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Goldenseal root was identified as the most potent inhibitor of CYP3A4 in a study that tested 21 popular herbal products for in vitro inhibitory activity. The purpose of this investigation was to examine the influence of goldenseal root on the disposition of the CYP3A4 substrate indinavir in humans. Using a crossover study design, the pharmacokinetics of indinavir were characterized in 10 healthy volunteers before and after 14 days of treatment with goldenseal root (1140 mg twice daily). Indinavir was given as a single 800-mg oral dose, and blood samples were collected for 8 hours following the dose. No statistically significant differences in peak concentration (11.6 vs. 11.9 mg/L) or oral clearance (26.8 vs. 23.9 mg*h/L) were observed following treatment with goldenseal root. Half-life and time to reach peak concentration were also unchanged by goldenseal. These results suggest that patients being treated with indinavir can safely take goldenseal root and that interactions with other drugs metabolized by CYP3A4 in the liver are unlikely. [ABSTRACT FROM AUTHOR]

Background: The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical procedures are associated with an increased risk of chronic opioid use in the post-operative period of opioid-naïve patients. We aimed to assess whether providing feedback on the average morphine milligram equivalents (MMED) and opioid utilization by selected post-operative patients would impact the provider opioid prescribing patterns. Methods: An opioid stewardship educational intervention provided didactic and email feedback to general surgeons about their prescribing patterns and summary feedback on opioid usage among post-operative patients from the pre-intervention period. We used descriptive statistics, Chi Square, Fisher's Exact test, Wilcoxon Rank Sum, two sample t test, and Spearman's rho to analyze the data gathered. Results: A total of 5142 patients with an average age of 43.9 years were included in the study period. Women accounted for 3096 (60.2%) and 2046 (39.8%) were men. The surgeries during the study period included 1928 (37.5%) appendectomies and 3214 (62.5%) cholecystectomies. The predominant surgical approach was laparoscopic 5028 (97.8%). In both groups, the total MMED and total number of pills prescribed decreased significantly after the intervention was implemented. There were no refill prescriptions nor 30-day readmissions among those discharged with an opioid prescription in either study phase. Discussion: An intervention that provided general surgeons with feedback about their post-operative prescription patterns and data on post-operative opioid utilization by patients decreased prescribed MMED., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Higher blunt cerebrovascular injury (BCVI) grade and lack of medical therapy are associated with stroke. Knowledge of stroke risk factors specific to individual grades may help tailor BCVI therapy to specific injury characteristics., Methods: A post-hoc analysis of a 16 center, prospective, observational trial (2018-2020) was performed including grade 1 internal carotid artery (ICA) BCVI. Repeat imaging was considered the second imaging occurrence only., Results: From 145 grade 1 ICA BCVI included, 8 (5.5%) suffered a stroke. Grade 1 ICA BCVI with stroke were more commonly treated with mixed anticoagulation and antiplatelet therapy (75.0% vs 9.6%, P <.001) and less commonly antiplatelet therapy (25.0% vs 82.5%, P = .001) compared to injuries without stroke. Of the 8 grade 1 ICA BCVI with stroke, 4 (50.0%) had stroke after medical therapy was started. In comparing injuries with resolution at repeat imaging to those without, stroke occurred in 7 (15.9%) injuries without resolution and 0 (0%) injuries with resolution (P = .005). At repeat imaging in grade 1 ICA BCVI with stroke, grade of injury was grade 1 in 2 injuries, grade 2 in 3 injuries, grade 3 in 1 injury, and grade 5 in one injury., Discussion: While the stroke rate for grade 1 ICA BCVI is low overall, injury persistence appears to heighten stroke risk. Some strokes occurred despite initiation of medical therapy. Repeat imaging is needed in grade 1 ICA BCVI to evaluate for injury progression or resolution.

