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Background Interstitial lung abnormalities (ILA) may represent undiagnosed early-stage or subclinical interstitial lung disease (ILD). ILAs are often observed incidentally in patients who subsequently develop clinically overt ILD. There is limited information on consensus definitions for, and the appropriate evaluation of, ILA. Early recognition of patients with ILD remains challenging, yet critically important. Expert consensus could inform early recognition and referral. Research Question Can consensus-based expert recommendations be identified to guide clinicians in the recognition, referral, and follow-up of patients with or at risk of developing early ILDs? Study Design and Methods Pulmonologists and radiologists with expertise in ILD participated in two iterative rounds of surveys. The surveys aimed to establish consensus regarding ILA reporting, identification of patients with ILA, and identification of populations that might benefit from screening for ILD. Recommended referral criteria and follow-up processes were also addressed. Threshold for consensus was defined a priori as ≥ 75% agreement or disagreement. Results Fifty-five experts were invited and 44 participated; consensus was reached on 39 of 85 questions. The following clinically important statements achieved consensus: honeycombing and traction bronchiectasis or bronchiolectasis indicate potentially progressive ILD; honeycombing detected during lung cancer screening should be reported as potentially significant (eg, with the Lung CT Screening Reporting and Data System “S-modifier” [which indicates clinically significant or potentially significant noncancer findings]), recommending referral to a pulmonologist in the radiology report; high-resolution CT imaging and full pulmonary function tests should be ordered if nondependent subpleural reticulation, traction bronchiectasis, honeycombing, centrilobular ground-glass nodules, or patchy ground-glass opacity are observed on CT imaging; patients with honeycombing or traction bronchiectasis should be referred to a pulmonologist irrespective of FVC and diffusion capacity values; and patients with systemic sclerosis should be screened with pulmonary function tests for early-stage ILD. Interpretation Guidance for identifying clinically relevant ILA, with subsequent referral and follow-up, was established. These results lay the foundation for developing practical guidance on managing patients with ILA.

Supported by the National Health and Medical Research Council Centre of Research Excellence in Pulmonary Fibrosis (GNT1116371), and by foundation partner, Boehringer Ingelheim, and program partners, Roche and Galapagos. Rationale : The interstitial lung disease (ILD) multidisciplinary meetings (MDM), composed of pulmonologists, radiologists, and pathologists, is integral to the rendering of an accurate ILD diagnosis. However, there is significant heterogeneity in the conduct of ILD MDMs, and questions regarding their best practices remain unanswered. Objectives : To achieve consensus among ILD experts on essential components of an ILD MDM. Methods : Using a Delphi methodology, semi-structured interviews with ILD experts were used to identify key themes and features of ILD MDMs. These items informed two subsequent rounds of online questionnaires that were used to achieve consensus among a broader, international panel of ILD experts. Experts were asked to rate their level of agreement on a five-point Likert scale. An a priori threshold for consensus was set at a median score 4 or 5 with an interquartile range of 0. Results : We interviewed 15 ILD experts, and 102 ILD experts participated in the online questionnaires. Five items and two exploratory statements achieved consensus on being essential for an ILD MDM following two questionnaire rounds. There was consensus that the presence of at least one radiologist, a quiet setting with a visual projection system, a high-quality chest high-resolution computed tomography, and a standardized template summarizing collated patient data are essential components of an ILD MDM. Experts also agreed that it would be useful for ILD MDMs to undergo an annual benchmarking process and a validation process by fulfilling a minimum number of cases annually. Twenty-seven additional features were considered to be either highly desirable or desirable features based on the degree of consensus. Although our findings on desirable features are similar to the current literature, several of these remain controversial and warrant further research. The study also showed an agreement among participants on several future concepts to improve the ILD MDM, such as performing regular self-assessments and conducting research into shared practices to develop an international expert guideline statement on ILD MDMs. Conclusions : This Delphi study showed consensus among international ILD experts on essential and desirable features of an ILD MDM. Our data represent an important step toward potential collaborative research into future standardization of ILD MDMs. Postprint

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.202907][1] Points cles L’immunotherapie cellulaire est un traitement novateur qui fait appel aux proprietes anticancereuses des cellules immunitaires du corps. L’une des techniques les plus prometteuses est

Double-allylation reagents allow for the construction of highly complex molecules in an expedient fashion. We have developed an efficient, modular, and enantioselective approach towards accessing novel variants of these reagents through Cu/Pd-catalyzed alkenylboration of alkenylboron derivatives. Importantly, we demonstrate novel use of an allylBdan reagent directly in a stereocontrolled allylation without initial deprotection to the boronic ester. These allylation products are employed in a second intermolecular allylation to access complex diol motifs, which has yet to be shown with these types of double-allylation reagents. Overall, the modularity of this approach and the ease in which complex structural motifs can be accessed in a rapid manner signify the importance and utility of this method.

