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Purpose: The purpose of this article is to review and analyze reported cases of ocular venous air embolism (OVAE) to develop a reliable clinical definition of OVAE and effective prevention strategies. Methods: We reviewed all reports of suspected air embolism during vitrectomy published in PubMed since the introduction of pars plana vitrectomy, and 5 cases found elsewhere and separately reported concurrent with this review. Results: OVAE is a precipitous drop in end-tidal CO2, a choroidal detachment, or a choroidal wound, followed by signs of impending or actual cardiovascular collapse, during vitrectomy air infusion. In each case meeting the above clinical definition, entrained air was found whenever it was sought (8/8, 100%), either by antemortem imaging or postmortem forensic investigations. Most OVAE cases were fatal (9/13, 69%), with 8 of 9 deaths (89%) occurring the day of surgery. Conclusions: OVEA is a rare but usually fatal complication of air infusion into the eye during vitrectomy. Although received with skepticism when first reported (2005), OVAE may be the most lethal type of surgical air embolization because of its high entrainment pressure and proximity to the heart. Because the effective response time to avoid a fatal OVAE outcome can be less than 1 minute, use of preventive measures is critical—most notably a “time out” before air infusion to confirm infusion cannula positioning, and immediate cessation of air infusion if choroidal detachment is detected.

The purpose of this study is to determine both the frequency of repeat CT performed within 1 month after a patient visits the emergency department (ED) and undergoes CT evaluation for abdominal pain and the frequency of worsened or new CT-based diagnoses.Secondary analysis was performed on data collected during a prospective multicenter study. The parent study included patients who underwent CT in the ED for abdominal pain between 2012 and 2014, and these patients constituted the study group of the present analysis. The proportion of patients who underwent (in any setting) repeat abdominal CT within 1 month of the index CT examination was calculated. For each of these patients, results of the index and repeat CT scans were compared by an independent panel and categorized as follows: no change (group 1); same process, improved (group 2); same process, worse (group 3); or different process (group 4). The proportion of patients in groups 1 and 2 versus groups 3 and 4 was calculated, and patient and ED physician characteristics were compared.The parent study included 544 patients (246 of whom were men [45%]; mean patient age, 49.4 years). Of those 544 patients, 53 (10%; 95% CI, 7.5-13%) underwent repeat abdominal CT. Patients' CT comparisons were categorized as follows: group 1 for 43% of patients (23/53), group 2 for 26% (14/53), group 3 for 15% (8/53), and group 4 for 15% (8/53). New or worse findings were present in 30% of patients (16/53) (95% CI, 19-44%). When patients with findings in groups 1 and 2 were compared to patients with findings in groups 3 and 4, no significant difference was noted in patient age (p = 0.25) or sex (p = 0.76), the number of days between scans (p = 0.98), and the diagnostic confidence of the ED physician after the index CT scan was obtained (p = 0.33).Short-term, repeat abdominal CT was performed for 10% of patients who underwent CT in the ED for abdominal pain, and it yielded new or worse findings for 30% of those patients.

Purpose: The purpose of this case series is to report 5 new cases of ocular venous air embolism (OVAE). We define OVAE as a precipitous drop in end-tidal carbon dioxide, a choroidal detachment, or a choroidal wound, followed by signs of impending or actual cardiovascular collapse, during vitrectomy air infusion. Methods: A case report series was retrospectively reviewed. Results: Four of the 5 OVAE cases (80%) were fatal, occurring in conjunction with repair of rhegmatogenous retinal detachment (2 cases); a large surgical wound of the choroid (1 case); and vitrectomy repair of an injured eye (1 case). One patient survived OVAE during choroidal melanoma endoresection after prompt discontinuance of air infusion by anesthesia personnel previously alerted to the OVAE risk. Conclusions: OVAE is a rare but usually fatal complication of air infusion into the eye during vitrectomy. Because the effective response time to avoid a fatal OVAE outcome can be less than 1 minute, use of preventive measures is critical.

In this study, eggshell (ES) powder was evaluated as a cheap and biocompatible waste material for the pre-treatment of acid mine drainage (AMD) leachate from coal dump. First, the composition of the AMD and physiochemical properties of the ES powder were determined using various standard characterization techniques. Then the removal efficiency of the target metal contaminants and the acid-neutralisation effect were explored in batch and kinetic set-ups. Thereafter, the settling rate of sludge formed after separately reacting ES and limestone powders with AMD was explored. Results revealed that the AMD leachate was highly acidic and contaminated with both cations and anions. Thermogravimetric analysis (TGA) and X-ray fluorescence (XRF) analyses demonstrated that ES powder was thermally stable up to 700 °C and CaO was the main component, respectively. Scanning electron microscopy (SEM) and EDX spectra confirmed the removal of contaminants. Both the decrease in particle size and increase in mass of ES enhanced the treatment efficiency. Although complete Fe and Al removal was achieved, Mn and sulphates posed a challenge as they were partially removed. Meanwhile, ES demonstrated superior acid-neutralizing effect to limestone and the mine water clarity and pH were shifted to acceptable levels. Both Fe and Al removal proceeded through an exothermic process while it was opposite for Mn. Kinetics were rapid and the sludge from ES powder settled faster compared with that from limestone powder. Cost analysis indicated that significant financial savings can be realised by substituting limestone with ES material. The findings suggest that ES waste could be an efficient and cheap material in the pre-treatment of AMD effluents.

