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This article presents an asset-level security risk management framework to assist stakeholders of critical assets with allocating limited budgets for enhancing their safety and security against terrorist attack. The proposed framework models the security system of an asset, considers various threat scenarios, and models the sequential decision framework of attackers during the attack. Its novel contributions are the introduction of the notion of partial neutralization of attackers by defenders, estimation of total loss from successful, partially successful, and unsuccessful actions of attackers at various stages of an attack, and inclusion of the effects of these losses on the choices made by terrorists at various stages of the attack. The application of the proposed method is demonstrated in an example dealing with security risk management of a U.S. commercial airport, in which a set of plausible threat scenarios and risk mitigation options are considered. It is found that a combination of providing blast-resistant cargo containers and a video surveillance system on the airport perimeter fence is the best option based on minimum expected life-cycle cost considering a 10-year service period. [ABSTRACT FROM AUTHOR]

BSTRACT: Histamine and other biogenic amines were evaluated in canned anchovies recalled by the U.S. Food and Drug Administration. In addition, bacteria were isolated from the products and identified to species. The recalled products were divided into 2 groups of high and low histamine, depending on the histamine contents as determined by the AOAC method. The high histamine group had the histamine contents >200 ppm, and 24 of the 30 cans analyzed belonged to this group. The most prevalent biogenic amine in this group was histamine followed by cadaverine. On the other hand, the low histamine group of 6 cans contained approximately 50 ppm histamine. The most prevalent biogenic amine found in this group of samples was cadaverine at levels >200 ppm. Other biogenic amines, such as putrescine, serotonin, and spermidine, were also detected in all the products, although at varied levels. Aerobic and anaerobic bacterial counts, if present in all of the recalled products, were below the detection limit of 102 colony-forming units (CFU)/g. Bacteria were recovered only after enrichment of the test samples. They were mostly halophilic bacteria. Bacillus spp. were most frequently identified, followed by Staphylococcus spp. However, these isolates produced negligible amounts of histamine in culture broth, indicating that they are not the contributors to histamine accumulation in the canned anchovies. [ABSTRACT FROM AUTHOR]

The incidence of colorectal cancer (CRC) is increasing in patients under the age of 50. The purpose of this study was to assess the cost-utility of available screening modalities starting at 40 years in the general population compared to standard screening at 50 years old. A decision tree modeling average-risk of CRC in the United States population was constructed for the cost per quality-adjusted life year (QALY) of the five most common and effective CRC screening modalities in average-risk 40-year olds versus deferring screening until 50 years old (standard of care) under a limited societal perspective. All parameters were derived from existing literature. We evaluated the incremental cost-utility ratio of each comparator at a willingness-to-pay threshold of $50,000/QALY and included multivariable probabilistic sensitivity analysis. All screening modalities assessed were more cost-effective with increased QALYs than current standard care (no screening until 50). The most favorable intervention by net monetary benefit was flexible sigmoidoscopy ($3284 per person). Flexible sigmoidoscopy, FOBT, and FIT all dominated the current standard of care. Colonoscopy and FIT-DNA were both cost-effective (respectively, $4777 and $11,532 per QALY). The cost-effective favorability of flexible sigmoidoscopy diminished relative to colonoscopy with increasing willingness-to-pay. Regardless of screening modality, CRC screening at 40 years old is cost-effective with increased QALYs compared to current screening initiation at 50 years old, with flexible sigmoidoscopy most preferred. Consideration should be given for a general recommendation to start screening at age 40 for average risk individuals. [ABSTRACT FROM AUTHOR]

Robotic surgery has increased for common general surgery procedures. This study evaluates how robotic use affects the case distributions of herniorrhaphy and cholecystectomy for general surgery residents according to postgraduate year (PGY). We reviewed Accreditation Council for Graduate Medical Education (ACGME) biliary or hernia cases logged by surgical residents in the academic year 2017-2018. Operative reports were reviewed to compare approaches (robotic, laparoscopic, and open) by resident role and PGY level. Open cholecystectomies were excluded. Overall, 470 hernia and 657 cholecystectomy cases were logged. Hernia repairs were performed robotically in 15.9%, laparoscopically in 9.5%, and open in 74.7%. Cholecystectomies were performed robotically in 16.4% and laparoscopically in 83.6%. Residents were teaching assistants in 1.8% of hernia repairs and 1.5% of cholecystectomies. Distribution of cases by technique and PGY level was significantly different for both procedures, with chief residents performing the majority of robotic cholecystectomies (52.6%, P < .0001) and hernia repairs (59.7%, P < .0001). Migration of robotic cases to senior resident level and low percentage of teaching assistant roles held by residents suggest exposure to common operations may be delayed during general surgery residency training. Introduction of new technology in surgical training should be carefully reviewed and may benefit from a structured curriculum.

Voriconazole prophylaxis is common following lung transplantation, but the value of therapeutic drug monitoring is unknown. A prospective, observational study of lung transplant recipients (n = 93) receiving voriconazole prophylaxis was performed. Serum voriconazole troughs (n = 331) were measured by high-pressure liquid chromatography. The median initial and subsequent troughs were 1.91 and 1.46 μg/ml, respectively. The age of the patient directly correlated with initial troughs (P = 0.005). Patients that were ≥ 60 years old and cystic fibrosis patients were significantly more likely to have higher and lower initial troughs, respectively. In 95% (88/93) of patients, ≥ 2 troughs were measured. In 28% (25/88) and 32% (28/88) of these patients, all troughs were ≤ 1.5 μg/ml or >1.5 μg/ml, respectively. Ten percent (10/93) and 27% (25/93) of the patients developed invasive fungal infection (tracheobronchitis) and fungal colonization, respectively. The median troughs at the times of positive and negative fungal cultures were 0.92 and 1.72 μg/ml (P = 0.07). Invasive fungal infections or colonization were more likely with troughs of ≤ 1.5 μg/ml (P = 0.01) and among patients with no trough of >1.5 μg/ml (P = 0.007). Other cutoff troughs correlated less strongly with microbiologic outcomes. Troughs correlated directly with aspartate transferase levels (P = 0.003), but not with other liver enzymes. Voriconazole was discontinued due to suspected toxicity in 27% (25/93) of the patients. The troughs did not differ at the times of suspected drug-induced hepatotoxicity, central nervous system (CNS) toxicity, or nausea/vomiting and in the absence of toxicity. Voriconazole prophylaxis was most effective at troughs of >1.5 μg/ml. A cutoff for toxicity was not identified, but troughs of >4 μg/ml were rare. The data support a target range of >1.5 to 4 μg/ml.