Purpose Magnetic resonance imaging (MRI) is often used to visualize and diagnose soft tissues. Hearing implant (HI) recipients are likely to require at least one MRI scan during their lifetime. However, the MRI scanner can interact with the implant magnet, resulting in complications for the HI recipient. This survey, which was conducted in two phases, aimed to evaluate the safety and performance of MRI scans for individuals with a HI manufactured by MED-EL (MED-EL GmbH, Innsbruck, Austria). Methods A survey was developed and distributed in two phases to HEARRING clinics to obtain information about the use of MRI for recipients of MED-EL devices. Phase 1 focused on how often MRI is used in diagnostic imaging of the head region of the cochlear implant (CI) recipients. Phase 2 collected safety information about MRI scans performed on HI recipients. Results 106 of the 126 MRI scans reported in this survey were performed at a field strength of 1.5 T, on HI recipients who wore the SYNCHRONY CI or SYNCHRONY ABI. The head and spine were the most frequently imaged regions. 123 of the 126 scans were performed without any complications; two HI recipients experienced discomfort/pain. One recipient required reimplantation after an MRI was performed using a scanner that had not been approved for that implant. There was only one case that required surgical removal of the implant to reduce the imaging artefact. Conclusion Individuals with either a SYNCHRONY CI or SYNCHRONY ABI from MED-EL can safely undergo a 1.5 T MRI when it is performed according to the manufacturer’s safety policies and procedures.

KEY POINTS Cellular immunotherapy is a novel therapy where the body’s own immune cells are harnessed for their anticancer effect. One of the most exciting of these approaches is chimeric antigen receptor T-cell therapy (CAR-T). This therapy is now standard of care for relapsed or refractory B-cell

Lunar IceCube is a NASA nanosatellite mission designed to prospect, locate, and measure volumes and composition of water ice deposits and other volatiles on the Moon in support of future exploitation by robots and human explorers. Lunar IceCube is one of several public -private partnerships selected under NASA's Next Space Technologies for Exploration Partnerships Broad Agency Announcement for the development of advanced exploration systems. Among the first small satellites planned to explore deep space, Lunar IceCube, along with the 12 other Exploration Mission One (EM -1) missions will help lay a foundation for future small-scale planetary missions. In addition to providing useful scientific data, Lunar IceCube will help inform NASA's strategy for sending humans farther into the solar system.

The acceleration process of charged particle beams often requires the use of few acceleration stages to provide the beam with the desired energy. The extraction of the beam from one acceleration stage and the injection to the next, both require a special type of magnet which comes under the name septum magnet. Such a magnet generates a strong field in one region and a very low field in another region with the two regions separated by a very thin material (septum). The septum thickness of such a magnet should be as thin as possible to reduce the strength of other devices, like kickers, which are involved in the extraction or injection processes. A thin septum is also advantageous during the slow beam extraction process to reduce the beam losses at the septum. One of the methods which in theory can generate very large differences in field strength in adjacent field regions separated by a thin septum, is the use of two thin parallel current sheets of infinite dimensions. In practice we use other devices that can approximate such an abrupt change of the magnetic field within the septum thickness. In this paper we describe such a device, the DC current septum, we present results from the study of its electromagnetic properties, and we discuss a method to minimize the magnetic field in the region which requires a very small magnetic field. We also provide some results from the experimental measurements of the magnetic field generated by the “D6” current septum magnet which is installed in the experimental beam line of the NASA’s Space Radiation Laboratory (NSRL) facility (Tsoupas et al., 2007; Brown et al., 2010) at Brookhaven National Laboratory (BNL). This septum magnet is part of the beam’s extraction system from the AGS-Booster into the NSRL beam line for material and biological studies.

Background Trunk stability is a risk factor commonly associated with lower extremity injuries, particularly in females. Performance on trunk stability tasks, such as the Trunk Stability Push Up (TSPU), is less than optimal in females. Current corrective programs include few females, and clinically, improvements for females have been minimal. Purpose/Hypothesis The purpose of this pilot study was to determine the effectiveness of a novel trunk stability intervention program in improving TSPU performance in a cohort of active female participants. It was hypothesized that ≥60% of participants would improve their TSPU scores to ≥2 via Functional Movement Screen™ (FMS™) criteria following a novel six-week intervention program. Study Design Pilot Cohort Study Methods Participants were screened for pain with lumbar and shoulder clearing tests and hypermobility was assessed using Beighton scores. Additional testing included a breathing screen, the FMS™, Y-Balance Test-Lower Quarter and Y-Balance Test-Upper Quarter. Participants who scored a 1 on the TSPU received a home exercise program instructed by student physical therapists. Exercises focused on improving awareness of lumbar spine position and thoracic spine mobility. Participants returned for follow-ups after two and four weeks for instruction in exercise progression, which increased postural demand on the lumbar spine and upper extremities, and utilized closed-chain, multiplanar stability strategies. Results Nine of 20 participants (45%) scored ≥2 on the TSPU at posttest. Due to the COVID-19 pandemic, only 12 participants were able to complete all posttest outcome measures. No significant differences were noted in the remaining outcome measures. Conclusion: The results of this study indicate that a multiplanar exercise approach, combining anti-extension and anti-rotation training, was beneficial for inducing trunk stability improvements in some active females. Level of Evidence 2b

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal malignancies of the gastrointestinal tract. GISTs can occur in the background of neurofibromatosis 1 (NF-1), where chemotherapeutic treatment is not optimal and surgical intervention is the only management option. In this case report, we present a case involving a 61-year-old gentleman with NF-1. The patient presented with acute blood loss anemia that was initially controlled with embolization of a hyper-vascular mass abutting the distal jejunum. The patient was taken to the operating room for excision of the mass. All macroscopic disease was excised and the pathology noted GISTs. Surgical decision making is not clearly delineated in the literature for GISTs in patients with NF-1, where targeted therapy is not a treatment option. Resection of all disease should be considered, since NF-1 associated GISTs generally do not have harbor mutations that can be targeted.

