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Purpose/Objective(s) Radiation therapy (RT) remains a critical treatment modality for unresectable hepatocellular carcinoma (HCC), with proton beam therapy (PBT) being widely utilized due to its decreased exit dose compared to photon-based RT. We hypothesize that patients with HCC receiving definitive PBT would experience decreased acute toxicity when compared to those receiving photon-based RT. Materials/Methods Electronic medical records were retrospectively reviewed at a single institution for patients diagnosed with unresectable HCC and treated with definitive RT between 1/2011 and 12/2020. Patients treated with prior surgery or radiofrequency ablation were excluded. Progress notes and treatment summaries were reviewed to determine baseline characteristics including age at diagnosis, Child-Pugh classification (CPC), AJCC 8th edition T stage, performance status, and RT dose. Acute treatment toxicities were evaluated using Common Terminology Criteria for Adverse Events v5.0. Descriptive statistics were quantified for baseline characteristics. Odds ratios (OR) with 95% confidence intervals (CI) were generated to determine the association between PBT vs. photon therapy and acute radiation toxicities in bivariate and multivariate logistic regression models. Results Forty-six patients were included in the analysis. 24 (52%) patients received PBT while 22 (48%) received photon-based RT. Median age for the PBT and photon-based RT groups were 67 (interquartile range (IQR): 58.6 to 72.5) and 65.5 years (IQR: 61.0 to 73.0), respectively (P = 0.991). 50% of patients who received PBT had a T stage greater than T2, compared to 71% of patient in the photon group (P = 0.148). 42% of the PBT group had CPC B or worse, compared to 38% in the photon group (P = 0.813). Performance status and total dose did not significantly differ between groups (P = 0.351 and P = 0.773, respectively). PBT was associated with higher odds of any grade radiation dermatitis (RD) (OR = 6.00, 95% CI: 1.13 to 31.9) and lower odds of any grade anorexia (OR = 0.21, 95% CI 0.05 to 0.91). Odds of any grade diarrhea and fatigue, did not significantly differ between groups (P = 0.086 and P = 0.958, respectively). After controlling for performance status, total dose, T stage, CPC, and age at diagnosis, PBT was still associated with higher odds of RD (OR = 11.07, 95% CI: 1.14 to 107.71) and lower odds of anorexia (OR = 0.14, 95% CI: 0.02 to 0.93). Conclusion This study provides evidence that although PBT appears to have a superior safety profile in regard to acute anorexia, patients treated with PBT have higher odds of acute RD; these effects persist even after controlling for relevant confounding factors. PBT may result in fewer GI toxicities at the cost of greater skin toxicity.

Introduction Anomalous origin of the right coronary artery (RCA) from the left coronary cusp of the aorta is a moderately rare but potentially life-threatening incident. Myocardial infarction (MI) and sudden cardiac death have been described with this anomaly, especially in those who engage in excessive exercise. However, this case study shows this incidence in association with hyperthyroidism. Case description A previously healthy 51-year-old female with history of hypothyroidism presented with acute onset chest pain for 1 day. Patient's electrocardiogram was normal, however, she had elevated troponins and given her typical chest pain, she was diagnosed with acute coronary syndrome (ACS). The patient had been on levothyroxine and was found to have a subnormal thyroid-stimulating hormone level suggesting hyperthyroidism. Echocardiogram was normal. Coronary angiogram showed an anomalous RCA arising from the left coronary cusp of the sinus of Valsalva and no evidence of atherosclerosis. A coronary computed tomography angiogram was done confirming this finding and showed a slit-like deformity of the coronary ostium with at least 50% luminal stenosis. The patient was referred to a cardiothoracic surgeon for potential coronary artery bypass graft. Discussion This case illustrates a rare presentation of ACS due to hyperthyroidism in an anomalous RCA. MI is a rare manifestation of hyperthyroidism, but in combination with an anatomical defect, it can potentiate adverse outcomes. The mechanisms by which thyroid hormones influence cardiovascular hemodynamics are by causing a hyperdynamic circulatory state, increasing myocardial oxygen demand, and increasing the risk of coronary vasospasm. The combination of anatomic and metabolic defects is what likely precipitated this patient's outcome.

