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Splenectomy is often required in the pediatric population as part of the treatment of hematologic disorders and can be performed laparoscopically or open. We evaluated the comparative effectiveness of laparoscopic (LS) and open (OS) splenectomies using the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) data set.The NSQIP-P data set was used to identify children who underwent elective splenectomy between January 2012 and December 2016. Thirty-day outcomes between OS and LS, and LS alone and concurrent LS and cholecystectomy were compared using univariate and multivariate analysis.Most of the splenectomies (91%) were performed laparoscopically. There was no difference in overall complications between OS (n = 60) and LS (n = 613), although OS had a higher risk of perioperative transfusion (OR 3.19, 95% CI 1.52-6.69). LS was associated with a shorter median hospital length of stay (2 versus 4 d, P 0.001) and similar mean operative times compared to OS (120 versus 133 min, P = 0.559). There was no difference in outcomes of children undergoing LS versus LS and concurrent cholecystectomy (n = 129).LS has become the standard approach for elective splenectomies in the pediatric population and has minimal morbidity, and when indicated, concurrent cholecystectomies do not increase the risk of complications.III.

BACKGROUND. The small bowel and pancreas are the most common primary sites of neuroendocrine tumors (NETs) giving rise to metastatic disease. Some patients with small bowel NETs (SBNETs) present with synchronous or metachronous pancreatic NETs (PNETs), and it is unclear whether these are separate primaries or metastases from one site to the other. METHODS. A surgical NET database including patients undergoing operations for SBNETs or PNETs was reviewed. Patients with synchronous or metachronous tumors in both the small bowel and pancreas were identified, and available tissues from primary tumors and metastases were examined using a 4-gene quantitative polymerase chain reaction (qPCR) and immunohistochemistry (IHC) panel developed for evaluating NETs of unknown primary. RESULTS. Of 338 patients undergoing exploration, 11 had NETs in both the small bowel and pancreas. Tissues from 11 small bowel tumors, 9 pancreatic tumors, and 10 metastases were analyzed. qPCR and IHC data revealed that three patients had separate SBNET and PNET primaries, and five patients had SBNETs that metastasized to the pancreas. Pancreatic tissue was unavailable in two patients, and qPCR and IHC gave discrepant results in one patient. CONCLUSIONS. NETs in both the small bowel and pancreas were found in 3% of our patients. In nearly two-thirds of evaluable patients, the pancreatic tumor was a metastasis from the SBNET primary, while in the remaining one-third of patients it represented a separate primary. Determining the origin of these tumors can help guide the choice of systemic therapy and surgical management.

Die eosinophile Gastroenteropathie ist eine allergengetriggerte, immunvermittelte, lokal-entzundliche Erkrankung des oberen und unteren Gastrointestinaltrakts, die immer haufiger bereits im Kindes- und Jugendalter diagnostiziert wird. Erweist sich die Erkrankung als therapierefraktar gegenuber gangigen Behandlungsoptionen, kann dies zu einer erheblichen Einschrankung der Lebensqualitat fuhren. Im Rahmen eines „case report“ wird uber die erste erfolgreiche Behandlung mit Dupilumab bei einem 16-jahrigen Jugendlichen mit bisher therapierefraktarer eosinophiler Gastroenteropathie berichtet.

Theological libraries and scholarly publishing in religion and theology operate within multiple overlapping contexts and economic markets: faith communities, theological education, scholars, libraries, and publishing. This paper will complete an analysis of available religious publishing and theological library purchasing trends in order to create a thicker description of the system of scholarly communication. Even allowing for degrees of uncertainty in the data presented, there remains a significant disconnect in the rising collective costs for publishing versus the declining expenditures among theological libraries. The trend appears to be that the average theological library is purchasing a declining portion of the scholarship. The evidence may suggest an increasingly unsustainable market.

BACKGROUND: Cytoreductive surgery for neuroendocrine tumor liver metastases improves survival and symptomatic control. However, the feasibility of adequate cytoreduction in patients with many liver metastases remains uncertain. We compared patient outcomes based on the number of lesions treated to better define the efficacy of cytoreductive surgery for numerous neuroendocrine tumor liver metastases. METHODS: Patients undergoing hepatic cytoreductive surgery for gastroenteropancreatic neuroendocrine tumors were identified in our institutional surgical neuroendocrine tumor database. Imaging studies were reviewed to determine the liver tumor burden and percent cytoreduced. Overall survival and progressionfree survival were compared, using the number of lesions treated, percent tumor debulked, and additional clinicopathologic characteristics. RESULTS: A total of 188 hepatic cytoreductive procedures were identified and stratified into groups according to the number of metastases treated: 1–5, 6–10, and >10. Median overall survival and progressionfree survival were 89.4 and 22.5 months, respectively, and did not differ significantly between groups. Greater than 70% cytoreduction was associated with significantly better overall survival than 70% cytoreduction led to improved overall survival and progression-free survival and was achieved reliably in patients undergoing debulking of > 10 lesions. These data support an aggressive approach to patients with numerous neuroendocrine tumor liver metastases to achieve >70% cytoreduction.