Purpose of Review: To summarize recent experience with robotic vesicovaginal fistula repair and describe the contemporary technique., Recent Findings: Robotic vesicovaginal repair has been tested at multiple centers, with similar outcomes to open surgery. It has benefits including decreased hospital stay, less blood loss, and similar long-term outcomes. As long as the surgeon is experienced in robotic surgery, this technique appears to be promising. Robotic vesicovaginal repair results in similar outcomes to open surgery with decreased morbidity., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: Self-care behaviour is fundamental in preventing hypertension in the general population. According to the Health Belief Model, health beliefs and perceptions influence the success in adopting disease prevention strategies. While factors influencing hypertension self-care behaviour have been examined previously in patient populations, they have not been assessed in the general community., Methods: This was a cross-sectional study conducted between 12 June 2020 to 26 July 2021. An online survey was administered via email and social media to Malaysians in the Selangor and Kuala Lumpur communities. Respondents were over 18 years old, without a formal diagnosis of hypertension. The survey evaluated hypertension knowledge, Health Belief Model constructs, self-care behaviour frequency, and motivators and barriers to self-care behaviour. Multiple linear regression was performed to determine the main predictors of self-care behaviour, and descriptive statistics were used to characterise motivators and barriers of each self-care behaviour., Results: Only health motivations (β = 0.217, p < 0.001) and perceived barriers (β = 0.571, p < 0.001) significantly influenced self-care behaviour. Maintaining a healthy diet, regular physical activity and blood pressure checks need to be improved in the community, particularly in reducing salt and calorie intake. Lack of time, limited choices and laziness are the biggest challenges that need to be tackled in adopting a healthy diet and an active lifestyle in the community. Many are ignorant towards their health status, therefore, do not prioritize blood pressure screenings, suggesting a need to enhance community blood pressure checks for early diagnosis of hypertension., Conclusion and Implications: Motivations and barriers were the main determinants of self-care behaviour in the Selangor and Kuala Lumpur community. Targeting these aspects of self-care behaviour should be considered when developing interventions and education programmes tailored to local cultural, environmental and personal factors, to more effectively reduce the hypertension prevalence and burden., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Tan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy., Methods: This is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories., Results: 636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p <  0.001) as was the median AIS head score (2.0 vs 1.0, p <  0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively., Conclusions: Modern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI., Competing Interests: Conflict of interest None., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown., Methods: A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use., Results: From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI ( P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI., Discussion: Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use.

Background: Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care., Methods: An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only., Results: Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without., Conclusion: Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management., Level of Evidence: Prognostic and Epidemiologic, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Over the past decade, increased awareness about leptospirosis disease in developing and industrialized countries has resulted in increased numbers of leptospirosis cases being reported worldwide. About 5% to 15% of leptospirosis patients end up with severe forms of the disease. Complication due to leptospirosis requires monitoring, specific treatments, and intensive care admission, thus increasing the cost of treating severe leptospirosis cases. Currently, we have data on incident and mortality rates, but we do not have data on the number of patients with severe form of leptospirosis or how many patients have complications, and whether or not these complications were resolved. Therefore, we carried out this study to determine the predictive factors for severe leptospirosis cases in Kedah. We conducted a cross-sectional study. The data of patients diagnosed with leptospirosis were obtained from the surveillance unit, Kedah Health Department, through the e-notification system. These data were then sorted according to the hospitals where the patients were admitted. The patients' medical records were collected, and their information was obtained using a checklist. A total of 456 confirmed leptospirosis cases were included in the study, with 199 patients classified as severe cases and 257 patients as mild cases, based on the Malaysian leptospirosis guidelines. Most patients were male (71.5%) with a mean SD age of 36.62 ± 20.75 years. The predictive factors for severe leptospirosis include abnormal lung sounds (OR: 3.07 [CI 1.58-6.00]), hepatomegaly (OR: 7.14 [1.10-45.98]), hypotension (OR: 2.16 [1.08-4.34]), leukocytosis (OR: 2.12 [1.37-3.29]), low hematocrit (OR: 2.33 [1.43-3.81]), and increased alanine aminotransferase (SGPT ALT) (OR: 2.12 [1.36-3.30]). In conclusion, knowing these predictive factors will help clinicians identify severe leptospirosis cases earlier and develop their treatment plans accordingly, to reduce the complications and death from severe leptospirosis.

Floral authenticity of coriander ( Coriandrum sativum ) honey samples was confirmed by melissopalynology. Effect of temperature, time and pH on quality parameters i.e. hydroxymethylfurfural (HMF) content, diastase and invertase activity of coriander honey was analysed using response surface methodology. Central composite rotatable design was adopted for optimization of process variables. An increased in HMF content was observed with increase in temperature and pH whereas diastase activity decreased with increase in temperature and with a pH value other than the optimum value of 4.6-5.6. Invertase activity was maximum at 4.8 pH. Interaction effect of temperature and pH was significant for HMF whereas interaction effect of temperature and time was significant for HMF, diastase and invertase activity. Optimization of variables was done by the mathematical method, and optimized values of HMF content, diastase, and invertase activity were obtained as 7.78 (mg/kg), 17.95 DN and 13.96 IN, respectively at 47.5 °C (temperature), 4.7 (pH) and 9 min (time)., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interests.