Human immunodeficiency virus (HIV) patients are living longer due to the availability of antiretroviral therapies, and non-AIDS-defining cancers are becoming more prevalent in this patient population. A paucity of data remains on post-operative outcomes following resection of non-AIDS-defining cancers in the HIV population. The National Inpatient Sample was utilized to identify patients who underwent surgical resection for malignancy from 2005 to 2015 (HIV, N = 52,742; non-HIV, N = 11,885,184). Complications were categorized by international classification of disease (ICD)-9 diagnosis codes. Cohorts were matched on insurance, household income, zip code and urban/rural setting. Logistic regression assessed whether HIV was an independent predictor of post-operative complications. Descriptive statistics found HIV patients to have an increased rate of complications following select oncologic surgical resections. Univariate and multivariate logistic regression found HIV to only be an independent predictor of complications following pulmonary lobectomy (p = 0.011; OR 2.93, 95% CI 1.29–6.73). Length of stay was statistically longer following colectomy (2.61 days, 95% CI 1.98–3.44) in those with HIV. Our findings are hypothesis generating and highlight the potential safety of major cancer surgery in the HIV population. However, care providers need be cognizant of the potential increased risk of post-operative complications following pulmonary lobectomy and the potential for increased length of stay. These findings are an initial insight into quality of care and outcomes metrics on HIV patients undergoing major cancer operations.

BACKGROUND: Although racial/ethnic and sex disparities have been examined in health care generally and pain management more specifically, the combined influence of these sociodemographic factors together has not been well documented. The aim of this study was to examine the association between administration of opioid analgesics in the emergency department (ED) and interaction of race/ethnicity and sex. METHODS: We conducted a retrospective cohort study using 2010–2014 Center for Disease Control-National Hospital Ambulatory Medical Care Survey data for patients 12–5 years of age presenting to EDs with a primary diagnosis of appendicitis or gallbladder disease as defined by International Classification of Diseases, Ninth Revision codes. The primary outcome was the receipt of opioid analgesic medications. Secondary outcomes included: receipt of nonopioids, receipt of antiemetic medications, wait time to see a provider, and length of visit in the ED. The association between sex and analgesic receipt within Caucasian non-Hispanic and non-Caucasian groups was evaluated adjusting for pain score on presentation, patient age, emergent status, number of comorbidities, time of visit (month, day of the week, standard versus nonstandard working hours, year), and US region. RESULTS: After exclusions, a weighted sample of 553 ED visits was identified, representing 2,622,926 unique visits. The sample population was comprised of 1,858,035 (70.8%) females and 1,535,794 (58.6%) Caucasian non-Hispanics. No interaction was found in adjusted sampling-weighted model between sex and race/ethnicity on the odds of receiving opioids (P = .74). There was no difference in opioid administration to males as compared to females (odds ratio [OR] = 0.96, 95% CI, 0.87–1.06; P = .42) or to non-Caucasians as compared to Caucasians (OR = 0.99, 95% CI, 0.89–1.10; P = .84). In adjusted weighted models, non-Caucasian males, 123,12½39,457 (51.4%) did not differ from Caucasian non-Hispanic males, 317,427/525,434 (60.4%), on odds of receiving opioids, aOR = 0.88, 95% CI, 0.39–1.99; P = .75. Non-Caucasian females, 547,709/847,675 (64.6%) also did not differ from Caucasian females, 621,638/1,010,360 (61.5%), on odds of receiving opioids, aOR = 1.01, 95% CI, 0.53–1.90; P = .98. Across both sexes, non-Caucasians did not differ from Caucasians on receipt of nonopioid analgesics or antiemetics. Neither wait time to see a provider nor the length of the hospital visit was significantly different between sexes or race/ethnicities. CONCLUSIONS: Based on National Hospital Ambulatory Medical Care Survey data from 2010 to 2014, there is no statistically significant interaction between race/ethnicity and sex for administration of opioid analgesia to people presenting to the ED with appendicitis or gallbladder disease. These results suggest that the joint effect of patient race/ethnicity and sex may not manifest in disparities in opioid management. (Anesth Analg 2019;128:1005–12)