IntroductionA large proportion of malaria-infected individuals in endemic areas do not experience symptoms that prompt treatment-seeking. These asymptomatically infected individuals may retain their infections for many months during which sexual-stage parasites (gametocytes) are produced that may be transmissible to mosquitoes. Reductions in malaria transmission could be achieved by detecting and treating these infections early. This study assesses the impact of enhanced community case management (CCM) and monthly screening and treatment (MSAT) on the prevalence and transmissibility of malaria infections.Methods and analysisThis cluster-randomised trial will take place in Sapone, an area of intense, highly seasonal malaria in Burkina Faso. In total, 180 compounds will be randomised to one of three interventions: arm 1 - current standard of care with passively monitored malaria infections; arm 2 - standard of care plus enhanced CCM, comprising active weekly screening for fever, and detection and treatment of infections in fever positive individuals using conventional rapid diagnostic tests (RDTs); or arm 3 - standard of care and enhanced CCM, plus MSAT using RDTs. The study will be conducted over approximately 18 months covering two high-transmission seasons and the intervening dry season. The recruitment strategy aims to ensure that overall transmission and force of infection is not affected so we are able to continuously evaluate the impact of interventions in the context of ongoing intense malaria transmission. The main objectives of the study are to determine the impact of enhanced CCM and MSAT on the prevalence and density of parasitaemia and gametocytaemia and the transmissibility of infections. This will be achieved by molecular detection of infections in all study participants during start and end season cross-sectional surveys and routine sampling of malaria-positive individuals to assess their infectiousness to mosquitoes.Ethics and disseminationThe study has been reviewed and approved by the London School of Hygiene and Tropical Medicine (LSHTM) (Review number: 14724) and The Centre National de Recherche et de Formation sur le Paludisme institutional review board (IRB) (Deliberation N° 2018/000002/MS/SG/CNRFP/CIB) and Burkina Faso national medical ethics committees (Deliberation N° 2018-01-010).Findings of the study will be shared with the community via local opinion leaders and community meetings. Results may also be shared through conferences, seminars, reports, theses and peer-reviewed publications; disease occurrence data and study outcomes will be shared with the Ministry of Health. Data will be published in an online digital repository.Trial registration numberNCT03705624.

The increasing adoption of ultra-low pressure (ULP) membrane systems for drinking water treatment in small rural communities is currently hindered by a limited number of studies on module design. Detailed knowledge on both intrinsic membrane transport properties and fluid hydrodynamics within the module is essential in understanding ULP performance prediction, mass transfer analysis for scaling-up between lab-scale and industrial scale research. In comparison to hollow fiber membranes, flat sheet membranes present certain advantages such as simple manufacture, sheet replacement for cleaning, moderate packing density and low to moderate energy usage. In the present case study, a numerical model using computational fluid dynamics (CFD) of a novel custom flat sheet membrane module has been designed in 3D to predict fluid flow conditions. The permeate flux through the membrane decreased with an increase in spacer curviness from 2.81 L/m2h for no (0%) curviness to 2.73 L/m2h for full (100%) curviness. A parametric analysis on configuration variables was carried out to determine the optimum design variables and no significant influence of spacer inflow or outflow thickness on the fluid flow were observed. The numerical model provides the necessary information on the role of geometrical and operating parameters for fabricating a module prototype where access to technical expertise is limited. ispartof: Membranes vol:11 issue:1 ispartof: location:Switzerland status: published

Purpose To determine the effect of computed tomography (CT) results on physician decision making in three common clinical scenarios in primary care. Materials and Methods This research was approved by the institutional review board (IRB) and was HIPAA compliant. All physicians consented to participate with an opt-in or opt-out mechanism; patient consent was waived with IRB approval. In this prospective multicenter observational study, outpatients referred by primary care providers (PCPs) for CT evaluation of abdominal pain, hematuria, or weight loss were identified. Prior to CT, PCPs were surveyed to elicit their leading diagnosis, confidence in that diagnosis (confidence range, 0%-100%), a rule-out diagnosis, and a management plan if CT were not available. Surveys were repeated after CT. Study measures were the proportion of patients in whom leading diagnoses and management changed (PCP management vs specialist referral vs emergency department transfer), median changes in diagnostic confidence, and the proportion of patients in whom CT addressed rule-out diagnoses. Regression analyses were used to identify associations between study measures and site and participant characteristics. Specifically, logistic regression analysis was used for binary study measures (change in leading diagnosis, change in management), and linear regression analysis was used for the continuous study measure (change in diagnostic confidence). Accrual began on September 5, 2012, and ended on June 28, 2014. Results In total, 91 PCPs completed pre- and post-CT surveys in 373 patients. In patients with abdominal pain, hematuria, or weight loss, leading diagnoses changed after CT in 53% (131 of 246), 49% (36 of 73), and 57% (27 of 47) of patients, respectively. Management changed in 35% (86 of 248), 27% (20 of 74), and 54% (26 of 48) of patients, respectively. Median absolute changes in diagnostic confidence were substantial and significant (+20%, +20%, and +19%, respectively; P ≤ .001 for all); median confidence after CT was high (90%, 88%, and 80%, respectively). PCPs reported CT was helpful in confirming or excluding rule-out diagnoses in 98% (184 of 187), 97% (59 of 61), and 97% (33 of 34) of patients, respectively. Significant associations between primary measures and site and participant characteristics were not identified. Conclusion Changes in PCP leading diagnoses and management after CT were common, and diagnostic confidence increased substantially.

