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Background and ObjectiveTo examine the verification of a referring hospital's practice of determining death by neurologic criteria (DNC) by an organ procurement organization (OPO) pursuant to the Center for Medicaid and Medicare Services rule §486.344(b).MethodsIn this retrospective cohort study, we examined prevalence and factors associated with deviations from acceptable DNC standards, the performance of additional ancillary testing requested by the OPO, resolution of concerns about deviations between referring hospitals and the OPO, and interactions between referring hospitals and the OPO.ResultsThe OPO reviewed DNC processes for 645 adult potential organ donors from 64 referral hospitals. Concerns about practice deviations from acceptable standards were identified by the OPO's medical director (also a practicing neurointensivist) on call in 19% (n = 120) and were related to clinical prerequisites (27.2%, n = 49), clinical examination (23.9%, n = 67), and apnea testing (25.3%, n = 97). The top 3 concerns were apnea test results not meeting PCO2 targets (6.7%, n = 43), errors in documentation of the clinical examination (5.3%, n = 34), and potential confounding effects of CNS depressants (2.5%, n = 16). Compared with the “no medical director concerns” group which includes all patients, where the coordinator felt that DNC determination met all the conditions on the checklist, medical director concerns were less likely to occur in hospitals with a dedicated neurocritical care unit (odds ratio [OR] 0.33, 95% CI 0.17–0.66, p < 0.001), prevalent across hospitals independent of whether their policies conformed to updated DNC guidelines (OR 0.92, 95% CI 0.57–1.45, p = 0.720). The OPO requested additional ancillary testing (6%, n = 41) when clinical prerequisites were not met (OR 12.7, 95% CI 4.29–33.5), p < 0.001). Resolution of concerns and organ donation was achieved in 99.4% (n = 641). Four patients were rejected as brain-dead donors because of the presence of cerebral blood flow on the nuclear medicine perfusion test. Referring hospitals requested support from the OPO regarding the determination of DNC (10%, n = 64) and declaring physicians were reported to lack knowledge about the institutional DNC policy (4%, n = 23).DiscussionOngoing review of institutional DNC standards and adherence to those standards is an urgent unmet need. Both referring hospitals and OPOs jointly carry responsibility for preventing errors in DNC leading up to organ recovery.

Study Objectives Eye movement quantification in polysomnograms (PSG) is difficult and resource intensive. Automated eye movement detection would enable further study of eye movement patterns in normal and abnormal sleep, which could be clinically diagnostic of neurologic disorders, or used to monitor potential treatments. We trained a long short-term memory (LSTM) algorithm that can identify eye movement occurrence with high sensitivity and specificity. Methods We conducted a retrospective, single-center study using one-hour PSG samples from 47 patients 18–90 years of age. Team members manually identified and trained an LSTM algorithm to detect eye movement presence, direction, and speed. We performed a 5-fold cross validation and implemented a “fuzzy” evaluation method to account for misclassification in the preceding and subsequent 1-second of gold standard manually labeled eye movements. We assessed G-means, discrimination, sensitivity, and specificity. Results Overall, eye movements occurred in 9.4% of the analyzed EOG recording time from 47 patients. Eye movements were present 3.2% of N2 (lighter stages of sleep) time, 2.9% of N3 (deep sleep), and 19.8% of REM sleep. Our LSTM model had average sensitivity of 0.88 and specificity of 0.89 in 5-fold cross validation, which improved to 0.93 and 0.92 respectively using the fuzzy evaluation scheme. Conclusion An automated algorithm can detect eye movements from EOG with excellent sensitivity and specificity. Noninvasive, automated eye movement detection has several potential clinical implications in improving sleep study stage classification and establishing normal eye movement distributions in healthy and unhealthy sleep, and in patients with and without brain injury.