Of all patients diagnosed with pancreatic adenocarcinoma, only 15–20% present with resectable disease. Despite curative-intent resection, the prognosis remains poor with the majority of patients recurring, prompting the need for adjuvant therapy. Historical data support the use of adjuvant 5-fluorouracil (5-FU) or gemcitabine, but recent data suggest either gemcitabine plus capecitabine or modified FOLFIRINOX can improve overall survival when compared to gemcitabine alone. The use of adjuvant chemoradiation therapy remains controversial, primarily due to limitations in study design and mixed results of historical trials. The ongoing Radiation Therapy Oncology Group (RTOG)-0848 trial hopes to further define the role of adjuvant chemoradiation therapy. Intraoperative radiation therapy (IORT) and adjuvant immunotherapy represent additional possibilities to improve outcomes, but evidence supporting their use is limited. This article reviews adjuvant therapeutic strategies for resectable pancreatic adenocarcinoma, including chemotherapy, chemoradiation therapy, IORT and immunotherapy.

Prior studies examining the risk of second primary malignancy (SPM) after a first primary cancer generally have used large datasets such as the Surveillance, Epidemiology, and End Results (SEER) registry and excluded survivors of previous primaries and developers of synchronous primaries. The goal of this study was to provide a more complete representation of multiple cancer risk in squamous cell carcinoma of the anus (SCCA) patients. A single-institution retrospective study of 46 patients treated definitively for SCCA between January 2006 and July 2017 was conducted. Of the 46 patients, 18 (39%) had either a primary malignancy before SCCA (n=9) or SPM after an index SCCA (n=9). Six patients had ≥3 total malignancies. In our cohort, patients without SPMs tended to die from SCCA recurrence, while patients with SPMs were more likely to die from their SPM than from SCCA. Our study suggests that patients with SCCA are often either survivors of previous cancers or develop later malignancies. Several risk factors may play a role including HPV infection, HPV-related or treatment-related immunosuppression, somatic mutations due to chemotherapy, and genetic factors. Patients with SCCA require lifelong surveillance given their elevated risk of malignancy. Future work should focus on identifying genomic or immunologic factors that may predispose SCCA patients to develop multiple primary malignancies.

We report the two-step synthesis of a molecular trefoil knot in 90 % overall yield through the self-assembly of a twelve-component trimeric circular zinc helicate followed by ring closing metathesis of six pendant alkene chains. Both the trimeric circular helicate intermediate and the resulting trefoil knot were characterized by NMR spectroscopy, mass spectrometry and X-ray crystallography.

Computational scientists are typically not expert programmers, and thus work in easy to use dynamic languages. However, they have very high performance requirements, due to their large datasets and experimental setups. Thus, the performance required for computational science must be extracted from dynamic languages in a manner that is transparent to the programmer. Current approaches to optimize and parallelize dynamic languages, such as just-in-time compilation and highly optimized interpreters, require a huge amount of implementation effort and are typically only effective for a single language. However, scientists in different fields use different languages, depending upon their needs.This paper presents techniques to enable automatic extraction of parallelism within scripts that are universally applicable across multiple different dynamic scripting languages. The key insight is that combining a script with its interpreter, through program specialization techniques, will embed any parallelism within the script into the combined program that can then be extracted via automatic parallelization techniques. Additionally, this paper presents several enhancements to existing speculative automatic parallelization techniques to handle the dependence patterns created by the specialization process. A prototype of the proposed technique, called Partial Evaluation with Parallelization (PEP), is evaluated against two open-source script interpreters with 6 input linear algebra kernel scripts each. The resulting geomean speedup of 5.10× on a 24-core machine shows the potential of the generalized approach in automatic extraction of parallelism in dynamic scripting languages.

Locally advanced rectal cancer has broadly been defined as T3, T4, or lymph node-positive disease. In the 1990s, adjuvant chemoradiation was considered the optimal management for locally advanced rectal cancer. However, the paradigm shifted when the German CAO/ARO/AIO-94 Rectal Cancer trial established neoadjuvant chemoradiation as the standard of care, based on reduced rates of toxicity and local recurrence, as well as higher rates of sphincter preservation compared with postoperative chemoradiation. Both short-course radiation and long-course chemoradiation are currently accepted methods for neoadjuvant treatment, with recent trials showing equivalence in outcomes. While surgery remains the cornerstone of treatment, there are data supporting the use of magnetic resonance imaging for risk stratification in rectal cancer and encouraging prospective data regarding nonoperative management. This review summarizes data on the evolution of treatment for locally advanced rectal cancer and discusses emerging evidence for nonoperative management.