BACKGROUND Juvenile osteochondritis dissecans (OCD) of the medial femoral condyle (MFC) is one of the most common causes of knee pain in adolescents. Wilson sign reproduces knee pain with internal rotation of the tibia during extension of the knee from 90 to 30 degrees due to impingement of the tibial eminence on the MFC. This impingement may result in microtrauma and contribute to lesion formation. The purpose of this study was to evaluate anatomic factors that may increase the likelihood of impingement by using magnetic resonance imaging scans of patients with MFC OCD lesions to measure tibial eminence height and femoral notch width. METHODS A retrospective, case-control study was performed using the radiology database at our institution between July 2009 and February 2014. Magnetic resonance imagings of patients with MFC OCD lesions and matched controls were identified. For each patient, tibial eminence height and femoral notch width were measured and then normalized for patient size [creating the tibial eminence height normalized, and the notch width index (NWI), respectively]. Values for OCD and control knees were compared using Student t test. Interrater and intrarater reliability were calculated using intraclass correlation coefficients. RESULTS Thirty-five MFC OCD patients and matched controls were identified. Comparison of the groups showed a significantly smaller NWI in MFC OCD knees than in the matched controls (0.2620±0.0248 vs. 0.2886 ±0.0323, P=0.0003). There was no difference in tibial eminence height normalized between groups (0.1387±0.0161 vs. 0.1428±0.0108, P=0.21). Interrater and intrarater reliability of all measurements was good to excellent (0.81 to 1.00) when measurements were made using bony margins. CONCLUSIONS Knees with MFC OCD lesions have significantly smaller NWIs than matched controls. This anatomic factor may increase the likelihood of tibial eminence impingement and contribute to OCD lesion formation. LEVEL OF EVIDENCE Level III-case-control study.

In terms of supporting veteran populations, little is known of the experiences of chaplains professionally active outside of Department of Veterans Affairs (VA) healthcare settings. The present study looks to examine how involved non-VA chaplains are in supporting veterans as well as their familiarity with the VA. An online survey was distributed in a convenience sample of chaplains, of which n = 39 met the inclusion criterion for this study (i.e., no past or present VA affiliation). The results find that most of the non-VA chaplains encounter veteran service users either on a weekly or monthly basis. Though familiar with VA services, non-VA chaplains were not sure of their veteran service users' VA enrollment status nor did they feel able to adequately advise their veteran service users on VA enrollment. The results suggest that non-VA chaplains actively support veteran populations. Opportunities for enhancing chaplaincy services and VA outreach programs are discussed.

This essay moves beyond questions of source study and reception to show how “The Unparalleled Adventure of One Hans Pfaall” mixes genres of satire and realism. In doing so, Poe not only participates in the early development of science fiction but also explores emerging relationships between scientific and literary discourses during the nineteenth-century print revolution, which made it difficult to distinguish between fictions and facts. “Hans Pfaall” self-consciously dramatizes through stylistic turbulence how knowledge is generically produced within unruly media ecologies and is thus epistemologically unstable. In this sense, the story—not in spite but precisely because of its generic and aesthetic inconsistencies—can be regarded less as an unsuccessful hoax and more as a narrative about the dynamics of writing and reading fiction under conditions of doubt.

Matrix-induced autologous chondrocyte implantation (MACI) is an established technique to treat articular cartilage defects in the knee. Traditionally, the chondral graft is harvested arthroscopically and then implanted via an open or mini-open technique. However, an arthroscopic implantation technique carries with it the potential for reduced pain, improved rehabilitation, and reduced arthrofibrosis. The arthroscopic implantation first involves a standard arthroscopic biopsy followed by cell culture and seeding onto a collagen membrane. The implantation procedure itself is performed 6–8 weeks later. A standard arthroscopy is performed and the defect is debrided to stable vertical walls using curettes and arthroscopic shavers. All irrigation fluid is subsequently evacuated such that the rest of the procedure is performed as a dry arthroscopy. The defect is sized using a graduated probe. If required, a template may be cut out of the supplied membrane. A wide-bore valveless cannula, inserted through the working portal, permits the repeated atraumatic passage of the prepared membrane. The probe is used to position the graft and check for size. A definitive graft is then cut and placed in the knee. Fibrin glue is applied to the base of the defect, the membrane is positioned, and an embolectomy or indwelling catheter balloon is inflated to apply even pressure to the graft while the glue sets. A validated, accelerated rehabilitation program is recommended, with full weight-bearing at 8-week post-procedure. Results using this technique have shown this to be a safe, reliable, and reproducible procedure with good clinical and radiological outcomes at the 5-year follow-up.

