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Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary lymph node dissection (ALND) has been challenged. Following publication of the ACOSOG Z0011 trial, national trends demonstrated significant reductions in ALND performance. Axillary radiotherapy in lieu of ALND is a consideration for select patients with a positive sentinel lymph node, while ongoing studies are investigating the role of adjuvant regional radiotherapy in women with positive nodes prior to neoadjuvant chemotherapy. Efforts toward de-escalation of axillary surgery continue to evolve, as do the indications for sentinel node biopsy omission in select subsets of patients. This review highlights the recent advances and neoteric approaches to local therapy of the axilla in breast cancer.

Preoperative imaging in clinical stage II melanoma is not indicated per National Comprehensive Cancer Network (NCCN) guidelines but remains common in clinical practice.Patients presenting with cutaneous clinical stage II melanoma from 2007 to 2019 were retrospectively reviewed. A clinical decision analysis with cost data was designed to understand ideal practice patterns in managing stage II melanoma, with pre-versus selective post-operative imaging as the initial decision node.There were 277 subjects included, and 143 underwent preoperative imaging (49.5%). This changed management (i.e. no surgery) in one patient (0.4%). Overall, 16 patients had additional findings on imaging (5.8%). Upfront surgery with selective postoperative imaging was a more cost-effective strategy than routine performance of preoperative imaging, with savings of $1677 per patient.Preoperative imaging is a low yield, costly approach for patients with clinical stage II melanoma with minimal impact on the decision to proceed with surgical management.

Virtual reality (VR) is emerging as a treatment modality across a variety of healthcare settings. Integrating a new technology as a form of therapy requires informed analysis to ensure that it is an effective, efficient, safe and valuable addition to the client experience. Using the Alberta Quality Matrix for Health as a framework, this detailed analysis examines the application of VR in pain management, mental health, stroke rehabilitation and palliative care. Through this multifocal lens, gaps are identified and a glimpse is provided into VR's potential for widespread adoption across healthcare settings.

Sexual choking/strangulation has become prevalent among young U.S. adults, yet little is known about media articles that teach readers about choking. We conducted a content analysis of 27 Internet articles, examining how choking is described, information related to health risks and healthcare, and article accuracy. Most articles described choking in positive terms and indicated choking can be done safely or properly, even while acknowledging potential dangers. Only two articles indicated having undergone expert/medical review. Few gave information about signs that would warrant seeking healthcare. Sexuality professionals need to be aware of choking-related information and misinformation in online media articles.

Spontaneous recovery of motor and cognitive function occurs in many individuals after stroke. The mechanisms are incompletely understood, but may involve neurotransmitter systems that support neural plasticity, networks that are involved in learning and regions of the brain that are able to flexibly adapt to demand (such as the ‘multiple-demand system'). Forty-two patients with first symptomatic ischaemic stroke were enrolled in a longitudinal cohort study of cognitive function after stroke. High-resolution volumetric, diffusion MRI and neuropsychological assessment were performed at a mean of 70 ± 18 days after stroke. Cognitive assessment was repeated 1 year after stroke, using parallel test versions to avoid learning effects, and change scores were computed for long-term episodic, short-term and working memory. Structural MRI features that predicted change in cognitive scores were identified by a two-stage analysis: a discovery phase used whole-brain approaches in a hypothesis-free unbiased way; and an independent focused phase, where measurements were derived from regions identified in the discovery phase, using targeted volumetric measurements or tractography. Evaluation of the cholinergic basal forebrain, based on a validated atlas-based approach, was included given prior evidence of a role in neural plasticity. The status of the fornix, cholinergic basal forebrain and a set of hippocampal subfields were found to predict improvement in long-term memory performance. In contrast to prior expectation, the same pattern was found for short-term and working memory, suggesting that these regions are part of a common infrastructure that supports recovery across cognitive domains. Associations between cholinergic basal forebrain volume and cognitive recovery were found primarily in subregions associated with the nucleus basalis of Meynert, suggesting that it is the cholinergic outflow to the neocortex that enables recovery. Support vector regression models derived from baseline measurements of fornix, cholinergic basal forebrain and hippocampal subfields were able to explain 62% of change in long-term episodic and 41% of change in working memory performance over the subsequent 9 months. The results suggest that the cholinergic system and extended hippocampal network play key roles in cognitive recovery after stroke. Evaluation of these systems early after stroke may inform personalized therapeutic strategies to enhance recovery.