Background and Objectives Surgical management of colorectal cancer liver metastases continues to evolve to optimize oncologic outcomes while maximizing parenchymal preservation. Long-term data after intraoperative microwave ablation are limited. This study investigates outcomes and patterns of recurrence in patients who underwent intraoperative microwave ablation. Methods A retrospective analysis of 33 patients who underwent intraoperative microwave ablation of colorectal cancer liver metastases from 2009 to 2013 at our institution was performed. Perioperative and long-term data were reviewed to determine outcomes and patterns of recurrence. Results A total of 49 tumors were treated, ranging 0.5–5.5 cm in size. Median Clavien–Dindo classification was one. Median follow-up was 531 days, with 13 (39.4%) patients presenting with a recurrence. Median time to first recurrence was 364 days. In those patients, 1 (7.8%) presented with an isolated local recurrence in the liver. Only 1 of 7 ablated tumors greater than 3 cm recurred (14.3%). Overall survival was 35.2% at 4 years, with a 19.3% disease-free survival at 3.5 years. No perioperative variables predicted systemic or local recurrence. Conclusion Intraoperative microwave ablation is a safe and effective modality for use in the treatment of colorectal cancer liver metastases in tumors as large as 5.5 cm in size. J. Surg. Oncol. 2015 111:410–413. © 2014 Wiley Periodicals, Inc.

SummaryBackground Electrical Cardiometry™ (EC) estimates cardiac parameters by measuring changes in thoracic electrical bioimpedance during the cardiac cycle. The ICON®, using four electrocardiogram electrodes (EKG), estimates the maximum rate of change of impedance to peak aortic blood acceleration (based on the premise that red blood cells change from random orientation during diastole (high impedance) to an aligned state during systole (low impedance)). Objective To determine whether continuous cardiac output (CO) data provide additional information to current anesthesia monitors that is useful to practitioners. Methods After IRB approval and verbal consent, 402 children were enrolled. Data were uploaded to our anesthesia record at one-minute intervals. Ten-second measurements (averaged over the previous 20 heart beats) were downloaded to separate files for later comparison with routine OR monitors. Results Data from 374 were in the final cohort (loss of signal or improper lead placement); 292 012 measurements during 58 049 min of anesthesia were made in these children (1 day to 19 years and 1 to 107 kg). Four events had a ≥25% reduction in cardiac index at least 1 min before a clinically important change in other monitored parameters; 18 events in 14 children confirmed manifestations of other hemodynamic measures; eight events may have represented artifacts because the observed measurements did not seem to fit the clinical parameters of the other monitors; three other events documented decreased stroke index with extreme tachycardia. Conclusions Electrical cardiometry provides real-time cardiovascular information regarding developing hemodynamic events and successfully tracked the rapid response to interventions in children of all sizes. Intervention decisions must be based on the combined data from all monitors and the clinical situation. Our experience suggests that this type of monitor may be an important addition to real-time hemodynamic monitoring.

Background Recent studies on perioperative fluid administration in patients undergoing major abdominal surgery have suggested that increased fluid loads are associated with worse perioperative outcomes. However, results of retrospective analyses of the relationship between intraoperative fluid (IOF) administration and perioperative outcomes in patients undergoing pancreaticoduodenectomy (PD) are conflicted. We sought to investigate this relationship in patients undergoing PD at our academic center. Methods A retrospective analysis of 124 patients undergoing PD from 2007 to 2012 was performed. IOF administration rate (ml/kg/hr) was correlated with perioperative outcomes. Outcomes were also stratified by preoperative serum albumin level. Results Regression analyses were performed comparing independent perioperative variables, including IOF rate, to four outcomes variables: length of stay, severity of complications, number of complications per patient, and 30-day mortality. Both univariate and multivariate regression analyses showed IOF rate correlated with one or more perioperative outcomes. Patients with an albumin ≤3.0 g/dl who received more than the median IOF rate experienced more severe complications, while patients with an albumin >3.0 g/dl did not. Conclusion Increased IOF administration is associated with worse perioperative outcomes in patients undergoing PD. Patients with low preoperative serum albumin levels (≤3.0 g/dl) may be a group particularly sensitive to volume overload. J. Surg. Oncol. 2013 108:242–247. © 2013 Wiley Periodicals, Inc.

