOAC group. Conclusions Our-single center retrospective analysis demonstrates acceptable primary patency rates when using DOAC therapy compared with those treated with warfarin or LMWH.

Background Chronic venous insufficiency (CVI) is a widely prevalent condition. Saphenous venous reflux is the most common underlying pathology that leads to CVI. Endovenous thermal ablations (ETA) are the current gold standard. However, some patients present with some unique challenges making ETA less ideal. Nonthermal nontumescent therapies could be considered as alternative therapy in these patients. Methods We performed a retrospective review of treatment effects with United States Food and Drug Administration-approved polidocanol endovenous microfoam (PEM; Varithena® 1%) on venous symptomology in 10 (n = 10) C3-C6 patients with CVI and concomitant complex disease/pathology that limited the use of ETA. The pathology included risk of bruising or bleeding, severe lipodermatosclerosis, hidradenitis suppurativa, chronic fibrosis of the vein from prior superficial thrombosis, risk for nerve injury, and failed prior ETA. Before treatment, all patients underwent a venous incompetence study by duplex ultrasound (DUS). Preprocedure pain, symptoms, and Venous Clinical Severity Scores (VCSSs) were recorded. Clinical assessments and DUS were performed 4 days, 6 weeks, 6 months, and 1 year after treatment. Results DUS demonstrated reflux in the great saphenous vein (GSV), anterior accessory GSV, and/or the small saphenous vein. Pain scores and VCSS were reduced 4 days and 6 weeks after treatment. These lower scores were maintained for up to 1 year after treatment. Conclusions PEM use in C3-C6 patients resulted in successful improvement in VCSS, CVI symptoms, and wound healing among patients in whom ETA was not considered to be the optimal therapy.

Objective Fetal myelomeningocele closure results in better infant outcomes than postnatal closure at the cost of potential prematurity and maternal morbidity. Our aim is to describe the setup of a fetal myelomeningocele closure program in Canada and document its outcomes. Methods We conducted a retrospective review of all open fetal myelomeningocele closure surgeries performed at the Ontario Fetal Centre in its first 3 years of operation (2017–2020). Maternal and fetal baseline characteristics, surgical details, pregnancy outcomes, and infant follow-up until 1 year of age were recorded. Results Twenty-seven women underwent fetal myelomeningocele closure surgery, 10 of whom (37%) resided outside of Ontario. Mean gestational age at surgery was 25.0 ± 0.7 weeks. All surgeries were technically uncomplicated and no fetal deaths occurred. There was a significant negative correlation between increasing experience and skin-to-skin surgical time (R² = 0.36; P = 0.001). Of the 26 patients who have delivered, 4 (15.4%) experienced preterm prelabour rupture of membranes. Mean gestational age at delivery was 34.9±3.0 weeks. All but 1 patient delivered by cesarean. Maternal complications occurred in 9 women (34.6%). There were no maternal deaths, but 3 (11.5%) infant deaths. Of the 14 surviving infants who have reached at least 1 year of age, 5 (35.7%) underwent ventriculo-peritoneal shunting. Of the 9 infants who have not yet reached 1 year of age, 3 (33.3%) underwent endoscopic third ventriculostomy and none underwent shunting. Conclusion Fetal open spina bifida closure can be performed in Canada, with results similar to those reported by other international expert centres. Long-term follow-up is ongoing.

Summary Background Clostridium difficile infection is the most common health-care-associated infection in the USA. We assessed the safety and efficacy of ridinilazole versus vancomycin for treatment of C difficile infection. Methods We did a phase 2, randomised, double-blind, active-controlled, non-inferiority study. Participants with signs and symptoms of C difficile infection and a positive diagnostic test result were recruited from 33 centres in the USA and Canada and randomly assigned (1:1) to receive oral ridinilazole (200 mg every 12 h) or oral vancomycin (125 mg every 6 h) for 10 days. The primary endpoint was achievement of a sustained clinical response, defined as clinical cure at the end of treatment and no recurrence within 30 days, which was used to establish non-inferiority (15% margin) of ridinilazole versus vancomycin. The primary efficacy analysis was done on a modified intention-to-treat population comprising all individuals with C difficile infection confirmed by the presence of free toxin in stool who were randomly assigned to receive one or more doses of the study drug. The study is registered with ClinicalTrials.gov, number NCT02092935. Findings Between June 26, 2014, and August 31, 2015, 100 patients were recruited; 50 were randomly assigned to receive ridinilazole and 50 to vancomycin. 16 patients did not complete the study, and 11 discontinued treatment early. The primary efficacy analysis included 69 patients (n=36 in the ridinilazole group; n=33 in the vancomycin group). 24 of 36 (66·7%) patients in the ridinilazole group versus 14 of 33 (42·4%) of those in the vancomycin group had a sustained clinical response (treatment difference 21·1%, 90% CI 3·1–39·1, p=0·0004), establishing the non-inferiority of ridinilazole and also showing statistical superiority at the 10% level. Ridinilazole was well tolerated, with an adverse event profile similar to that of vancomycin: 82% (41 of 50) of participants reported adverse events in the ridinilazole group and 80% (40 of 50) in the vancomycin group. There were no adverse events related to ridinilazole that led to discontinuation. Interpretation Ridinilazole is a targeted-spectrum antimicrobial that shows potential in treatment of initial C difficile infection and in providing sustained benefit through reduction in disease recurrence. Further clinical development is warranted. Funding Wellcome Trust and Summit Therapeutics.