Extrusion behavior of extrudates prepared from short (PR113) and long (PUSA1121) Indica rice cultivars milled to 0-8% degree of milling (DOM) extruded at variable extrusion temperature (150-190 °C) and feed moisture (15-19%) was studied. The physico-chemical and functional properties of extrudates prepared from both the cultivars varied significantly with variation in DOM as well as extrusion variables. DOM showed more pronounced effect for all the responses studied for both the cultivars. Expansion, L*, water absorption and overall acceptability increased whereas hardness, water solubility and bulk density decreased with increase in DOM. Extrusion temperature increase led to increase in expansion and water solubility and decreased L*, bulk density and water absorption. Feed moisture showed significant positive effect on hardness and water absorption and negative effect on expansion, L* and water solubility. Formation of amylose-lipid complexes were also observed during extrusion cooking for both the cultivars which showed negative correlation with DOM. Both the cultivars also showed different behavior for these responses at same values of independent variables.

The effects of degree of milling (DOM) between 0 and 8% on physico-chemical, structural, pasting and cooking properties of short and long grain Indica rice cultivars were studied. Ash, protein, lipids and minerals decreased while blue value and crystallinity increased with increase in DOM. The colour parameters (a∗, b∗) and cooking time (CT) decreased while L∗(lightness) increased with increase in DOM. Elongation ratio (ER), gruel solid loss (GSL), length/breadth (L/B) and paste viscosities during cooking increased with increase in DOM. Short grain rice contained lower ash, protein, lipids, Mn, K, Ca, CT and GSL than long grain while the later showed higher crystallinity, Mn, P, K, Ca and ER. Paste and dough characteristics measured using Rheometer and Mixolab, respectively correlated well and differed with cultivar and DOM. Short and long grain cultivars showed variation in loss of different chemical constituents during varied DOM causing variation in cooking characteristics., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Shear-wave elastography of the kidney has emerged as a potential clinical application of this novel imaging tool. However, normal velocity values for shear-wave elastography involving the cortex of healthy kidneys have not been definitively established, and both inter- and intraobserver reliability has yet to be comprehensively evaluated., Methods: This prospective study involved ultrasound examination of 11 healthy adults. Shear-wave velocity values were obtained at the renal cortex in the longitudinal and transverse planes by both junior (fellow) and senior (attending) radiologists., Results: The mean shear-wave velocity values ranged between 2.82 and 2.9 m/s, which did not vary significantly between observers (junior vs. senior) or method of measurement (longitudinal vs. transverse planes), P = 0.533. However, there was a wide variation for these measurements (0.51-4.99 m/s). Separate analysis of the measurement depth demonstrated no statistically significant association with the shear-wave velocity values, P = 0.477., Conclusion: Our results agree with previous publications and help establish normal shear-wave velocity values and their range for the renal cortex in adults., Competing Interests: There are no conflicts of interest.

The LOINC-RSNA Radiology Playbook represents the future direction of standardization for radiology procedure names. We developed a software solution ("RadMatch") utilizing Python 2.7 and FuzzyWuzzy, an open-source fuzzy string matching algorithm created by SeatGeek, to implement the LOINC-RSNA Radiology Playbook for adult abdomen and pelvis CT and MR procedures performed at our institution. Execution of this semi-automated method resulted in the assignment of appropriate LOINC numbers to 86% of local CT procedures. For local MR procedures, appropriate LOINC numbers were assigned to 75% of these procedures whereas 12.5% of local MR procedures could only be partially mapped. For the standardized local procedures, only 63% of CT and 71% of MR procedures had corresponding RadLex Playbook identifier (RPID) codes in the LOINC-RSNA Radiology Playbook, which limited the utility of RPID codes. RadMatch is a semi-automated open-source software tool that can assist radiology departments seeking to standardize their radiology procedures via implementation of the LOINC-RSNA Radiology Playbook.

