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INTRODUÇÃO: Os pacientes vítimas de eventos de violência e cinemática do trauma condizente a acidentes automobilísticos apresentam-se no pronto-socorro com lesões de diferentes gravidades. OBJETIVOS: Identificar paciente com trauma torácico no atendimento pré-hospitalar e quais as múltiplas manifestações que podem resultar em parada cardiorrespiratória. METODOLOGIA: O corpus da pesquisa será uma busca em bases de dados online. Para isso, serão utilizados estudos indexados nas bases de dados: LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde) PUBMED (National Library of Medicine NationalInstitutesof Health dos EUA) e BVS (Biblioteca Nacional em Saúde) no período entre janeiro de 2021 a junho de 2021, Nos últimos 10 anos. RESULTADOS E DISCUSSÕES: De acordo com o exposto no quadro 1 a seguir, são apresentadas informações a respeito dos 7 artigos contidos na discussão desta revisão de literatura. As lesões torácicas traumáticas são comumente instaladas juntamente a lesões em outro local (60% -70%). A principal origem das lesões torácicas são os acidentes de trânsito, geralmente associados à ingestão de álcool e direção noturna ou sem escrúpulos CONCLUSÃO: O estudo permitiu identificar que as informações sobre a dinâmica de condução do trauma torácico no atendimento pré hospitalar e seu desfecho resultante em parada cardiorrespiratória (pcr) que ainda são escassas. PALAVRA-CHAVES: Lesão Cardíaca por Trauma Torácico Fechado; Lesão Cardíaca por Traumatismo Contundente; Lesão Cardíaca por Traumatismo não Penetrante; e Parada Cardiorrespiratória.

Introduction Accurate coding is essential to ensure correct remuneration for clinical procedures. However, coders are non-clinical, and use operative and discharge notes to infer what they think are appropriate codes. As plastic surgery encompasses a huge variety of procedures, the codes used may not reflect the procedures performed. Methods Electronic records from July/August 2019 were consulted to identify commonly performed procedures on elective lists that were then reviewed retrospectively by a coding auditor and a clinician. Procedures were chosen to reflect a range of plastic surgery, including hand surgery, breast surgery and general plastic surgery. The changes to the clinical codes (procedural and diagnostic) and Healthcare Resource Group tariff implications were analysed. The audit loop was completed in July 2020 after the introduction of clinical coding improvement strategies. Results A total of 65 relevant cases were included. Changes were made in 31 cases (24 changes to OPCS-4 codes and 7 changes to ICD-10 codes). Significant remunerative implications for the department were noted (£209 per patient on average). Conclusions This study has demonstrated a clear need for collaboration between clinicians and coders. Increased surgeon awareness of clinical coding and clear documentation are essential. We have presented strategies to improve coding as part of a continued quality improvement.

Integrative local health delivery models in the UK, under the framework of Enhanced Health in Care Homes (EHICH), have been developed to improve joint working between health and social care to benefit the patient. Despite this drive toward health and social care integration, research on the barriers, facilitators, and impact of partnership working on role of care home staff is underdeveloped. This study set out to explore views on how closer working between health and social care can impact on the role of care home staff and any barriers to effective integration. Staff from 25 care homes and GPs from their partnered practices were interviewed to explore the impact of the partnership. Homes receiving regular visits from the same health professional found the relationship between the two sectors had benefitted both residents and staff. The development of trusting relationships, access to support and information, and recognition and respect were all seen as facilitating the partnership and enhancing patient care. Regular and effective interactions with health-care professionals were key and had the potential to empower and increase confidence of care home staff in their role around health care. Factors negatively impacting on strength of relationship such as visits by inconsistent professional and high turnover of care home staff were a barrier to successful partnerships. Experiences of poor interactions with those from health-care services where there was an absence of a trusting relationship were disempowering to care home staff and remain a barrier to effective wider health and social care collaboration.