Guest encapsulation underpins the functional properties of self-assembled capsules yet identifying systems capable of strongly binding small organic molecules in solution remains a challenge. Most coordination capsules rely on the hydrophobic effect to ensure effective solution-phase association. In contrast, we show that using non-interacting anions in apolar solvents can maximize favorable interactions between a cationic Pd2L4 host and charge-neutral guests resulting in a dramatic increase in binding strength. With quinone-type guests, association constants in excess of 108 m−1 were observed, comparable to the highest previously recorded constant for a metallosupramolecular capsule. Modulation of optoelectronic properties of the guests was also observed, with encapsulation either changing or switching-on luminescence not present in the bulk phase.

Radical depolymerisation is the method of choice for the depolymerisation of glycosaminoglycans (GAGs), especially when enzymatic depolymerisation cannot be performed due to the lack of suitable enzymes. The established Fenton type free radical depolymerisation generates radicals from a solution of H2O2 in the presence of Cu(2+) or Fe(2+). When applied to dermatan sulfate (DS), the Fenton type depolymerisation of DS (Panagos, Thomson, Bavington, & Uhrin, 2012) produced exclusively oligosaccharides with reducing end GalNAc, which was partially oxidised to acetylgalactosaminic acid. We report here the results of the TiO2 catalysed photochemical depolymerisation of DS. NMR analysis of these DS oligosaccharides revealed the presence of reducing end IdoA, observed for the first time. The reducing end acetylgalactosaminic acid was also detected. The photochemical depolymerisation method thus enables preparation of new types of GAG oligosaccharides suitable for further biochemical and biological investigation.

The SPARCHS project proposed a new computer systems design methodology that considers defensive security as a first-order design requirement at all levels in computer systems stack. A defensive mindset to system design means that each component, be it hardware, software or the security mechanism, should be designed assuming that it can be compromised, each component must individually have the ability to detect attacks, limit losses, recover from attacks and learn to prevent future attacks.

Malnutrition and weight loss negatively affect outcomes in surgical cancer patients. Decades of research have sought to identify the most appropriate use of nutrition support in these patients. National and international guidelines help to direct clinicians' use of nutrition support in surgical patients, but a number of specific issues concerning the use of nutrition support continue to evolve. This review focuses on 5 key issues related to perioperative nutrition support in cancer patients: (1) Which perioperative cancer patients should receive nutrition support? (2) How can the nutrition status and requirements of these patients be optimally assessed? (3) What is the optimal route of administration (parenteral nutrition vs enteral nutrition) and composition of nutrition support in this setting? (4) When should feedings be initiated? (5) What is the role of glycemic control in these patients?

Workload, platform, and available resources constitute a parallel program's execution environment. Most parallelization efforts statically target an anticipated range of environments, but performance generally degrades outside that range. Existing approaches address this problem with dynamic tuning but do not optimize a multiprogrammed system holistically. Further, they either require manual programming effort or are limited to array-based data-parallel programs. This paper presents Parcae, a generally applicable automatic system for platform-wide dynamic tuning. Parcae includes (i) the Nona compiler, which creates flexible parallel programs whose tasks can be efficiently reconfigured during execution; (ii) the Decima monitor, which measures resource availability and system performance to detect change in the environment; and (iii) the Morta executor, which cuts short the life of executing tasks, replacing them with other functionally equivalent tasks better suited to the current environment. Parallel programs made flexible by Parcae outperform original parallel implementations in many interesting scenarios.

We report the effects of 88 μg·kg(-1) of epinephrine (1:10,000) injected into the caudal epidural space of a 42-week postconceptual age infant. No long-term neurological or cardiovascular sequelae occurred. Noninvasive cardiac output (CO) monitoring revealed increased CO, contractility, and stroke volume for about an hour, accompanied by a reduction in peripheral vascular resistance and a modest increase in pulse and blood pressure.

Board certification and credentialing in nutrition for physicians are problematic issues. Many board examinations are offered, but have few candidates and poor recognition. This discussion focuses on the feasibility of establishing a single board examination body. Some key considerations were identified to improve credentialing and examination in nutrition for physicians. Increasing the number of nutrition physicians and improving recognition of their credentials should ultimately translate to better patient health and safety. Consolidation of board examinations may be in the best interest of physician nutritionists.

