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Objective Cervical spine surgeries for degenerative conditions are rapidly increasing. Cervical post-surgery syndrome consisting of chronic pain, adjacent segment disease, recurrent disc herniation, facet joint pain, and/or epidural scarring is common. Repeat surgery is regularly recommended, though patients are often unable to undergo or decline further surgery. Manual therapy is included in clinical practice guidelines for neck pain and related disorders, however clinical guidance for utilization of manual therapy in adults with prior cervical spine surgery is lacking. This study aimed to synthesize available literature and characterize outcomes and adverse events for manual therapy interventions in adults with prior cervical spine surgery due to degenerative conditions. Methods Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews was followed. PubMed, Cumulative Index of Nursing and Allied Health Literature, physiotherapy evidence database, and Index to Chiropractic Literature were searched from inception through October 2021. English-language literature comprised of randomized clinical trials (RCT), case–control, cohort, and case report designs were included. Adults undergoing manual therapy, with or without combination of other interventions, with prior cervical spine surgery due to degenerative conditions were included. Results Twelve articles were identified, including 10 case reports, 1 low-quality RCT, and 1 acceptable-quality RCT. Eight case reports described 9 patients with history of fusion surgery. Two case reports described 2 patients with history of discectomy. One case report described one patient with separate operations of a discectomy at one level and a fusion at another level. One case report described 2 patients with history of cervical disc replacement surgery. The two RCTs included 63 and 86 participants, respectively. Use of manual joint mobilization/manipulation, table/instrument assisted mobilization/manipulation, and multimodal interventions were described in eligible studies. Favorable clinical outcomes were reported in 10 studies. Six case reports/series involving 8 patients described use of unclassified forms of manual therapy. Eight studies described the use of multimodal interventions along with manual therapy. One study described high patient satisfaction. Two studies, accounting for 3 patients, reported serious adverse events. Conclusions There is a lack of literature informing evidence related to clinical outcomes, patient satisfaction, and adverse events associated with manual therapy for patients with prior cervical spine surgery due to degenerative conditions. High-quality studies of higher-level hierarchical study design are needed to understand the clinical utility and safety profile of manual therapy for this population.

This piece reflects rather admiringly on the methods and conceptual framework of Martin Krygier’s various contributions to our understanding of the rule of law. It examines his use of the idea of the telos of the rule of law, contrasting it with the approaches of theorists who seek to analyse the essence or ‘anatomy’ of the rule of law idea or of law itself. It then examines his notion of how the rule of law should be understood as the tempering of power. Largely agreeing with Krygier’s conception, the essay nevertheless suggests that the project might be improved by focusing on the telos or social functions of law rather than those claimed to be immanent in the rule of law. It also nudges Krygier to deepen the metaphor of tempering by clarifying the relationship between the rule of law and other key concepts such as liberty, human rights, and democracy.

Written constitutions have often been viewed as a bridle for unchecked political majoritarianism, as a restraint on government, and hence as a limiting device rather than form of democratic political expression. Breaking with that tradition, this article sets out a democratic case for a written constitution and contrasts it with the rights-based and clarity-based cases. It then proceeds to show why the case against written constitutions – which is broadly located in a conservative critique, an anti-rationalist critique and an anti-judicialisation critique – is misguided. Nevertheless, a democratic case for a written constitution necessarily raises challenging questions about how the constitution would be enacted, and how rigidly entrenched it should be. In relation to the former, the author argues for a constituent assembly consisting of party and direct citizen representation. As for the latter, he defends a model of entrenchment that permits amendment through a simple majoritarian parliamentary procedure in conjunction with a referendum, and, most controversially, a provision requiring a new constitutional convention about once in a generation. This is the type of democratic constitution, in the author’s view, that accommodates the need for the United Kingdom constitutional order to take both rights and democracy seriously.

Critical reflection and transformative learning theories generally place emphasis on individual change, giving little consideration to the organizational and societal aspects. Consequently, it is individual and not collective dilemmas that are reinforced in higher education. However, a call for an education initiative for sustainable development requires a shift in focus. This article considers transformative learning for sustainability within the context of an American university whose mission encompasses being a center for excellence in transformative teaching and learning. The analysis is divided into three parts as follows: The organizing reflection process of the university; b) how professors concretize collective dilemma in their teaching; and c) student engagement levels in collective dilemmas with regard to the tenets of service learning and civic engagement. Despite its unique trajectory, this qualitative case study presents an argument – in order to achieve a paradigmatic shift toward sustainability, we need to create an organizing process of reflection to address collective dilemmas and engage faculty and students in a continuous and institutionalized transformative learning process. The results show the potential and limitations of the analyzed experience; further, it addresses the theoretical implications and practical insights for fostering critical reflection and transformative learning toward sustainability.