Clinical applications of 3D printing are increasingly commonplace, likewise the frequency of inclusion of 3D printed objects on imaging studies. Although there is a general familiarity with the imaging appearance of traditional materials comprising common surgical hardware and medical devices, comparatively less is known regarding the appearance of available 3D printing materials in the consumer market. This work detailing the CT appearance of a selected number of common filament polymer classes is an initial effort to catalog these data, to provide for accurate interpretation of imaging studies incidentally or intentionally including fabricated objects. Furthermore, this information can inform the design of image-realistic tissue-mimicking phantoms for a variety of applications, with clear candidate material analogs for bone, soft tissue, water, and fat attenuation.

Accidental hypothermia can lead to untoward cardiac manifestations and arrest. This report presents a case series of severe accidental hypothermia with cardiac complications in three emergency patients who were treated with extracorporeal membrane oxygenation (ECMO) and survived after re-warming. The aim of this discussion was to encourage more clinicians to consider ECMO as a re-warming therapy for severe hypothermia with circulatory collapse and to prompt discussion about decreasing the barriers to its use. Niehaus MT , Pechulis RM , Wu JK , Frei S , Hong JJ , Sandhu RS , Greenberg MR . Extracorporeal membrane oxygenation (ECMO) for hypothermic cardiac deterioration: a case series. Prehosp Disaster Med. 2016;31(5):570-571.

Quantifying the systemic risk and fragility of financial systems is of vital importance in analyzing market efficiency, deciding on portfolio allocation, and containing financial contagions. At a high level, financial systems may be represented as weighted graphs that characterize the complex web of interacting agents and information flow (for example, debt, stock returns, and shareholder ownership). Such a representation often turns out to provide keen insights. We show that fragility is a system-level characteristic of "business-as-usual" market behavior and that financial crashes are invariably preceded by system-level changes in robustness. This was done by leveraging previous work, which suggests that Ricci curvature, a key geometric feature of a given network, is negatively correlated to increases in network fragility. To illustrate this insight, we examine daily returns from a set of stocks comprising the Standard and Poor's 500 (S&P 500) over a 15-year span to highlight the fact that corresponding changes in Ricci curvature constitute a financial "crash hallmark." This work lays the foundation of understanding how to design (banking) systems and policy regulations in a manner that can combat financial instabilities exposed during the 2007-2008 crisis.

Purpose: To compare the per-lesion sensitivity and positive predictive value (PPV) of ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) for the diagnosis of hepatocellular carcinoma (HCC)., Materials and Methods: The meta-analysis of sensitivity included 242 studies (15,713 patients); 116 studies (7492 patients) allowed calculation of PPV. Pooled per-lesion sensitivity and PPV for HCC detection were compared using empirical Bayes estimates of a beta-binomial model., Results: The pooled per-lesion sensitivity and PPV of contrast-enhanced CT (73.6%, 85.8%) and gadolinium-enhanced MRI (77.5%, 83.6%) are not significantly different (P = 0.08, P = 0.2). However, if the hepatobiliary agent gadoxetate is used, MRI has significantly higher pooled per-lesion sensitivity and PPV (85.6%, 94.2%) than CT (P < 0.0001) or than MRI with other agents (P < 0.0001). Non-contrast-enhanced US has the lowest overall sensitivity and PPV (59.3%, 77.4%). Pooled per-lesion sensitivity and PPV of contrast-enhanced US (84.4%, 89.3%) are relatively high, but no contrast-enhanced US study used the most rigorous reference standards., Conclusion: MRI utilizing the hepatobiliary agent gadoxetate has the highest overall sensitivity and PPV, and may be the single optimal method for diagnosis of HCC. Non-contrast-enhanced US has the lowest sensitivity and PPV. More rigorous reference standards are needed to compare the performance of contrast-enhanced US with CT and MRI. Differences in sensitivity and PPV between CT and conventional gadolinium-enhanced MRI are not statistically significant overall.

