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Esophageal intramural pseudodiverticulosis (EIP) is a rare condition characterized by outpouchings from the esophageal lumen into the outer esophageal wall. It can lead to complications such as esophageal strictures presenting as dysphagia and esophagobronchial fistula (EBF) presenting as recurrent aspiration pneumonia. Only 1 other report of EIP with EBF has been reported in the literature. EIP itself is typically managed medically while a complication such as EBF, on the other hand, elicits far more invasive approaches in the form of open surgical intervention. We present the case of a 50 year-old male newly diagnosed with EIP complicated by EBF who was palliated with esophageal stenting. Upper endoscopy with esophageal stent placement offers a safe, feasible, and non-operative therapy for EIP and EBF.

Background: Point-of-care ultrasound (POCUS) has been reported as a valuable tool for bedside diagnoses of abdominal Aortic Aneurysms (AAA). However, no data exist regarding POCUS in measuring follow-up AAA diameter studies in patients with existing AAAs. The purpose of this study was to determine the variability of aortic measurements performed by a non-physician using POCUS vs standard of care (SOC) measurements by a registered vascular technologist or an abdominal/pelvic CT scan. Methods: A prospective observational ultrasound study was performed from 1/1/2019 to 3/31/2021 on patients with a diagnosis of an AAA (≥3.0 cm). A research coordinator (non-physician) underwent a 3-hour training session in ultrasound operation and basic human anatomy to measure AAA diameter. The maximum aortic diameter was documented and compared to measurements obtained by SOC ultrasonography or CT scan. The POCUS and SOC ultrasounds were separated by no more than 90 days. Clinical risk factors including age, race, body mass index, coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular disease, diabetes, and current smoking were also collected. Results: Eighty-one patients (mean age: 73.6 ± 5.8 years, body mass index: 29.5 ± 6.2 kg/m2) were being followed in a vascular clinic and underwent both a POCUS and SOC ultrasounds. One indeterminant study was reported in identifying an AAA diagnosis, due to an overlying colostomy. The average follow-up time from initial screening aortic diameter to POCUS was 4.4 ± 3.7 years. Overall average aortic diameter measurements obtained were 4.1 ± .9 cm for POCUS and 4.0 ± .9 cm for SOC (P = NS). Average difference in aortic measurement for POCUS and SOC was −.1 ± .3 cm. Conclusions: POCUS is an accurate method to follow AAA diameter in patients. POCUS could improve patient follow up with AAA diameter measurements, streamline care and reduce overall burden for both patients and Radiology Departments in assessing follow up AAA diameters.

OBJECTIVE: In 2007, Medicare established ultrasound screening guidelines to identify patients at risk for abdominal aortic aneurysm (AAA). The purpose of this study was to evaluate AAA diagnosis rates and compliance with screening during 10 years (2007–2016) of the Screen for Abdominal Aortic Aneurysms Very Efficiently Act implementation within a regional health care system. METHODS: A retrospective chart review of all patients screened for AAA from 2007 to 2016 within a regional Veterans Affairs health care system was conducted. Screening criteria were men 65 to 75 years of age who smoked a minimum of 100 cigarettes in their lifetime. An AAA was defined as a maximum aortic diameter ≥3 cm. A comparison was made of the AAA diagnosis rate and clinical adherence rate of screening criteria between the first 5 years and total years evaluated. AAA-related mortality was identified by using terminal diagnosis notes or autopsy reports. All data were recorded by August 31, 2017. RESULTS: A total of 19,649 patients (70.7 ± 4.8 years of age, mean ± standard deviation) were screened from January 1, 2007, to December 31, 2016. There were 9916 new patients screened from 2012 to 2016. A total of 1232 aneurysms (6.3% total patients) were identified during the 10-year period. The overall AAA diagnosis rate has declined from 7.2% in the first 5 years to 6.3% in 10 years (13.5% decrease; P < .01). There were 66 patients found with AAA ≥5.5 cm (5.3% of AAAs), and 54 of these patients received successful elective repair. A total of 2321 patients died (11.8%) and 6 deaths were suspected AAA ruptures (0.03%) within the analysis period. A total of 3680 patients screened (18.7%) did not meet screening criteria: 593 patients were 75 years of age, and 59 patients were women. This rate has declined from 28.2% within the first 5 years to 18.7% overall in 10 years (33.7% decrease; P < .01). The compliance of screened patients using screening criteria improved significantly from 61.7% in 2007 to 92.4% in 2016 (P < .01). The overall compliance rate since implementation of the screening program during the past 10 years is 81.3%. CONCLUSIONS: The overall 10-year rate of AAA diagnosis is 6.3%. There are more smaller aneurysms (3.0–4.4 cm) detected and fewer large AAAs ≥5.5 cm in the last 5 years compared with the first 5 years of the screening program. The overall AAA-related mortality rate of all screened patients is 0.03%. There were 54 patients with AAA ≥5.5 cm who underwent successful elective repair resulting from the AAA screening program. The overall compliance of screened patients using screening criteria improved significantly from 61.7% in 2007 to 81.3% since implementation of the screening program during the past 10 years.