BACKGROUND: The small bowel (SB) is the most common site of neuroendocrine tumors (NETs) of the GI tract. These are described as being predominantly jejunoileal, but their exact locations within the SB have not been well defined. We sought to determine prospectively the spectrum of SBNET locations. METHODS: Patients undergoing exploration for SBNET primaries had measurement of bowel length, tumor locations, and resection length recorded. Correlations of clinicopathologic factors were performed, and analysis done utilizing Welch’s t test, Chi square test, and the Kaplan-Meier method. RESULTS: Measurements were recorded in 123 patients, 107 of whom had complete information. Multifocal tumors (MTs) were found in 69 (56%) and unifocal (UTs) in 54 (44%) patients. Only 1 of 107 patients had a tumor within 100 cm of the ligament of Treitz (LT), whereas 77 of 107 (72%) had tumors within 100 cm of the ileocecal valve (ICV). No MTs were found within 100 cm of LT, whereas 41 of 60 (68%) patients had all (10) or at least one tumor (31) located within 100 cm of the ICV. MTs required a mean resection length of 108 versus 59 cm for UTs (p < 0.01). Seventy-seven percent of UTs (36/47) were within 100 cm of ICV. Tumors occurring only between > 100 cm from the LT and ICV were seen in 29 of 107 (27%) patients. CONCLUSIONS: SBNETs are frequently multifocal and most commonly located within 100 cm of the ICV. SBNETs are less prevalent proximally in the small bowel, which may result from anatomic differences in enterochromaffin cell density, hormonal factors, or environmental exposures in the distal SB.

Despite the relatively indolent course of neuroendocrine tumor (NETs), the incidence of NET liver metastases (NETLMs) is relatively common in patients with NETs. The surgical approach to NETLMs is based upon proper patient selection, the distribution of lesions, percent of liver replacement, and the ability to achieve significant cytoreduction. Goals of therapy are symptom improvement, as well as increased progression-free and overall survival. While other modalities such as systemic therapy, embolic approaches, and peptide receptor radionuclide therapy (PRRT) may slow progression and occasionally show objective responses, surgical debulking leads to the most immediate and potentially substantive reduction in tumor volume.

Objectives Many patients with small bowel neuroendocrine tumors (SBNETs) have multifocal tumors (MFTs), but the frequency of MFTs has varied widely across SBNET studies. It is also unclear whether patients with MFTs have more advanced disease or worse clinical course than do those with unifocal SBNETs. We set out to determine the frequency of multifocal and unifocal SBNETs and compare clinicopathologic factors, somatostatin receptor 2 expression, and survival. Methods Clinicopathologic variables from 179 patients with surgically managed SBNETs were collected. Statistical comparisons were made using Welch t-test, Wilcoxon test, and Fisher's exact test. Survival was assessed using the Kaplan-Meier method. Somatostatin receptor 2 expression was analyzed by quantitative polymerase chain reaction, and Ki-67 expression by immunohistochemistry. Results Multifocal tumors were found in 45% of patients with SBNETs. Clinicopathologic factors such as grade, TNM stage, presence of distant metastases, mean somatostatin receptor 2 expression, success of imaging modalities, and preoperative and postoperative hormone levels were not significantly different between multifocal and unifocal groups. Progression-free survival and overall survival were also not significantly affected by multifocality. Conclusions Clinicopathologic features and survival of patients with MFTs and unifocal tumors are remarkably similar. Although the etiology of MFTs is unclear, patients with MFTs do not have a more aggressive clinical course than patients with unifocal SBNETs.

Tumor grade is an important predictor of survival in gastroenteropancreatic (GEP) neuroendocrine tumors (NETs), as determined by Ki-67 expression and mitotic rate. NETs generally grow indolently, but some cells may acquire traits facilitating metastasis. It is unclear how frequently metastases differ in grade from their primary tumors, and whether increasing grade in metastases affects prognosis. Ki-67 immunohistochemistry was performed on resected GEPNET specimens and cases with results for both primary tumors and concurrent metastases were identified. Grade was determined using a modified World Health Organization classification (Ki-67: G1 = 0–2%; G2 > 2–20%; G3 > 20%). Ki-67 was performed on both the primary tumor and metastases in 103 patients. Tumor grade was higher in metastases from 25 (24%) patients, 24 increased from G1 to G2, and 1 increased from G2 to G3; 68 (66%) patients had no change in grade (42 G1 and 26 G2), and 10 (10%) decreased from G2 to G1. No clinicopathologic factors were predictive of higher grade in metastases. The 5-year progression-free survival (PFS) was 55% for patients with stable grade versus 8% of patients with increased grade, while 5-year overall survival (OS) was 92 and 54%, respectively. The 5-year OS of patients who had stable grade with G1 and G2 primaries was 92 and 64%, respectively. Nearly one-third of patients had metastases with a different grade than their primary, and, when grade increased, both PFS and OS significantly decreased. Determining the grade in both the primary tumor and a metastasis is important for estimating prognosis and to help inform decisions regarding additional therapies.