ATRX is a chromatin remodelling ATPase that is involved in transcriptional regulation, DNA damage repair and heterochromatin maintenance. It has been widely studied for its role in ALT-positive cancers, but its role in neurological function remains elusive. Hypomorphic mutations in the X-linked ATRX gene cause a rare form of intellectual disability combined with alpha-thalassemia called ATR-X syndrome in hemizygous males. Clinical features also include facial dysmorphism, microcephaly, short stature, musculoskeletal defects and genital abnormalities. Since complete deletion of ATRX in mice results in early embryonic lethality, the field has largely relied on conditional knockout models to assess the role of ATRX in multiple tissues. Given that null alleles are not found in patients, a more patient-relevant model was needed. Here, we have produced and characterised the first patient mutation knock-in model of ATR-X syndrome, carrying the most common causative mutation, R246C. This is one of a cluster of missense mutations located in the chromatin binding domain and disrupts its function. The knock-in mice recapitulate several aspects of the patient disorder, including craniofacial defects, microcephaly, reduced body size and impaired neurological function. They provide a powerful model for understanding the molecular mechanisms underlying ATR-X syndrome and for testing potential therapeutic strategies.

Actinic cystitis hematuria is a frequent complication after pelvic radiotherapy, present in approximately 5% of patients exposed to this therapy. The management of these cases seems to be a challenge for today’s urologists. In this article, we present the case of a 73- year-old man diagnosed with actinic cystitis after pelvic radiotherapy and admitted to our service with a clinical picture of refractory macroscopic hematuria. During admission, the patient underwent multiple procedures and blood transfusions, without success in controlling hematuria. After a review of the literature, we chose to use Potassium Alum in the patient’s treatment. Under general anesthesia, we performed a cystoscopy with the evacuation of clots and subsequently infused a 1% solution of potassium alum into the bladder at a rate of 200 ml/h for 25 hours. Less than 24 hours after Alum infusion, there were no more clinical signs of hematuria, which remained until hospital discharge. After 6 months of treatment, the patient did not present another episode of hematuria.

Objetivo: O presente estudo objetiva descrever, por meio da literatura, as limitações para inserção dos homens nos serviços de saúde, à luz da política de atenção integral à saúde do homem. Metodologia: O método de construção dessa pesquisa foi o de revisão integrada, aliada à pesquisa bibliográfica, revisão de literatura, com métodos dedutivos, análises descritivas de natureza qualitativa. Os resultados foram obtidos com a coleta de dados por meio de artigos científicos, teses, dissertações e livros divulgados publicados em periódicos indexados nas bases de dados do SCIELOme LILACS entre os meses de novembro de 2021 a abril de 2022. Resultados: No total, houve 35 menções às barreiras limitantes para o processo de inserção dos homens aos serviços de saúde. Destas, três (3) estão ligadas a limitações da própria instituição de saúde ou a gestão e duas (2) estão ligadas a limitações intrínsecas do indivíduo. As barreias mais mencionadas neste trabalho foram as limitações do próprio indivíduo (n=10), entraves importantes na implantação do processo de cuidado, seguido do despreparo da Unidades Básicas de Saúde para atender o público masculino (n=9) e das ações em saúde não centralizadas no público masculino (n=7). Conclusão: As barreiras mais limitantes para o acesso dos homens aos serviços de saúde foram, em sequência: 1) limitações do próprio indivíduo; 2) despreparo da Unidades Básicas de Saúde para atender o público masculino; 3) ações em saúde não centralizadas no pú­blico masculino; 4) falta de capacitação profissional; e 5) procura tardia ao serviço de saúde. As limitações encontradas neste trabalho são indicadores importantes no aumento da taxa de adoecimento da população masculina.

The late 1960s were a turbulent time on Canadian postsecondary campuses. University students were both the subjects of and participants in the broader discourse regarding the counterculture...