Background Abdominal aortic aneurysm (AAA) screening has demonstrated to be cost-effective in reducing AAA-related morbidity and all-cause mortality. However, the downstream care costs of an implemented AAA screening in clinical practice have not been reported. The purpose of this study is to determine direct regional Department of Veterans Affairs (VA) costs in implementing and sustaining an AAA screening program over a 10-year period. Methods A cost data analysis (adjusted to 2021 U.S. dollars) of an AAA screening program was conducted from 2007 to 2016, where 19,649 veteran patients aged 65-75 with a smoking history were screened at a regional VA medical center. A decision support system tracked direct and indirect encounter costs from Medicare billing codes associated with AAA care. Costs from a patient’s initial screening, follow-up imaging, to AAA repair or at the end of the analysis period, March 31, 2021, were recorded. Costs for AAA repairs outside the VA system were also tracked. Results A total of 1,183 patients screened were identified with an AAA ≥3.0 cm without history of repair. Estimated screening costs were $2.8 million or $280,000 annually ($143/screening) in the care of 19,649 screened patients. There were 221 patients who required repair (143 repairs in VA, 78 repairs outside VA). The average cost of elective endovascular repair was $43,021 and that of open repair was $49,871. The total costs for all elective repairs were $9,692,591. Screening, implementation, maintenance, and surgical repair cost involved in the management of patients with AAA disease was $13.7 million, with $10,686 per life-year lived after repair (5.8 ± 3.5 mean life-years) and $490 per life-year lived after screening (6.9 ± 3.5 mean life-years) for all patients screened. There were 13 deaths of unknown causes and one patient with a ruptured AAA that required emergency repair at a cost of $124,392. CONCLUSIONS Despite known limitations, the implementation of an AAA ultrasound screening program is feasible, cost-effective, and a worthwhile endeavor.

Fifth-grade students from two urban school districts completed an integrated unit on wolves. Classes received either direct instruction (DI) or collaborative group work (CG). Analysis of reasoning in classroom talk indicated that CG students more often used connective and contrastive words and the performative verb phrases I think and I know than DI students. Analysis of written arguments about a controversial question raised by the unit indicated that, compared to DI students, CG students included more logical connectives, contrastives, and performative verbs, produced fewer unelaborated arguments, more frequently asked rhetorical questions, and more often considered both sides of the policy issue. The study provides fresh insight into how instructional frameworks can affect how students view themselves as writers in relation to a prospective audience.

Collaborative argumentation can enhance students’ reasoning, content learning, and interest, but these benefits are contingent upon high levels of student engagement. This study examined the influence of teacher framing strategies that provided autonomy support and structure on students’ engagement during Collaborative Reasoning discussions through the lens of self-determination theory. Transcripts and video recordings of 52 discussions in six fourth-grade classrooms were analyzed for (a) teacher framing strategies used to communicate structure and autonomy support for the upcoming discussion, (b) teacher scaffolding strategies used to enhance thinking and interaction during the discussion, and (c) students’ cognitive-behavioral and social-emotional engagement during the discussion. The findings identified certain teacher framing and teacher scaffolding strategies that had a significant influence on student engagement. Notably, one teacher framing strategy, collaborative rule-setting, predicted higher cognitive-behavioral and social-emotional engagement after controlling for the effects of teacher scaffolding during the discussions. The evidence suggests that providing task structure in autonomy-supportive ways can enhance student engagement during collaborative argumentation.