With the elimination of HCFC-141b in the United States over the next few years, appliance manufacturers have two major categories of blowing agents to choose from as potential replacements. Hydrocarbons offer low raw material costs, high capital costs and a moderate to high cabinet energy consumption. A large amount of work has been performed outside the United States on hydrocarbon usage, with successful manufacturing implementation. However, it appears that the combination of cabinet energy penalties, capital conversion costs and flammability concerns are currently detouring appliance manufacturers from choosing this route for the next blowing agent in the U.S. The second major option is gaseous blowing agents, either Hydrofluorocarbons (HFC’s) or Hydrochlorofluorocarbons (HCFC’s). The most common of which include HFC-245fa, HFC-365mfc, HCFC-142b, HCFC-22 and HFC-134a. Of the potential HCFC-141b replacements, many appliance manufacturers have chosen to use HFC-245fa since this yields the lowest cabinet energy consumption. The biggest drawback to HFC-245fa has been the cost of the material and the perceived difficulty in passing the increased costs along to the consumer in the appliance market. A blend of HCFC-142b/HCFC-22 offers another option with similar k-factor and factory costs, but a significantly lower raw material cost at the head. The major problem with this blend is its timeline for acceptance. Depending on the EPA’s latest ruling, the phase out date for these materials could potentially move from 2010 to 2005 in the United States. Another option is HFC-134a, as it produces a moderate cost part but at a penalty in cabinet energy consumption. Recent developments using HFC-134a provide data that address these two shortcomings prompting another look at this potential blowing agent. A new polyol was developed which significantly improved the thermal conductivity of foams produced using HFC-134a. The new polyol is responsible for lowering thermal conductivity of the foam from 0.152 to 0.147 btu. This k-factor improvement could provide near equivalent cabinet energy performance to a hydrocarbon based appliance system without the flammability issue. Another option recently identified is a reduced cost HFC-134a system. This system has both a lower head cost, due to a reduced level of the HFC-134a, and a reduced in-place density, while maintaining the k-factor of the system. This combination reduces the overall cost of the system by greater than 10%. Both of these improvements make foams blown with HFC-134a more attractive than in the past.

Delegated legislation is produced by the executive branch of government, usually under powers conferred by legislatures. Such powers have provoked controversy in most contemporary democracies. There is a widely perceived need to bolster the democratic legitimacy of law produced in this way, either through greater legislative oversight or enhanced participation, or both. This chapter explores how the organically evolved UK constitution has struggled to meet this challenge since the outset of the twentieth century. It examines how the powers to adopt delegated legislation arose, the constitutional tensions it produced, and how that prehistory relates to the dramatic resort to such powers in recent legislation adopted to facilitate the UK’s departure from the European Union. More specifically, it surveys the experience of making and laying delegated legislation before Parliament, and the track record of parliamentary scrutiny, before considering how that background may play an important role in how Brexit-related delegated legislation may fare in legal challenges in the coming years.

This introductory chapter provides an overview of a collection of essays exploring the foundations and future of UK and EU public law. The collection of chapters in this book is inspired by the work of Professor Paul Craig, University of Oxford. It explores six thematic building blocks of public law: theory, case law, legislation, institutions, process, and constitutions. This chapter provides an introduction to each of these foundations and comments on the questions and issues raised by the distinguished group of jurists gathered in the volume as they reflect on the nature and future directions of public law.