Side‐scan sonar and Compressed High Intensity Radar Pulse mapping of Great Salt Lake, Utah, linked to reprocessing of acoustic data from bathymetric surveys, has enabled the distribution of microbial bioherms to be assessed. Bioherms occupy an estimated area >700 km2 in the south arm and >300 km2 in the north arm. Distributions vary from statistically dispersed to clustered, and in this latter case, are predominantly located on metre‐scale, fault‐controlled topographic highs, with sediment infilling intervening lows between adjacent offsets. Individual bioherms are circular to oblate and range from centimetres to over 2 m in diameter. In some areas, bioherm heights were measured at more than 1.5 m above adjacent substrate. Sublittoral bioherms are made of aragonite, calcite and minor dolomite precipitated due to physico‐chemical, biologically induced and influenced carbonate mineralization processes in association with microbial mats. Bioherm fabrics vary at the millimetre to centimetre‐scale and consist of leiolitic and clotted peloidal micrite‐grade carbonate, sinuous threads of spherulitic fibrous aragonite crystals, laminated micrite boundstone and internal carbonate mud sediment with peloids and ooids. The identification of factors that influence microbial bioherm occurrence and spatial distribution in Great Salt Lake is limited to a set of collinear physical, chemical and biological variables that are confined to a localised closed system, such as salinity, water depth, wave energy, stable substrate and sediment accumulation. Anthropogenic modifications to Great Salt Lake resulting in increased salinity have exceeded the salinity range in which bioherm‐mediating microbial communities can survive, effectively defining an upper limit of salinity for bioherm microbial community viability. The better understanding of the distribution of microbial bioherms has significant implications for managing and protecting the lake ecosystem and may provide insights into the physical and chemical controls that existed during the formation of fossil microbialites in deep time.

The IEC 61000–2–2 standard defines the compatibility levels to evaluate the conducted disturbances in the low voltage grid for the 2-150 kHz range. For frequencies 9–150 kHz, they are defined in terms of quasi peak values measured according to CISPR 16–1–1 standard, but no clear guidance is given on how to apply this standard to grid measurements. The definition of the method in CISPR 16–1–1 accepts a wide range of different implementations, all of them fulfilling the compliance requirements. The reasons are that the standard does not propose a fixed implementation but a ‘black-box’ approach, and some of the proposed configuration values are non-normative and/or wide tolerances are allowed. In this context, some parameters have a pivotal role in the results provided by the method. The impact of variation of these parameters on the measurement results is addressed in this work. In particular, the accuracy requirements and the reproducibility issues of the standard are studied. For that purpose, a high number of different compliant implementations have been developed and the influence of different features of the CISPR 16–1–1 method on the results of these implementations is identified and analyzed. The results show that the wide tolerances allowed by the CISPR 16 specification impede the comparison of results provided by measuring receivers based on different implementations of the standard. Results of the study also show that reproducibility issues for the same input signal may be relevant and generate inconsistences. Moreover, a fixed specific configuration does not ensure that uncertainty issues are solved, as the technical approach used in the implementation of the damped meter has a strong influence on the outputs. An unambiguous guidance of digital implementation of the standard could fix these issues.

We numerically compare the performance benefits and viability of deploying hollow-core-fibre (HCF) and ultra-low-loss (ULL) fibre in metro-core optical network considering practical traffic growth, limitations of transceiver OSNR and output power from commercial optical amplifiers.

This paper presents a strategy for the description of new test waveforms for static electricity meters to be included in international standards. The need of extending the existing standardisation frame arises from several recent studies that have reported conducted electromagnetic interference problems of type-approved static electricity meters, resulting in significant errors in the measured electricity consumption. The proposed method is based on discrete wavelet transform and allows for a compact and parsimonious representation of test waveforms, suitable for inclusion in standards. Very few wavelet parameters are concentrating the relevant information to accurately reproduce all the characteristics that the meters need to be tested against. The same parsimonious description cannot be performed with the current practises based on Fourier transform methods since the new test signals need to be highly non-sinusoidal. The discrete wavelet transform is proposed as a more effective tool to sparsely describe the most relevant waveform features. The effect of different discrete wavelet transform decomposition settings on compactness and reconstruction accuracy is studied using suitable metrics. Finally, results from experimental validation with several different waveforms are presented to demonstrate that the error-inducing features can be preserved using only 0.1% of the original signal information.

Regional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care.This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients.Between March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in 48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months.The median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for48 hours (48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses.Selected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule.