The goal of this study was to evaluate instructional influences on the storytelling of English Language Learners (ELLs). Participants were 210 fifth-grade Spanish-speaking ELLs (mean age = 10.8) from schools serving low-income neighborhoods in the Midwest of the United States. They received a six-week socio-scientific unit involving collaborative group work or direct instruction, or were in control classes that continued regular instruction. In an essay to evaluate mastery of the instructional unit, students from collaborative groups produced significantly longer chains of reasoning (more chains with 5–8 links) than direct instruction students (more chains with 3 or 4 links), while control students were unable to display any extended reasoning. Following the unit, students individually told a story prompted by a wordless picture book to evaluate their oral English proficiency. The stories were coded for several features of basic language production, story completeness, and multi-link causal reasoning. The results indicated that students who received the socio-scientific unit told stories with more complicated syntax than the control students, while no difference in complexity of syntax was observed between students from the two instructional conditions. Stories told by students who had participated in collaborative groups contained significantly more elaboration of essential story elements than the stories produced by direct instruction students or control students. Students who had interacted in collaborative groups also generated significantly longer chains of reasoning (many 5–7 link chains) connecting story events than students in the other two conditions (mostly 1 or 2 link chains). The results suggest collaborative group work may be an effective instructional approach to foster ELLs' communicative competence and causal reasoning.

Social skills involved in leadership were examined in a problem-solving activity in which 252 Chinese 5th-graders worked in small groups on a spatial-reasoning puzzle. Results showed that students who engaged in peer-managed small-group discussions of stories prior to problem solving produced significantly better solutions and initiated significantly more effective leadership than control students. A mediation analysis suggested that it was because of effective leadership that groups who had experienced discussions achieved better problem solutions.

ObjectiveCurrent abdominal aortic aneurysm (AAA) surveillance guidelines lack any follow-up recommendations after initial abdominal aortic screening diameter of less than 3.0cm. Some reports have demonstrated patients with late AAA formation and late ruptures after initial ultrasound screening detection of patients with an aortic diameter of 2.5 to 2.9cm (ectatic aorta). The purpose of this study was to determine ectatic aorta prevalence, AAA development, rupture risk, and risk factor profile in patients with detected ectatic aortas in a AAA screening program.MethodsA retrospective chart review of all patients screened for AAA from January 1, 2007, to December 31, 2016, within a regional health care system was conducted. Screening criteria were men 65 to 75years of age that smoked a minimum of 100 cigarettes in their lifetime. An ectatic aorta was defined as a maximum aortic diameter from 2.5 to 2.9cm. An AAA was defined as an aortic diameter of 3cm or greater. Patients screened with ectatic aortas who had subsequent follow-up imaging of the aorta with a minimum of 1-year follow-up were analyzed for associated clinical and cardiovascular risk factors. All data were collected through December 3,/2018. A logistic regression of statistically significant variables from univariate and χ2 analyses were performed to identify risks associated with the development of AAA from an initially diagnosed ectatic aorta. A Cox proportional hazard model was used to assess survival data. A P value of less than .05 was considered statistically significant.ResultsFrom a screening pool of 19,649 patients, 3205 (16.3%) with a mean age of 72.1± 5.3years were identified to have an ectatic aorta from January 1, 2007, to December 31, 2016. The average screening ectatic aortic diameter was 2.6± 0.1cm. There were 672 patients (21.0%) with a mean age of 73.0± 5.7years who received subsequent imaging for other clinical indications and 193 of these patients (28.7%) with ectatic aortas developed an AAA from the last follow-up scan (4.2± 2.5years). The average observation length of all patients was 6.4± 2.9years. No ruptures were reported, but 27.8% of deaths were of unknown cause. One patient had aortic growth to 5.5cm or greater (0.15%). Larger initial screening diameter (P< .01), presence of chronic obstructive pulmonary disease (P< .01), and active smoking (P= .01) were associated with AAA development.ConclusionsPatients with diagnosed ectatic aortas from screening who are active smokers or have chronic obstructive pulmonary disease are likely to develop an AAA.