Research Design: In this study, we describe patients from a tertiary care safety-net hospital endocarditis registry with tricuspid valve infective endocarditis (TVIE), and concomitant acute or subacute ischemic stroke predominantly associated with injection drug use (IDU). We retrospectively obtained data pertinent to neurologic examinations, history of injection drug use (IDU), blood cultures, transthoracic/transesophageal echocardiography (TTE/TEE), neuroimaging, and Modified Rankin Scale (mRS) scores at discharge. Only those patients with bacteremia, tricuspid valve vegetations, and neuroimaging consistent with acute to subacute ischemic infarction and microhemorrhages in two cases were included in this series. Results: Of 188 patients in the registry, 66 patients had TVIE and 10 of these were complicated by ischemic stroke. Neurologic symptoms were largely non-specific, eight patients had altered mental status and only 3 had focal deficits. Nine cases were associated with IDU. Two patients had evidence of a patent foramen ovale on echocardiography. Blood cultures grew S. aureus species in 9 of the patients, all associated with IDU. Three patients died during hospitalization. The mRS score at discharge for survivors ranged 0-4. Conclusions: Patients with strokes from TVIE had heterogeneous presentations and putative mechanisms. We noted that robust neuroimaging is lacking for patients with TVIE from IDU and that such patients may benefit from neuroimaging as a screen for strokes to assist peri-operative management. Further inquiry is needed to elucidate stroke mechanisms in these patients.

The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days.Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life.By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference -3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference -2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01).Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.

Introduction & Hypothesis: Diffusion-weighted imaging (DWI), a technique sensitive to acute brain ischemia, may hold utility in predicting neurological outcome in comatose post-cardiac arrest patients. Outcome studies are biased by early withdrawal of life sustaining therapy (WLST), leading to a self-fulfilling prophecy. This creates a need to reassess the use of DWI as a neuroprognostic tool in patients who have not undergone WLST. We hypothesize that DWI abnormalities is a robust predictor of poor neurological outcome in our WLST - controlled cohort. Methods: We leveraged the MOCHA database, a registry of over 300 comatose post-cardiac arrest patients, to retrospectively examine neurological outcomes in a cohort of patients who did not undergo WLST. A good outcome was defined by a cerebral performance category (CPC) score at discharge of 1 - 3, while a poor outcome CPC 4 - 5 (n=43). We first examined the relationship between the number of brain regions with DWI abnormalities and CPC score using a linear regression. We then examined how DWI abnormalities in specific brain regions correlated with CPC score outcome groups using a fisher exact test. DWI abnormalities were qualitatively determined by two vascular neurologists. Results: We found a positive correlation between the number of brain regions with DWI abnormalities and CPC score ( linear regression , R 2 =0.572, p=2.670x10 -9 ). Interestingly, the association between DWI abnormalities and CPC score exhibited brain region-specific variability. DWI abnormalities exhibited the strongest association with poor neurological outcome in the occipital lobe ( fisher exact test , p=7.413x10 -10 ), parietal lobe (p=9.125x10 -9 ), frontal lobe (p=5.385x10 -9 ), temporal lobe (p=3.904x10 -8 ) and basal ganglia (p=2.342x10 -7 ); and the weakest association in the white matter (p=1.000) and brain stem (p=6.612x10 -2 ). Conclusion: Our preliminary results suggest that the region of ischemia is an important factor to consider in predicting neurological outcome. This warrants a larger scale WLST-controlled study examining region-specific DWI abnormalities and neurological outcome - the findings of which would improve our neuroprognostication capabilities in comatose post-cardiac arrest patients.

Although the Uniform Determination of Death Act (UDDA) has served as a model statute for 40 years, there is a growing recognition that the law must be updated. One issue being considered by the Uniform Law Commission's Drafting Committee to revise the UDDA is whether the text “all functions of the entire brain, including the brainstem” should be changed. Some argue that the absence of diabetes insipidus indicates that some brain functioning continues in many individuals who otherwise meet the “accepted medical standards” like the American Academy of Neurology's. The concern is that the legal criteria and the medical standards used to determine death by neurologic criteria are not aligned. We argue for the revision of the UDDA to more accurately specify legal criteria that align with the medical standards: brain injury leading to permanent loss of the capacity for consciousness, the ability to breathe spontaneously, and brainstem reflexes. We term these criteria neurorespiratory criteria and show that they are well-supported in the literature for physiologic and social reasons justifying their use in the law.