Objective: The objectives of this study were to define the range of apparent diffusion coefficients (ADCs) from whole-body DWI in normal abdominal organs and bone marrow, to identify ADC differences between sexes and changes occurring with age, and to evaluate the effect of the fat fraction (FF) on the ADC of normal liver parenchyma and bone marrow., Materials and Methods: Fifty-one healthy volunteers (mean age = 38 years; age range = 23-68 years) underwent whole-body DWI using single-shot echo-planar imaging (b = 0, 150, 400, 750, and 1000 s/mm(2)). A two-point Dixon technique was used to evaluate the FF. Perfusion-sensitive ADCs, which we refer to as "ADCALL," and perfusion-insensitive ADCs, which we refer to as "ADCHIGH," of the liver and renal parenchyma, spleen, pancreatic tail, and red and yellow bone marrow were calculated. The relationships between ADC and sex, age, and FF were examined., Results: ADCALL and ADCHIGH were significantly higher in female volunteers for the pancreatic tail (p = 0.046 and 0.008, respectively), red bone marrow (p = 0.029 and 0.001), and yellow bone marrow (p < 0.001 for both) but with considerable overlap. There were significant negative correlations between ADCALL and ADCHIGH and age in the liver parenchyma (p = 0.008 and 0.01, respectively) and in the yellow bone marrow (p = 0.013 and 0.039) for all subjects. ADCALL and ADCHIGH were also negatively correlated with FF in the liver parenchyma (p = 0.006 and 0.008, respectively) and in yellow bone marrow (p < 0.001 and p = 0.001) in all subjects., Conclusion: The ADCs of normal liver parenchyma and bone marrow change significantly with age. The ADCs of bone marrow in women are significantly higher than those of men and correlate strongly with FF. These effects may have an impact on image interpretation when using whole-body DWI to assess disease burden and treatment response.

Context: An estimated 39% of people in California suffer from at least one chronic condition or disease. While the increased coverage provided by the Affordable Care Act will result in greater access to primary health care, coordinated strategies are needed to prevent chronic conditions. To identify cost-effective strategies, local health departments and other agencies need accurate information on the costs of chronic conditions in their region., Objective: To present a methodology for estimating the cost of chronic conditions for counties., Methods: Estimates of the attributable cost of 6 chronic conditions-arthritis, asthma, cancer, cardiovascular disease, diabetes, and depression-from the Centers for Disease Control and Prevention's Chronic Disease Cost Calculator were combined with prevalence rates from the various sources and census data for California counties to estimate the number of cases and costs of each condition. The estimates were adjusted for differences in prices using Medicare geographical adjusters., Results: An estimated $98 billion is currently spent on treating chronic conditions in California. There is significant variation between counties in the percentage of total health care expenditure due to chronic conditions and county size, ranging from a low 32% to a high of 63%. The variations between counties result from differing rates of chronic conditions across age, ethnicity, and gender., Conclusions: Information on the cost of chronic conditions is important for planning prevention and control efforts. This study demonstrates a method for providing local health departments with estimates of the scope of the problems in their region. Combining the cost estimates with information on current prevention strategies can identify gaps in prevention activities and the prevention measures that promise the greatest return on investment for each county.