Introduction: The use of genomic tests for the prediction of breast cancer recurrence is becoming more common. MammaPrint® (MP, Agendia Inc.) is a 70-gene microarray assay designed to assess the 10-year risk of recurrence in an untreated population that was not selected for ER/HER2 results. The Oncotype DX® Recurrence Score® (RS, Genomic Health, Inc.) is a 21-gene RT-PCR assay that is clinically validated to predict the 10-year risk of distant recurrence in ER+ patients treated with Tamoxifen. MammoStrat® (MS, Clarient, Inc.) is an IHC assay that uses 5 antibodies and has been validated in a similar population as RS. Several recent reports show that these assays classify patients differently with significant discordances for all risk groups (Shivers, et al., SABCS 2013; Denduluri, et al., ASCO Breast 2011; Poulet, et al., SABCS 2012; Schneider, et al., ASCO 2013). The present study is an analysis of long-term follow-up in a cohort of patients who have results for all three of these risk-stratifying assays side by side in the same samples. Methods: Patients with ER+ N0-N1 early-stage breast cancer with an MP result obtained as part of their routine clinical care were identified at the University of South Florida (USF, N=65) and Morton Plant Hospital (N=83). After local IRB approval, slides and/or blocks were cut and de-identified at USF and sent to Genomic Health and Clarient for blinded testing. Clinicopathological features were also reviewed by 3 breast pathologists. Results: 148 patients with an MP result had tissue available to send for RS and MS assays. These patients had a median age of 62 years; median tumor size 1.8 cm; 9% low grade, 59% intermediate grade and 32% high grade. In our previous analysis of this study, of 148 patients with MP results, 53% were low risk and 47% were high risk. Of 135 samples that yielded enough RNA to produce an RS result, 53% were low risk, 26% were intermediate risk and 21% were high risk. Of 129 samples that yielded an MS result, 44% were low risk, 28% were moderate risk and 28% were high risk. Of 121 patients with results for all 3 assays, only 22% were concordant for low risk and 9% were concordant for high risk across all 3 assays. Overall, 30% of cases showed a major discordance such as low risk for one assay and high risk for another. After median follow-up of 54 months, 9 patients have had a distant metastasis and/or 8 patients have died (11 patients total). One patient who had bone metastasis and died had been classified as low risk by all 3 assays. Three patients with distant metastases had a major discordance between assays, with two high risk and one low risk result. Seven patients were classified as high or intermediate/moderate risk by all 3 assays. Conclusions: This direct comparison demonstrates that although the assays classify a large proportion of patients differently, the patients who ended up with a distant metastasis and/or died of breast cancer had been classified as high risk by at least two of the three assays. This study has important clinical implications since these assays are used to help make treatment decisions regarding which patients might benefit from chemotherapy. Citation Format: Shivers SC, Russell S, Blumencrancz L, Mehindru A, Acs G, Ellis D, Vrcelj V, Zanchi A, Blumencrancz PW, Carter E, King J, Cox CE. Long-term follow-up of early stage breast cancer patients with results of MammaPrint®, Oncotype DX® and MammoStrat® risk classification assays [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-45.

Written constitutions have often been viewed as the bridle for unchecked political majoritarianism, as a restraint on government, and hence as a limiting device rather than a form of democratic political expression. Breaking with that tradition, this article sets out a democratic case for a written constitution and contrasts it with the rights-based and clarity-based cases. It then proceeds to show why the case against written constitutions—which are broadly located in a conservative critique, an anti-rationalist critique and an anti-judicialization critique—are misguided. Nevertheless, a democratic case for a written constitution necessarily raises challenging questions about how the constitution will be enacted, and how rigidly entrenched it should be. Answers to these questions are presented in Parts III and IV of the article. In the former, it is argued for a constituent assembly consisting of party and direct citizen representation. In the latter, defence of a model of entrenchment is discussed that permits amendment through a simple majoritarian parliamentary procedure in conjunction with a referendum, and, most controversially, a provision requiring a new constitutional convention about once in a generation. This is the type of democratic constitution, in the author’s view, that accommodates the need for a liberal egalitarian constitutional order that takes both rights and democracy seriously.

In order to present an overview of American Indians and Alaska Natives mental health issues, the authors have purposefully avoided specific examples or generalizable guidelines that would mislead the readers due to the extreme cultural and historical differences that comprise the many American Indian and Alaska Native nations. It is also important to note that in the context of diversity, American Indian and Alaska Native identity is defined politically due to their collective history of being citizens of sovereign nations, not solely by racial, ethnic, or cultural terms. The chapter assesses the current knowledge available that describes mental health processes occurring among American Indians and Alaska Natives. The inquiry further clarifies the structure and function of mental health programs that have been established. We conclude that there is a need for a revision in a basic conceptualization of the research models and the types of data analysis that are or have been used, as well as their subsequent utilization.

The Challenge Finding a sense of authentic self as an institution, a true sense of mission, and the means to live that mission were the central focus of a strategic planning process addressed by the University of Central Oklahoma about fifteen years ago. As the institution grew within a metropolitan-serving mission, the goal to transform students from adolescents to adults and find new potential in their lives led to an exciting journey that is still vibrant and relevant today. Potential Consequences The theoretical base provided within transformative learning has helped students, staff, and faculty align efforts. Description This case study provides replicable processes and specifics that may help others find a clearer path for fulfilling their mission. The study describes how the University of Central Oklahoma’s (UCO’s) transformative learning focus coalesced and became the point of distinction for a UCO education, helping to ensure that all activity supported our mission—helping students learn. Reflection The compelling, lived sense of mission developed from the initial strategic planning process has helped to strengthen the learner-centered culture of the campus while providing a structure that facilitates implementation and assessment.