BACKGROUND This study investigates tumor recurrence patterns and their effect on postrecurrence survival following curative-intent treatment of colorectal liver metastases (CRLM) to identify those who stand to benefit the most from adjuvant liver-directed therapy. METHODS This is a retrospective analysis of all patients that underwent liver resection and/or ablation for CRLM between 2007 and 2019. Postrecurrence survival was compared between recurrence locations. Risk factors for liver recurrence were sought. RESULTS The study included 227 patients. Majority were treated with resection (71.0%) while combination resection/ablation (18.9%) and ablation alone (11.0%), were less common. At a median follow-up of 3.0 years, recurrence was observed in 151 (66.5%) patients. Of those, liver, lung, and peritoneal recurrence were most common at 66.9%, 49.6%, and 9.2%, respectively. Median postrecurrence survival after liver, lung, and multisite recurrence was 39.6-, 68.4-, and 33.6 months, respectively. High tumor grade (p

Disease-tolerant cultivars maintain yield in the presence of disease. When disease intensity is high, they can improve a grower's net return compared to less tolerant cultivars. Many authors report a trade-off, whereby higher fully protected yields are correlated with a lower disease tolerance. We analyse the question for breeders: to what extent should they breed for tolerance when it compromises maximizing fully protected yield? Field trials with 147 progeny from five parental crosses of wheat were used to measure yield and tolerance under a range of disease intensities from Septoria tritici blotch (STB; causal organism Zymoseptoria tritici) at a range of sites and seasons. The data define the variation for these traits from which breeders can select. A simple data-driven descriptive model was used to calculate the combination of tolerance and fully protected yield that maximizes actual yield for any given level of disease—quantified by loss of healthy canopy area duration (HAD-loss). This model was combined with data on the year-to-year variability of HAD-loss in the UK to calculate the tolerance and fully protected yield that maximizes the mean actual yield. We found that even when an effective fungicide treatment programme is applied, breeding for tolerance increases the mean actual yield. Some commercially available cultivars were found to have a level of tolerance that leads to yields close to the maximum yield in the presence of disease, others had a lower tolerance leading to suboptimal yields.

Talimogene laherparepvec (T-VEC) is an oncolytic virus approved for the treatment of unresectable, recurrent melanoma. The role of T-VEC after progression on systemic immunotherapy (IO) remains undefined. The goal of this study was to characterize the efficacy of T-VEC after failure of IO in patients with unresectable metastatic melanoma. An international, multi-institutional review of AJCC version 8 stage IIIB-IV melanoma patients treated with T-VEC after failure of IO was performed at six centers from October 2015-December 2020. Primary outcome was in-field response; secondary outcomes included analyses of in-field and overall progression-free survival (PFS) and in-field and overall disease-free survival (DFS) after a complete response. Subset analysis of T-VEC initiation sequentially after or concurrently with IO was performed. Of 112 patients, median age at T-VEC initiation was 69 years (range 21–93); 65 (58%) were male. Before T-VEC, 57% patients received one IO regimen, 42% received two or more, with most patients (n = 74, 66%) receiving T-VEC sequential to IO. Most were stage 3C (n = 51, 46%) at T-VEC initiation, 29 (26%) received injections to nodal disease. Over median follow-up of 14 months, in-field response at final T-VEC injection was 37% complete (CR), 14% partial (PR). T-VEC initiation sequentially or concurrently did not significantly affect in-field response (p = 0.26). Median in-field PFS was 15 months (95% confidence interval 4.6-NE). Median overall DFS after CR was 32 months (95% confidence interval 17-NE). T-VEC after failure of IO is effective in unresectable, metastatic stage IIIB-IV melanoma. T-VEC initiation sequentially or concurrently did not significantly affect in-field response.

Abstract. The effects of pornography have been of central focus to communication scholars for decades. Despite this, recent meta-analyses reveal a need for additional longitudinal studies probing pornography’s socializing effects, in general; a need for attitudinal studies, specifically; and a need for studies of US adults, in particular. In response to these needs and recent calls for replication studies across the social and behavioral sciences, the present study replicated and extended an early US longitudinal study finding that pornography consumption predicted over time interindividual change in adults’ sexually permissive attitudes among liberal, but not conservative, pornography consumers. The results provided (a) evidence that the original study was neither a sampling fluke nor a product of model misspecification; (b) further evidence that longitudinal associations between pornography use and content congruent outcomes are not simply due to reverse-causation; and (c) preliminary optimism for the reproducibility of findings in the field of pornography effects.