Mentoring programs in nutrition are essential to the survival of clinical nutrition as we know it today. The best method known to maintain an influx of talent to a discipline is by developing an active mentoring program. This paper describes 1 concept for development of a viable mentor program. Mentoring should be flexible and based on mentees' training background. Realistic goals should be set, with written and verbal feedback, to sustain a successful program. Programs should incorporate the Socratic Method whenever possible. Factors that leave doubt about the survival of nutrition as a viable area of focus for physicians include the inability to generate adequate funds to support oneself and limited numbers of mentors available with dedicated time to be a mentor. A healthy, sustainable mentoring program in clinical nutrition will ensure survival of physician-based nutrition programs.

One obstacle that may discourage physician trainees from pursuing a career in clinical nutrition is the perception that such physician practice does not generate sufficient income. A review of the history of Medicare and the current payment system for healthcare services by the U.S. government is essential to understand which members and what services provided by a nutrition support team (NST) will be reimbursed. Patients who require nutrition therapy tend to have multiple comorbidities, which should allow for a higher level of billing under evaluation and management codes. Despite the fact that an intact NST improves outcome and helps ensure patient safety, such teams may not be able to function independently and remain financially sustainable. Hospital administration should be mandated to support an institutional nutrition service. Strategies to define malnutrition and identify measures of quality nutrition care should help demonstrate the value and promote the importance of a functioning NST.

In this panel discussion from the 2009 Workshop on Computer Architecture Research Directions, David August and Keshav Pingali debate whether explicitly parallel programming is a necessary evil for applications programmers, assess the current state of parallel programming models, and discuss possible routes toward finding the programming model for the multicore era.

Pediatric anesthesiologists care for children with penetrating trauma from nonpowder (BB and pellet) guns. We present the case of a 9-year-old boy who required urgent median sternotomy for cardiac tamponade after sustaining a close-range BB gun injury to the chest. After summarizing the epidemiology of nonpowder gun injuries in children, we clarify the nomenclature, ballistics, and mechanisms of these guns, discuss the tendency to minimize these kinds of injuries, explain bullet embolization, and review (by body area) current clinical management issues.

It is clear that cancer patients develop complex nutrition issues. Nutrition support may or may not be indicated in these patients depending on individual patient characteristics. This review article, the first in a series of articles to examine the A.S.P.E.N. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients Cancer Guidelines, evaluates the evidence related to the use of nutrition screening and nutrition assessment in cancer patients. This first article will provide background concerning nutrition issues in cancer patients as well as discuss the role of nutrition screening and nutrition assessment in the care of cancer patients. The goal of this review is to enrich the discussion contained in the Clinical Guidelines, cite the primary literature more completely, and suggest updates to the guideline statements in light of subsequent published studies. Future articles will explore the guidelines related to nutrition support in oncology patients receiving anticancer therapies.

A transient hardware fault occurs when an energetic particle strikes a transistor, causing it to change state. Although transient faults do not permanently damage the hardware, they may corrupt computations by altering stored values and signal transfers. In this paper, we propose a new scheme for provably safe and reliable computing in the presence of transient hardware faults. In our scheme, software computations are replicated to provide redundancy while special instructions compare the independently computed results to detect errors before writing critical data. In stark contrast to any previous efforts in this area, we have analyzed our fault tolerance scheme from a formal, theoretical perspective. To be specific, first, we provide an operational semantics for our assembly language, which includes a precise formal definition of our fault model. Second, we develop an assembly-level type system designed to detect reliability problems in compiled code. Third, we provide a formal specification for program fault tolerance under the given fault model and prove that all well-typed programs are indeed fault tolerant. In addition to the formal analysis, we evaluate our detection scheme and show that it only takes 34% longer to execute than the unreliable version.

Simulator development is already a huge burden for many academic and industry research groups; future complex or heterogeneous multi-cores, as well as the multiplicity of performance metrics and required functionality, will make matters worse. We present a new simulation environment, called UNISIM, which is designed to rationalize simulator development by making it possible and efficient to distribute the overall effort over multiple research groups, even without direct cooperation. UNISIM achieves this goal with a combination of modular software development, distributed communication protocols, multilevel abstract modeling, interoperability capabilities, a set of simulator services APIs, and an open library/repository for providing a consistent set of simulator modules.