This study investigated whether orthographic consistency and individual learner differences including working memory (WM), first language (L1) background, and second language (L2) proficiency affect Chinese L2 learners’ literacy acquisition. Seventy American college students in beginning or intermediate Chinese classes participated in a character learning-and-reading experiment, and completed WM tasks and an L2 proficiency test. In the learning phase of the experiment, participants were asked to master 18 unfamiliar Chinese characters of three levels of consistency—consistent, semi-consistent, and inconsistent. Then in the transfer test of the experiment, participants read 60 novel, artificial characters analogous to the learned characters. Significant consistency effects for learning and reading new characters were found, with no effects of WM and L1. In particular, an interaction effect between consistency and L2 proficiency found in the learning phase indicated that participants with higher L2 proficiency learned the fully consistent characters better and faster than those with lower proficiency. These results suggest that L2 proficiency facilitates awareness of consistency, enabling learners to learn novel characters faster and more accurately. The findings of this study are compared with the character acquisition of beginning L1 Chinese readers and with L2 learners’ acquisition of other types of characters.

Instructional influences on productive use of academic vocabulary were investigated among 460 mostly African American and Latina/o fifth graders from 36 classrooms in eight public schools serving low-income families. Students received a 6-week unit on wolf management involving collaborative group work (CG) or direct instruction (DI). The big question that students tried to answer during the unit was whether a community should be permitted to destroy a pack of wolves. In an individual oral interview about an analogue to the wolf question, whether whaling should be allowed, both CG and DI students used more general and domain-specific academic vocabulary from the Wolf Unit than uninstructed control students. CG students used more general academic vocabulary in the whale interview than DI students, and this was mediated by the CG students' greater use of general academic vocabulary in classroom dialogue during the Wolf Unit. These results suggest that CG is an effective instructional approach to promote acqu...

This research examined the influence of contrasting instructional approaches on children’s decision-making competence. A total of 764 fifth graders, mostly African Americans and Hispanic Americans, from 36 classrooms in eight public schools serving children from low-income families completed a six-week unit on wolf management, using either direct instruction or collaborative groups, or were waited-listed controls. Analysis of children’s essays on a topic unrelated to wolves revealed that students who participated in collaborative groups but not students who received direct instruction acquired decision-making strategies and transferred them to the novel task. Students in collaborative group work classrooms wrote essays that were significantly better than essays of students from direct instruction classrooms in each of the three aspects of decision making that were evaluated—considering more than one side of a dilemma, comprehensiveness of reasons, and weighing the importance of reasons. In contrast, direct instruction students performed no better than uninstructed control students.

This chapter explains schema theory, give illustrations of the supporting evidence, and suggest applications to classroom teaching and the design of instructional materials. It urges publishers to include teaching suggestions in manuals designed to help children activate relevant knowledge before reading. The chapter explains the teachers' manuals accompanying basal programs and content area texts ought to include suggestions for building prerequisite knowledge when it cannot be safely presupposed. It calls for publishers to feature lesson activities that will lead children to meaningfully integrate what they already know with what is presented on the printed page. The chapter urges publishers to employ devices that will highlight the structure of text material. It explains the implications of schema theory is that minority children may sometimes be counted as failing to comprehend school reading material because their schemata do not match those of the majority culture. As a consequence, large differences in comprehension, learning, and memory for the letters were expected.

Thoracic Epidural has long been the most recommended treatment for postoperative pain management in general thoracic surgery. This study compares liposomal bupivacaine (LB) as an alternative method for pain control and compares it to the standard.LB was compared to thoracic epidural bupivacaine hydrochloride (TE BH) in 387 patients who underwent video-assisted thoracoscopic pulmonary resection (VATS-R) at our institution. Patients received either continuous TE BH or intraoperative LB at a predetermined dose. A total of 237 patients received TE BH from April 2010 to March 2014 and 143 patients received LB from April 2014 to March 2016. After propensity matching, 95 patients in each group had similar demographics and clinical characteristics including gender, age, race, American Society of Anesthesia (ASA) classification, Zubrod scores, and FEV1 and DLCO percent predicted measurements. Outcome measures included hospital costs, length of stay (LOS), adverse events, postoperative opioid medication use, and pain scores.Compared to the TE BH group, the LB group had significantly lower pain scores (average visual analogue scale the day of surgery: 3.9 versus 4.5, p 0.05), decreased postoperative opioid medication (morphine equivalent dose during the first 3 days: 344.5 versus 269.5, p 0.05), and lower total and direct hospital costs ($2906 and $1865 respectively, p 0.05). Although a shorter LOS in the LB group was not statistically significant (4.3 versus 5.1 days, p = 0.156), more patients in the LB group were discharged directly home than the control group (44.2% versus 28.4%, p 0.05). There was no difference noted in overall adverse events including 30-day readmissions between the two groups.LB is a viable alternative for pain management in patients undergoing VATS-R. With recent scrutiny on healthcare costs and the opioid epidemic, these results are encouraging and should be further investigated.