Background Small bowel neuroendocrine tumors (SBNETs) present frequently with metastases, yet little is known about the molecular basis of this progression. This study sought to identify the serial differential expression of genes between normal small bowel, primary small bowel neuroendocrine tumors, and liver metastases. Methods RNA isolated from matched normal small bowel tissue, primary small bowel neuroendocrine tumors, and liver metastases in 12 patients was analyzed with whole transcriptome expression microarrays and RNA-Seq. Changes in gene expression between primary small bowel neuroendocrine tumors and normal small bowels, and liver metastases versus primary small bowel neuroendocrine tumors were calculated. Common genes that were differentially expressed serially (increasing or decreasing from normal small bowel to primary small bowel neuroendocrine tumors to liver metastases) were identified, and 10 were validated using qPCR. Results Use of 2 transcriptome platforms allowed for a robust discrimination of genes important in small bowel neuroendocrine tumors progression. Serial differential expression was validated in 7/10 genes, all of which had been described previously in abdominal cancers, and with several interacting with members of the AKT, MYC, or MAPK3 pathways. Liver metastases had consistent underexpression of PMP22, while high expression of SERPINA10 and SYT13 was characteristic of both pSBTs and liver metastases. Conclusion Identification of the serial differential expression of genes from normal tissues to primary tumors to metastases lends insight into important pathways for SBNETs progression. Differential expression of various genes, including PMP22, SYT13 and SERPINA10, are associated with the progression of SBNETs and warrant further investigation.

Aim Eighty per cent of patients with Crohn’s disease require surgery, of whom 70% will require a further operation. Recurrence occurs at the anastomosis. Although often recommended, the impact of postoperative colonoscopy and treatment adjustment is unknown. Method Patients with a bowel resection over a 10-year period were reviewed and comparison made between those who did and did not have a postoperative colonoscopy within 1 year of surgery, and those who did or did not have a step-up in drug therapy. Results Of 222 patients operated on, 136 (65 men, mean age 33 years, mean disease duration 8 years, median follow-up 4 years) were studied. Of 70 patients with and 66 without postoperative colonoscopy, clinical recurrence occurred in 49% and 48% (NS) and further surgery in 9% and 5% (NS). Eighty-nine per cent of colonoscoped patients had a decision based on the colonoscopic findings: of these, 24% had a step-up of drug therapy [antibiotics (n = 10), aminosalicylates (n = 2), thiopurine (n = 5), methotrexate (n = 1)] and 76% had no step-up in drug therapy. In colonoscoped patients clinical recurrence occurred in 9 (60%) of 15 patients with, and 23 (49%) of 47 without step-up and surgical recurrence in 2 (13%) of 15 and 4 (9%) of 47 (NS). Conclusion Clinical recurrence occurs in a majority of patients soon after surgery. In this cohort, there was no clinical benefit from colonoscopy or increased drug therapy within 1 year after operation. However, the response to the endoscopic findings was not standardized and immunosuppressive therapy was uncommon. Standardizing timing of colonoscopy and drug therapy, including more intense therapy, may improve outcome, although this remains to be proven.

Patients with gastroenteropancreatic neuroendocrine tumors often present with metastases. Identification of the primary tumor is important for operative management, and therefore we sought to determine our success at identifying primary tumors with diagnostic testing and operative exploration.A clinical neuroendocrine tumor database was reviewed to identify patients presenting with metastases and primary tumor in situ. Results of radiologic, endoscopic, and operative procedures were evaluated to determine which correctly identified the primary tumor.There were 197 patients presenting with metastases and unresected primaries, 134 who had an operation and 63 managed nonoperatively. Primaries were identified preoperatively in 168 (84%), at operative exploration in 7, and were not found in 22 patients. Computed tomography found 150/197 primary tumors, somatostatin-receptor scintigraphy 88/155, and endoscopy 43/107. The sensitivity of computed tomography surpassed scintigraphy (76% vs 57%, P .01). The primary was removed in 130/134 (97%) patients, and hepatic debulking was performed in 67%. Median survival for operative patients with small bowel and pancreatic tumors was 145 and 71 months, respectively.Imaging and endoscopy identified the primary tumor in most patients, and the majority of the others were found at exploration. Preoperative testing facilitated operative planning, allowing for resection of the primary and hepatic debulking in most patients.

Background Surgical complications after resection for locally advanced rectal cancer may influence adjuvant treatment outcomes and survival. Few studies have examined this effect. Objective This study aimed to examine the impact of surgical complications on adjuvant therapy delivery and survival in patients with locally advanced rectal cancer treated with long-course chemoradiation followed by surgery. Design This is a retrospective analysis of a prospectively collected multicenter colorectal cancer database. Settings Data were collected from the Australian Comprehensive Cancer Outcomes and Research Database. Patients All patients who completed neoadjuvant chemoradiotherapy followed by surgery for locally advanced rectal cancer between January 2003 and December 2014 were selected. Main outcome measures We examined the types and frequency of surgical complications and their impact on the delivery of adjuvant chemotherapy and survival. Results Data were available for 517 patients, of whom 147 (28%) had a surgical complication. Patients with a surgical complication were less likely to commence adjuvant chemotherapy (33% vs 66%; p = 0.0005) and more likely to have adjuvant treatment commencing more than 8 weeks from surgery (71.8% vs 21.2%; p = 0.004). Wound-related complications (p = 0.001), return to operating theater (p = 0.004), and readmission within 30 days (p = 0.02) had the most significant negative impact on the delivery of adjuvant chemotherapy. Surgical complications were significantly more likely in males (31.6% vs 20.8%, p = 0.003) and laparoscopic converted cases (47.8% vs 21.8%, p = 0.03). For the entire patient population, adjuvant chemotherapy compared with surveillance was not associated with an improved recurrence-free survival (HR, 1.06; p = 0.83) but was associated with an improved overall survival (HR, 0.53; p = 0.04). Limitations This study was limited by its retrospective design. Conclusion Surgical complications in patients having surgery following neoadjuvant chemoradiotherapy for locally advanced rectal cancer were associated with significantly reduced uptake and delays to receiving adjuvant therapy. Surgical complications, however, were not associated with either significantly reduced recurrence-free or overall survival. Adjuvant chemotherapy delivery was associated with improved overall survival.