Deliberative democratic theory emphasises the importance of informed and reflective discussion and persuasion in political decision-making. The theory has important implications for constitutionalism - and vice versa - as constitutional laws increasingly shape and constrain political decisions. The full range of these implications has not been explored in the political and constitutional literatures to date. This unique Handbook establishes the parameters of the field of deliberative constitutionalism, which bridges deliberative democracy with constitutional theory and practice. Drawing on contributions from world-leading authors, this volume will serve as the international reference point on deliberation as a foundational value in constitutional law, and will be an indispensable resource for scholars, students and practitioners interested in the vital and complex links between democratic deliberation and constitutionalism.

Background and Objectives: The standard preoperative technique for localizing non-palpable breast lesions is wire localization (WL). Radioactive seed localization (RSL) has been described as an alternative approach to address the number of clear disadvantages associated with WL. Yet, despite its proven advantages, the adoption of RSL has been impacted by considerable regulatory requirements for the handling of radioactive materials. To advance the progress made with RSL and eliminate the issues associated with radioactive components, the SAVI Scout® surgical guidance system has been developed. The SAVI Scout surgical guidance system is an FDA-cleared medical device that utilizes passive non-radioactive electromagnetic wave technology to provide real-time guidance during excisional breast procedures. The purpose of this pilot study is to determine the safety and efficacy of the SAVI Scout system in localizing and directing the removal of non-palpable breast lesions during excisional biopsy and lumpectomy procedures. The preliminary results from two institutions are reported. Materials and Methods: Following a feasibility study using the SAVI Scout system in resected breast tissues ex vivo, Institutional Review Board approval was granted for both institutions for women with a non-palpable breast lesion requiring preoperative localization for excision. Participating patients underwent localization and excision with the SAVI Scout system, which consists of an electromagnetic wave reflective device (reflector), handpiece and console. Using mammographic or ultrasound guidance, the reflector was placed percutaneously up to 7 days prior to the scheduled excisional procedure. At surgical excision, the surgeon used the SAVI Scout handpiece to locate the reflector, which was removed along with the surrounding breast tissue. The console provides audible feedback of reflector proximity to the handpiece. Successful reflector placement, localization and retrieval were the primary endpoints. Results: After the first training case (data not used), a total of 17 patients have participated in the study to date. The reflectors were successfully placed with mammographic guidance in 9/9 patients and with ultrasound guidance in 8/8 patients. Reflectors were placed an average of 1.7 days (range 0-6 days) before surgery. Five patients underwent excisional biopsy and 12 patients had a lumpectomy. The intended lesion and reflector were successfully removed in 17/17 patients. Reflector migration did not occur and no adverse events occurred. Of the 14 patients in which final pathology is currently available, 6 patients had no invasive or in situ carcinoma identified, 4 had no tumor in the excision, and 3/4 patients with tumor had clear margins. One patient had a focally positive margin and was recommended for re-excision. Conclusions: The preliminary data show the SAVI Scout system to be a safe and effective tool for the localization of non-palpable breast lesions. Ongoing accrual to this pilot study will validate these findings with planned enrollment of a total of additional 50 patients in the next 60 days at up to 3 additional sites. Citation Format: Charles E Cox, Melissa Themar-Geck, Ronald Prati, Michelle Jung, Jeff King, Steven C Shivers. Pilot study of a passive non-radioactive electromagnetic wave technology to localize non-palpable breast lesions [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-16-10.

It is often assumed that the United States of America is exceptional in according poor legal status to socio-economic rights, and that its judges show a distinct reticence towards enforcing positive entitlements. This article challenges this view by identifying two ironies in the American brand of exceptionalism about social rights. It argues that, notwithstanding America's exceptionally low public commitment to social spending, its judges have often enforced positive duties to provide social services in a manner that is in fact strikingly interventionist by international comparison. It also shows how this more robust involvement in welfare rights adjudication has often not produced the results desired by advocates of social rights, and may even in some cases have been regressive. The article explores the causes and consequences of the experience, and suggests what lessons it may hold out for other countries.