We quantify the impacts of poaching, Ebola, and habitat degradation on western lowland gorillas and central chimpanzees., We present a range-wide assessment of sympatric western lowland gorillas Gorilla gorilla gorilla and central chimpanzees Pan troglodytes troglodytes using the largest survey data set ever assembled for these taxa: 59 sites in five countries surveyed between 2003 and 2013, totaling 61,000 person-days of fieldwork. We used spatial modeling to investigate major drivers of great ape distribution and population trends. We predicted density across each taxon’s geographic range, allowing us to estimate overall abundance: 361,900 gorillas and 128,700 chimpanzees in Western Equatorial Africa—substantially higher than previous estimates. These two subspecies represent close to 99% of all gorillas and one-third of all chimpanzees. Annual population decline of gorillas was estimated at 2.7%, maintaining them as Critically Endangered on the International Union for Conservation of Nature and Natural Resources (IUCN) Red List. We quantified the threats to each taxon, of which the three greatest were poaching, disease, and habitat degradation. Gorillas and chimpanzees are found at higher densities where forest is intact, wildlife laws are enforced, human influence is low, and disease impacts have been low. Strategic use of the results of these analyses could conserve the majority of gorillas and chimpanzees. With around 80% of both subspecies occurring outside protected areas, their conservation requires reinforcement of anti-poaching efforts both inside and outside protected areas (particularly where habitat quality is high and human impact is low), diligent disease control measures (including training, advocacy, and research into Ebola virus disease), and the preservation of high-quality habitat through integrated land-use planning and implementation of best practices by the extractive and agricultural industries.

Surgical and catheter-based cardiovascular procedures and adjunctive pharmacology have an inherent risk of neurological complications. The current diversity of neurological endpoint definitions and ascertainment methods in clinical trials has led to uncertainties in the neurological risk attributable to cardiovascular procedures and inconsistent evaluation of therapies intended to prevent or mitigate neurological injury. Benefit-risk assessment of such procedures should be on the basis of an evaluation of well-defined neurological outcomes that are ascertained with consistent methods and capture the full spectrum of neurovascular injury and its clinical effect. The Neurologic Academic Research Consortium is an international collaboration intended to establish consensus on the definition, classification, and assessment of neurological endpoints applicable to clinical trials of a broad range of cardiovascular interventions. Systematic application of the proposed definitions and assessments will improve our ability to evaluate the risks of cardiovascular procedures and the safety and effectiveness of preventive therapies.

Character motion synthesis is the process of artificially generating natural motion for a virtual character. In film, motion synthesis can be used to generate difficult or dangerous stunts without putting performers at risk. In computer games and virtual reality, motion synthesis enriches the player or participant experience by allowing for unscripted and emergent character behavior. In each of these applications the ability to adapt to changes to environmental conditions or to the character in a smooth and natural manner, while still conforming with user-specified constraints, determines the utility of a method to animators and industry practitioners. This focus on adaptation capability distinguishes our survey from other reviews which focus on general technology developments. Three main methodologies (example-based; simulation-based and hybrid) are summarised and evaluated using compound metrics: adaptivity, naturalness and controllability. By assessing existing techniques according to this classification we are able to determine how well a method corresponds to users' expectations. We discuss optimization strategies commonly used in motion synthesis literature, and also contemporary perspectives from biology which give us a deeper insight into this problem. We also present observations and reflections from industry practitioners to reveal the operational constraints of character motion synthesis techniques. Our discussion and review presents a unique insight into the subject, and provide essential guidance when selecting appropriate methods to design an adaptive motion controller.

This research examined the effect that a relatively new Computer Supported Collaborative Learning (CSCL) device, specifically an interactive tabletop, has on elementary students’ attitudes toward collaborative technologies, mathematical achievement, and the gender gap in mathematics. Prior research has shown many positive effects of CSCL technologies on mathematics education, such as increased math performance and an increased interest in math. Further, previous research has shown inconsistent results regarding gender differences in mathematics and has not examined the effect that CSCL technology has on the gender gap. Therefore, the effects of interactive tabletops on math performance, attitudes, and gender differences were examined. This study was conducted using a sample of 53 elementary students. The technology was brought to the classroom twice each week for an entire academic semester. To obtain a more accurate understanding of the influence of the CSCL technology, both self-report data and performance data were collected. Specifically, changes in students’ attitudes and reactions and changes in cognitive learning were measured. The results show that students learn and react favorably towards interactive tabletops. Implications for future research are discussed.