This brief report looks at the demographics as well as professional background and experiences of a sample of Israeli chaplains. An online survey was distributed to 39 Israeli chaplains, yielding a response rate of n = 6 (15.4%). The findings notably highlight the role of women as chaplains, supporting a religiously diverse population, and differing perspectives on the functional role of a chaplain. These findings could help facilitate discussion and future research into chaplaincy services in Israel.

The objective of our study was to determine whether specific patient and physician factors-known before CT-are associated with a diagnosis of nonspecific abdominal pain (NSAP) after CT in the emergency department (ED).We analyzed data originally collected in a prospective multicenter study. In the parent study, we identified ED patients referred to CT for evaluation of abdominal pain. We surveyed their physicians before and after CT to identify changes in leading diagnoses, diagnostic confidence, and admission decisions. In the current study, we conducted a multiple regression analysis to identify whether the following were associated with a post-CT diagnosis of NSAP: patient age; patient sex; physicians' years of experience; physicians' pre-CT diagnostic confidence; and physicians' pre-CT admission decision if CT had not been available. We analyzed patients with and those without a pre-CT diagnosis of NSAP separately. For the sensitivity analysis, we excluded patients with different physicians before and after CT.In total, 544 patients were included: 10% (52/544) with a pre-CT diagnosis of NSAP and 90% (492/544) with a pre-CT diagnosis other than NSAP. The leading diagnoses changed after CT in a large proportion of patients with a pre-CT diagnosis of NSAP (38%, 20/52). In regression analysis, we found that physicians' pre-CT diagnostic confidence was inversely associated with a post-CT diagnosis of NSAP in patients with a pre-CT diagnosis other than NSAP (p = 0.0001). No other associations were significant in both primary and sensitivity analyses.With the exception of physicians' pre-CT diagnostic confidence, the factors evaluated were not associated with a post-CT diagnosis of NSAP.

To compare life expectancy (LE) losses attributable to three imaging strategies for appendicitis in adults-computed tomography (CT), ultrasonography (US) followed by CT for negative or indeterminate US results, and magnetic resonance (MR) imaging-by using a decision-analytic model.In this model, for each imaging strategy, LE losses for 20-, 40-, and 65-year-old men and women were computed as a function of five key variables: baseline cohort LE, test performance, surgical mortality, risk of death from delayed diagnosis (missed appendicitis), and LE loss attributable to radiation-induced cancer death. Appendicitis prevalence, test performance, mortality rates from surgery and missed appendicitis, and radiation doses from CT were elicited from the published literature and institutional data. LE loss attributable to radiation exposure was projected by using a separate organ-specific model that accounted for anatomic coverage during a typical abdominopelvic CT examination. One- and two-way sensitivity analyses were performed to evaluate effects of model input variability on results.Outcomes across imaging strategies differed minimally-for example, for 20-year-old men, corresponding LE losses were 5.8 days (MR imaging), 6.8 days (combined US and CT), and 8.2 days (CT). This order was sensitive to differences in test performance but was insensitive to variation in radiation-induced cancer deaths. For example, in the same cohort, MR imaging sensitivity had to be 91% at minimum (if specificity were 100%), and MR imaging specificity had to be 62% at minimum (if sensitivity were 100%) to incur the least LE loss. Conversely, LE loss attributable to radiation exposure would need to decrease by 74-fold for combined US and CT, instead of MR imaging, to incur the least LE loss.The specific imaging strategy used to diagnose appendicitis minimally affects outcomes. Paradigm shifts to MR imaging owing to concerns over radiation should be considered only if MR imaging test performance is very high.

International audience; As part of the Mars Science Laboratory, the ChemCam instrument acquires remote laser induced breakdown spectra at distances that vary between 1.56 m and 7 m. This variation in distance affects the intensities of the measured LIBS emission lines in non-trivial ways. To determine the behavior of a LIBS emission line with distance, it is necessary to separate the effects of many parameters such as laser energy, laser spot size, target homogeneity, and optical collection efficiency. These parameters may be controlled in a laboratory on Earth but for field applications or in space this is a challenge. In this paper, we show that carefully selected ChemCam LIBS emission lines acquired from the Martian dust can be used to build an internal proxy spectroscopic standard. This in turn, allows for a direct measurement of the effects of the distance of various LIBS emission lines and hence can be used to correct ChemCam LIBS spectra for distance variations. When tested on pre-launch LIBS calibration data acquired under Martian-like conditions and with controlled and well-calibrated targets, this approach yields much improved agreement between targets observed at various distances. This work lays the foundation for future implementation of automated routines to correct ChemCam spectra for differences caused by variable distance.