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of

Introduction and Objectives: Multiple surgical therapies for benign prostatic hyperplasia (BPH) have been developed to decrease complications and increase provider efficiency. We investigated contemporary BPH treatment device-related adverse events by searching a publicly available database. Materials and Methods: The Manufacturer and User Facility Device Experience (MAUDE) database was queried for contemporary BPH treatments. All devices were evaluated for malfunction, patient complications, and manufacturer review. The MAUDE adverse event classification system was used to standardize complications. Univariate analysis was performed to identify associations between BPH devices and adverse events. Results: A total of 2567 reports were identified: transurethral resection of the prostate (TURP) 197 (7.67%), holmium laser enucleation of the prostate (HoLEP) 39 (1.52%), GreenLight™ 2315 (90.2%), and UroLift(®) 16 (0.62%). The most common deviations for each modality included cutting loop detachment during TURP 116 (58.9%), morcellator dysfunction for HoLEP 23 (58.9%), tip fracture/detachment for GreenLight (68.8%), and failure to deploy during UroLift 10 (62.5%). Only 18 (0.7%) patients required medical/surgical management (MAUDE II–IV) due to a device complication. No significant relationship was seen between each modality and complications; however, morcellator use (27.8%) was observed in higher grade complications. Manufacturer review occurred in 61.7% of cases, with 41.3% of reviewed cases finding the operator the cause of the malfunction. Conclusion: Each BPH modality investigated had minimal patient harm with over 99% of patients experiencing no complication after device malfunction. Of note, great care should be taken with morcellator use during HoLEP as it had the greatest number of MAUDE II to IV complications among all devices. Manufacturer review revealed that over 40% of cases were due to misuse by the user. Therefore, urologists should select the modalities they are most familiar with to decrease patient harm and prevent device malfunctions.

Cleft orthognathic surgery is an important component of a comprehensive cleft care plan. Applying combined orthodontic and orthognathic treatment principles to a cohort of patients with cleft lip and palate raises many challenges not encountered in conventional orthognathic care. Cleft patients share a commonality in their midfacial anatomy that is characterized by a 3-dimensionally deficient maxilla. The residual sequelae of multiple previous surgeries along with dental differences and unhealed fistulae are considerations when embarking on treatment. This article describes many of these challenges and highlights approaches that are used to address the specific needs of this special group of patients.

In the military population, there is high comorbidity between mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) due to the inherent risk of psychological trauma associated with combat. These disorders present with long-term neurological dysfunction and remain difficult to diagnose due to their comorbidity and overlapping clinical presentation. Therefore, we performed cross-sectional analysis of blood samples from demographically matched soldiers (total, n = 120) with mTBI, PTSD, and mTBI+PTSD and those who were considered cognitively and psychologically normal. Soldiers were genotyped for apolipoprotein E (APOE) ɛ4, and phospholipids (PL) were examined using liquid chromatography/mass spectrometry analysis. We observed significantly lower levels of several major PL classes in TBI, PTSD, and TBI+PTSD, compared with controls. PTSD severity analysis revealed that significant PL decreases were primarily restricted to the moderate-to-severe PTSD group. An examination of the degree of unsaturation showed that monounsaturated fatty acid-containing phosphatidylcholine (PC) and phosphatidylinositol (PI) species were lower in the TBI and TBI+PTSD groups. However, these PLs were unaltered among PTSD subjects, compared with controls. Similarly, ether PC (ePC) levels were lower in PTSD and TBI+PTSD subjects, relative to controls. Ratios of arachidonic acid (AA) to docosahexaenoic acid (DHA)-containing species were significantly decreased within PC and phosphatidylethanolamine (PE) classes. APOE ɛ4 (+) subjects exhibited higher PL levels than their APOE ɛ4 (-) counterparts within the same diagnostic groups. These findings suggest that PL profiles, together with APOE genotyping, could potentially aid to differentiate diagnosis of mTBI and PTSD and warrant further validation. In conclusion, PL profiling may facilitate clinical diagnosis of mTBI and PTSD currently hindered by comorbid pathology and overlapping symptomology of these two conditions.

Purpose: To evaluate the 1- and 2-year patency and reintervention rates with the Zilver PTX drug-eluting stent (DES) in long complex femoropopliteal disease. Methods: A retrospective review was conducted of 89 consecutive patients (mean age 68.7±9.8 years; 86 men) with femoropopliteal occlusive disease (Rutherford category 2–6) treated with the Zilver PTX between December 2012 and December 2013. Mean lesion length for the entire cohort was 24.2±11.3 cm (median 24.0, range 4–48). The patient population was dichotomized into a short lesion (≤20 cm) group (n=41; mean lesion length 13.3±5.6 cm) and the full DES jacket (>20 cm) group (n=48; mean lesion length 33.0±6.5 cm). Primary endpoints were duplex-derived restenosis (peak systolic velocity ratio >2.5), clinically driven reintervention, and major amputation. Results: The incidence of restenosis was lower in the short lesion group at 1 year (19% vs 40% for the longer lesions, p=0.050) and 2 years (39% vs 54%, respectively; p=0.331). The short lesion group had significantly lower rates of reintervention at both 1 year (2% vs 21% in long lesions, p=0.009) and 2 years (12% vs 33%, p=0.019). Conclusion: Treatment of femoropopliteal lesions >20 cm with the Zilver PTX appears to be a clinically effective therapy for patients with symptomatic peripheral artery disease. However, there is an increase in restenosis and a need for reintervention that continues to progress up to 2 years.

We sought to determine our rate of postoperative sepsis after ureteroscopy as well as identifying associative factors, common antibiotic practices along with culture data.Records of all patients who underwent elective ureteroscopy from 2010 to 2015 at an urban tertiary care facility were retrospectively reviewed. Factors thought to be associated with infection were collected, along with comorbidities depicted as Charlson Age-Adjusted Comorbidity Index (CAACI) and American Society of Anesthesia (ASA) score. Each patient's course was reviewed to determine if they were treated for postoperative sepsis as defined by standardized criteria.A total of 345 patients underwent elective ureteroscopy with 15 (4.3%) being treated for sepsis postoperatively. This resulted in an additional 5.33 ± 3.84 days of hospitalization per patient. The sepsis group grew three gram positive organisms and five multi-drug resistant (MDR) gram negatives while 7/15 (46.7%) had negative cultures. The most common preoperative antibiotics used in the sepsis group were cefazolin (60.0%), gentamicin (48.5%) and ciprofloxacin (20.0%). Univariate analysis showed prior endoscopic procedures, recent treatment for urinary tract infections (UTI), multiple comorbidities and longer operative times associated with sepsis. However, significant variables after multivariate analysis were treatment for UTI within the last month, (OR) 7.19 (2.25-22.99), p = 0.001.Patients with multiple comorbidities, prior endoscopic procedures, longer operative times and especially those recently treated for a urinary infection should be carefully monitored after ureteroscopy for signs of sepsis. Perioperative antibiotics in these patients should be selected to cover both MDR organisms and gram positives.