The study site, Dipikar Island (2° 10’-2°18’N, 2° 17’-2°14’E), is located in the Campo Ma’an National Park (CMNP), in South Region, Cameroon. In late 2010, after assessing the feasibility for gorilla habituation, the World Wide Fund for Nature’s (WWF) Kudu—Zombo Program, in collaboration with the Ministry of Forestry and Wildlife of Cameroon (MINFOF), selected this site in order to develop a controlled ecotourism program for gorilla viewing. We began the preliminary phase of fieldwork in May 2011 with the priority of establishing an extensive trail system, developing and refining the habituation protocol and identifying gorilla groups within the study area. From March 2012, the trail of the focal group Akiba was followed with varying success from nest to nest. We rarely noted signs of other gorilla groups during our consecutive monitoring of the Akiba group. The group size was extrapolated based on nest counts and the average nest size was 32.4. We superimposed a 500 m x 500 m grid system on the map to allow comparative measurements of home range size. Home range, monthly range and the frequency of quadrant use by the Akiba group were calculated as the sum of all 500 m x 500 m quadrants entered. The “core area” was defined as the sum of quadrants that, in descending order of entry, cumulatively accounted for 75% of the group’s total quadrant entries. Daily path length (DPLs) was calculated from the maps by measuring the distance traveled between each consecutive nest site. From March 2012 through December 2014, the Akiba group was followed during 596 days, representing 74% of the effort days, when the teams were in the field (n=807 days). Group Akiba entered a total of 256 quadrants, resulting in a contiguous home range of 64 Km2 over three years and an average annual home range of 40.4 km2 with an annual home range of 39.8 km2 in 2012 (Y1), 45.5 km2 in 2013 (Y2) and 36 km2 in 2014 (Y3). For the total number of quadrants entered by Akiba, 62% was visited in Y1, 71% in Y2 and 56% in Y3. However, the size of the area used on a monthly basis was smaller averaging 11 Km2 (N = 29, range = 5.8 - 20.5, SD = 3.4). Of their total home range, the Akiba group intensely used an even smaller area, resulting in a core area of 3.5 Km2: 75% of the group’s visits were concentrated in 5.5% of the total home range visited throughout the study period. On a monthly basis, Akiba group moved in limited areas, with frequent visits outside in neighboring quadrants. For the total number of quadrants visited by the group during the period of study, it appears that the group concentrated its movements around the core area. In fact, 30% of the quadrants, including the core area, were visited in the three years, while 8% in Y1 and Y2, 5% in Y2 and Y3, 16% in Y1 and Y2. Only 18. 4% of quadrants were visited exclusively in Y2, 15% in Y3 and 7.4 in Y1. Throughout the study period, the mean daily path length (DPL) was 1600 m (N = 502, range = 180-5300 m, SD = 858). Interestingly, the group’s home range seemed to gradually decrease after the first year of follows and a mean monthly DPL of 1845 m (N=12, range =1408–2273 m, SD = ± 275 m) was recorded between March 2012 to February 2013 (P1) and a mean monthly DPL of 1268.3 m (N= 17, range = 958.4-1637 m, SD = ± 225 m) was recorded between March 2013 to December 2014 (P2), excluding August 2014). The difference between the mean monthly DPL during P1 and the mean monthly DPL during P2 is significant (P

The objectives were to investigate the effect of grain type and a Yucca schidigera extract based product (Grain Prep ® surfactant, GP) on ruminal fermentation and ammonia utilization by mixed microbial populations in vitro (Study 1) and ruminal degradation parameters of flaked corn DM and starch in sacco (Study 2). In Study 1, three 8 h incubations were completed with ruminal inoculum from two lactating dairy cows. A GP treated feed mixture, containing alfalfa hay, grain, and soybean meal, was incubated with buffer and ruminal inoculum. The grain part of the feed mixture was either corn (C) or 50:50 corn and high amylopectin barley grain (CB). GP was applied to the feed mix at 0, 60, and 120 ppm (as is basis). At time 0 h, the ammonia pool was labeled with 15 N . Inclusion of barley in the grain mixture increased media pH and decreased ammonia concentration (13.0 mM versus 12.7 mM, respectively), but the concentration of total and individual VFA, or incorporation of 15 N into bacterial protein, was not affected by grain type, and GP had no effect on ammonia or VFA concentrations. At the incubation end-point (8 h), GP tended ( P =0.11) to linearly increase the proportion of bacterial N originating from ammonia N. In Study 2, flaked corn grain produced in a commercial feed preparation facility was treated with GP at 22 ppm (as is basis; GP) or with water (control) and incubated in the rumen of three lactating Holstein cows for 0, 2, 4, 6, 16, 24, 48, and 72 h. Solubility of corn DM and starch increased with GP, compared to the control, by 16 and 18%, respectively. The proportion of potentially degradable DM and starch was reduced, and effective degradability of DM and starch were increased, by GP. A 50% substitution of corn by barley grain had a positive effect on ammonia N utilization in the rumen in vitro. The saponin based surfactant did not affect fermentation or ammonia utilization, but GP treated corn had a higher in sacco degradability of DM and starch in the rumen of lactating dairy cows, mostly due to an increase in the soluble/instantly degradable DM, or starch, with the GP treated corn grain.