BackgroundMalaria elimination and its ultimate eradication will require drugs targeting all stages of the parasite’s life cycle. Yet, very few drugs are known to be effective on the sexual stages (gametocytes) of Plasmodium falciparum. Artemisinin-based combination therapy (ACT) has been shown to have some early-stage gametocytocidal effects on in vitro and in feeding experiments. However, field studies showed that artesunate reduces but does not prevent post-treatment transmission of P. falciparum to mosquitos.Methods763 children and adult patients with acute uncomplicated Plasmodium sp. malaria were included in a phase IIIb/IV comparative, randomised, multi-centre, open label, parallel 3-arm clinical trial to assess safety and efficacy of repeated administration of pyronaridine-artesunate, dihydroartemisinin-piperaquine or artemether-lumefantrine or artesunate-amodiaquine over a two-year period. Drugs were given based on the body weight and volunteers were followed up for 42 days. Clinical signs and symptoms were recorded and filter paper and blood smears collected during each visit. Malaria parasites were assessed and parasite density development stages determined by light microscopy.ResultsP. falciparum gametocyte was 1.9%, during the two years of follow-up. From the three treatment arms, artesunate-amodiaquine was the arm bearing more P. falciparum gametocyte with 68.7%, dihydroartemisinin-piperaquine accounted for 6.3% and pyronaridine-artesunate for 25%. P. falciparum gametocyte was more pronounced in populations having parasite density ≤1 00 000 parasites/µl compared to above parasitaemia.ConclusionRepeated ACTs treatment didn’t clear P. falciparum gametocyte in a population infected with uncomplicated malaria.

Background Bohler's historical tuber-joint angle of the calcaneus has been used since 1931. Surprisingly, there is a paucity of literature on its use. Objectives To confirm the normal range for Bohler's angle and determine the angle with the highest accuracy in the diagnosis of calcaneal fractures. Methods A retrospective cohort study was performed. The study cohort comprised 424 patients spanning a 5-year period from April 2005 to March 2010. Bohler's angle was measured by two independent observers on lateral x-ray study using the digital angle tool from the Picture Archival and Communication System. Data were analyzed using Stata 8 statistical software package. Results The mean Bohler's angle in patients without calcaneal fracture was 29.4°. In this group there was no difference in Bohler's angle between male and female patients, left and right feet, or across age. In those patients with calcaneal fractures, a Bohler's angle below 25° was moderately predictive of calcaneal fracture (sensitivity = 100%, specificity = 82%), an angle below 23° was highly predictive of calcaneal fracture (sensitivity = 100%, specificity = 89%), and an angle below 21° was strongly suggestive of calcaneal fracture (sensitivity = 99%, specificity = 99%). A Bohler's angle of ≤ 20° had the highest diagnostic accuracy. Conclusion A Bohler's angle of 20° or less is highly accurate in determining the presence or absence of calcaneal fracture. Bohler’s angle serves as a useful screening tool in fracture diagnosis.

NASA is developing the MARS 2020 mission, which includes a rover that will land and operate on the surface of Mars. MARS 2020, scheduled for launch in July, 2020, is designed to conduct an assessment of Mars’ past habitability, search for potential biosignatures, demonstrate progress toward the future return of samples to Earth, and contribute to NASA’s Human Exploration and Space Technology Programs.

This descriptive study examines the involvement of professional chaplains in addressing loss of dignity, inconsequential life or not having a legacy, fear of burdensomeness, and fear of pain in veterans at the end of life. A convenience sample of Jewish chaplains responded to an online survey gauging their involvement in these areas. Results are presented descriptively. Most respondents stated either rarely (≤1 x month) or sometimes (≥1 x month) encountering veterans with end-of-life issues. Respondents reported varying degrees of involvement in supporting veterans at the end of life with respect to the aforementioned areas. As research into the end-of-life care needs of veterans continues to develop, recognising chaplains as a source of both spiritual and psychosocial support can serve as an opportunity for better meeting the needs of this population.

This book was written to help expand the productive utilization of traditional group methodology in the form of team coaching into the realm and world of nonclinical work such as business. As part ...

Background: Intranasal (IN) midazolam is a potential alternative to rectal diazepam for the acute treatment of epileptic seizures. Objective: The purpose of this pilot study was to investigate the pharmacokinetics and tolerability of IN midazolam (50 mg/mL) compared with intravenous (IV) midazolam (2.5 mg) in healthy adult volunteers. Methods: In this single-dose, randomized-sequence, open-label, 2-period crossover pilot study subjects were randomly assigned to receive IN or IV midazolam, with a washout period of at least 5 days between treatments. The 50-mg/mL IN midazolam formulation consisted of 5 mg midazolam base per 0.1 mL (1 spray) and was administered once in 1 nostril. The IV midazolam solution (2.5 mg) was infused over 10 seconds. Blood samples were taken before and at regular intervals up to 240 minutes after dosing. Pharmacokinetic data (ie, C-max, T-max, t(1/2), and AUC) were analyzed using a 2-compartment model. Results: Of 9 volunteers screened and enrolled, 7 completed the study (mean age 34.1 [9.0] years; mean weight, 68.6 [10.4] kg, range 53-89 kg; 6 men, 3 women; all white). The mean C-max of 78 (40) ng/mL was reached 44 minutes after IN administration, whereas the mean C-max was 51 (5) ng/mL after IV administration. The mean estimated C-t=5 min was 31.4 (28.1) ng/mL after IN administration. The elimination t(1/2) was 1.9 (0.41) hours for IN midazolam and 2.3 (0.19) hours for IV midazolam. The bioavailability of IN midazolam was 82%. There were few adverse events, with a local burning feeling in the nose being the most reported event (6 of 7 subjects). Conclusions: In this select group of healthy volunteers, concentrations of midazolam >30 ng/mL were reached within 5 minutes of IN administration at a dose of 5 mg/0.1 mL. A burning feeling in the nostril was the main adverse effect. Additional research is needed to evaluate the safety profile, convenience, satisfaction, and efficacy of nasal midazolam in the treatment of adults with seizures. This trial is registered at www.isrctn.org, No. ISRCTN79059168. (Clin Ther. 2011;33:2022-2028)