Highlights • 20% of 250 staff working in 6 care homes with a COVID-19 outbreak were SARS-CoV-2 positive • SARS-CoV-2 positivity was similar (15-17%) in staff with regular, occasional or no resident contact • SARS-CoV-2 positivity was 4-fold higher in staff working across different care homes • Whole genome sequencing identified distinct clusters involving staff only, Background Care homes have been disproportionately affected by the COVID-19 pandemic and continue to suffer large outbreaks even when community infection rates are declining, thus representing important pockets of transmission. We assessed occupational risk factors for SARS-CoV-2 infection among staff in six care homes experiencing a COVID-19 outbreak during the peak of the pandemic in London, England. Methods Care home staff were tested for SARS-COV-2 infection by RT-PCR and asked to report any symptoms, their contact with residents and if they worked in different care homes. Whole genome sequencing (WGS) was performed on RT-PCR positive samples. Results In total, 51 (20%) of 250 staff were SARS-CoV-2 positive but only 11/51 (22%) were symptomatic. Among staff working in a single care home, SARS-CoV-2 positivity was 15% (2/13), 16% (7/45) and 17% (28/165) in those reporting no, occasional and regular contact with residents. In contrast, staff working across different care homes (14/27, 52%) had a 4.2-fold (95% CI, 2.1-8.4; P

Lunar Ice Cube, scheduled to be launched on ARTEMIS I in late 2021, is a deep space cubesat mission with the goals of demonstrating 1) a cubesat-scale instrument (BIRCHES) capable of addressing NASA HEOMD Strategic Knowledge Gaps related to lunar volatile distribution (abundance, location, and transportation physics of water ice), and 2) cubesat propulsion, via the Busek BIT 3 RF Ion engine. The mission will also demonstrate the AIM/IRIS microcryocooler for the first time in deep space. BIRCHES integration is nearly complete, with several changes made to the thermal design to improve detector performance. Final preflight instrument testing and calibration, our ongoing concern to be emphasized here, have been delayed due to the mandated closure rules of NASA facilities. Lunar Ice Cube, along with two other cubesats deployed from ARTEMIS I, Lunar Flashlight and LunaH-Map, will be the first deep cubesat missions to deliver science data to the Planetary Data System.

Background:No current technology exists to ensure the dose of insulin administered in hospitals matches the physician order.Objective:Assess the feasibility of using computer vision to identify insulin syringe preparation errors.Methods:Twenty-two nurses prepared 50 insulin doses (n=1100) each. A computer vision device (CVD) measured the volume drawn up and identified air present. Syringes identified as inaccurate by the CVD were confirmed by two observers, and a random sample of 100 syringes identified as accurate was validated by two independent observers.Results:Ten syringes (1.0%) had the wrong volume prepared, and 68 syringes (6.5%) contained air sufficient to meet the definition of inaccuracy. All errors were confirmed by two independent observers.Conclusion:CVDs could reduce insulin administration errors in hospitalized patients.

Background: Mobile Stroke Units (MSUs) are capable of rapid initiation of intravenous thrombolysis and have the potential to improve acute stroke patient routing by providing conclusive imaging diagnosis of LVO (arterial sequences) and intracranial hemorrhage (parenchymal/extraparenchymal sequences). However, the incremental increase in diagnostic accuracy and effect on patient disposition have not been well delineated. Methods: Consecutive transports in a regionally-deployed MSU from September 2017-August 2019) were analyzed, comparing patient routing that would have occurred under standard ambulance protocols to routing and process outcomes after CT/CTA MSU imaging. Standard ambulance regional routing policy was direct to nearest PSC if Los Angeles Motor Scale (LAMS) 0-3 and direct to nearest CSC within 30m if LAMS 4-5. Results: Among 83 MSU transports, final diagnosis was acute cerebral ischemia in 68% and intracranial hemorrhage in 10%. Among 57 acute cerebral ischemia patients, Los Angeles Motor Scale (LAMS) score was 0-3 in 65% and 4-5 in 35%. All (100%) of patients with ICA/M1 occlusions had LAMS score 4-5. However, among patients with expanded range endovascular target occlusions (M2, basilar), LAMS scores were 0-3 in 56%, and MSU imaging permitted improved routing. Among 8 intracranial hemorrhage patients (2 IPH, 5 SDH, 1 SAH), MSU imaging permitted improved direct-to-CSC routing in the 62% of patients with LAMS scores 0-3. Among all MSU admissions, 15% (13) were rerouted based solely upon in-vehicle imaging, including 7% for radiographically proven endovascularly treatable occlusion, 7% for neurosurgical/NICU intracranial hemorrhage care, and 1% for neurosurgical tumor care. Transport times for re-routed patients was median 12 minutes, compared to closest stroke center median 6 minutes. Conclusion: More than 1 in 7 MSU evaluations result in improved routing of comprehensive stroke center-appropriate patients directly to a CSC facility, including AIS patients potentially eligible for thrombectomy, intracranial hemorrhage patients, and acutely-presenting brain tumor patients. In addition to speeding start of intravenous thrombolysis, MSUs can substantially improve timely access to CSC care.