Objective: To evaluate the effects of coital lubricants and oils on sperm motility., Design: Comparative prospective in vitro study., Setting: University Andrology laboratory., Patient(s): Twenty-two normozoospermic donors., Intervention(s): Semen samples were incubated in modified human tubal fluid (mHTF) control and in 10% Pre-Seed, Astroglide, and KY products (Sensitive, Warming, and Tingling) and baby, canola, sesame, and mustard oils. Total and progressive sperm motility was evaluated before and at 5, 30, and 60 minutes of incubation., Main Outcome Measure(s): Sperm motility., Result(s): Control samples exhibited no significant decrease in sperm motility. Pre-Seed showed a slight (∼4%) but significant drop in progressive motility after 30 minutes. Total and progressive sperm motility significantly declined under Astroglide, KY products (Sensitive, Warming, and Tingling) and sesame oil incubation. Canola oil significantly decreased total motility after 30 minutes and progressive motility after 5 minutes of incubation. Similarly, baby oil decreased total motility after 60 minutes and progressive motility after 5 minutes. After initial decline, total and progressive sperm motility under Pre-Seed and canola and baby oils remained high. Exposure to mustard oil caused persistent hyperactivation of sperm in each sample with no decrease in motility., Conclusion(s): Sesame oil and synthetic coital lubricants impaired sperm motility and may hamper fertility. Pre-Seed and canola, mustard, and baby oils showed no deleterious effect and may be considered sperm-friendly coital lubricants. Mustard oil exposure resulted in hyperactivation of sperm and needs to be studied further., (Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: The objective of this study was to review the outcomes of scaphocephaly management. We hypothesized that differential treatment of scaphocephaly based on age at correction and degree of severity yields consistently satisfying results while reducing the operative morbidity., Study Design: Retrospective patient record review., Methods: Three cranial vault-remodeling procedures with varying levels of aggressiveness (limited-access, partial, and total cranial-vault remodeling) were performed on patients with scaphocephaly from 1995 to 2010. More-aggressive procedures were performed on older patients and patients having more-severe deformities. Patient records were reviewed for age, weight, blood loss, and length of hospital stay, and cephalic indices (CIs) were calculated from computed tomography scans and clinical photographs., Results: Fifty-one patients underwent surgery for scaphocephaly during the study period. The average estimated blood volume fraction lost was 0.41. The average length of hospital stay was 4.49 days. Pre- and postoperative CIs were calculable for 36 patients. The average preoperative CI was 68.7. The average postoperative CI was 79.3, for an average operative change of 15%. The three procedures had statistically different values for average length of stay. A trend was suggested for estimated blood loss and volume fraction lost. There was no statistically significant difference in CI outcomes., Conclusions: This study supports the concept of a proportionate response in the management of scaphocephaly. Less-aggressive procedures do not yield less-desirable results when properly selected to match the clinical situation of the individual patient., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Introduction: There exist, currently, no clear guidelines regarding standards for surgical implant labelling. Dimensions of the laminar flow canopies in orthopaedic use fixes the distance at which implant labels can be read. Mistakes when reading the label on an implant box can pose health risks for patients, and financial consequences for medical institutions., Subjects and Methods: Using scientifically validated tools such as the Snellen Chart Formula, a theoretical minimum standard for text on implant labels was reached. This theoretical standard was then tested under real operating conditions. After discovering a minimum practical standard for implant labels, the authors then audited current labels in use on a wide range of orthopaedic implant packages. Furthermore, other non-text-related labelling problems were also noted., Results: There is a definite minimum standard which should be observed when implant labels are manufactured. Implants in current use bear labels on the packaging that are of an insufficient standard to ensure patient safety in theatre., Conclusions: The authors have established text parameters that will increase the legibility of implant labels. In the interests of improving risk management in theatre, therefore, the authors propose a standard for orthopaedic implant labelling, and believe this will provide a useful foundation for further discussion between the orthopaedic community and implant manufacturers.

Background: Blunt trauma-induced aortic injury traditionally has been treated with early open surgical repair. However, recently endovascular stent-graft technology is considered a less-invasive therapeutic alternative, and flexible stent-grafts, such as the Matsui-Kitamura stent-graft (MKSG), are being used widely. We report our experience with the curved MKSG in treating thoracic aortic injuries., Methods: Nine patients with traumatic thoracic aortic injury underwent endovascular surgery (8, emergency; 1, elective) with curved MKSG. The study variables were Injury Severity Score, endovascular surgery duration, aortic and stent-graft diameter, stay in the intensive care unit, follow-up period, and mortality. An MKSG was constructed using the Matsui-Kitamura stent and a polyester fabric graft. The stent-graft was placed using the transfemoral approach and the wire-tug technique., Results: The mean Injury Severity Score was 42.3; 5 patients required 6 emergency procedures before the endovascular procedure (pneumothorax or hemothorax drainage, 5; transarterial embolization, 1). In 8 patients (88.9%), we achieved complete pseudoaneurysm exclusion or hemostasis in the injured portion. There were no postoperative complications; blood loss was minimal, and the intensive care unit stay was 13.4 days. The overall hospital mortality was 22.2% (n = 2; causes of death were unrelated to MKSG placement). Neither intervention-related mortality during follow-up (mean, 237.7 days) nor late endovascular graft-related complications (endoleak or graft migration) were noted., Conclusions: Although this study is limited by a small sample size and short follow-up period, no collapse or stent-graft fractures were noted. Thus, MKSG placement for traumatic thoracic aortic injury appears a safe and effective therapy.