Purpose The purpose of this study was to determine the relative roles of the sympathetic (SNS) and parasympathetic nervous system (PNS) in pupillary hippus. Methods We used a paired-eye control study design with three cohorts receiving either 1.0% tropicamide (PNS antagonist) in light (TL), 1.0% tropicamide in dark (TD), or 10% phenylephrine (SNS) in light (PL), n = 12 in each. Each subject received one drop to the randomly determined treatment eye, while the other eye served as control. Bilateral measures of pupil size and dynamics were made over 2.6 seconds using an infrared eye-tracker sampling at 500 Hz. Measures were taken at baseline, then every 5 minutes for 40 minutes. Hippus, analyzed in both time and frequency domains, was compared between eyes and cohorts. Results Pupillary hippus with a distinct dominant frequency was present in all measures at baseline (mean: 0.62 Hz, SD: 0.213 Hz), and that frequency did not change in any group (P = 0.971). Hippus magnitude (treatment eye relative to control eye) decreased in the TL (-72.8 ± 4.7%, P < 0.0001) and TD (-71.3 ± 2.6%, P < 0.0001) groups, but did not change in the PL (+5.4 ± 13.7%, P = 0.173) group, despite PL pupils dilating to a proportion similar to TD. Conclusions Pupillary hippus can be extinguished by antagonizing the PNS, whereas agonizing the SNS dilates the pupil without affecting hippus. This suggests that hippus originates from central PNS activity, and not from SNS activity, or oscillations in the balance between PNS and SNS at the pupil.

To evaluate a newly developed noninvasive ambulatory, quantitative polymerase chain reaction (Q-PCR) Epstein-Barr virus (EBV) DNA detection and screening system (NP Screen™) for nasopharyngeal carcinoma (NPC).Correlation of the nasopharyngeal epithelial EBV-DNA levels and clinical findings by nasopharyngoscopy and final pathologic diagnosis of NPC with biopsy.Multicenter ENT/Oncology clinics in Hong Kong (Radiation Oncology Clinic at the Queen Elizabeth Hospital and Radiation Oncology Clinic and Head and Neck Clinic, Queen Mary Hospital, University of Hong Kong) and in Toronto, Canada (the Otolaryngology-Head and Neck Clinic at the Rouge Valley Health System and 2 large ENT practices in Toronto).A single-use trans-oral brush was used for rapid, nontraumatic nasopharyngeal (NP) epithelial cells DNA harvest in 600 Chinese patients, combined with a preservation and shipping kit for remote, real-time Q-PCR EBV DNA determinations.All 600 patients had NP brushings using NP Screen in an ambulatory environment, and no adverse events or complications were recorded. A final 578 patients were included with sufficient amount of DNA for completion of the Q-PCR assay. Of these 578 patients, 94 were confirmed positive for NPC histologically. The study yielded a sensitivity of 98.9%, specificity of 99.3%, positive predictive value (PPV) of 96.9%, and negative predictive value (NPP) of 99.7% for NP Screen in detecting NPC. Endoscopy had a sensitivity of 94%, specificity 97.1%, PPV 85%, and NPP 98.9%.The trans-oral brushing system fulfills the characteristics of a noninvasive, sensitive, specific detection method suitable for routine, large-scale ambulatory NPC risk assessment for high-risk NPC populations.

First-line treatment for problematic infantile hemangiomas (IH) consists of systemic corticosteroids or, more recently, beta-blockers, while treatment failures or residual lesions may require surgical intervention. There is limited knowledge if prior medical intervention is associated with a better surgical outcome. This retrospective cohort study revealed that medical intervention, whether systemic steroids or beta-blockers, did not influence ultimate surgical outcomes when compared with patients who were not medically treated. However, patients who received prior medical treatment and those who received beta-blockers underwent surgical intervention at an earlier age.

PURPOSE A number of optical methods for slowing myopia progression have been tested and are now available. However, data on real-world use in clinical use is scarce. Here, we present a review of the clinical outcomes for patients attending a specialist myopia control clinic at The University of Auckland Optometry School, NZ. CASE SERIES We report a comparative case series of 110 patients (aged 4-33 years, mean: 12.13 ± 4.58 years, 62% female) who attended the clinic between 2010 and 2014. Fifty-six were prescribed orthokeratology, 32 dual focus soft contact lenses, and 22 received advice only. Initial myopia, vitreous and axial eye length, previous myopia progression, age, number of myopic parents, and gender were not significantly different between orthokeratology and dual focus soft contact lens groups. Mean follow-up time for the orthokeratology and dual focus lens groups was the same (orthokeratology: 1.30 ± 0.88 years; dual focus lens: 1.33 ± 0.80 years (p = 0.989)). There was a significant reduction in the annualized myopia progression in both groups (orthokeratology: -1.17 ± 0.55 to -0.09 ± 017 D/yr, p < 0.001; dual focus soft contact lens: -1.15 ± 0.46 to -0.10 ± 0.23 D/yr, p < 0.001). There was no difference between orthokeratology and dual focus lens treatment efficacy (p = 0.763), nor in axial or vitreous chamber length changes after treatment (p = 0.184). One adverse event was reported over the 4-year period. CONCLUSIONS Both orthokeratology and dual focus soft contact lenses are effective strategies for targeting myopia progression in the clinic. We saw no significant difference in the efficacy of the two methods in this regard, and so we believe there are very few barriers for any contact lens practitioner to be actively promoting myopia control treatment to at-risk patients.

In March 2012 the West Virginia legislature passed a law that mandates birth hospitals to perform pulse oximetry screening for all well-babies in the newborn nursery to improve the detection of critical congenital heart disease (CCHD). CCHD screening data collection began on September 1, 2012 at all 28 birthing hospitals. The purpose of this study was to review the first year of pulse oximetry screening outcomes and identify barriers to implementation and solutions to improve tracking and policy.All WV birth hospitals were provided with the U.S. Department of Health and Human Services recommendations for CCHD screening, and the Center for Disease Control's recommended screening algorithm for review and reference. 20,115 infants were entered into the Birth Score database between September 1, 2012 and August 31, 2013. 19,283 (91%) infants were screened for CCHD.17,101 (88.5%) infants passed, 19 infants failed, and 2,163 (11.2%) infants had missing data for the screening. 832 infants were not screened due to being admitted to the neonatal intensive care unit for reasons unknown. 17 of the 19 infants who failed the screening had a transthoracic echo report available for review. Of those 17 infants reviewed, seven were diagnosed with CCHD.85% of the infants born in WV who received a Birth Score during the year reviewed were screened for CCHD. Given that the goal is to have 100% compliance with the pulse oximetry screening, additional investigations into factors affecting compliance may be necessary.