Clinical Considerations Concerning Detection of Venous Air Embolism. By Maurice S. Albin, Robert G. Carroll, Joseph C. Maroon. Neurosurgery 1978; 3:380-84. Abstract used with permission from the Congress of Neurological Surgeons, copyright 1978. Venous air embolism during neurosurgical procedures (detected by Doppler ultrasound and aspiration via a right atrial catheter) was noted in 100 of 400 patients in the sitting position, 5 of 60 patients in the lateral position, 7 of 48 patients in the supine position, and 1 of 10 patients in the monitored prone position. We confirmed venous air embolism in many of these patients by using serial technetium-microaggregated albumin lung scans. Gravitational gradients from the venous portal of entrance to the right side of the heart were as small as 5.0 cm, with aspiration of 200 ml of air occurring. Doppler ultrasonic air bubble detection and aspiration through a previously inserted right atrial catheter are critical factors in the diagnosis and treatment of this condition.

Many chemical reactions are carried out using stirred tanks, and the efficiency of such systems depends on the quality of mixing, which has been a subject of research for many years. For solid-liquid mixing, traditionally the research efforts were geared towards determining mixing features such as off-bottom solid suspension using experimental techniques. In a few studies that focused on the determination of solids concentration distribution, some methods that have been used have not been accurate enough to account for some small scale flow mal-distribution such as the existence of dead zones. The present review shows that computational fluid dynamic (CFD) techniques can be used to simulate mixing features such as solids off-bottom suspension, solids concentration and particle size distribution and cloud height. Information on the effects of particle size and particle size distribution on the solids concentration distribution is still scarce. Advancement of the CFD modeling is towards coupling the physical and kinetic data to capture mixing and reaction at meso- and micro-scales. Solids residence time distribution is important for the design; however, the current CFD models do not predict this parameter. Some advances have been made in recent years to apply CFD simulation to systems that involve fermentation and anaerobic processes. In these systems, complex interaction between the biochemical process and the hydrodynamics is still not well understood. This is one of the areas that still need more attention.

Mixing in stirred tanks influences conversion of reactants for fast reactions, and the efficiency of a mixing process can be determined from the power consumption and mixing time, which are the two parameters that define homogenization energy. In this study, the computational fluid dynamics (CFD) and laser Doppler velocimetry (LDV) techniques were employed to study the effect of the Rushton turbine bottom clearance on the flow field, mixing time and power consumption in a stirred tank. Experimental and simulation studies were conducted in a tank with and without a draft tube where a conductivity meter and decolourization methods were employed in validating the mixing time simulation results. A good agreement between the experimental and simulation results for the flow field and mixing time was obtained. The results showed a reduction in mixing time and power consumption at a low impeller clearance, with reference to the standard clearance, and a further reduction of the same parameters was obtained for a system fitted with a draft tube. At the low clearance, there was an increase in mixing efficiency by 46%, for a system without draft tube and 61% for that with the draft tube.

Mixing efficiency in stirred tanks is an important consideration in the design of many industrial processes. Computational fluid dynamics (CFD) techniques have been employed in the present work to study the hydrodynamics in a tank stirred by a Rushton turbine. The effect of the impeller clearance on the velocity field and mixing has been investigated. It has been shown that at a low impeller clearance, the Rushton turbine generates a flow field that evolves from the typical two loops to a single loop flow pattern similar to that of an axial impeller. This single loop flow pattern resulted in an increase in axial flow and a decrease in mixing time at a constant power number. It has been found that a draft tube can be used with a single Rushton turbine, at a low clearance to aid axial flow and mixing, and this resulted in 50% reduction in mixing time. There was a good comparison between laser Doppler velocimetry (LDV) experimental and CFD simulation flow fields, both of which showed that the draft tube improved mixing in the tank by suppressing secondary circulation loops.