A study involving 106 fourth graders and two teachers from a school in Beijing investigated the impact of a peer-led, open-format discussion approach, called collaborative reasoning (CR), on students’ reading comprehension and teacher’s professional learning. Mixed results of effects of CR on children’s reading comprehension were found. After participating in eight discussions over an eight-week period, the CR group performed significantly better than the control group on the Progress in International Reading Literacy Study constructed-response items requiring integrating and evaluating information, but no better on multiple-choice items calling for information retrieval and simple inferences. No CR group’s advantage was found on the National Assessment of Educational Progress items. Compared to the baseline discussions prior to the intervention, CR increased the volume, complexity, and fluency of student talk, decreased teacher talk and teacher control of topic. Both CR teachers successfully altered the traditional recitation discourse pattern and adapted to an open-format discussion. CR teachers’ weekly reflections and interviews showed that teachers experienced four developmental stages from being lost to applying CR in subsequent reading instruction practice.

This study examined the influence of teachers’ instructional moves on students’ relational thinking during small-group collaborative discussions. One hundred and twenty 4th grade students and 6 teachers participated in a series of 10 discussions, generating a video-recorded corpus containing 32,511 turns for speaking. A microanalysis of a subset of the corpus showed that teacher prompts for relational thinking, rather than lower level prompts or prompts for evaluation, had an immediate effect on student relational thinking, triggering further relational thinking from students over several speaking turns. Students were unlikely to emulate a teacher’s relational thinking strategy but highly likely to emulate another student’s. Behavioral management but not cognitive management increased the likelihood of relational thinking. Specific praise for cognitive or social strategies enhanced relational thinking, and the bidirectional association between praise and relational thinking suggested a transactional model of teacher–student interaction. The results underscore the importance of teacher influences in peer collaboration, even when the absolute rate of teacher talk is low.

This microgenetic study strived to understand instantaneous peer influences on the moment-by-moment and session-by-session development of relational thinking within and across dialogic small-group discussions using an approach called Collaborative Reasoning. An analysis encompassing 32,511 turns for speaking during 176 discussions indicated that peer support and refutation influenced the development of relational thinking within (micro-level) and across (macro-level) discussions, and was mediated by friendship and peer status. Support was mainly mediated by friends and children with high status. Observing reciprocated friends' supportive talk encouraged students to generate confirmational relational thinking in the next turn for speaking. Refutation was mainly mediated by children with high status. Quiet students generated less refutation. The study documents the proximal effects of peer status and friendship on the social and cognitive dynamics of collaborative discussions.

This chapter reviews selected empirical research on the meanings of words in context. A word considered without context permits many interpretations. When considered in context, its meaning is further articulated in a process of inferential interpolation based on knowledge of the world. Words vary in the extent to which, without context, they constrain interpretation. Full comprehension of most utterances requires people to form a representation that is more particularized than could be generated solely on the basis of the abstract semantics of the constituent words. Without context, every word places some boundaries on possible instantiations. Instantiation entails "deep" processing, but people sometimes are content to process discourse at a "shallow" level. A pervasive effect of context is to allow people to narrow or focus the encoded representation of a word, a process that we have termed instantiation. A most important difference is that a context is less rich with instantiation-guiding information.

I’d like to address a question to Hugh Petrie about the negative feedback model. It seems rather nice in terms of both an individual’s output and the perceptions that control the behavior. What I do not understand is how that model applies when one is speaking in terms of the individual’s comprehension of an input.