The central nervous system (CNS)-based symptoms of Gulf War Illness (GWI) include motor dysfunction, anxiety, and cognitive impairment. Gulf War (GW) agents, such as pyridostigmine bromide (PB), permethrin (PER), N,N-diethyl-meta-toluamide (DEET), and stress, are among the contributory factors to the pathobiology of GWI. This study characterizes disturbances in phosphocholine-containing lipids that accompany neurobehavioral and neuropathological features associated with GW agent exposure. Exposed mice received PB orally, dermal application of PER and DEET and restraint stress daily for 28 days, while controls received vehicle during this period. Neurobehavioral studies included the rotarod, open field, and Morris water maze tests. Histopathological assessments included glial fibrillary acid protein, CD45, and Nissl staining. Liquid chromatography/mass spectrometry with source collision-induced dissociation in negative and positive ionization scanning modes was performed to characterize brain phosphatidylcholine (PC) and sphingomyelin (SM). A significant increase in ether containing PC (ePC34:0, ePC36:2, and ePC36:1) or long-chain fatty acid-containing PC (38:1, 40:4, 40:2) was observed in exposed mice compared with controls. Among differentially expressed PCs, levels of those with monounsaturated fatty acids were more affected than those with saturated and polyunsaturated fatty acids. Sensorimotor deficits and anxiety, together with an increase in astrocytosis, were observed in exposed mice compared with controls. These lipid changes suggest that alterations in peroxisomal pathways and stearoyl-CoA desaturase activity accompany neurobehavioral and neuropathological changes after GW agent exposure and represent possible treatment targets for the CNS symptoms of GWI.

Purpose Previous studies suggest that the refractive status of the peripheral retina may influence the progression of myopia. Our aim was to investigate peripheral refractions in human eyes with high myopia when corrected with a conventional soft spherical contact lens (CL). Methods Ten young adults with high myopia (over -6.00 D) were investigated. An open-field auto-refractor was used to measure on- and off-axis refractions in primary gaze, with and without a CL, every 5° out to 20° horizontally in nasal and temporal retina. Results were analyzed as mean sphere (M) and astigmatic (J(0) and J(45)) vector components. Partial coherence interferometry measures of eye size were also made on- and off-axis at 10 and 20° in nasal and temporal retina. Results Subjects (mean age, 22 years; range, 20 to 26 years) had an average on-axis spherical refractive error of -8.31 ± 2.10 D and an average on-axis eye length of 27.39 ± 1.18 mm. Mean sphere exhibited a significant shift from hyperopic relative peripheral refraction (RPR) in the uncorrected state to myopic RPR on correction, in both nasal and temporal retina. Mean RPR of all subjects across all eccentricities was hyperopic when uncorrected (M = +0.20 ± 0.49 D: mean ± 1 SEM) becoming myopic when corrected (M = -0.45 ± 0.56 D: p = 0.0003, reaching -1.21 ± 0.82 D at 20° in the temporal retina). Peripheral J(0) astigmatism also became significantly more negative on correction (p = 0.002), whereas J(45) astigmatism remained unchanged. On- and off-axis measures of eye length indicated a relatively prolate retinal contour. Uncorrected off-axis mean sphere refractive error reduced with eccentricity, and this was accurately predicted (R > 0.98) by the measured retinal contour. Conclusions Correcting the foveal refractive error in high myopia with standard spherical soft CLs can result in significant absolute myopic defocus in the peripheral retina. If peripheral refraction does indeed influence myopia progression, then our results suggest that in high myopia, standard soft CLs may be beneficial in reducing myopia progression.

There is controversy over the existence, nature, and cause of error in egocentric distance judgments. One proposal is that the systematic biases often found in explicit judgments of egocentric distance along the ground may be related to recently observed biases in the perceived declination of gaze (Durgin & Li, Attention, Perception, & Psychophysics, in press), To measure perceived egocentric distance nonverbally, observers in a field were asked to position themselves so that their distance from one of two experimenters was equal to the frontal distance between the experimenters. Observers placed themselves too far away, consistent with egocentric distance underestimation. A similar experiment was conducted with vertical frontal extents. Both experiments were replicated in panoramic virtual reality. Perceived egocentric distance was quantitatively consistent with angular bias in perceived gaze declination (1.5 gain). Finally, an exocentric distance-matching task was contrasted with a variant of the egocentric matching task. The egocentric matching data approximate a constant compression of perceived egocentric distance with a power function exponent of nearly 1; exocentric matches had an exponent of about 0.67. The divergent pattern between egocentric and exocentric matches suggests that they depend on different visual cues.

To correlate clinical low-risk prostate cancers with pathologic outcomes in men who are considered for active surveillance (AS), interstitial radiation therapy, or radical prostatectomy (RP).Clinical and pathologic data of 76 consecutive patients who underwent RP by a single surgeon between October 2001 and July 2008 were reviewed. The retrospective review identified men with clinical low-risk disease--defined as a prostate-specific antigen (PSA) level10 ng/mL, no Gleason pattern3, no2 cores positive, and no core50%--who would also have been considered for AS and/or brachytherapy based on these features. Pathologic specimens were examined for Gleason primary, secondary, and tertiary patterns, perineural invasion, capsular involvement, margins, nodal disease, and seminal vesicle involvement.Of the patients who underwent RP, 42/76 (55%) had low-risk clinical staging; 8/76 (19%) had low-risk features on final pathologic staging. Fifty-four of 76 (71%) were pT2c; 10% were pT3. Gleason 6 was seen in 41/76 (53%) of RP specimens; Gleason 7 and 8 in 41% and 4%, respectively. Favorable brachytherapy parameters were identified in 63% of those who underwent surgery, but 39 of 48 (81%) would have been inappropriately selected based on features of the pathologic specimen.Clinical staging based on PSA level and biopsy findings correlates poorly with pathologic outcome when stratifying for low-risk features in men who may be candidates for brachytherapy and/or AS.