PURPOSE: Mesenteric embolization is an established treatment for lower gastrointestinal bleeding. The aim of this study was to determine the outcome of angiography and embolization and its influencing factors. METHODS: A prospective database of all mesenteric angiograms performed for lower gastrointestinal bleeding at a tertiary center between 1998 and 2008 was analyzed in combination with chart review. RESULTS: There were 107 angiograms performed during 83 episodes of lower gastrointestinal bleeding in 78 patients. Active bleeding was identified in 40 episodes (48%), and embolizations were performed in 37 (45%). One patient without active bleeding on angiogram also underwent embolization, making a total of 38 embolizations. Overall mortality was 7% with 4 deaths due to rebleeding and 2 deaths due to a medical comorbidity (respiratory failure, pneumonia). Short-term complications of angiography were false aneurysm (1 patient) and Enterobacter sepsis (1 patient). Long-term complications were groin lymphocele (1 patient) and late rebleed from collateralization (1 patient). In 43 episodes, angiography did not demonstrate active bleeding. Twelve (28%) of these patients continued to bleed, 9 of whom had successful surgery. Of the 38 patients who had embolizations, all had immediate cessation of bleeding. Nine patients (24%) later rebled; 5 of these patients required surgery and 3 had reembolizations. Of the 3 patients who underwent reembolization, 2 developed ischemic bowel and 1 stopped bleeding; surgery was required in 1 patient. CONCLUSIONS: Mesenteric angiography for lower gastrointestinal bleeding effectively identifies the site of bleeding in 48% of patients and allows embolization in 45%. Embolization achieves clinical success in 76% of patients but repeat embolization is associated with a high rate of complications.

Der Einfluss der Positronenemissionstomographie in der Behandlung des rezidivierenden Rektumkarzinoms steht fest; ihre Rolle bei der Behandlung des primaren Rektumkarzinoms bleibt jedoch ungeklart. Die vorliegende Untersuchung soll daher die Auswirkungen eines Scannings mittels Positronenemissionstomographie auf die Behandlung des primaren Rektumkarzinoms prospektiv bewerten. 46 Patienten mit fortgeschrittenem primaren Rektumkarzinom, bei denen eine adjuvante praoperative Therapie in Betracht gezogen wurde, unterzogen sich einem Scanning mittels Positronenemissionstomographie. Die uberweisenden Arzte zeichneten prospektiv das Stadium jedes einzelnen Patienten nach konventionellen bildgebenden Verfahren sowie den vorgeschlagenen Behandlungsplan vor dem Scanning mittels Positronenemissionstomographie auf. Dies wurde dann mit dem in der Folge eruierten genauen Stadium und der tatsachlich durchgefuhrten Behandlung verglichen; die Genauigkeit der mit Positronenemissionstomographie eruierten Veranderungen wurde in der anschliesenden klinischen Nachuntersuchung festgelegt. Die operative Behandlung von 36 der 46 Patienten (78%) blieb als Ergebnis der Positronenemissionstomographie unverandert, auch wenn die Positronenemissionstomographie das Erkrankungsstadium bei drei dieser 36 Patienten (8%) hoher und bei funf von 36 Patienten (14%) niedriger einstufte. In acht von 46 Fallen (17%) wurde die Behandlung aufgrund der Befunde der Positronenemissionstomographie verandert; dazu gehorten sechs Patienten (13%), bei denen die Operation abgesagt wurde, und zwei weitere Falle (4%), bei denen das Bestrahlungsfeld verandert wurde. Wenn vorhanden, bestatigte die Nachuntersuchung die Zweckmasigkeit der durch die Positronenemissionstomographie induzierten Behandlungsanderung in jedem einzelnen Fall. Bei zwei Patienten wurde die Therapie unabhangig von der Positronenemissionstomographie aufgrund klinischer Umstande geandert. Das Gesamttumorstadium wurde bei 18 der 46 Patienten (39%) nach der Positronenemissionstomographie berichtigt. Ein Scanning mittels Positronenemissionstomographie scheint bei einem Drittel der Patienten mit fortgeschrittenem primaren Rektumkarzinom eine Korrektur des Tumorstadiums bzw. eine Anpassung der Therapie zu ermoglichen. In Anbetracht dessen schlagen wir vor, ein positronenemissionstomographisches Scanning als Teil der standardisierten Behandlung bei diesen Patienten zu erwagen, insbesondere wenn eine neoadjuvante Radiochemotherapie als Teil der Primarbehandlung vorgesehen ist.