This chapter contains 99 questions relevant for the Pediatric Subspecialty Exam about the topic of the cardiovascular system.

Esophagectomy is associated with significant morbidity. Optimizing perioperative fluid administration is one potential strategy to mitigate morbidity. We sought to investigate the relationship of intraoperative fluid (IOF) administration to outcomes in patients undergoing transhiatal esophagectomy with particular attention to malnourished patients, who may be more susceptible to the effects of fluid overload.Patients who underwent transhiatal esophagectomy from 2000-2013 were identified from a retrospective database. IOF rates (mL/kg/hr) were determined and their relationship to outcomes compared. To examine the impact of malnutrition, we stratified patients based on median preoperative serum albumin and compared outcomes.211 patients comprised the cohort. 74% of patients underwent esophagectomy for esophageal adenocarcinoma. Linear regression analyses were performed comparing independent perioperative variables to four outcomes variables: length of stay, complications per patient, major complications, and Clavien-Dindo classification. IOF rate was significantly associated with three of four outcomes on univariate analysis. Significantly more patients with a preoperative albumin level ≤3.7 g/dL who received more than the median IOF rate experienced more severe complications.Increased intraoperative fluid administration is associated with perioperative morbidity in patients undergoing transhiatal esophagectomy. Patients with lower preoperative albumin levels may be particularly sensitive to the effects of volume overload.

Objective Standard postoperative therapy for pancreatic cancer consists of both chemotherapy alone and chemoradiation. We sought to investigate whether the sequence of chemotherapy and chemoradiation and overall time to initiation of adjuvant therapy would impact local vs. distant recurrence. Methods After Institutional Review Board approval, resected pancreas cancer patient charts were evaluated for medical background, surgical, pathological, chemoradiation (CRT), and follow-up. Local recurrence (LR) was defined as failures occurring in the postoperative bed and regional lymph nodes. Early vs. late CRT was defined by whether CRT was given early (within 1-2 cycles of adjuvant chemotherapy) or late in the course of adjuvant chemotherapy (after the 3rd cycle of chemotherapy). The postoperative interval variance was compared to LR factors such as progression-free survival (PFS) and overall survival (OS). Results Of the 34 eligible patients, 47% (n=16) underwent early CRT and 41% (n=14) underwent late CRT. 12% (n=14) did not undergo any induction chemotherapy. At median follow-up of 22 months, 53% (n=18) had metastases, 24% (n=8) had LR, and 24% (n=8) were disease free. Kaplan-Meier curves revealed that early vs. late CRT did not appear to significantly impact OS (p=0.63), PFS (p=0.085) or LR (p=0.19). Postoperative interval did not affect PFS (p=0.42) or OS (p=0.93). Conclusions Early vs. late CRT and the time to initiation of adjuvant therapy were not significantly associated with LR in patients with resected pancreatic cancer. Future prospective studies are required to determine if sequencing of chemotherapy, CRT, or the postoperative interval impact survival and patterns of recurrence.

Procedures have long been the basic units of compilation in conventional optimization frameworks. However, procedures are typically formed to serve software engineering rather than optimization goals, arbitrarily constraining code transformations. Techniques, such as aggressive inlining and interprocedural optimization, have been developed to alleviate this problem, but, due to code growth and compile time issues, these can be applied only sparingly.This paper introduces the Procedure Boundary Elimination (PBE) compilation framework, which allows unrestricted whole-program optimization. PBE allows all intra-procedural optimizations and analyses to operate on arbitrary subgraphs of the program, regardless of the original procedure boundaries and without resorting to inlining. In order to control compilation time, PBE also introduces novel extensions of region formation and encapsulation . PBE enables targeted code specialization , which recovers the specialization benefits of inlining while keeping code growth in check. This paper shows that PBE attains better performance than inlining with half the code growth.

We focus on problems suited to the current evaluation infrastructure. The current limitation and trends in evaluation techniques are troublesome and could noticeably slow the rate of computer system innovation. New research has been recommended to help and make quantitative evaluations of computer systems manageable. We support research in the areas of simulation frameworks, benchmarking methodologies, analytic methods, and validation techniques.