Prostatectomy for benign disease, also known as a 'simple prostatectomy', is neither simple in indication nor approach. In the post-Medical Therapy of Prostatic Symptoms (MTOPS), NCT00021814 trial era, the medical management of benign prostatic hyperplasia (BPH) and consequent bladder outlet obstruction (BOO) has shifted surgical intervention to those patients who are medical-non responders, present with advanced signs of BOO and obstructive uropathy, and those with prostate gland volumes beyond the size normally approachable with standard transurethral resection of the prostate (TURP). Simple prostatectomy through an open surgical approach is associated with improvements in BOO and lower urinary tract symptoms (LUTS) but at the expense of considerable surgical and perioperative morbidity. Advances in technology have made it possible for patients to be offered standard open surgical approaches as well as transurethral approaches with photon-based energy sources (i.e. laser prostatectomy) and laparoscopic simple prostatectomy. A review of the historical challenges of BPH and the standard-of-care of open prostatectomy will put into perspective the potential advantages and disadvantages of laparoscopic and robotic prostatectomy for the treatment of benign BOO due to BPH.A careful review of the literature was performed utilizing PubMed and ClinicalKey searches to identify relevant articles. Search terms 'simple prostatectomy', 'robotic simple prostatectomy' and 'laparoscopic simple prostatectomy'.Over 14 series of open simple prostatectomies and over 20 minimally invasive series were identified and used as a reference. Additionally, several review articles were identified and incorporated.Simple prostatectomy may be performed safely in appropriately selected patients utilizing either open or minimally invasive approaches. Clinical criteria should be used to determine the appropriateness of either retropubic versus transvesical approach.

Purpose To describe the time-course and amplitude of changes to sub-foveal choroidal thickness (SFCT) induced by imposed hyperopic and myopic retinal defocus and to compare the responses in emmetropic and myopic subjects. Methods Twelve East Asian subjects (age: 18–34 years; six were emmetropic and six had myopia between −2.00 and −5.00 dioptres (D)) viewed a distant target (video movie at 6 m) for 60 min on two separate occasions while optical coherence tomography (OCT) images of the choroid were taken in both eyes every 5 min to monitor SFCT. On each occasion, one eye was optimally corrected for distance with a contact lens while the other eye wore a contact lens imposing either 2.00 D hyperopic or 2.00 D myopic retinal defocus. Results Baseline SFCT in myopic eyes (mean ± S.D.): 256 ± 42 μm was significantly less than in emmetropic eyes (423 ± 62 μm; p

This article describes a rare cause of orbital apex syndrome in a child - juvenile nasopharyngeal angiofibroma. A high leveí of suspicion while treating an adolescent male with chronic nasal obstruction, epistaxis, and a nasal mass will promote early diagnosis. Multidisciplinary care is advisable, especially for advanced disease. / Pediatr Ophthalmol Strabismus 2004;4l:l 16-121.

Reverse phase protein arrays represent a new proteomics microarray technology with which to study the fluctuating state of the proteome in minute quantities of cells. The activation status of cell signaling pathways controls cellular fate and deregulation of these pathways underpins carcinogenesis. Changes in pathway activation that occur between early stage prostatic epithelial lesions, prostatic stroma and the extracellular matrix can be analyzed by obtaining pure populations of cell types by laser capture microdissection (LCM) and analyzing the relative states of several key phosphorylation points within the cellular circuitry. We have applied reverse phase protein array technology to analyze the status of key points in cell signaling involved in pro-survival, mitogenic, apoptotic and growth regulation pathways in the progression from normal prostate epithelium to invasive prostate cancer. Using multiplexed reverse phase protein arrays coupled with LCM, the states of signaling changes during disease progression from prostate cancer study sets were analyzed. Focused analysis of phospho-specific endpoints revealed changes in cellular signaling events through disease progression and between patients. We have used a new protein array technology to study specific molecular pathways believed to be important in cell survival and progression from normal epithelium to invasive carcinoma directly from human tissue specimens. With the advent of molecular targeted therapeutics, the identification, characterization and monitoring of the signaling events within actual human biopsies will be critical for patient-tailored therapy.

Alkylresorcinols (AR) are amphiphilic 1,3-dihydroxy-5-alkyl phenolic lipids. AR in food are only found in the outer layers of wheat and rye grains, and in whole grains are present at concentrations of 500–1000 μg/g. In wheat and rye, there are five main homologues, differing in the length of the odd-numbered alkyl chain (from seventeen to twenty-five C atoms long). Because AR may be bioactive, and might serve as biomarkers for these cereals, their absorption was investigated in model experiments with pigs and rats. Pigs with a cannula in the terminal ileum were fed four diets containing rye fractions with different levels of AR and the ileal effluents were analysed. The ileal recovery of AR was found to vary between 21 and 40 %, with no major difference between different chain-length homologues. The absorption of AR by rats was investigated by feeding14C-labelled heneicosylresorcinol (C21:0). Of the total activity, about 34% was recovered in the urine, showing that the labelled AR was absorbed and metabolised by rats. AR were mostly cleared from rats by 60h. It is concluded that AR are absorbed in the small intestine of single-stomached animals and excreted in metabolised form in the urine, and might contribute to the nutritional qualities of wholegrain wheat and rye diets.

Familial pulmonary fibrosis is a heterogeneous group of interstitial lung diseases of unknown cause that is associated with multiple pathologic subsets. Mutations in the surfactant protein C (SP-C) gene (SFTPC) are associated with familial desquamative and nonspecific interstitial pneumonitis. Genetic studies in familial usual interstitial pneumonitis have been inconclusive. Using a candidate gene approach, we found a heterozygous exon 5 + 128 T--A transversion of SFTPC in a large familial pulmonary fibrosis kindred, including adults with usual interstitial pneumonitis and children with cellular nonspecific interstitial pneumonitis. The mutation is predicted to substitute a glutamine for a conserved leucine residue and may hinder processing of SP-C precursor protein. SP-C precursor protein displayed aberrant subcellular localization by immunostaining. Electron microscopy of affected lung revealed alveolar type II cell atypia, with numerous abnormal lamellar bodies. Mouse lung epithelial cells transfected with the SFTPC mutation were notable for similar electron microscopy findings and for exaggerated cellular toxicity. We show that an SFTPC mutation segregates with the pulmonary fibrosis phenotype in this kindred and may cause type II cellular injury. The presence of two different pathologic diagnoses in affected relatives sharing this mutation indicates that in this kindred, these diseases may represent pleiotropic manifestations of the same central pathogenesis.