Purpose: The influence of positron emission tomography in the management of recurrent rectal cancer is well established but its role in primary rectal cancer remains uncertain. This study therefore prospectively assesses the impact of position emission tomography scanning on the management of primary rectal cancer. Methods: Forty-six patients with advanced primary rectal cancer referred for consideration of adjuvant preoperative therapy underwent position emission tomography scanning. The referring physicians prospectively recorded each patient’s stage following conventional imaging and the proposed treatment plan prior to position emission tomography scanning. This was then compared with subsequent stage and actual management implemented, and the appropriateness of position emission tomography-induced changes was noted by subsequent clinical follow-up. Results: The surgical management of 36 of 46 patients (78 percent) was unchanged as a result of position emission tomography, even though position emission tomography upstaged disease in 3 of 36 cases (8 percent) and downstaged disease in 5 of 36 cases (14 percent). In 8 of 46 cases (17 percent), management was altered because of the position emission tomography scan findings, including 6 cases (13 percent) in which surgery was cancelled and 2 other cases (4 percent) in which the radiotherapy field was changed. Where available, follow-up confirmed the appropriateness of position emission tomography-induced management change in each case. Two patients had a change in therapy independent of the position emission tomography scan due to clinical circumstances. Overall tumor stage was changed following position emission tomography in 18 of 46 patients (39 percent). Conclusion: Position emission tomography scanning appears to accurately change the stage or appropriately alter the therapy of almost a third of patients with advanced primary rectal cancer. In view of this, we suggest that position emission tomography scanning be considered part of standard workup for such patients, particularly if neoadjuvant chemoradiation is being considered as part of primary management.

SUMMARY The library Web site is a significant access point to a library's collections, resources, and services. A Web site can and should provide information about the library in a way that can be efficiently navigated and used by all library patrons. The usability of a library Web site can be improved through changes in organization and design informed by the experiences of real users. User expectations should be primary in determining the content, purpose, organization, and design of the site.

Mittels elektromechanischen Mappings kann eine Identifizierung der Zielregion fur die perkutane myokardiale Lasertherapie erfolgen. Narbengebiete von vitalem Myokard mit hoher Genauigkeit zu trennen ist dabei von groser Bedeutung. Eine besondere Rolle kommt der unipolaren Voltage als Amplitude des unipolaren endokardialen EKG zu. Werte uber 5 mV weisen mit hoher Sicherheit auf vitales, das heist behandlungswurdiges, myokardiales Gewebe hin. Weiterhin ist durch die hohe raumliche Auflosung eine Abgabe von Laserimpulsen an gleicher Stelle vermeidbar. Sicherheit und Effizienz der myokardialen Lasertherapie konnen somit erhoht werden. Die Wirksamkeit der myokardialen Lasertherapie wird derzeit in einer multizentrischen, randomisierten Studie untersucht.

This study examines the utility of a sleeve anastomosis with comparison to conventional end to end anastomosis. Thirty New Zealand white rabbits were randomized to sleeve (n = 15) or end-to-end (n = 15) small bowel anastomosis. Five rabbits of each group were sacrificed at 3 days, 7 days, and 6 weeks. Anastomoses were assessed for integrity, bursting strength, and stenosis and examined histologically. Ten control specimens of small bowel were tested for bursting pressure. Three rabbits died postoperatively (1 sleeve and 2 end-to-end). A fourth rabbit (sleeve) was sacrificed early at 3 weeks and had a total stenosis at the anastomosis. The remaining 26 rabbits were reoperated at the prescribed times. There was no evidence of infection or dehiscence in any of these rabbits. Both end-to-end and sleeve anastomoses were equivalent for bursting pressure at all times and, at 7 days and 6 weeks, were similar to controls. The stenotic index revealed no evidence of proximal dilation suggestive of obstruction in the 26 rabbits. For sleeve anastomoses the length of the projected bowel into the lumen persisted at the 6-week stage. Histologically there was good evidence of healing in both the sleeve and end-to-end anstomoses and the serosal surface of the sleeved bowel had epithelialized. Sleeve anastomosis has been demonstrated to heal well and to be as strong as conventional end-to-end anastomosis. Further studies are warranted to determine its role in intestinal anastomosis and potential as a valve.

Background: A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported. Methods: Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24–48 h. Results: There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group. Conclusion: Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.

3074Background: Humanized mice engrafted with tumors enable in vivo investigation of the interactions between the human immune system and human cancer. We have recently found that humanized NOD-sci...

Multilayer dielectric (MLD) diffraction gratings are an essential component for the OMEGA EP short-pulse, highenergy laser system. The MLD gratings must have both high-optical-diffraction efficiency and high laser-damage threshold to be suitable for use within the OMEGA EP Laser System. Considerable effort has been directed toward optimizing the process parameters required to fabricate gratings that can withstand the 2.6-kJ output energy delivered by each beam. In this paper, we discuss a number of conventional semiconductor chemical cleaning processes that have been investigated for grating cleaning, and present evidence of their effectiveness in the critical cleaning of MLD gratings fabricated at LLE. Diffraction efficiency and damage-threshold data were correlated with both scanning electron microscopy (SEM) and time-of-flight secondary ion-mass spectrometry (ToF-SIMS) to determine the best combination of cleaning process and chemistry. We found that using these cleaning processes we were able to exceed both the LLE diffraction efficiency (specification >97%) and laser-damage specifications (specification >2.7 J/cm2).