Background: EMS 911 dispatchers must rapidly assess patient calls and allocate appropriate responding resources including, for stroke, advanced (rather than basic) life support standard ambulances and, in an increasing number of regions, specialty Mobile Stroke Units. While dispatcher accuracy in distinguishing stroke from other high risk conditions is not crucial for selecting ALS rather than BLS response, specialized MSU response necessitates a higher level of accuracy. Methods: We analyzed all transports between January 2018-August 2019 identified as stroke by dispatchers at sendout or by paramedics upon patient assessment in a large urban EMS system -LA County FD EMS, serving 4.1 million lives, 59 cities, 3,000 square miles, via 174 fire stations. Dispatchers are instructed to decide upon the appropriate diagnosis and responding resource within 60s of start of 911 call conversation. “Dispatcher Impression” (DI) and on scene paramedic “Provider Impression” (PI) were compared, and other care metrics analyzed. Results: In total, 12,528 runs were evaluated, of which 79.1% (9913) were dispatched as stroke and paramedics identified stroke in 47.6%. The sensitivity of dispatcher impression of stroke was 56.2% and the positive predictive value was 33.9%. The most common paramedic impressions in non-concordant patients dispatched as stroke were: generalized weakness in 24% (1587), altered mental status in 17% (1111), and syncope in 6% (403). In patients with a dispatcher impression of non-stroke but paramedic impression of stroke, the most common dispatcher impressions were: sick person in 29% (758), unconscious in 28.7% (750), and seizure in 4.6% (121). In dispatcher impressions of stroke, 100% were dispatched at ALS level; and in dispatcher impressions of non-stroke but eventual paramedic impression of stroke, 98.3% were dispatched at ALS level. Patient age over/under 40 & patient sex did not modify rates of dispatcher - paramedic impression concordance. Conclusions: Dispatchers identify more than half of paramedic-identified stroke patients and allocate appropriate ALS standard ambulances in almost all stroke patients. However, for efficient attaching of specialized MSU resources, improved dispatcher identification of stroke is desirable.

Background: Care homes are experiencing large outbreaks of coronavirus disease 2019 (COVID-19) associated with high case-fatality. We conducted detailed investigations in six London care homes reporting suspected COVID-19 outbreaks during April 2020. Methods: Residents and staff had nasal swabs taken for SARS CoV-2 testing using RT-PCR and were followed-up for 14 days. They were categorized as symptomatic, post-symptomatic or pre-symptomatic if they had symptoms at the time of testing, in the two weeks before or two weeks after testing, respectively, or asymptomatic throughout. Virus isolation and whole genome sequencing (WGS) was also performed. Findings: Across the six care homes, 107/268 (39.9%) residents were SARS CoV-2 positive, including 29 (27.1%) symptomatic, 9 (8.4%) post-symptomatic, 21 (19.6%) pre-symptomatic and 48 (44.9%) who remained asymptomatic. Case-fatality was highest among symptomatic SARS-CoV-2 positive residents (10/29, 34.5%) compared to asymptomatic (2/48, 4.2%), post-symptomatic (2/9, 22.2%) or pre-symptomatic (3/21,14.3%) residents. Among staff, 51/250 (20.4%) were SARS CoV-2 positive and 29/51 (56.9%) remained asymptomatic. RT-PCR cycle threshold s and live virus recovery were similar between symptomatic/asymptomatic residents/staff. WGS identified multiple introductions of different SARS-CoV-2 strains into individual care homes. SARS-CoV-2 strains from residents and staff had identical sequences, as did strains from fatal and non-fatal cases. Interpretation: In care homes reporting a COVID-19 outbreak, a high rate of SARS-CoV-2 positivity was found among residents and staff, half of whom were asymptomatic and are potential reservoirs for on-going transmission. Symptomatic SARS-CoV-2 residents had high case-fatality, while asymptomatic infection was rarely fatal. Symptom-based screening alone is not sufficient for outbreak control. Funding Statement: This study did not receive any funding. The authors are all employed by Public Health England, the study funder, which is a public body — an executive agency of the Department of Health. Declaration of Interests: None. Ethics Approval Statement: PHE has legal permission, provided by Regulation 3 of The Health Service (Control of Patient Information) Regulations 2002, to process patient confidential information for national surveillance of communicable diseases and as such, individual patient consent is not required.

Background and purpose: Several studies have investigated multi leaf collimator (MLC) leaf design. We performed a systematic review and meta-analysis of those studies to compare the impact of MLC leaf width used for different radiotherapy techniques. Materials and methods: We decided to focus on 2.5, 3.0 and 5.0 mm leaf width MLCs as it appeared to be the most contentious area from literature. We adopted Cochrane and PRISMA guidelines and computed the association between MLC leaf width and conformity index (CI) across the selected studies as pooled mean difference (PMD) with 95% confidence interval. Results: A total of 43 papers were selected from the literature search, of which ten compare MLC leaf width of 2.5 mm or 3.0 mm (MLC2.5 mm) versus 5.0 mm (MLC5 mm) in terms of CI. There was a slight, but significant, difference between MLC2.5 mm and MLC5 mm in favor of the former (mean difference −0.036; 95% confidence interval: −0.068 to −0.005). A subgroup analysis was performed by comparing techniques (intensity modulated radiation therapy vs conformal). In the intensity modulated radiation therapy (IMRT) subgroup, the difference between MLC2.5 mm and MLC5 mm appeared to be negligible (mean difference: −0.006; 95% confidence interval: −0.013 to 0.001) and not significantly different from zero. In the subgroup of studies which used conformal techniques, there was a significant difference between MLC2.5 mm and MLC5 mm (mean difference: −0.054; 95% confidence interval: −0.096 to −0.012). Conclusions: Introduction of IMRT produced comparable target coverage (CI) between 2.5 or 5.0 mm leaf width MLCs. Keywords: Multi leaf collimators, Treatment planning system, Intensity modulated radiation therapy, Systematic review, Meta-analysis