To quantify the tear spreading velocity and stabilization time after blinks in healthy patients.Video recordings (magnification, x130) were made of the movements of naturally occurring particles in the tear film while patients blinked naturally. After each blink, tear spreading velocity was computed every 40 milliseconds from particle displacements determined from a frame-by-frame analysis of the records.After a blink, tears moved rapidly upward over the cornea. Forty milliseconds after passage of the lid, the velocity was 7.34 +/- 2.73 mm/s (mean +/- standard deviation, n = 20). The time to tear stabilization (i.e., zero velocity) was 1.05 +/- 0.30 seconds. The decay of spreading velocity with time was well described by a logarithmic function for all individual patient data (R2 range, 0.88-0.99; n = 20). We have shown that initial velocity and stabilization time are independent descriptors of tear spreading. Meibomian gland expression markedly reduced initial velocity leaving a normal stabilization time, whereas inhalation of an irritant reduced stabilization time leaving a normal initial velocity. In a patient with Sjögren syndrome, punctal plugs rapidly restored initial velocity and stabilization time from near zero values to normal values.We provide normal values for two descriptors of tear spreading, namely initial velocity and time to stabilization. These values can be modified by manipulations that alter tear constituents. Consequently, these descriptors may provide a basis for quantitative, noninvasive tear assessment.

Deletions of 3p25, gains of chromosomes 7 and 10, and isochromosome 17q are known cytogenetic aberrations in sporadic renal cell carcinoma (RCC). In addition, a majority of RCCs have loss of heterozygosity (LOH) of the Von Hippel-Lindau (VHL) gene located at chromosome band 3p25. Patients who inherit a germline mutation of the VHL gene can develop multifocal RCCs and other solid tumors, including malignancies of the pancreas, adrenal medulla, and brain. VHL tumors follow the two-hit model of tumorigenesis, as LOH of VHL, a classic tumor suppressor gene, is the critical event in the development of the neoplastic phenotype. In an attempt to define the cytogenetic aberrations from early tumors to late RCC further, we applied spectral karyotyping (SKY) to 23 renal tumors harvested from 6 unrelated VHL patients undergoing surgery. Cysts and low-grade solid lesions were near-diploid and contained 1-2 reciprocal translocations, dicentric chromosomes, and/or isochromosomes. A variety of sole numerical aberrations included gains of chromosomes 1, 2, 4, 7, 10, 13, 21, and the X chromosome, although no tumors had sole numerical losses. Three patients shared a breakpoint at 2p21-22, and three others shared a dicentric chromosome 9 or an isochromosome 9q. In contrast to the near-diploidy of the low-grade lesions, a high-grade lesion and its nodal metastasis were markedly aneuploid, revealed loss of VHL by fluorescence in situ hybridization (FISH), and contained recurrent unbalanced translocations and losses of chromosome arms 2q, 3p, 4q, 9p, 14q, and 19p as demonstrated by comparative genomic hybridization (CGH). By combining SKY, CGH, and FISH of multiple tumors from the same VHL kidney, we have begun to identify chromosomal aberrations in the earliest stages of VHL-related renal cell tumors. Our current findings illustrate the cytogenetic heterogeneity of different VHL lesions from the same kidney, which supports the multiclonal origins of hereditary RCCs. Published 2001 Wiley-Liss, Inc.

Purpose To document ocular outcomes and prevalence of ocular disease in very low birth-weight infants with intraventricular hemorrhage. Methods We retrospectively reviewed the records of all surviving very low birth-weight infants (1,500 g or less) admitted to the neonatal intensive care unit of our institution during 1992 and 1993. Of 252 survivors, 74 had complete ophthalmologic examinations at a mean adjusted age of 11 months. Of these 74 infants, 38 had intraventricular hemorrhage. Chi-square and multivariate analysis were used for statistical testing, in controlling for race, sex, and birth weight, and for other disease processes associated with prematurity. Results Of 38 infants with intraventricular hemorrhage, strabismus occurred in 14 (37%), esotropia in 12 (32%), and exotropia in two (5%). Of the 20 infants with grades III and IV intraventricular hemorrhage, 11 (55%) had esotropia; none had exotropia. Infants with grades III and IV intraventricular hemorrhage were at significantly greater risk for the development of esotropia than were infants with less severe or no hemorrhage (odds ratio, 5.0; P = .04). Mean adjusted age at diagnosis of strabismus was 8.5 months. Infants with periventricular leukomalacia (odds ratio, 6.3; P = .036) and neonatal seizures (odds ratio, 7.3; P = .019) were at significantly greater risk of developing optic atrophy. Conclusions Very low birth-weight infants with more severe neurologic morbidity are at significant risk for development of esotropia and optic atrophy. Ophthalmologic screening of all very low birth-weight survivors may allow earlier diagnosis and intervention for these at-risk infants.

From a total of 114 encephaloceles treated surgically at The Hospital for Sick Children in the 15 years to 1994, the case records of 17 patients with sincipital and 5 patients with basal defects were reviewed retrospectively. The condition was evident at birth in 64% of patients, while the remainder presented with either cerebrospinal fluid (CSF) rhinorrhea, nasal obstruction, or feeding difficulty. Hypertelorism affected 73% of patients. All encephaloceles were repaired transcranially, at a mean age of 2 years, usually by means of an intradural pericranial graft. Five children with gross hypertelorism underwent orbital translocation at the time of encephalocele repair. Of those not corrected, primary and secondary hypertelorism regressed in most instances where the encephalocele was treated before the age of 2 years. There were no deaths. The only case of CSF rhinorrhea occurred in a patient with a basal defect, in whom intradural repair was not possible because of adherence of diencephalic structures to the sac wall. Hypertelorism recurred in 1 patient after orbital translocation, requiring recorrection 2 years later. One patient with untreated secondary hypertelorism failed to regress after the encephalocele was excised at the age of 4 months. Developmental outcome was normal in 59% of children, whilst 18% have mild mental or physical disability, and 23% are severely impaired. A child with a sincipital or basal defect and mild hypertelorism should have the encephalocele treated in early childhood to allow the facial skeleton to remodel with growth. When an encephalocele is accompanied by gross hypertelorism or a facial cleft, one-stage correction can be undertaken safely in early childhood with minimal mortality and acceptable morbidity.