Background: Anti-tumour necrosis factor (anti-TNF) therapy has been an important development for the treatment of rheumatoid arthritis (RA) but the impact of its delivery on hospital resources in still emerging., Aims: We audited the effect of starting anti-TNF on the use of other anti-rheumatic therapies and hospital resources in a routine secondary care setting., Methods: A retrospective study of resource use before and after anti-TNF was conducted. Hospital records of 54 RA patients were studied and data taken from the time of commencing anti-TNF to 1 October 2004 and an equal time period prior to commencing anti-TNF. Identical data were collected for 54 controls not on anti-TNF. Relevant figures were extrapolated to per annum rates. Results were analysed using two-factor ANOVAs comparing the pre- versus post-anti-TNF period. Cases on intravenous (IV) versus subcutaneous (SC) anti-TNF were also compared in separate ANOVAs., Results: Mean duration of anti-TNF therapy was 17.04 months (range 3.60-42.36). Mean pre- and 3-months post-anti-TNF Disease Activity Scores (DAS28) were 6.93 and 3.88, respectively. Cases were more likely than controls to be on oral prednisolone pre- and post-anti-TNF. Methylprednisolone requirement, number of disease-modifying anti-rheumatic drugs (DMARDs), telephone helpline contacts and duration as an inpatient reduced significantly post-anti-TNF. Day case admissions increased but outpatient appointments decreased only in cases on IV anti-TNF., Conclusions: In a pragmatic setting, anti-TNF therapy led to reduced need for steroid injections and other DMARDs, as well as reductions in use of several hospital resources. Wider replication of these findings will be important for planning delivery., (Copyright: (c) 2006 John Wiley & Sons, Ltd.)

Isolated aneurysms of the iliac arteries are extremely rare, comprising less than 2% of all aneurysmal disease. These aneurysms are typically seen in older men. Their natural history, although fairly indolent, carries a significant risk of rupture when the aneurysms have attained a large size. Their operative mortality is significantly higher when undertaken as an emergent versus elective procedure, underscoring the importance of early diagnosis and appropriate management. This article reviews the literature with regard to the natural history, diagnostic workup, and treatment of iliac artery aneurysms. For patients undergoing elective repair, preoperative imaging with computed tomography or magnetic resonance is advocated. Repair is recommended for good-risk patients with aneurysms larger than 3.5 cm. A working classification based on aneurysmal anatomy is provided along with an outline of the suggested open and endovascular surgical options. Results of open and endovascular strategies are summarized and follow-up recommendations are proposed.

Rationale: Guanfacine is an alpha2-adrenergic receptor agonist that has been shown to have beneficial effects on working memory and attentional functions in monkeys and in patients with attention deficit hyperactivity disorder., Objectives: The aim of this study was to further investigate the cognitive-enhancing properties of guanfacine using an established battery of tasks measuring executive and memory functions., Methods: Sixty healthy male volunteers were randomised into three groups. Cognitive testing was performed from +2 to +4 h after double-blind administration of a single oral dose of 1 or 2 mg of guanfacine or placebo., Results: Systolic blood pressure was significantly reduced by both doses of guanfacine at the end of the testing session. There were no statistically significant effects on any of the cognitive measures. Two trend effects were observed with poorer performance on digit span backward and slower 'Go' reaction times after guanfacine., Conclusion: This study found no improvement of prefrontal memory or executive functions after guanfacine. Negative effects on blood pressure and trend effects on digit span backward and go reaction time indicate a mild sedative effect of guanfacine at these doses, possibly via mechanisms of autoreceptor down-regulation.

This article is a review of the scientific literature with respect to fine particulate matter (PM), 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, and coronary artery disease (CAD). The association between air pollution and respiratory diseases has been extensively investigated for decades; however, the role of air pollution in exacerbating heart disease has only recently become a focus of attention. It has been shown that for every 10-microg/m(3) increase in fine PM in the air, there appears to be a 2.1% increase in the number of deaths related to ischemic heart disease. PM has been linked to increased levels of systemic inflammation biomarkers such as C-reactive proteins (CRP). Daily variation of ambient pollution is correlated with rises and falls in CRP levels. Increased CRP levels have been associated with increased morbidity and mortality in individuals with CAD. Seventy-five percent of patients with elevated CRP levels have reportedly experienced a major cardiac event despite low-density lipoproteins (LDL) levels that were below the threshold recommended for pharmacological intervention. HMG CoA reductase inhibitors (statins) have been shown to cause a reduction in coronary events by lowering LDL levels. However, recently it has been shown that statins have the effect of lowering CRP levels. This may explain why individuals with normal lipid levels may benefit from statin therapy. Ambient PM exposure levels and its effects on CRP are risk factors associated with coronary events and should be considered as a target for the treatment of CAD.