This article will consider certain art objects and underlying acts of patronage in the waning days of the ancien regime in Europe, partly through a trifecta of personalities who either produced or consumed art. Michel-Paul-Joseph Dewez (1742–1804) was a Brussels goldsmith and bronze caster; James Lockhart (1727–1790) was a Scottish military officer in the Austrian service and a court official; and Prince Charles Alexandre of Lorraine (1712–1780) was the governor general of the Austrian Netherlands from 1744 until his death in 1780. The works by Dewez that form the focus of this study include a pair of silver candlesticks that he made and Lockhart bought in about 1778, a rare survival from an age that ended in chaos and catastrophe as the ancien regime fell and revolutions erupted across Europe. Dewez also produced massive quantities of gilt bronze (ormolu) ornaments for a new Audience Chamber and Grand Salon commissioned by Prince Charles Alexandre of Lorraine for his Winter Palace in Brussels. While they...

Introduction:Hepatic venous occlusive disease (VOD) is a well-described early complication of allogeneic hematopoietic stem cell transplant (HSCT). The disease presents with elevated bilirubin, hepatomegaly, right upper quadrant pain, ascites and weight gain. Multi organ failure (MOF) can also occur, mainly renal and pulmonary failure, in severe cases. The incidence, pathogenesis, risk factors, and treatment of VOD remain poorly defined. Purpose:We aimed to determine the incidence of, risk factors, treatment patterns and resource utilization associated with VOD in Canada. Methods:Using the Cell Therapy and Transplant Canada (CTTC) database, which collects data from 15 stem cell transplant programs across Canada, a retrospective observational study was performed. Using patient demographics, disease and transplant characteristics, and the Center for International Blood & Marrow Transplant Research (CIBMTR) Form 2553 which collects information on patients diagnosed with VOD, data was collected. All allogeneic transplants performed on both children and adults between 2013 and 2019 were included in the analysis. Children and adults were analyzed as two separate cohorts. Results:The total incidence of VOD was 64/2507 (2.55%). The incidence of VOD was 27/464 (5.82%) in children and 24/2030 (1.18%) in adults. Risk factors for VOD for children and adults are shown in Tables 1 and 2, respectively. The most common treatments for VOD in children and adults were defibrotide (74.1% and 29.2%, respectively), diuretics (70.4% and 62.5%, respectively) and ursodiol (48.0% and 63.6%, respectively). The mean intensive care unit (ICU) visit duration and hospitalization in children with VOD was 7.0 days and 37.1 days, respectively. The mean ICU visit duration and hospitalization in adults with VOD was 8.2 days and 37.1 days, respectively. There were no differences in overall survival, relapse rates or non-relapse mortality between VOD patients and non-VOD patients in both children and adults. Discussion:Between 2013 and 2019, the incidence of VOD in allogeneic HSCT in Canada was 2.55%. This is consistent with recent reports from other countries including from the CIBMTR and a report from the United States at 3.3% and 5.4%, respectively. An unexpected finding was the difference in incidence between children and adults. Possible explanations for this include younger age being an actual risk factor for VOD, increased clinical vigilance amongst pediatric clinicians, reporting bias, alternative diagnoses because of more hepatic comorbidities in adults or a more obvious clinical presentation of VOD in children. This requires further investigation. Further to this, a higher proportion of children diagnosed with VOD received defibrotide than did adults diagnosed with VOD. It is unclear why this occurred. The significant risk factors identified in our study are similar to previously published risk factors for VOD. Although, comparative data with non-VOD patients was not available in this data set, VOD patients in both the pediatric and adult populations have longer hospitalizations than historical controls which have an average hospitalization of 23.6 days. No survival or relapse differences were found in our data however VOD cases were not divided into VOD and VOD-MOF. VOD-MOF has been associated with significant mortality of >80%. Weaknesses of our study include its retrospective nature, potential for reporting bias, variable reporting quality from multiple centres and lack of uniform diagnostic criteria for VOD. Conclusion:The incidence and risk factors for VOD in 15 Canadian HSCT centres are similar to previous reports from other countries. Children made up a higher proportion of VOD patients and a high proportion of children received defibrotide. Further study of the resource utilization associated with VOD is required. Acknowledgements:Veronique Baribeau and Jean Lachaine of PeriPharm Inc. for data analysis and Jazz Pharmaceuticals for funding, study design, data analysis and editorial contributions. Disclosures Paulson: Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Traumatic vascular injuries involving the carotid and vertebral arteries can be some of the most difficult injuries to diagnose and treat. Blunt injuries frequently result in asymptomatic periods with little to no evidence of vascular injury, and if left untreated can result in significant morbidity and mortality due to embolic strokes. Morbidity and mortality from penetrating cervical vascular injuries, on the other hand, are more commonly due to ischemic stroke and exsanguination. Operative management has traditionally been open repair; however, these exposures can be morbid to the patient and technically challenging for the surgeon. Over recent years there has been an increasing use of endovascular techniques to manage both blunt and penetrating cervical vascular injuries. In this chapter we will discuss blunt cerebrovascular injuries and the growing body of data regarding endovascular treatment options. This will be followed by a discussion about the equally challenging topic of penetrating cervical vascular injuries and their management.

Covering: January 2000 to July 2018 gem-Dimethylcyclobutanes are a common motif found in a multitude of natural products, and thus these structures have captivated synthetic chemists for years. However, until the turn of the century, most synthetic efforts relied upon the use of widely available terpenes, such as pinene or caryophyllene, that already contain the gem-dimethylcyclobutane motif. This approach limits the scope of molecules that can be accessed readily. This review highlights recent syntheses in which the gem-dimethylcyclobutane is assembled via de novo approaches. An outlook on the future of this research area is also provided.