The sexual dimorphism of aggression has led to a search for its Y chromosomal correlates. We have previously confirmed that initiation of attack behavior against a conspecific male is Y-dependent in two strains of laboratory mice (NZB and CBA/H). We provide evidence that the non-pseudoautosomal region of the Y is not involved and that only the pseudoautosomal region of the Y is correlated with initiation of attack behavior. The autosomal correlates also contribute to this behavior in an additive or interactive manner with the pseudoautosomal correlates.

Infants with craniosynostosis involving the metopic and coronal sutures require cranio-orbital reshaping to correct craniofacial dysmorphologic feature and to improve facial balance. Currently, surgical techniques to create a balanced fronto-orbital region are based on the surgeon's subjective approach and artistic vision in creating a normal shape to the forehead. To date, the use of age-matched templates and computer-assisted design/computer-assisted manufacturing techniques in optimizing the outcomes of surgical intervention in this area have not been explored. The aim of this article was to describe the process of template generation and application based on age-matched controls using computer-assisted design/computer-assisted manufacturing technology and to present this application in 2 cases.

Gulf War Illness (GWI) is a chronic multisymptom condition with a central nervous system (CNS) component, for which there is no treatment available. It is now believed that the combined exposure to Gulf War (GW) agents, including pyridostigmine bromide (PB) and pesticides, such as permethrin (PER), was a key contributor to the etiology of GWI. In this study, a proteomic approach was used to characterize the biomolecular disturbances that accompany neurobehavioral and neuropathological changes associated with combined exposure to PB and PER. Mice acutely exposed to PB and PER over 10 days showed an increase in anxiety-like behavior, psychomotor problems and delayed cognitive impairment compared to control mice that received vehicle only. Proteomic analysis showed changes in proteins associated with lipid metabolism and molecular transport in the brains of GW agent-exposed mice compared to controls. Proteins associated with the endocrine and immune systems were also altered, and dysfunction of these systems is a prominent feature of GWI. The presence of astrogliosis in the GW agent-exposed mice compared to control mice further suggests an immune system imbalance, as is observed in GWI. These studies provide a broad perspective of the molecular disturbances driving the late pathology of this complex illness. Evaluation of the potential role of these biological functions in GWI will be useful in identifying molecular pathways that can be targeted for the development of novel therapeutics against GWI.

Objective To assess the predictors of residents' pursuit of fellowship training by surveying current urology residents and recent graduates. Postgraduate fellowship training of urologists could be an important source of urologic physician-scientists and continued innovation in urologic care. Methods A Web-based survey was electronically mailed to urology residents and recent graduates of urologic residency. Variables concerning sex, marital status, debt load, research and clinical exposure, publications, and postgraduate careers were recorded. Results Of the 71 respondents, 46 (65%) were married and 45% had children/dependents. Of the 69% who applied for fellowship, the "most important" factors influencing the pursuit of fellowship were intellectual appeal (82%), mentors (79%), the desire for an additional point of view for surgical training (58%), and the desire to pursue a career in academics (52%). Forty of those completing a fellowship (87%) versus two of those completing residency alone (13%) would pursue a career in academics. Residents with a mentor were 20 times more likely to pursue a urology fellowship. A shorter residency (5 years), encouragement by a program director, and manuscript publication during residency were also independent predictors. Conclusion Mentorship, a shorter residency, and manuscript publication during residency were independent predictors of pursuing fellowship training. Debt load, age, marital status, and a desire to pursue a career in academic medicine were not significant factors.

The roughness of standardized surfaces (embossed dot arrays or gratings) was compared by scanning them with the little finger of either hand while the ulnar nerve was cooled unilaterally at the elbow; both hands remained warm. Across-hand comparison of roughness showed that a given surface felt smoother on the cooled side. When the surfaces were adjusted to feel equally rough, that on the cooled side would normally have felt appreciably rougher. The effect of the nerve cooling on axonal conduction was monitored during the psychophysical experiments by stimulating the ulnar nerve above the cooled region and recording the EMG of an ulnar-innervated hand muscle. During cooling, large myelinated axons remained unblocked, but prolongation of their absolute refractory period to 5–10 msec left them unable to transmit trains of impulses at high frequencies (Wedensky inhibition). By varying the length of nerve cooled and the cooling temperature, it was shown that the perceptual effects were not due to an increase in the normal temporal dispersion of impulses transmitted by different-sized afferents. The effect of increasing the absolute refractory period on the signals from the various types of cutaneous afferent was modeled mathematically, using earlier human single-fiber responses to dot arrays. It is concluded that the reduction of perceived roughness with nerve cooling is due to Wedensky inhibition, and that the percept of roughness is related to the local contrast in the afferent spatiotemporal image.

The spatial resolving capacities of the four classes of mechanoreceptive afferents innervating human fingerpad skin were investigated to determine which class sets the limit of tactile spatial resolution for scanning stimuli. The stimulus consisted of an array of embossed dots (0.7 mm diameter, 0.5 mm high) arranged in a tetragonal pattern with dot spacing decreasing linearly from 6.4 mm at one end of the array to 0.87 mm at the other. The pattern was wrapped around a drum and repeatedly scanned across the receptive field of single afferents by continuously rotating the drum. Responses to many closely spaced scans were obtained by imposing a lateral shift of the pattern between each revolution. Impulses were recorded microneurographically. Responses were plotted in raster form to produce a neural image of the pattern. Responses of rapidly and slowly adapting type I (FAI and SAI) afferents resolved dots down to a spacing of about 1.5 mm. Responses of type II (FAII and SAII) afferents resolved dots down to a spacing of about 3.5 mm. Variation in scanning speed (range, 20–90 mm/sec) and contact force (range, 0.4–1.0 N) had minimal effects on spatial resolution of all afferents. The response clusters associated with individual widely spaced dots were used to investigate receptive field structure. FAI and SAI fields (mean areas, 6.1 and 4.8 mm2, respectively) each contained several zones of maximal sensitivity. FAI fields had five to eight such zones, whereas SAI fields had three to five such zones. As dot spacing decreased, neighboring dots interacted to affect the responses associated with the individual zones within a field. Initially, one or more zones were deactivated, effectively reducing receptive field size and allowing representation of finer spatial detail than would be predicted from the overall area of the receptive field. At very close dot spacings responses were only obtained when more than one sensitive zone within a field were simultaneously activated by different dots.