Post-stroke depression is a common complication of stroke. To date, no consistent locus of injury is associated with this complication. Here, we probed network dynamics and structural alterations in post-stroke depression in four functional circuits linked to major depressive disorder and a visual network, which served as a control network. Forty-four participants with recent stroke (mean age = 69.03, standard deviation age = 8.59, age range = 51–86 and gender: female = 10) and 16 healthy volunteers (mean age = 71.53, standard deviation age = 10.62, age range = 51–84 and gender: female = 11) were imaged with 3-Tesla structural, diffusion and resting-state functional MRI. The Geriatric Depression Scale was administered to measure depression severity. Associations between depression severity and functional connectivity were investigated within networks seeded from nucleus accumbens, amygdala, dorsolateral prefrontal cortex and primary visual cortex. In addition, the default mode network was identified by connectivity with medial prefrontal cortex and posterior cingulate cortex. Circuits that exhibited altered activity associated with depression severity were further investigated by extracting within-network volumetric and microstructural measures from structural images. In the stroke group, functional connectivity within the nucleus accumbens-seeded network (left hemisphere: P = 0.001; and right hemisphere: P = 0.004) and default mode network (cluster one: P < 0.001; and cluster two: P < 0.001) correlated positively with depressive symptoms. Normal anticorrelations between these two networks were absent in patients with post-stroke depression. Grey matter volume of the right posterior cingulate cortex (Pearson correlation coefficient = −0.286, P = 0.03), as well as microstructural measures in the posterior cingulate cortex (right: Pearson correlation coefficient = 0.4, P = 0.024; and left: Pearson correlation coefficient = 0.3, P = 0.048), right medial prefrontal cortex (Pearson correlation coefficient = 0.312, P = 0.039) and the medial forebrain bundle (Pearson correlation coefficient = 0.450, P = 0.003), a major projection pathway interconnecting the nucleus accumbens-seeded network and linking to medial prefrontal cortex, were associated with depression severity. Depression after stroke is marked by reduced mutual inhibition between functional circuits involving nucleus accumbens and default mode network as well as volumetric and microstructural changes within these networks. Aberrant network dynamics present in patients with post-stroke depression are therefore likely to be influenced by secondary, pervasive alterations in grey and white matter, remote from the site of injury.

We report here the first implementation of chemically specific imaging in the exhaust plume of a gas turbine typical of those used for propulsion in commercial aircraft. The method used is chemical species tomography (CST) and the target species is C O 2 , absorbing in the near-infrared at 1999.4 nm. A total of 126 beams propagate transverse to the plume axis, along 7 m paths in a coplanar geometry, to probe a central region of diameter ≈ 1.5 m . The C O 2 absorption spectrum is measured using tunable diode laser spectroscopy with wavelength modulation, using the second harmonic to first harmonic (2f/1f) ratio method. The engine is operated over the full range of thrust, while data are recorded in a quasi-simultaneous mode at frame rates of 1.25 and 0.3125 Hz. Various data inversion methodologies are considered and presented for image reconstruction. At all thrust levels a persistent ring structure of high C O 2 concentration is observed in the central region of the measurement plane, with a raised region in the middle of the plume assumed to be due to the engine’s boat tail. With its potential to target various exhaust species, the CST method outlined here offers a new approach to turbine combustion research, turbine engine development, and aviation fuel research and development.

Background: Imaging features derived from T1-weighted (T1w) images texture analysis were shown to be potential markers of poststroke cognitive impairment, with better sensitivity than atrophy measurement. However, in magnetic resonance images, the signal distribution is subject to variations and can limit transferability of the method between centers. This study examined the reliability of texture features against imaging settings using data from different centers. Methods: Data were collected from 327 patients within the Stroke and Cognition Consortium from centers in France, Germany, Australia, and the United Kingdom. T1w images were preprocessed to normalize the signal intensities and then texture features, including first- and second-order statistics, were measured in the hippocampus and the entorhinal cortex. Differences between the data led to the use of 2 methods of analysis. First, a machine learning modeling, using random forest, was used to build a poststroke cognitive impairment prediction model using one dataset and this was validated on another dataset as external unseen data. Second, the predictive ability of the texture features was examined in the 2 remaining datasets by ANCOVA with false discovery rate correction for multiple comparisons. Results: The prediction model had a mean accuracy of 90% for individual classification of patients in the learning base while for the validation base it was ≈ 77%. ANCOVA showed significant differences, in all datasets, for the kurtosis and inverse difference moment texture features when measured in patients with cognitive impairment and those without. Conclusions: These results suggest that texture features obtained from routine clinical MR images are robust early predictors of poststroke cognitive impairment and can be combined with other demographic and clinical predictors to build an accurate prediction model.

Purpose Services are increasingly exploring the use of remote conferencing to deliver psychological interventions, which have become particularly important given the COVID-19 pandemic and infection control guidelines. This paper aims to explore the feasibility, acceptability and preliminary effectiveness of delivering psychological therapy remotely to adults with intellectual disabilities (ID). Design/methodology/approach As part of routine practice within an adult ID community health service, this paper develops a six-session programme based on compassion-focused therapy (CFT) and delivered it to six clients. Clients completed the psychological therapy outcome scale for ID 2nd edition, at assessment, pre- and post-therapy, as well as a feasibility and acceptability measure. Findings Six clients engaged in telephone therapy; four clients individually, while the remaining two were supported by their caregiver. Most clients found the intervention helpful, enjoyable and were pleased that they received telephone-delivered psychological therapy. A reduction was observed at post-therapy in distress (g = 0.33) and risk (g = 0.69). No difference was reported in psychological well-being. Five clients were subsequently discharged from psychological therapy. Originality/value To the knowledge, this is the first study examining the use of telephone therapy (including CFT) for individuals with ID. Findings add to the growing evidence suggesting individuals with ID can benefit from receiving adapted psychological therapies. Research is required to further explore the effectiveness of remote-therapies, who would most likely benefit from this approach and how remote treatments could be used within existing pathways.