The OMEGA EP Facility includes two high-energy, short-pulse laser beams that will be focused to high intensity in the OMEGA target chamber, providing backlighting of compressed fusion targets and investigating the fast-ignition concept. To produce 2.6-kJ output energy per beam, developments in grating compressor technology are required. Gold-coated diffraction gratings limit on-target energy because of their low damage fluence. Multilayer dielectric (MLD) gratings have shown promise as high-damage-threshold, high-efficiency diffraction gratings suitable for use in high-energy chirped-pulse amplification [ B. W. Shore et al., J. Opt. Soc. Am. A 14 , 1124 (1997).] Binary 100-mm-diam MLD gratings have been produced at the Laboratory for Laser Energetics (LLE) using large-aperture, holographic exposure and reactive ion-beam etching systems. A diffraction efficiency of greater than 99.5% at 1053 nm has been achieved for gratings with 1740 grooves/mm, with a 1:1 damage threshold of 5.49 J/cm 2 diffracted beam fluence at 10 ps. To demonstrate the ability to scale up to larger substrates, several 100-mm substrates have been distributed over an aperture of 47 × 43 cm and successfully etched, resulting in high efficiency over the full aperture. This paper details the manufacture and development of these gratings, including the specifics of the MLD coating, holographic lithography, reactive ion etching, reactive ion-beam cleaning, and wet chemical cleaning.

Multilayer dielectric (MLD) diffraction gratings are a key component for the construction of high-peak-power, pulse-compressed laser systems. While a great deal of effort has been devoted to the design of optimal grating structures and the etching of these structures into the MLD coating, there has not been the same effort put into the optimization of the MLD coating itself. The primary characteristics of the multilayer that must be considered during design include minimization of the standing wave created in the photoresist because of the reflectivity of the coated optical surface, creation of a sufficiently high reflectivity at the use wavelength and incidence angle in a dry environment, proper balance of the individual layer materials to yield a coating with an overall neutral or slightly compressive stress, and a high laser-damage threshold for the wavelength and pulse duration of use. This work focuses on the modification of a standard MLD mirror, while considering these characteristics, to allow the fabrication of a diffraction grating with higher efficiency and laser-damage threshold than is typically achieved. Scanning electron microscopy (SEM) images of the grating structures demonstrate smoother shapes with lower roughness due to the holographic exposure. Damage testing performed at 1053 nm with a pulse width of 10 ps demonstrates the MLD coating has a sufficiently high laser-damage threshold to form the basis of reflection gratings that survive in high-fluence applications.

Thin-film polarizers are essential components of large laser systems such as OMEGA EP and the NIF because of the need to switch the beam out of the primary laser cavity (in conjunction with a plasma-electrode Pockels cell) as well as providing a well-defined linear polarization for frequency conversion and protecting the system from back-reflected light. The design and fabrication of polarizers for pulse-compressed laser systems is especially challenging because of the spectral bandwidth necessary for chirped-pulse amplification. The design requirements for a polarizer on the OMEGA EP Laser System include a T p greater than 98% over a spectral range of 1053±4 nm while maintaining a contrast ratio ( T p / T s ) of greater than 200:1 (500:1 goal) over the same range. An allowance must be made for the uniformity of the film deposition such that the specifications are met over the aperture of the component while allowing for some tolerance of angular misalignment. Production results for hafnia/silica designs will be shown, illustrating high transmission and contrast over an extended wavelength/angular range suitable for the 8 nm spectral bandwidth of OMEGA EP. Difficulties in production will also be illustrated, as well as the methods being implemented to overcome these challenges. A key challenge continues to be the fabrication of such a coating suitable for use on fused-silica substrates in a dry environment. Laser-damage thresholds for 1-ns and 10-ps pulse widths will be discussed.

Purpose The need for more accredited advanced surgical training positions has been identified by the Royal Australasian College of Surgeons. This study aimed to explore the perceptions of a sample of patients on surgical education and training in a private hospital setting. Methodology This is a prospective study where patients undergoing elective surgery in a private hospital were recruited over a 6-week period. A Likert Scale questionnaire was used to assess patient perception on choice of private healthcare, the role of the surgical resident in a private hospital and surgical training within a private hospital environment. Results Sixty-eight patients were recruited. Choice of surgeon was the most important reason for having private health insurance (59%). Almost all (97%) patients supported surgical training within a private hospital. There was support for a surgical trainee to liaise with the consultant surgeon about their care (95%), to perform minor procedures on the ward (91%) and assist the consultant at surgery (86%). Patients supported options for the trainee to perform part (73.4%), the majority (50.0%) and the entire operation (40.6%) under supervision of the consultant surgeon. Conclusion A representative group of patients surveyed supported surgical training within a private hospital environment. The increasing demand for surgical training within the public environment necessitates the consideration of additional training resources such as the private healthcare system. It appears that the private health sector could be explored as a potential avenue for provision of surgical education and training.

unaffected by TPMT (30.8 vs 33.0 pmol/hb/ml, p = 0.16), site of disease, behaviour, family history, smoking, surgery or, extraintestinal manifestations. Conclusions: Consistent with previous data, this, the largest series to date, with substantial follow-up, has shown that MP is a safe alternative for up to 60% of AZA-I patients, including some with a previous major intolerance. Patients with previous gastrointestinal intolerance or hepatotoxicity may be more likely to tolerate a trial of MP.