The Gleason grading system is a standard method of assessing prostate cancer. Very little is known, however, about the person behind the system, Donald Floyd Gleason, MD, PhD. Our objective was to construct a biography of Gleason and show how his work advanced prostate cancer diagnosis. We reviewed Gleason's notes, letters, and publications with the Veteran's Administration Cooperative Urology Research group (VACURG) between 1960 and 1980. Gleason described seeing five recurring histologic "pictures" in his review of 280 initial cases of prostate cancer from 1960 to 1964. By 1966, NIH statisticians combined Gleason's "pictures" with VACURG clinical data into a scoring system. By 1974, over 4,000 cases had been analyzed, and by 1978 the Gleason scale had reached widespread use. Donald F. Gleason recognized trends in histologic patterns which had eluded earlier, more sophisticated pathologic approaches and which lie as the basis for the sophisticated neural networks and nomograms in use today.

This study examined 85 consecutive patients undergoing total pancreatectomy (+/-islet cell transplant), examining pain relief, insulin requirements, and glycemic control postoperatively.A prospective database of all patients undergoing total pancreatectomy for chronic pancreatitis was used to record preoperative and postoperative details from 1996 to 2006.There were 3 postoperative deaths (1 islet recipient and 2 nonislet patients). The median number of acute admissions for pain fell from 5 to 2 after pancreatectomy, and the median length of stay from 6.2 days to 3.3 days. At 12 months postoperatively, the number of patients on regular opiate analgesia fell from 90.6% to 40.2% and by 5 years to 15.9%. There was a significant reduction in the patients' visual analogue pain score after surgery from 9.7 to 3.7 (P0.001). Five patients were insulin independent at 5 years. Median 24-hour insulin requirements were significantly lower in the islet group (15.5 vs 40 units at 5 years postoperatively; P0.001).Total pancreatectomy is effective in reducing pain and dependence on opioid analgesia in patients with chronic pancreatitis. The addition of an islet cell transplant results in a reduction in 24-hour insulin demands, as well as potentially achieving insulin independence.

Aim: To evaluate the acceptability, effectivity, and side effects of a monovision spectacle correction designed to reduce accommodation and myopia progression in schoolchildren. Methods: Dominant eyes of 11 year old children with myopia (−1.00 to −3.00 D mean spherical equivalent) were corrected for distance; fellow eyes were uncorrected or corrected to keep the refractive imbalance ⩽2.00 D. Myopia progression was followed with cycloplegic autorefraction and A-scan ultrasonography measures of vitreous chamber depth (VCD) for up to 30 months. Dynamic retinoscopy was used to assess accommodation while reading. Results: All children accommodated to read with the distance corrected (dominant) eye. Thus, the near corrected eye experienced myopic defocus at all levels of accommodation. Myopia progression in the near corrected eyes was significantly slower than in the distance corrected eyes (inter-eye difference = 0.36 D/year (95% CI: 0.54 to 0.19, p = 0.0015, n = 13); difference in VCD elongation = 0.13 mm/year (95% CI: 0.18 to 0.08, p = 0.0003, n = 13)). After refitting with conventional spectacles, the resultant anisometropia returned to baseline levels after 9–18 months. Conclusions: Monovision is not effective in reducing accommodation in juvenile myopia. However, myopia progression was significantly reduced in the near corrected eye, suggesting that sustained myopic defocus slows axial elongation of the human eye.

Pressure ulcers of the heel are a major and growing health-care problem. Although prevention and aggressive local wound care and pressure reduction remain the gold standard for treatment of most heel ulcers, recalcitrant wounds may require surgical intervention. Limb salvage when dealing with heel ulcers remains a challenge. Nine feet (eight patients) that underwent partial calcanectomy for chronic nonhealing heel ulcers were evaluated retrospectively. Complete healing occurred in seven of nine feet. Patients who were ambulatory before surgery remained ambulatory after healing. (J Am Podiatr Med Assoc 95(4): 335–341, 2005)

Hereditary papillary renal carcinoma (HPRC) is characterized by a predisposition to multiple, bilateral papillary type 1 renal tumors caused by inherited activating missense mutations in the tyrosine kinase domain of the MET proto-oncogene. In the current study we evaluated the clinical phenotype and germline MET mutation of 3 new HPRC families. We describe the early onset clinical features of HPRC.We identified new HPRC families of Italian (family 177), Spanish (family 223) and Cuban (family 268) descent. We evaluated their clinical features, performed MET mutation analysis by denaturing high performance liquid chromatography and DNA sequencing, and estimated age dependent penetrance and survival using Kaplan-Meier analysis. We characterized renal tumors by histology and fluorescence in situ hybridization.Identical germline MET c.3522G --A mutations (V1110I) were identified in families 177 and 268 but no evidence of a founder effect was found. Affected members of family 223 carried a germline c.3906G --C.3522G --A MET mutation (V1238I). Age dependent penetrance but not survival was significantly earlier for the c.3522G --A mutation than for the c.3906G --A mutation in these HPRC families. Trisomy of chromosome 7 and papillary renal carcinoma type 1 histology were detected in papillary renal tumors.HPRC can occur in an early onset form. The median age for renal tumor development in these 3 HPRC families was 46 to 63 years. HPRC associated papillary renal tumors may be aggressive and metastasize, leading to mortality. Median survival age was 60 to 70 years. Families with identical germline mutations in MET do not always share a common ancestor. HPRC is characterized by germline mutations in MET and papillary type 1 renal tumor histology.