Background Pancreatic ductal adenocarcinoma has a high rate of recurrence after resection. We aimed to investigate patterns of recurrence of pancreatic ductal adenocarcinoma to identify opportunities for targeted intervention toward improving survival. Methods This was a retrospective analysis of consecutive patients that underwent curative-intent resection for pancreatic ductal adenocarcinoma between 2007 and 2015. Recurrence and survival were analyzed based on site of recurrence. Multiple clinicopathologic factors were calculated for likelihood of site-specific recurrence. Results The study included 221 patients with median follow-up of 83 months. Median overall and recurrence-free survival was 19 and 13 months, respectively. Recurrence was observed in 71.9% patients. Local recurrence occurred in 16.4%, distant recurrence in 67.3%, and combined in 15.9%. The most common site of distant recurrence was the liver (49.7%) followed by lung (31.8%) and peritoneum (16.6%). Median time to liver recurrence was shortest (5 months, 95% confidence interval 1.7–8.3) and post recurrence survival was poor (4 months, 95% confidence interval 1.9–6.1). Patients with poorly differentiated tumors on pathology were 4.8 times more likely to recur in the liver (odds ratio 4.83, 95% confidence interval 1.7–13.9). Conclusion Liver metastasis after resection of pancreatic ductal adenocarcinoma occurs most frequently, earliest after surgery, and is rapidly fatal. Liver-directed therapies represent a target for future study.

The utility of pre-operative MRI in patients with newly diagnosed invasive breast cancer remains a topic of debate. Those who advocate for pre-treatment imaging contend that MRI may detect additional disease not otherwise appreciated on conventional imaging and may provide more accurate staging information to guide treatment. Additionally, it has been proposed that MRI can be utilized to assess extent of residual disease in patients undergoing neoadjuvant chemotherapy. Conversely, those in opposition maintain that routine pre-operative MRI subjects patients to unnecessary ipsilateral mastectomies and prophylactic contralateral mastectomies with no difference in oncologic outcome. When stratified based on tumor biology and patient characteristics, the data suggests that pre-treatment MRI may be advantageous in certain subsets when compared to the general cohort of breast cancer patients. This review recapitulates the current literature on the impact of breast MRI on the surgical management and outcomes of newly diagnosed breast cancer.

Background: Contrast-induced nephropathy (CIN), an acute kidney injury resulting from the administration of intravascular iodinated contrast media, is a significant cause of morbidity/mortality following coronary angiographic procedures in high-risk patients. Despite preventative measures intended to mitigate the risk of CIN, there remains a need for novel effective treatments. Evidence suggests that delivery of nitric oxide (NO) through chemical reduction of inorganic nitrate to NO may offer a novel therapeutic strategy to reduce CIN and thus preserve long term renal function. Design: The NITRATE-CIN trial is a single-center, randomized, double-blind placebo-controlled trial, which plans to recruit 640 patients presenting with acute coronary syndromes (ACS) who are at risk of CIN. Patients will be randomized to either inorganic nitrate therapy (capsules containing 12 mmol KNO3) or placebo capsules containing potassium chloride (KCl) daily for 5 days. The primary endpoint is development of CIN using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. A key secondary endpoint is renal function over a 3-month follow-up period. Additional secondary endpoints include serum renal biomarkers (e.g. neutrophil gelatinase-associated lipocalin) at 6 h, 48 h and 3 months following administration of contrast. Cost-effectiveness of inorganic nitrate therapy will also be evaluated. Summary: This study is designed to investigate the hypothesis that inorganic nitrate treatment decreases the rate of CIN as part of semi-emergent coronary angiography for ACS. Inorganic nitrate is a simple and easy to administer intervention that may prove useful in prevention of CIN in at-risk patients undergoing coronary angiographic procedures.