To determine how physicians' diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings.This study was approved by the institutional review board and compliant with HIPAA. Data were collected between July 12, 2012, and January 13, 2014. The requirement to obtain patient consent was waived. In this prospective, four-center study, patients presenting to the emergency department who were referred for CT with abdominal pain, chest pain and/or dyspnea, or headache were identified. Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence (on a scale of 0% to 100%), alternative "rule out" diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (eg, to emergency department) at 1-month follow-up. Regression analysis was used to identify associations between primary measures and site and participant characteristics.Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P.0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P.0001); median post-CT confidence was high (95% for all three groups). CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%). During follow-up, 70 of 450 patients with abdominal pain (15%), 53 of 387 with chest pain and/or dyspnea (14%), and 49 of 433 with headache (11%) returned for the same indication. In general, changes in leading diagnosis, diagnostic confidence, and admission decisions were not well explained with site or participant characteristics.Physicians' diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.

Background Although esophageal strictures caused by epidermolysis bullosa are often treated with balloon dilations, complete obstruction has few effective therapies except esophagectomy with colonic replacement. Objective Resolution of esophageal obstructive lesion without surgical intervention. Design Case study. Setting Interventional radiology. Patient Epidermolysis bullosa with esophageal stricture. Intervention Endoscopic- and guidewire-guided sharp recanalization. Main Outcome Measurement Radiologic evidence of stricture resolution. Results Successful recanalization. Limitations Experience of operators (anesthesiologist, endoscopist, interventional radiologist). Conclusions Sharp recanalization of a complete stricture in patients with epidermolysis bullosa is feasible in a controlled setting.

We examined the effects of thyroid hormones (THs) on left ventricular (LV) function and myocyte remodeling in rats with spontaneously hypertensive heart failure (SHHF). SHHF rats were treated with three different TH doses from 20–21 mo of age. In terminal experiments, LV function (as determined by echocardiography and catheterization) and isolated myocyte shape were examined in SHHF rat groups and age-matched Wistar-Furth control animals. Compared with Wistar-Furth rats, the ratio of α- to β-myosin was reduced in untreated SHHF rats. The α-to-β-myosin ratio increased in all TH groups, which suggests a reversal of the fetal gene program. Low-dose TH produced no changes in LV myocyte size or function, but high-dose TH produced signs of hyperthyroidism (e.g., increased heart weight, tachycardia). The chamber diameter-to-wall thickness ratio declined with increasing dose due to reduced chamber diameter and increased wall thickness. This resulted in a 38% reduction in LV systolic wall stress in the middle- and high-dose groups despite sustained hypertension. Isolated myocyte data indicated that chamber remodeling and reduced wall stress were due to a unique alteration in myocyte transverse shape (e.g., reduced major diameter and increased minor diameter). Based on our present understanding of ventricular remodeling and wall stress, we believe these changes are likely beneficial. Results suggest that TH may be an important regulator of myocyte transverse shape in heart disease.

Engineering education is getting global. This article assesses the present scenario in engineering education, which is undergoing a paradigm shift because of the Internet, innovation, and internationalization. The influence of information technology, industrial development, national politics, and economic policies on internationalization of engineering education has been discussed. Quality control and accreditation practices in some countries have been reviewed, and a link between technology advancement and engineering curricula has been drawn. A stable political and economic system is necessary to retain the highly qualified African engineers who are the drivers of the engineering education toward achieving this goal.

The Dialysis Outcome Quality Initiative (DOQI) mandates that 50% of permanent hemodialysis (HD) access be native arteriovenous fistulae (AVFs). Recent reports have shown that when these guidelines are followed, the percentage of new AVFs can exceed DOQI guidelines. From July 1998 to July 2001, 330 HD access procedures were performed in an academic tertiary care center. Patients were categorized into two groups. Group I followed DOQI guidelines and underwent history and physical examination; duplex vein mapping; use of basilic vein transposition; and a postoperative protocol to determine maturation and start needle access in a stepwise progression. Group II had history and physical examination and basilic vein transposition was not used. Patient data were retrospectively reviewed. Overall, 100 (31%) HD shunts were AVFs. Group I (42/183, 23%) had significantly less AVFs (p = 0.005) than group II (58/147, 39%). For first-time placement of HD access, there was no significant difference (p = 0.95) in the percentage of AVFs in group I (26/62, 42%) and group II (29/68, 43%). For patients with prior history of HD access, significantly less AVFs (p0.001) were placed in group I (16/121, 13%) than in group II (29/79, 37%). Group I had significantly less first-time HDS (P = 0.03) than group II, 34% VS. 46%, respectively. AVF maturation for hemodialysis occurred in 79% of group I and 71% of group II (P = 0.52). There were no significant differences (P0.05) when comparing age, gender, and incidence of diabetes between the two groups. AVF formation based largely on duplex vein mapping in group I and lack of basilic vein transposition in group II contributed to the inability to achieve DOQI guidelines. Integration of knowledge and practice among vascular surgeons may help to avoid these pitfalls.