The empty follicle syndrome was assessed using transvaginal ultrasonography in a group of 152 consecutive women with unmedicated menstrual cycles being studied because of primary or secondary infertility or repetitive miscarriage. The overall frequency of the empty follicle syndrome was found to be 43.4%. The frequency increased with age but was independent of gravidity. The empty follicle syndrome may be a significant etiologic factor in infertility or other reproductive abnormalities, and transvaginal ultrasound represents a good, non-invasive means of evaluating it.

Purpose: Ileocolic resection is the commonest surgical resection performed for Crohn's disease. The aim of the study was to review outcomes of primary ileocolic resections for Crohn's disease with particular emphasis on complications, recurrence and impact of prophylactic medication. Methodology: Retrospective chart review was undertaken on all patients undergoing ileocolic resection for Crohn's disease between July 1998 and June 2008 at a tertiary centre. Data collected included patient demographics, pre-operative medication, technical aspects of surgery, complications, prophylactic medical therapy and recurrence of disease. Results: There were 64 patients (28 male, 36 female), mean age 30.2 years (SD 10.6). Surgery was elective in 49 patients (76.6 %) and urgent in 15 (23.4%). Laparoscopic surgery was undertaken in 31 (48.4%) with 3 converted to open (9.7 %). High anterior resection was performed in addition in 9.4% for contiguous disease. Post-operative complication rate was 17.2% (anastomotic leak 6.3%; intra-abdominal abscess 4.7%; pulmonary embolus 3.1%; other 3.1%). Endoscopic disease recurrence occurred in 27 (42.2%) of patients with mean time to recurrence 1.8 years (SD 1.3). Surgical intervention for recurrent disease was required in 5 (7.8%) and 40% of these developed further recurrence on imaging after repeat surgery. Prophylactic medications following primary resection did not reduce risk of recurrence (recurrence [prophylaxis/no prophylaxis], 21 vs. 6; no recurrence, 26 vs. 11; p = NS). Conclusion: Almost half of patients who have an ileocolic resection for Crohn's disease will develop recurrence though less than 10% require further surgery. Prophylactic medical therapy does not reduce recurrence.

Purpose An attenuated or disrupted anal sphincter can lead to faecal incontinence. One means of augmenting the sphincter is with the use of the silicone-based biomaterial PTQ. The aim of this study was to evaluate the effectiveness of PTQ for the symptoms of passive faecal incontinence caused by a weak sphincter mechanism. Methods The patient records of 37 patients with passive faecal incontinence treated by 2 surgeons were examined. Their faecal incontinence scores were recorded from pre-operative consultations and then in a follow-up phone interview. Any adverse effects of treatment were recorded including significant pain, development of perianal abscesses and loss of injected silicone. Results Thirty-seven patients received PTQ injections and completed follow up interviews. The main cause of faecal incontinence for this group was obstetric trauma. The follow-up period was from 1–43 months with a median of 9 months. Twenty-five patients experienced improvements in their faecal incontinence with 7 patients remaining unchanged and 5 worse symptomatically. The median improvement in faecal incontinence scores was 3 with an average of 3.76. It was important to note that the improvement was more marked in follow-up over 18 months, with an average of 4.5. Four patients developed post injection abscesses, the most common adverse outcome and these were successfully treated with surgical drainage. Conclusion PTQ injections are a successful and minimally invasive treatment in the management of passive faecal incontinence. Two thirds of patients were improved with the injection of PTQ. Ten percent of the patients developed injection related abscesses.

The interocular transfer of the motion aftereffect (MAE) was used to probe for the existence of binocularity in subjects with strabismus. The interocular transfer was measured with coarse and fine gratings subtending 2° and 8° of visual angle. Strabismic subjects were categorized by the extent of their binocular vision, particularly with respect to extrafoveal fusion and retinal correspondence. Subjects classified as having the monofixation syndrome consistently showed a substantial, though less than normal, amount of transfer with the larger 8° gratings. This is consistent with the peripheral binocular cooperation usually found in these subjects, and establishes interocular transfer of the MAE as a suitable test for binocularity in strabismus. The test is especially suitable in patients with suppression in which an existing binocularity may be masked by suppression on clinical testing. The tests were found to be applicable in children as young as eight years. MAE tansfer for large coarse gratings is believed to imply the existence of an early cortical binocularity, which provides the potential for sufficient binocular cooperation to permit stable ocular alignment.

The motion aftereffect resulting from adaptation to moving vertical gratings has been measured as a function of the grating contrast from threshold up to 10.5%. The gratings consisted of spatial sinusoidal intensity modulations which were generated on the face of an oscilloscope. The contrasts of the adapting grating and of the test grating could be varied independently. Both the duration and the initial apparent speed of the aftereffect were measured. When the test grating contrast was held constant, the motion aftereffect magnitude increased rapidly with the contrast of the adapting grating up to about 3%; for higher contrasts incremental increases in contrast resulted in much smaller aftereffect increases than at the lower contrasts. When the adapting grating contrast was held constant, the aftereffect was found to be strongest for the lowest test contrasts and became weaker as the test contrast was increased. These psychophysical results support the hypothesis that foveal direction-specific motion detecting mechanisms show only a limited or compressed response to stimulus contrast.