Lunar Ice Cube (LIC) is one of 13 6U cubesats that will be deployed by EM1 in cislunar space. LIC along with Lunar Flashlight and LunaH-Map, all focused on the search for volatiles but with very different payloads, will be the first deep space cubesats designed to address goals for both demonstrating new technologies and collecting scientific data. Effectively, as their developments are occurring in parallel, they are acting as prototypes for future deep space cubesats missions. One useful outcome of this ‘experiment’ is to evolve a working paradigm for the development and operation of compact, cost-capped, standardized (supporting subsystems) spacecraft to serve the needs of diverse user communities. The lunar ice cube mission was developed as the test case in a GSFC R and D study to determine whether the cubesat paradigm could be applied to deep space, science requirements driven missions, and BIRCHES was its payload. Here, we present the design and describe the ongoing development, and testing, in the context of the challenges of using the cubesat paradigm to fly a broadband IR spectrometer in a 6U platform, including a very harsh environment, minimal funding and extensive need for leveraging existing assets and relationships on development, and minimum command and telemetry bandwidth translating into simplified or canned operation and the collection of only essential data.

The development of pyridylidene-Cu-complexes and their application in Cu/Pd-catalyzed heteroarylboration of alkenylheteroarenes is reported. The significance of 1,1'-heteroarylalkanes as building blocks for drug discovery, as well as the straightforward and modular sequence to prepare the pyridylidene-Cu-complexes, makes this catalyst and it applications attractive for chemical synthesis. Furthermore, chiral variants of the pyridylidene-Cu-complexes have been prepared and utilized in the enantioselective arylboration of E-alkenes, further demonstrating the value and potential of this class of catalysts.

Background: Mobile stroke units (MSUs) permit advanced cerebrovascular diagnosis, triage, and treatment to be delivered in the field. While the range of acute cerebral ischemia and intraparenchymal hemorrhage patients encountered by MSUs has been described, the frequency, determinants, and outcomes of patients presenting with extraparenchymal intracranial hemorrhages (subdurals/subarachnoid/epidural) has not been well delineated. Methods: We analyzed consecutive transports among MSU programs in 3 cites, Los Angeles, Houston and Cleveland from program inception through August 2018 in the two former and through 2015 in the latter. Frequency and demographic, presenting, and treatment features of patients with subdural hematoma (SDH) and subarachnoid hemorrhage (SAH) were quantified. Results: Among 850 overall transports, extraparenchymal intracranial hemorrhages accounted for 18 (2.1%), and included 11 (1.3%) SDH and 7 (0.8%) SAH. Among the SDH patients, age was mean 70/median 77 (range 28 to 85). Special features of SDH cases included: acute on chronic blood on CT in 36%, seizures in 9%, and isolated head trauma in 9%. Among SAH patients, mean age was 57 (range 41-75). Special features of SDH/SAH cases included accompanying intraparenchymal hemorrhage in 17%. Of the 18 combined SDH/SAH patients (67% women), 4 (22%) required field intubation, 1 (5%) was actively treated in the field with KCentra to reverse anticoagulation, and 5 (28%) were treated in the field with antihypertensives. (See Figure for exemplar cases.) Conclusions: Extraparenchymal intracranial hemorrhages account for about 1 in 50 cases managed in Mobile Stroke Units. MSU response permits immediate definitive diagnosis by CT imaging, earlier start of indicated medical therapies, and direct routing to neurosurgically-capable stroke centers.

In the late 1920s, American scenic designer Robert Edmond Jones conceived of the ‘New Theatre’, a hybrid art form created through the combination of theatre and cinema. For Jones, this strategy’s function was to illuminate what he called the ‘dual nature’ of humanity. By examining Jones’ largely ignored and forgotten writings on what he called ‘the dream medium’, we can gain insight into new ways of utilizing combinations of living actors and media to inspire us and lead us to a deeper understanding of what it means to be human. Jones saw a multitude of benefits from such an arrangement, including as a way to tap into the unconscious world of the inner self and dreams. Jones saw the relationship between the body of the actor and the projected image as the relationship between the ‘outer’ and ‘inner’ eye – the conscious and the unconscious. These methods, first proposed by Jones, are being used in contemporary performance to explore the dual nature of self and to disrupt and dislocate singular noti...

Though David Mitchell's novel Cloud Atlas was only published in 2004, critics have already written a number of articles and book chapters about this work. The complex structure and numerous ideas Mitchell explores lend themselves to viewing the novel through a variety of critical lenses, leading to more articles than one might expect on a novel less than a decade old. Thus far, though, people have been writing on subjects such as the novel's comments on environmentalism, genetics, or cloning, while others focus on Mitchell's view of history. Whenever the novel's structure is discussed, critics spend most of their time identifying Mitchell's literary inspirations or discussing the story-within-story structure as little more than a postmodern trick. However, Mitchell uses metafiction and intertextuality differently than those who have come before him, using such devices as a way of forcing the reader to consider the importance of narrative in one's life and in the world, in general.