This chapter focuses on the implications of the concept of schema for education. Schema is an interesting concept only if there are structures which are more than aggregations of primitive elements. Returning to the arena of interest to educators and psychologists, the implication of schema theory is that the mental representations which are used during perception and comprehension, and which evolve as a result of these processes, have a holistic character which cannot be understood as simple functions of their constituents. This issue is currently the subject of vigorous debate and active experimental investigation. To perceive something is to place a construction upon it that plausibly accounts for the sensory input. To comprehend a message is to discover a formulation which coherently explains its contents. Socratic teaching would appear to force students to deal with counterexamples and face contradictions.

Dialogue based approaches to education have been shown to benefit students through the quality of shared discourse. Warm conceptual change theories propose that these benefits are also mediated by increasing student engagement. Discourse and engagement effects were isolated in this study by having 130 third and fourth grade students read a science text for different purposes (no stated purpose, to prepare for a regular classroom discussion, or to prepare for an argumentative discussion) and then testing children before the discussion took place. Children who anticipated a discussion, especially an argumentative discussion, read more slowly than other children after controlling for fluency. A subset of reading times predicted conceptual growth. Finally some children who participated in argumentative discussions had higher rates of conceptual growth. Results substantiate the efficacy of argumentative discussion as a context for reading scientific texts, and they support the central mechanism of dual-processing theories of warm conceptual change.

Fourth- and fifth-grade students’ motivation and engagement during classroom discussions were investigated in 2 studies. Study 1 examined students’ moment-by-moment engagement during collaborative peer-managed small-group discussions in comparison to conventional teacher-managed whole-class discussions. Study 2 evaluated the long term effects of discussions on self-reported motivation. Both studies showed that collaborative discussions produced greater interest and engagement than conventional discussions. Student self-ratings of engagement as well as adult ratings of engagement during a 6-min episode of one discussion had relatively high correlations with student self-reported interest and engagement several months later. Girls reported greater interest and engagement than boys in both conventional and collaborative discussions and were rated as more engaged by both themselves and adults; however, boys showed a greater boost in interest from collaborative discussions. Talkative children reported greater interest and engagement than less talkative children. Low-ability children put a higher value on discussion than high-ability children.

This study investigated the effects of argument scaffolding and source credibility on science text comprehension. Eighty-seven college students were randomly assigned to an argument scaffolding activity, or no scaffolding, and read 2 science texts, attributed to a high- or a low-credibility source. The argument-scaffolding group recalled less text-based information but generated more knowledge-based inferences than did the no-scaffolding group. High source credibility enhanced readers’ text-based recall but had little effect on knowledge-based inferences or situation models. Overall, results suggest that argumentation facilitates deeper text comprehension and better argument understanding, while at the same time reducing the effect of source credibility on text processing.

BACKGROUND: Esophagectomy with reconstruction using a gastric conduit is associated with a relatively high rate of anastomotic leakage. We used indocyanine green tissue angiography to evaluate the gastric conduit intraoperatively before gastroesophageal anastomosis to identify ischemia. METHODS: We performed an institutional review board–approved retrospective review of all esophagectomies performed from 2010 to the beginning of 2011. Patient histories and perioperative outcomes were reviewed retrospectively. Postoperative morbidity and 30-day mortality were determined. RESULTS: Eleven patients had an esophagectomy performed using this technology. All had adequate perfusion on gross examination. All but 1 had good perfusion with tissue angiography, and there were 2 anastomotic leakages leaks including this patient. There were no mortalities at 30 days. CONCLUSIONS: We report preliminary results using this imaging system in esophageal reconstructive surgery. Larger randomized controlled studies are needed to determine if surgical outcomes can be improved using this technology. 2013 Elsevier Inc. All rights reserved. In 2010, an estimated 16,640 patients in the United States were diagnosed with esophageal cancer with over 14,500 deaths from the disease. For those with resectable disease, surgery offers the best chance for a cure. The choice of procedure is based on tumor location, adherence to surrounding tissues, and surgeon preference. Our preferred approach to lower esophageal tumors is a transhiatal approach with conversion to a 3-hole esophagectomy