The interocular transfer of the motion aftereffect (MAE) was measured in three groups of strabismic subjects (six with monofixation, nine with alternation, four with anomalous retinal correspondence) and compared with a group of four normal subjects. The duration of the MAE was measured using sinusoidal gratings of 0.5 c/deg subtending a visual angle of 8. Contrary to previous findings, a substantial amount of MAE transfer was found in some stereoblind individuals with strabismus. The mean amount of transfer for each group was found to correlate with binocularity; the order of decreasing transfer being: normal, monofixation, alternation, and anomalous retinal correspondence (ARC). This reduction in transfer which accompanied the loss of binocularity was asymmetric, that is. right-left transfer did not equal left-right transfer. The amount of asymmetry was found to correlate inversely with the amount of transfer. The direction in which the greatest transfer occurred did not correlate with visual acuity. These data substantiate the overall poor binocularity in subjects with ARC. and the relatively good binocularity of subjects with monofixation. Furthermore, the substantial amount of transfer found in subjects with alternating strabismus may be a measure of potentially achievable binocularity.

The attenuation $\ensuremath{\alpha}$ of ultrasonic waves propagating in the [110] direction of InAs has been measured by the pulse-echo technique between 1.5 and 100\ifmmode^\circ\else\textdegree\fi{}K in the frequency range 150 to 510 MHz. Both transverse and longitudinal waves have been employed. At the lowest temperatures, the measured attenuation ${\ensuremath{\alpha}}_{0}$ was found to be independent of temperature and the type of wave propagated, but dependent on frequency. At higher temperatures, the increased attenuation was found to be the result only of interactions with the lattice. (Electronic or impurity-related effects do not appear to cause any measurable attenuation.) The temperature and frequency dependence of $\ensuremath{\alpha}\ensuremath{-}{\ensuremath{\alpha}}_{0}$ indicates that the interactions with the lattice which are responsible for absorption are the three-phonon collision processes between the low-energy phonons of the sound wave and the transverse thermal phonons of the lattice. This was found to be the case both for longitudinal and for slow transverse sound waves. The dependence on temperature for various modes and frequencies is compared with theoretical expressions derived by Maris for the attenuation of ultrasonic waves by the above processes.

If one adapts to a moving repetitive stimulus of stripes that is suddenly stopped, the stripes will appear to move backward. This apparent backward motion is the motion aftereffect (MAE), and its duration is a measure of its magnitude. If one eye adapts to the moving stimulus and the other eye experiences the aftereffect to the stationary stimulus, the aftereffect has been transferred from one eye to the other and is termed the interocular transfer of the MAE. Experimental evidence indicates that the degree of MAE transfer correlates with clinical binocularity. This study compares the MAE transfer in six subjects with the monofixation syndrome to five normal subjects. The stimuli used are sinusoidal stripes generated on two cathode-ray tubes, subtending either 8° or 2° of visual angle with a periodicity of either 0.5 or 3 cycles/degree presented haploscopically. Subjects with the monofixation syndrome differed significantly from normal subjects in the amount of MAE transferred, implying a lack of central neuronal connections in addition to those mediating conscious central fusion in clinical sensory testing.

Children are a unique group at risk of injury from firearms because of their immaturity, curiosity, and imitative behavior. All unintentional firearm deaths in persons younger than age 20 years that occurred in Oklahoma in 1982 and 1983 were reviewed. There were 32 unintentional deaths from firearms in children from birth to age 19 years. The death rate in rural counties was four times that of urban counties. Twenty-seven deaths (85%) occurred at home, with an adult present in only two cases. The home death rate for males was 5.2 times that of females, with 15- to 19-year-old males most at risk. The rates among whites and Native Americans were similar, at 1.5 and 1.2 per 100,000, respectively, with no deaths among the black population. This review concurs with previous studies that firearms are a significant cause of mortality in the pediatric age group. Counseling parents about the hazards of firearms may prevent deaths through better supervision and more responsible gun care and storage.

Short-term adaptation to moving sinusoidal gratings results in a motion aftereffect which decays in time. The time decay of the motion aftereffect has been measured psychophysically, and it is found to depend on (i) the spontaneous recovery from the adapted state, and (ii) the contrast of the test grating. We have measured the decays for various test conditions. An extrapolation of the measurements allows us to obtain a decay which represents the time course of the spontaneous recovery of the direction-sensitive mechanisms.

To the Editor.— The recent article by Wintemute et al 1 was enlightening in its discussion of the factors contributing to unintentional deaths due to the use of firearms among the pediatric population. The large number of these accidental shootings and the tragic circumstances in which they happen, as described by the authors, are sobering. Not discussed was the morbidity also incurred by unintentional firearm use. In addition to the more than 1000 pediartic fatalities occurring in the United States annually, there are more than 8000 nonfatal injuries due to firearm use as well. 2 Combining these statistics with those for deaths and injuries incurred during intentional use of firearms in all age groups, more than 30 000 fatal shootings and 100 000 to 150 000 woundings each year, makes the seriousness of the problem of children and guns even greater. 3 Use of firearms accounts for a significant proportion