Background According to the guidelines of the Burkina Faso National Malaria Control Programme, artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL) are the first-line drugs for uncomplicated malaria treatments. However, in some contexts where individuals will experience more than 1 episode of clinical malaria per year, it is unknown to what extent giving any of these ACTs repeatedly is safe. In the framework of the activities of the West African Network for Antimalarial Drugs (WANECAM) network, we have compared the efficacy and tolerability of repeated use of dihydroartemisinin-piperaquine (DHA-PQ) or artesunate-pyronaridine (PYR) with artesunate-amodiaquine (ASAQ). Methods A randomised open-label parallel 3 arms trial was conducted to compare the efficacy of a three-day regimen of DHA-PQ and PYR with ASAQ. The trial involved children and adults with uncomplicated falciparum malaria. Participants were randomly assigned to one of the three treatment arms at the first clinical episode. During the subsequent clinical episodes, the same drug was administered. Follow-up duration was 42 days for each episode. Study duration was two years for each participant. Primary endpoints were the incidence rate of uncomplicated malaria over a period of 2 years and PCR corrected/uncorrected ACPR at day 28 and day 42. Safety parameters were also assessed. Results Of the 763 patients enrolled, the incidence rate of clinical malaria was 1.4, 1.2, and 1.5 episodes / person-year at risk in the ASAQ, DHA-PQ and PYRAMAX arms, respectively. The PCR-uncorrected efficacy at day 28 versus day 42 was: ASAQ 93.4% vs 79.5%; PYR 98.1% vs 74.8%; and DHA-PQ 99.5% vs 95.2%. Bronchitis, rhinitis, abdominal pain, cough, QTc prolongation, headache, and vomiting were registered as the main adverse events in each of the three groups. Conclusions The findings from our study support the current recommendations for using artemisinin-based combinations in the treatment of uncomplicated malaria in areas of high malaria transmission such as Burkina Faso.

Following disastrous earthquakes in Alaska and in Niigata, Japan in 1964, Professors H. B. Seed and I. M. Idriss developed and published a methodology termed the ''simplified procedure'' for evaluating liquefaction resistance of soils. This procedure has become a standard of practice throughout North America and much of the world. The methodology which is largely empirical, has evolved over years, primarily through summary papers by H. B. Seed and his colleagues. No general review or update of the procedure has occurred, however, since 1985, the time of the last major paper by Professor Seed and a report from a National Research Council workshop on liquefaction of soils. In 1996 a workshop sponsored by the National Center for Earthquake Engineering Research (NCEER) was convened by Professors T. L. Youd and I. M. Idriss with 20 experts to review developments over the previous 10 years. The purpose was to gain consensus on updates and augmen- tations to the simplified procedure. The following topics were reviewed and recommendations developed: (1) criteria based on standard penetration tests; (2) criteria based on cone penetration tests; (3) criteria based on shear-wave velocity measurements; (4) use of the Becker penetration test for gravelly soil; (4) magnitude scaling factors; (5) correction factors for overburden pressures and sloping ground; and (6) input values for earthquake magnitude and peak acceleration. Probabilistic and seismic energy analyses were reviewed but no recommen- dations were formulated.

The Civil War began 1 5 years after den­ tist W illiam Thomas Green Morton (fig. 1 ) used diethyl ether as an anesthetic for a surgical procedure at the Massachusetts General Hospital (MGH) on 1 6 October 1 846. The first reported clinical use of chlo­ roform, by James Young Simpson (fig. 2), took place in 1 847. However, the routine use of anesthetics in surgery had not yet permeated the medical culture in the United States, and a significant percent­ age of surgical procedures at the MGH were carried out without anesthetics during the period 1 849-1 877. It is a popular belief that anesthetics were not used to any signifi­ cant extent during the Civil War and that pain relief during surgical procedures was accomplished by imbibing alcoholic spir­ its or "biting the bullet." As we will note, the Civil War, with its hordes of wounded soldiers, accelerated the acceptance and the employment of anesthetic agents.

16 Foote 2: 610-11. 17 "Letter to Erastus Coming and Others," 12 June 1863, The Portable Abraham Lincoln, ed. Andrew Delbanco (New York: Penguin, 1993) 280. More generally, Edmund Wilson reads Grant's Memoirs as "part of that vision of the Civil War that Lincoln imposed on the nation" (159). 18 Melville 136. George B. McClellan's instructions to his troops in 1861 provide an instructive comparison with Grant's vision of complete conquest. "Bear in mind that you are in the country of friends, not of enemies: that you are here to protect, not to destroy." McClellan continued: "Remember that I have pledged my word to the people of Western Virginia, that their rights in person and property shall be respected. I ask every one of you to make good this promise in its broadest sense. We come here to save, not to upturn. [ ...] Show to the world that you differ from our enemies in the points of honor, honesty and respect for private opinion, and that we inaugurate no reign of terror where we go." See The Civil War Papers of George B. McClellan, ed. Stephen W. Sears (New York: Da Capo, 1992) 35-36. 19 Walt Whitman, "When Lilacs Last in the Dooryard Bloom'd," Leaves of Grass, ed. Sculley Bradley and Harold W. Blodgett (New York: Norton, 1973) 328-29. 20 Fehrenbacher and Fehrenbacher 315. 21 Buell 247.

The paper presents the proposition of non destructive testing (NDT) of the rocket engine propellant rod. It presents the actual state of the research and perspectives of its continuation. In this research, capacitance tomography system was used. The method was compared with the radiological and radiometric methods. Experiments were done with the use of solid propellant with different pyrotechnic mass and artificial defects incorporated. Authors suggest a new method of differential tomography.