Multidisciplinary team (MDT) diagnosis of interstitial lung disease (ILD) has been proposed as a gold standard, but there are no formal recommendations for MDT process or composition and limited knowledge regarding prevalence in routine practice. We performed a systematic evaluation of ILD diagnostic practice across a range of healthcare settings around the world. Electronic questionnaires were distributed across all global regions via society and collaborators networks. Responses from 457 unique centres across 64 countries were included in the analysis. Of the 350 (76.6%) centres holding formal meetings, the majority held face-to-face MDT meetings (80%), for a minimum of 30 min (93%), and discussed diagnosis (96.9%) and patient management (94.9%) at the meetings. Compared with non-academic and academic non-ILD centres, ILD academic centres reported a higher ILD caseload, held more formal MDT meetings, and were more likely to include histopathology and rheumatology specialists in their diagnostic team. Of the centres holding MDT meetings, 5.5% routinely discussed all new cases at such meetings. An MDT approach to ILD diagnosis is consistently interpreted and widely implemented across a range of routine care settings around the world. This observation will inform future ILD diagnostic agreement studies and diagnostic pathway recommendations., In real-world practice, ILD diagnosis uses a multidisciplinary team approach, irrespective of country or healthcare setting http://ow.ly/I1Di30nMNTX

Here we describe the Primitive Object Volatile Explorer (PrOVE), a smallsat mission concept to study the surface structure and volatile inventory of comets in their perihelion passage phase when volatile activity is near peak. CubeSat infrastructure imposes limits on propulsion systems, which are compounded by sensitivity to the spacecraft disposal state from the launch platform and potential launch delays. We propose circumventing launch platform complications by using waypoints in space to park a deep space SmallSat or CubeSat while awaiting the opportunity to enter a trajectory to flyby a suitable target. In our Planetary Science Deep Space SmallSat Studies (PSDS3) project, we investigated scientific goals, waypoint options, potential concept of operations (ConOps) for periodic and new comets, spacecraft bus infrastructure requirements, launch platforms, and mission operations and phases. Our payload would include two low-risk instruments: a visible image (VisCAM) for 5-10 m resolution surface maps; and a highly versatile multispectral Comet CAMera (ComCAM) will measure 1) H2O, CO2, CO, and organics non-thermal fluorescence signatures in the 2-5 μm MWIR, and 2) 7-10 and 8-14 μm thermal (LWIR) emission. This payload would return unique data not obtainable from ground-based telescopes and complement data from Earth-orbiting observatories. Thus, the PrOVE mission would (1) acquire visible surface maps, (2) investigate chemical heterogeneity of a comet nucleus by quantifying volatile species abundance and changes with solar insolation, (3) map the spatial distribution of volatiles and determine any variations, and (4) determine the frequency and distribution of outbursts.

IntroductionChildren who have experienced abuse and neglect are at increased risk of mental and physical health problems throughout life. This places an enormous burden on individuals, families and society in terms of health services, education, social care and judiciary sectors. Evidence suggests that early intervention can mitigate the negative consequences of child maltreatment, exerting long-term positive effects on the health of maltreated children entering foster care. However, evidence on cost-effectiveness of such complex interventions is limited. This protocol describes the first economic evaluation of its kind in the UK.Methods and analysisAn economic evaluation alongside the Best Services Trial (BeST?) has been prospectively designed to identify, measure and value key resource and outcome impacts arising from the New Orleans intervention model (NIM) (an infant mental health service) compared with case management (CM) (enhanced social work services as usual). A within-trial economic evaluation and long-term model from a National Health Service/Personal Social Service and a broader societal perspective will be undertaken alongside the National Institute for Health Research (NIHR)–Public Health Research Unit (PHRU)-funded randomised multicentre BeST?. BeST? aims to evaluate NIM compared with CM for maltreated children entering foster care in a UK context. Collection of Paediatric Quality of Life Inventory (PedsQL) and the recent mapping of PedsQL to EuroQol-5-Dimensions (EQ-5D) will facilitate the estimation of quality-adjusted life years specific to the infant population for a cost–utility analysis. Other effectiveness outcomes will be incorporated into a cost-effectiveness analysis (CEA) and cost-consequences analysis (CCA). A long-term economic model and multiple economic evaluation frameworks will provide decision-makers with a comprehensive, multiperspective guide regarding cost-effectiveness of NIM. The long-term population health economic model will be developed to synthesise trial data with routine linked data and key government sector parameters informed by literature. Methods guidance for population health economic evaluation will be adopted (lifetime horizon, 1.5% discount rate for costs and benefits, CCA framework, multisector perspective).Ethics and disseminationEthics approval was obtained by the West of Scotland Ethics Committee. Results of the main trial and economic evaluation will be submitted for publication in a peer-reviewed journal as well as published in the peer-reviewed NIHR journals library (Public Health Research Programme).Trial registration numberNCT02653716; Pre-results.

160 Diabetic Myonecrosis of Bilateral Thighs in Newly Diagnosed Type 2 Diabetes Mellitus Muhammad Imran, M.D., Zalina Ardasenov, M.D., Kevin Brown, M.D., Mehrdad Maz, M.D., Julian Magadan III, M.D. University of Kansas Medical Center, Kansas City, KS Department of Internal Medicine, Division of Allergy, Clinical Immunology and Rheumatology Division of General and Geriatric Medicine Department of Diagnostic Radiology