Summary Background The WHO VISION 2020 global initiative against blindness, launched in 2000, prioritised childhood visual disability by aiming to end avoidable childhood blindness by 2020. However, progress has been hampered by the global paucity of epidemiological data concerning childhood visual disability. The British Childhood Visual Impairment and Blindness Study 2 (BCVIS2) was done to address this evidence gap. Methods BCVIS2 was a prospective UK-wide, cross-sectional, observational study to establish an inception cohort of children newly diagnosed with visual impairment. Ophthalmologists and paediatricians reported cases from 89 hospitals and community centres across the UK. We included children aged 18 years or younger who were newly diagnosed with any condition causing impaired visual acuity to a level of 0·5 logMAR or worse (worse than 6/18 Snellen) in each eye, or equivalent vision as assessed by standard qualitative measures, between Oct 1, 2015, and Nov 1, 2016. Eligible children were notified simultaneously but independently by their managing ophthalmologists and paediatricians via the two national active surveillance schemes, the British Ophthalmological Surveillance Unit and the British Paediatric Surveillance Unit. Standardised detailed demographic, socioeconomic, and clinical data about detection, management, and treatment were collected at diagnosis and 1 year later. We calculated incidence estimates and relative rates by key sociodemographic factors. We did descriptive analyses of underlying ophthalmic disorders and non-ophthalmic comorbidities. Findings 61 (7%) of 845 eligible children initially notified were ineligible at follow-up because of improved vision after treatment. Thus, the study sample comprised 784 children with permanent newly-diagnosed all-cause visual impairment, severe visual impairment, or blindness. 559 (72%) of 778 children had clinically significant non-ophthalmic impairments or conditions. 28 (4%) of 784 children died within a year after diagnosis of visual disability (all had underlying systemic disorders). Incidence of visual disability in the first year of life was 5·19 per 10 000 children (95% CI 4·71–5·72), almost ten times higher than among 1-to-4-year-olds and between 20 times and 100 times higher than in the older age groups. The overall cumulative incidence (or lifetime risk) of visual impairment, severe visual impairment, or blindness was 10·03 per 10 000 children (9·35–10·76). Incidence rates were higher for those from any ethnic minority group, the lowest quintile of socioeconomic status, and those born preterm or with low birthweight. 345 (44%) of 784 children had a single affected anatomical site. Disorders of the brain and visual pathways affected 378 (48%) of 784 children. Interpretation BCVIS2 provides a contemporary snapshot of the heterogeneity, multi-morbidity, and vulnerability associated with childhood visual disability in a high-income country. These findings could facilitate developing and delivering health care and planning of interventional research. Our findings highlight the importance of including childhood visual disability as a sentinel event and metric in global child health initiatives. Funding Fight for Sight, National Institute for Health Research, and Ulverscroft Foundation.

An Electrical Impedance Tomography (EIT) system has been developed for dynamic three-dimensional imaging of changes in conductivity distribution in the human head, using scalp-mounted electrodes. We attribute these images to changes in cerebral perfusion. At 100 frames per second (fps), voltage measurement is achieved with full-scale signal-to-noise ratio of 105 dB and common-mode rejection ratio > 90 dB. A novel nonlinear method is presented for 3-D imaging of the difference in conductivity distribution in the head, relative to a reference time. The method achieves much reduced modelling error. It successfully localizes conductivity inclusions in experimental and simulation tests, where previous methods fail. For > 50 human volunteers, the rheoencephalography (REG) waveform is observed in EIT voltage measurements for every volunteer, with peak-to-peak amplitudes up to approx. 50 μVrms. Images are presented of the change in conductivity distribution during the REG/cardiac cycle, at 50 fps, showing maximum local conductivity change of approx. 1% in grey/white matter. A total of 17 tests were performed during short (typically 5s) carotid artery occlusions on 5 volunteers, monitored by Transcranial Doppler ultrasound. From EIT measurements averaged over complete REG/cardiac cycles, 13 occlusion tests showed consistently decreased conductivity of cerebral regions on the occluded side, and increased conductivity on the opposite side. The maximum local conductivity change during occlusion was approx. 20%. The simplicity of the carotid artery intervention provides a striking validation of the scalp-mounted measurement system in imaging cerebral hemodynamics, and the REG images indicate its unique combination of sensitivity and temporal resolution.

There is promising data on minimally invasive inguinal lymphadenectomy indicating decreased wound complications compared with the standard open approach. We examined our institutional experience with starting a minimally invasive inguinal lymphadenectomy program.This is a retrospective case series of consecutive patients undergoing videoscopic minimally invasive inguinal lymphadenectomy from August 2017 to March 2022 by a single surgeon. Patients meeting criteria for inguinal lymphadenectomy were considered for minimally invasive inguinal lymphadenectomy unless there was skin involvement by tumor or bulky disease. Data collected included patient characteristics, primary cancer, surgery, and postoperative complications.There were 26 patients included. The mean age was 60.6 ± 16.2 years. Most patients were female (n = 17, 65.4%), and the primary diagnosis was melanoma (n = 21, 19.2%). In 6 cases (23.1%), minimally invasive inguinal lymphadenectomy was combined with deep pelvic node dissection, but most patients did not have a concurrent procedure (n = 15, 57.7%). The median operative time was 119.0 minutes (range, 89.0-160.0), or 130.5 minutes (range, 89.0-345.0) when including concurrent procedures. The mean number of nodes retrieved was 9.8 ± 3.7, with a positive node identified in 19 patients (73.1%) during minimally invasive inguinal lymphadenectomy. There were 12 (46.2%) patients experiencing at least one postoperative complication within 30 days of surgery, the most common being infection (n = 4, 15.4%). One patient required reoperation for infected hematoma washout. Postoperative intervention for seroma was undertaken in 3 patients (11.5%).Minimally invasive inguinal lymphadenectomy is a safe approach to inguinal lymph node dissection, in terms of node retrieval and postoperative complications, and can feasibly be adopted into practice with minimal learning curve.