According to the doctrine of odious debt, loans which are knowingly provided to subjugate or defraud the population of a debtor state are not legally binding against that state under international law. Breaking with widespread scepticism, this groundbreaking book reaffirms the original doctrine through a meticulous and definitive examination of state practice and legal history. It restates the doctrine by introducing a new classification of odious debts and defines 'odiousness' by reference to the current, much more determinate and litigated framework of existing public international law. Acknowledging that much of sovereign debt is now governed by the private law of New York and England, Jeff King explores how 'odious debts' in international law should also be regarded as contrary to public policy in private law. This book is essential reading for practising lawyers, scholars, and development and human rights workers.

Objectives This study was a multicenter evaluation of the SAVI SCOUT(®) breast localization and surgical guidance system using micro-impulse radar technology for the removal of nonpalpable breast lesions. The study was designed to validate the results of a recent 50-patient pilot study in a larger multi-institution trial. The primary endpoints were the rates of successful reflector placement, localization, and removal. Methods This multicenter, prospective trial enrolled patients scheduled to have excisional biopsy or breast-conserving surgery of a nonpalpable breast lesion. From March to November 2015, 154 patients were consented and evaluated by 20 radiologists and 16 surgeons at 11 participating centers. Patients had SCOUT(®) reflectors placed up to 7 days before surgery, and placement was confirmed by mammography or ultrasonography. Implanted reflectors were detected by the SCOUT(®) handpiece and console. Presence of the reflector in the excised surgical specimen was confirmed radiographically, and specimens were sent for routine pathology. Results SCOUT(®) reflectors were successfully placed in 153 of 154 patients. In one case, the reflector was placed at a distance from the target that required a wire to be placed. All 154 lesions and reflectors were successfully removed during surgery. For 101 patients with a preoperative diagnosis of cancer, 86 (85.1 %) had clear margins, and 17 (16.8 %) patients required margin reexcision. Conclusions SCOUT(®) provides a reliable and effective alternative method for the localization and surgical excision of nonpalpable breast lesions using no wires or radioactive materials, with excellent patient, radiologist, and surgeon acceptance.

n Abstract: As the wave of the baby boomers shifts the age demographic of patients, the current surgical management of breast cancer in elderly women (‡70 years of age) becomes relevant because deviation from standard treatment often occurs in this group. The purpose of this study was to determine the operative mortality when treated with standard surgical procedures and to investigate trends in the surgical management of breast cancer in the elderly. A total of 5,235 patients undergoing either mastectomy or breast conservation surgery (BCS) for invasive and ductal carcinoma in situ (DCIS) were identified in a retrospective review of a prospectively accrued data base between the years of 1994 and 2007 at the Moffitt Cancer Center. Of the 5,235 patients, 1,028 (20%) patients were ‡70 years of age. The 30-day and 90-day mortality in the elderly group (age ‡70 years) was 0.2% (95% CI 0.02‐0.7%) and 0.7% (95% CI 0.3‐1.4%), respectively. The 30-day and 90-day mortality among patients

We present surgical modifications that improved the outcome of cutaneous ureterostomies.A total of 310 patients with a median age of 71 years (range 38 to 88) underwent cutaneous ureterostomy as urinary diversion. Median followup was 25 months (range 1 to 172). The technique included 1) transposition of the left ureter above the inferior mesenteric artery, 2) mobilization of the ileocecal segment with repositioning above each terminal ureter, 3) abdominal wall hiatus fixation with 4 angle sutures and 4) YV plasty of the ureters with edge-to-edge anastomosis for stomal creation. In the 161 group 1 patients (59.1%) the Double-J® stents were removed in less than 3 months. Stents remained longer than 3 months in the 111 group 2 patients (40.8%).Of the 272 patients ureteral obstruction developed in 36 (13.2%). Ureteral obstruction was on the right side in 6 patients (2.2%), on the left side in 27 (9.9%) and bilateral in 3 (1.1%). Ureteral obstruction was treated with restenting in 20 cases (55.4%), stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%). Ureteral obstruction developed on the right side, on the left side and bilaterally in 3.7%, 13.7% and 1.82% of the patients in group 1, and in 0%, 4.5% and 0%, respectively, of those in group 2. Stenting time impacted only the left ureter with less obstruction in the group with longer stent placement (greater than 3 months) (p = 0.01).As with other types of urinary diversion, left ureteral obstruction is a common complication of bilateral cutaneous ureterostomies. Long-term stenting for greater than 3 months and the applied surgical modifications improved the clinical outcome of this type of urinary diversion.