We examined the influence of ecological (diet, swamp use, and rainfall) and social (intergroup interaction rate) factors on ranging behavior in one group of western gorillas (Gorilla gorilla gorilla) during a 16-month study. Relative to mountain gorillas, western gorillas live in habitats with reduced herb densities, more readily available fruit (from seasonal and rare fruit trees), and, at some sites, localized large open clearings (swamps and “bais”). Ranging behavior reflects these ecological differences. The daily path length (DPL) of western gorillas was longer (mean=2,014 m) than that of mountain gorillas, and was largely related to fruit acquisition. Swamp use occurred frequently (27% of days) and incurred a 50% increase in DPL, and 77% of the variation in monthly frequency of swamp use was explained by ripe fruit availability within the swamp, and not by the absence of resources outside the swamp. The annual home-range size was 15.4 km2. The western gorilla group foraged in larger areas each month, and reused them more frequently and consistently through time compared to mountain gorillas. In contrast to mountain gorillas, intergroup encounters occurred at least four times more frequently, were usually calm rather than aggressive, and had no consistent effect on DPL or monthly range size for one group of western gorillas. High genetic relatedness among at least some neighboring males [Bradley et al., Current Biology, in press] may help to explain these results, and raises intriguing questions about western gorilla social relationships. Am J Primatol 64:207–222, 2004. © 2004 Wiley-Liss, Inc.

This document is the final summary report of the Security Engineering and Educational Initiatives for critical Information Infrastructures research grant project. The report provides project descriptions fo the 3 major research tasks, highlights specific project accomplishments, identifies project deliverables and lists the 40 publications that were generated over the 3 years of the grant.

ONE OF THE musical treasures in the Huntington Library is the sole surviving copy of the first edition of Parthenia, published c. 1612-13 and containing keyboard music by Bull, Byrd and Gibbons. Apart from its intrinsic musical value, this collection is also important as the earliest example of engraved music printed in England, and its fine title-page has been reproduced many times.1 Because of its rarity this first edition is known to most scholars only from the facsimile published in 1942.2 It comes as a surprise, therefore, on looking at the original, to discover that the two pages on the reverse of the title-page and dedication that are blank in the facsimile are not blank at all, but contain several additional pieces entered by hand. These pieces are discussed below, but they are mentioned here not just as a cautionary tale for users of facsimiles but also to illustrate the fact that the owners of early printed music sometimes wrote additional pieces into their copies, and that these are often overlooked by scholars, who naturally tend to consult printed sources for the printed music that they contain. The added material may be on blank pages, like the Parthenia addenda, or on extra leaves bound with the book, or in any empty spaces on the printed pages. Sometimes the blank staves inserted by printers to fill up a page at the end of a piece were pressed into service. Writing music into printed books was a convenient way of preserving favourite pieces without going to the trouble and expense of starting a separate manuscript collection. Of course, this phenomenon is not unknown to musicologists, and it even earns a few lines in the article 'Sources, MS' in The New Grove.3 But until recently there has been no attempt to survey such additions in a systematic way. The present writer is now engaged on a study of manuscript additions in English printed music up to 1650. In a previous article I surveyed manuscript additions in two major collections in Washington, DC, the Library of Congress and the Folger Shakespeare Library.4 In this second article I cover other American libraries, thus completing the survey of the United States of America. Before doing so, it will be as well to set out more precisely than in the previous article the scone of the survev. With a few excentionq it takes in a11 mniizi nrintpd in

This paper describes a scheme for enhancing collaboration by tracking users in a 3-D space and mapping their identities to a shared user interface. Spatial identity information is defined to characterize and transfer user identity and spatial features between devices. It fills the gap between physical access control and data access control, where the spatial relationship between user and device is concerned.

L'A. examine des recueils de miscellani poetiques et de ballades et chansons parus entre 1557 et 1600, et pour beaucoup d'entres eux repris avec quelques variantes dans lEnglish Helicon, qui portent temoignage de la poesie elizabhetaine et du role de la musique dans la tradition pastorale anglaise

Redaction is the process of removing privileged information from a document before it is presented to other parties. This paper discusses the major issues associated with the redaction of digital information from electronic devices. A novel technique involving a tokenized representation is presented as a solution to digital redaction in legal proceedings.