Background Surgical residency training has an extended tradition of long hours. Residency programs use a variety of call schedules to combat resident fatigue and sleep deprivation while maintaining adherence to duty hour restrictions. Nonetheless, there is a paucity of data regarding objective measurements of sleep during the different call schedules included in general surgery training. Objective The primary objective of this study was to compare the quantity of sleep in 24-hour time frames across all types of shifts worked by general surgery residents at our institution. The secondary objective was to measure activity level in total steps during various time frames. Methods This prospective observational study was performed between April 4 and August 26, 2018, with general surgery residents. Each resident was assigned a Fitbit Charge 2 to wear during all rotations, including general surgery and subspecialty services. Results Twenty-six out of 31 residents voluntarily participated in the study (84%). In-house call (IHC) had significantly less sleep in a 24-hour time frame than home call and night float (144 vs 283 vs 246 minutes, P < .001 and P < .028). IHC had significantly more steps than home call (11 245 vs 8756 steps, P = .039). The smallest number of steps was obtained when residents were not working (7904 steps). Conclusions Our data demonstrate that surgical residents on IHC have significantly less sleep compared to all other types of on-call time frames. Residents on IHC have the most steps across all time frames.

Breast cancer patients with triple-negative or human epidermal growth factor receptor 2 (HER2)-overexpressing phenotypes are recommended to receive chemotherapy for primary tumors greater than 1 cm regardless of nodal status. Neoadjuvant chemotherapy may eradicate subclinical nodal metastases and reduce the extent of axillary surgery performed.A query of the National Cancer Database Participant User File was performed for new cases of female breast cancer from 2012 to 2015. Inclusion criteria were clinical N0 status, receipt of chemotherapy, and receipt of axillary surgery. Exclusions included hormone-positive/HER2-negative tumors and/or distant metastatic disease. Subjects were divided into groups by receipt of neoadjuvant or adjuvant chemotherapy. The primary end point was the extent of axillary surgery, defined as sentinel lymph node biopsy alone or axillary lymph node dissection (ALND). Subgroup analyses were performed on the basis of tumor phenotype and surgery of the primary site.A total of 66,771 female patients were included, 15,967 of whom underwent neoadjuvant chemotherapy. ALND rates were higher in patients who received adjuvant chemotherapy (30.6% vs. 28.8%, P .001). Among tumor phenotypes, the extent of axillary surgery was reduced most significantly for hormone-negative, HER2-positive disease (30.0% vs. 25.8%, P .001). ALND rates were more substantially reduced for patients who underwent mastectomy (41.3% vs. 36.1%, P .001) compared to partial mastectomy (21.8% vs. 20.1%, P = .002). Adjuvant chemotherapy was an independent predictor of ALND (odds ratio, 1.26; 95% confidence interval, 1.19-1.33).Neoadjuvant chemotherapy reduces the extent of axillary surgery in clinically node-negative, nonluminal breast cancers.

Background and objectives Allogeneic blood transfusions are associated with worse postoperative outcomes in oncologic surgery. The aim of this study was to introduce a preoperative intervention to reduce transfusion rates in this population. Methods Adult patients undergoing major oncologic surgery in five categories with similar transfusion rates were recruited. Enrollees received a single preoperative intravenous dose of placebo or tranexamic acid (1000 mg). The primary outcome measure was perioperative transfusion rate. Secondary outcome measures included: estimated blood loss, thromboembolic events, morbidity, hospital length of stay, and readmission rate. Results Seventy-six patients were enrolled, 39 in the tranexamic acid group and 37 in the placebo group, respectively. Demographics and surgery type were equivalent between groups. The transfusion rates were 8 out of 39 (20.5%) in the tranexamic acid group and 5 out of 37 (13.5%) in the placebo group, respectively (P = .418). Median estimated blood loss was 400 mL (interquartile range [IQR] = 150-600) in the tranexamic acid group compared with 300 mL (IQR = 150-800) in the placebo group (P = .983). There was one pulmonary embolism in each arm and no deep venous thrombosis (P > .999). Conclusion Preoperative administration of tranexamic acid at a 1000 mg intravenous dose does not decrease transfusion rates or estimated blood loss in patients undergoing major oncologic surgery.