Introduction: Too few medical graduates choose to care for underserved populations. This qualitative study explores medical student perceptions of the benefits of participating in the Underserved Pathway (UP), a 4-year extracurricular program designed to nurture interest in, and develop skills to serve vulnerable populations. Methods: Fourteen of 28 graduating students in the class of 2013 who completed the UP were interviewed. Using conventional qualitative content analysis, an iterative process was used to code transcriptions until there was high concordance among the assigned codes. The research team analyzed the data for common themes, theme saturation, and unique perspectives. Results: Four major thematic areas emerged: 1) the underserved curriculum scaffold, 2) influence on career choice, 3) influence on residency choice, and 4) capacity to match. Of all participants, 78.6% thought the UP influenced their career choice, 64.3% stated the UP played a role in residency choice and rank, and 85.7% thought participation in the UP would improve match success. No single curricular component of the UP was individually responsible for career or specialty choice, or as being most useful to student understanding of the underserved. Conclusions: Students noted that participation in the UP provided them with a scaffold to support their interest in underserved careers, and influenced their specialty and residency choice. They also perceived it as making them more competitive as residency applicants. This study provides medical educators with insight into the importance of building robust frameworks, even extracurricular ones, to support student interests in serving vulnerable communities.

This study discusses the development of a coupled mesoscale–microscale framework for wind resource estimation and farm aerodynamics. WINDWYO is a computational framework for performing coupled mesoscale–microscale simulations. The framework is modular, automated and supports coupling of different mesoscale and microscale solvers using overset or matched grids. The modular nature of the framework and the support for overset grids allows the independent development of mesoscale and microscale solvers and the efficient coupling between the codes. The performance of the framework is evaluated by coupling Weather Research and Forecasting (WRF) model with three microscale computational fluid dynamics (CFD) codes of varying complexity. The solvers used are: (i) UWake: a blade element model with free-vortex wake, (ii) Flowyo: large eddy simulation code with actuator line/disk parametrization of the wind turbine and (iii) HELIOS: detached eddy simulation code with full rotor modeling and adaptive mesh refinement. Power predictions and wake visualization of single turbine and off-shore Lillgrund wind farm in uniform and turbulent inflow are used to demonstrate the capabilities of the framework.

The purpose of the study was to evaluate whether a peri-procedural povidone-iodine rectal preparation (PIRP) prior to transrectal ultrasound-guided prostate needle biopsy (TRUS PNB) can reduce microorganism colony counts and infectious complications. Our institutional TRUS PNB database was reviewed to identify infectious post-biopsy complications (defined as fever >38.5 °C with positive culture). The last 570 biopsy patients were divided into those administered only preoperative oral and/or parenteral antibiotics (n = 456; chronologically cohorts A–D) versus men receiving peri-procedural PIRP in conjunction with standard preoperative antibiotics (n = 114; cohort E). Rectal cultures were obtained in the PIRP cohort to quantify changes in microorganism colony counts. Mean baseline PSA for patients was 11.6 ng/ml, 63 % were undergoing an initial biopsy, and 17 % had documented use of antibiotic therapy within the previous 6 months. A reduction in infectious complications was observed when comparing the conventional antibiotic (cohorts A–D) versus PIRP (cohort E) group (1.8 vs. 0 %), with the largest magnitude of decline occurring in the concurrent contemporary cohorts (cohort D—5.3 % vs. cohort E—0 %, p = 0.03). Rectal cultures obtained in 92 men before and after PIRP administration noted a 97 % reduction in microorganism colonies (2.1 × 105 vs. 6.3 × 103 CFU/ml, p

A data providing service DPS in service-oriented architecture is tasked only with the retrieval of data that are annotated over a domain ontology. One particular motivating application of DPSs is their use within collaborative environments. An important characteristic for the enterprises of such a collaborative environment is the ability to employ data sharing with one another. A major concern in this situation is the protection of each enterprise's privacy while still permitting data sharing. One potential solution is to provide filtered data through access control. This work describes how to implement access control through fine-grained filtering of DPS response messages; it is accomplished using a filtering ontology and relations between the domain ontology of DPS and the proposed filtering ontology. Therefore, enterprises can write enterprise-specific access control policies referencing a common filtering ontology defined within a collaborative environment, enabling access control-based data sharing within the environment. This work additionally illustrates the implementation of our general solution to data providing web services, interpreted by an eXtensible Access Control Markup Language-based access control framework. The implementation is further evaluated in a case study of real world data, provided by a health research institute in London, Canada. Copyright © 2013 John Wiley & Sons, Ltd.

This study presents a new impact localization technique that can pinpoint the location of an impact event within a complex structure using a time-reversal concept, surface-mounted piezoelectric transducers, and a scanning laser Doppler vibrometer. First, an impulse response function between an impact location and a piezoelectric transducer is approximated by exciting the piezoelectric transducer instead and measuring the response at the impact location using scanning laser Doppler vibrometer. Then, training impulse response functions are assembled by repeating this process for various potential impact locations and piezoelectric transducers. Once an actual impact event occurs, the impact response is recorded by the piezoelectric transducers and compared with the training impulse response functions. The correlations between the impact response and the impulse response functions in the training data are computed using a unique concept of time reversal. Finally, the training impulse response function, which gives the maximum correlation, is chosen from the training data set and the impact location is identified. The proposed impact localization technique has the following advantages over the existing techniques: (a) it can be applied to isotropic/anisotropic plate structures with additional complex features such as stringers, stiffeners, spars, and rivet connections; (b) only simple correlation calculation based on time reversal is required, making it attractive for real-time automated monitoring; and (c) training is conducted using noncontact scanning laser Doppler vibrometer and the existing piezoelectric transducers that may already be installed for other structural health–monitoring applications. Impact events on an actual composite aircraft wing and an actual aluminum fuselage are successfully identified using the proposed technique.