A reliable method for the removal of selected information from digital devices remains an open problem. A solution is particularly necessary for the legal profession, where it is required to produce information to opposing counsel during the discovery portion of court proceedings. The method outlined in this paper provides an efficient and effective system for redacting digital information beyond recovery by conventional forensic techniques. This paper also describes the major obstacles to achieving practical and comprehensive redaction of digital information from electronic devices. Of particular issue is the lack of a rational process for systematically handling encoded, encrypted, or otherwise complex data objects. Applications for this method extend well beyond the courtroom-it can be used in government and business to remove classified and proprietary information from documents and records.

Habituation of western gorillas to human presence is generally an expensive, lengthy and difficult process. Here we describe the habituation process for two groups of western gorillas at the Mondika Research Center, with the hope that the lessons we learned will facilitate future gorilla studies. We expand upon earlier studies by describing the process through complete habituation for both males and females, and for more than one group. The major obstacle to habituation was developing sufficient tracking skills to follow gorilla trail on a daily basis. Once this was achieved, the silverback became semi-habituated (i.e. ignoring human presence during half of contacts) within a year, although the majority of group females continued to avoid humans. As female presence at contacts increased, a period of male recidivism followed, requiring an additional year before his complete habituation was reached. Habituating the females took longer than the male, but we found, contrary to earlier studies, that it consisted of the same stages, including avoidance, aggression, and curiosity before habituation. We compare results between groups and across sites and discuss how factors such as tracking abilities, group size and cohesion, population density and home range overlap, and the manner of approaching gorillas during contacts influence the habituation process.

The “two-bag” system, an adaptation of the euglycemic clamp technique, consists of simultaneous administration of 2 intravenous (IV) fluid bags of differing dextrose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. We sought to assess the benefits of the two-bag system in the initial acute emergency department management of children in diabetic ketoacidosis (DKA). Thirty-three children presenting to an urban pediatric emergency department in DKA were randomized into 2 groups: patients managed with the two-bag system and patients managed with the traditional “one-bag” system. Other aspects of the management were standardized. Outcome measures included rate of decline in serum glucose, rate of bicarbonate correction, time on IV insulin therapy, and response time for IV fluid changes. Study period was defined as time on IV insulin therapy. There were no differences between the 2 groups in demographic parameters, initial baseline metabolic parameters, or total time on IV insulin therapy. There were no differences between the groups in average rates of serum glucose decline: two-bag 33.1 mg/dL/hr (s.e. 5.57, 95% CI 22.2, 44), one-bag 30.2 mg/dL/hr (s.e. 5.72, 95% CI 19, 41.4); average rate of serum bicarbonate correction: two-bag 1.19 mEq/L/hr, one-bag 1.27 mEq/L/hr; or the average number of IV fluid bags used: two-bag 4.1 bags, one-bag 3.2 bags. However, there was a difference between the groups in regard to elapsed total time to make changes in the IV fluids: two-bag 1 minute, one-bag 42 minutes, (p < 0.001). The “two-bag” system enables a faster response time in making IV fluid therapy changes. This efficiency makes this system ideal for use in the emergency department.

We describe the resource availability and diet of western lowland gorillas (Gorilla gorilla gorilla) from a new study site in the Central African Republic and Republic of Congo based on 3 years of study. The results, based on 715 fecal samples and 617 days of feeding trails, were similar to those reported from three other sites, in spite of differences in herb and fruit availability. Staple foods (consumed year-round) included high-quality herbs (Haumania), swamp herbs (when present), and a minimal diversity of fruit. A variety of fruits (average of 3.5 species per day and 10 per month) were selectively consumed; gorillas ignored some common fruits and incorporated rare fruits to a degree higher than predicted based on availability. During periods of fruit abundance, fruit constituted most of the diet. When succulent fruits were unavailable, gorillas used low-quality herbs (i.e., low-protein), bark, and more fibrous fruits as fallback foods. Fibrous fruit species, such as Duboscia macrocarpa and Klainedoxa gabonensis, were particularly important to gorillas at Mondika and other sites as fallbacks. The densities of these two species are similar across sites for which data are available, in spite of major differences in forest structure, suggesting they may be key species in determining gorilla density. No sex difference in diet was detected. Such little variation in western lowland gorilla diet across sites and between sexes was unexpected and may partly reflect limitations of indirect sampling.