Current recommendations for early-stage breast cancer are largely based on the NSABP B-06 trial demonstrating equivalent survival between mastectomy and lumpectomy. We sought to compare breast-conserving therapy (BCT) with mastectomy for treatment of early-stage breast cancer in a contemporary patient population. A query of the NCDB PUF identified female breast cancer patients diagnosed from 2004 to 2015. Patients with stage I or II disease were included. BCT was defined as the receipt of lumpectomy plus radiation. Propensity scores were tabulated using race, age, Charlson/Deyo score, tumor site, laterality, histology, grade, size, number of nodes positive, lymph-vascular invasion, receptor status, receipt of chemotherapy, and endocrine therapy. Patients who received BCT versus mastectomy were matched using a 1:1 nearest neighbor technique. The primary outcome measured was overall survival. After exclusions and matching, two equal groups of 101,118 patients remained. Median follow-up was 42 months. The majority had invasive ductal histology (77%), and node-negative disease (84%). Receptor status included ER-positive (83%), PR-positive (73%), and HER2/Neu-positive (15%). Chemotherapy was received in 38% and endocrine therapy in 71%. Propensity score matching yielded equivalent groups across all target variables. The 5-year overall survival was superior for BCT compared with mastectomy (92.9% vs. 89.7%, p

Wind is an important yet understudied environmental influence on foraging behaviour. We investigated the direct and indirect effects of wind on foraging worker honey bees, Apis mellifera. Bees were trained to an array of artificial flowers providing nectar rewards in a location sheltered from natural wind. To examine the direct effect, fans produced four different wind speeds between 0 and 3 m/s at three different flower spacings: 5 cm (flowers touching) and 10 cm and 20 cm (flowers not touching). To examine the indirect effect of wind moving flowers, flowers were moved 10 cm at three frequencies between 50 and 110 cycles/min at zero wind speed. We recorded the number of successful flower visits, time spent flying, search time on a flower and hesitancy to take off. Bees visited significantly fewer flowers with increasing wind speed which was caused by a significant increase in hesitancy to take off. This difference in flower visits between wind speeds was highest at the 20 cm spacing. Flower movement had no effect on foraging rate; however, there was a significant positive relationship between flower movement and the total time spent flying. This was counterbalanced by a significant reduction in time spent searching for the nectary after landing on a flower at the higher flower frequencies. Our results suggest that it is the direct effect of wind on hesitancy to take off that has the greatest effect on honey bee foraging rate.

BACKGROUND: The Kirsten rat sarcoma (KRAS) mutation predicts negative outcomes following resection of colorectal liver metastases (CRLM) and adjuvant hepatic arterial infusion (HAI) pump chemotherapy. Less is known on the effects of KRAS mutation on tumor response in patients with unresectable CRLM undergoing HAI chemotherapy with floxuridine. METHODS: This is a retrospective cohort study investigating the effects of KRAS mutation on tumor response in patients with unresectable CRLM treated with HAI chemotherapy. Primary endpoint was objective response rate (ORR), secondary endpoints included overall tumor response and conversion to resectability. RESULTS: Twenty-five patients with unresectable liver metastases from colorectal cancer were treated with HAI chemotherapy between 2017–2019. Median number of liver lesions was 12 (range, 1–59) and almost all (n=24) had prior chemotherapy before starting HAI therapy. Median number of cycles administered via HAI pump was 6 (range, 3–12). Overall decrease in liver tumor burden was 63.5% (median; range, −257–100%) with an ORR of 20/25 (80%) and 10 (40%) patients converting to resectable status. Eleven (44%) patients had KRAS positive tumors. When compared to wild-type, KRAS positive tumors had less overall percent decrease (58% vs. 70%; P=0.04) and ORR (7/11 vs. 13/13; P=0.03). Fewer patients with KRAS positive tumors converted to resectable status during HAI therapy (2/11 vs. 8/13; P=0.05). At a median follow-up of 14.6 months (range, 4.0–36.6 months), overall survival is 45% among KRAS-positive and 77% for wild type patients. CONCLUSIONS: KRAS mutational status in patients with unresectable liver metastases from colorectal cancer predicts worse response to HAI chemotherapy compared to wild type.

We analytically compare HCF with SSMF in point-to-point core networks of BT-UK and TIM-Italy using GN model. HCF reduces line-amplifiers and high power consuming 400ZR+ links, allowing 400ZR, C+L WDM transmission at 23dBm input power.