Oral drug absorption is a complex process depending on many factors, including the physicochemical properties of the drug, formulation characteristics and their interplay with gastrointestinal physiology and biology. Physiological-based pharmacokinetic (PBPK) models integrate all available information on gastro-intestinal system with drug and formulation data to predict oral drug absorption. The latter together with in vitro-in vivo extrapolation and other preclinical data on drug disposition can be used to predict plasma concentration-time profiles in silico. Despite recent successes of PBPK in many areas of drug development, an improvement in their utility for evaluating oral absorption is much needed. Current status of predictive performance, within the confinement of commonly available in vitro data on drugs and formulations alongside systems information, were tested using 3 PBPK software packages (GI-Sim (ver.4.1), Simcyp® Simulator (ver.15.0.86.0), and GastroPlusTM (ver.9.0.00xx)). This was part of the Innovative Medicines Initiative (IMI) Oral Biopharmaceutics Tools (OrBiTo) project. Fifty eight active pharmaceutical ingredients (APIs) were qualified from the OrBiTo database to be part of the investigation based on a priori set criteria on availability of minimum necessary information to allow modelling exercise. The set entailed over 200 human clinical studies with over 700 study arms. These were simulated using input parameters which had been harmonised by a panel of experts across different software packages prior to conduct of any simulation. Overall prediction performance and software packages comparison were evaluated based on performance indicators (Fold error (FE), Average fold error (AFE) and absolute average fold error (AAFE)) of pharmacokinetic (PK) parameters. On average, PK parameters (Area Under the Concentration-time curve (AUC0-tlast), Maximal concentration (Cmax), half-life (t1/2)) were predicted with AFE values between 1.11 and 1.97. Variability in FEs of these PK parameters was relatively high with AAFE values ranging from 2.08 to 2.74. Around half of the simulations were within the 2-fold error for AUC0-tlast and around 90% of the simulations were within 10-fold error for AUC0-tlast. Oral bioavailability (Foral) predictions, which were limited to 19 APIs having intravenous (i.v.) human data, showed AFE and AAFE of values 1.37 and 1.75 respectively. Across different APIs, AFE of AUC0-tlast predictions were between 0.22 and 22.76 with 70% of the APIs showing an AFE > 1. When compared across different formulations and routes of administration, AUC0-tlast for oral controlled release and i.v. administration were better predicted than that for oral immediate release formulations. Average predictive performance did not clearly differ between software packages but some APIs showed a high level of variability in predictive performance across different software packages. This variability could be related to several factors such as compound specific properties, the quality and availability of information, and errors in scaling from in vitro and preclinical in vivo data to human in vivo behaviour which will be explored further. Results were compared with previous similar exercise when the input data selection was carried by the modeller rather than a panel of experts on each in vitro test. Overall, average predictive performance was increased as reflected in smaller AAFE value of 2.8 as compared to AAFE value of 3.8 in case of previous exercise. QC 20200930

This reflection paper addresses the importance of the interaction between voice perception and voice production, emphasizing the processes of auditory-vocal integration that are not yet widely reported in the context of voice clinicians. Given the above, this article seeks to 1) highlight the important link between voice production and voice perception and 2) consider whether this relationship might be exploited clinically for diagnostic purposes and therapeutic benefit. Existing theories on speech production and its interaction with auditory perception provide context for discussing why the evaluation of auditory-vocal processes could help identify associated origins of dysphonia and inform the clinician around appropriate management strategies. Incorporating auditory-vocal integration assessment through sensorimotor adaptation paradigm testing could prove to be an important addition to voice assessment protocols at the clinical level. Further, if future studies can specify the means to manipulate and enhance a person’s auditory-vocal integration, the efficiency of voice therapy could be increased, leading to improved quality of life for people with voice disorders. Resumen Este artículo de reflexión aborda la importancia de la interacción entre la percepción y la producción de la voz, haciendo hincapié en los procesos de integración auditivo-vocal, los cuales aún no han sido muy divulgados en el contexto de los clínicos de voz. Dado lo anterior, este articulo busca: 1) destacar la importante relación entre la producción y la percepción de la voz y 2) considerar si esta relación pudiese explotarse clínicamente con fines diagnósticos y terapéuticos. Las teorías existentes sobre la producción de la voz y su interacción con la percepción auditiva proporcionan el contexto para discutir por qué la evaluación de los procesos auditivo-vocales podría ayudar a identificar los orígenes asociados a cierto tipo de disfonías e informar al clínico sobre las estrategias de abordaje adecuadas. La incorporación de la evaluación de la integración auditivo-vocal a través de la prueba del paradigma de adaptación sensoriomotora podría ser una importante adición a los protocolos de evaluación de la voz a nivel clínico. Además, si los estudios futuros pueden especificar los medios para manipular y mejorar la integración auditivo-vocal de una persona, la eficacia de la terapia de la voz podría aumentar, lo que llevaría a mejorar la calidad de vida de las personas con trastornos de la voz.

The objective of this study was to evaluate the efficacy of ultraviolet C light (UVC) for inactivating Senecavirus A (SVA) on three different experimentally contaminated surfaces commonly found in swine farms. An experimental study under controlled conditions assessed the effect of UVC on an SVA isolate on coupons composed of three surface types: cardboard, cloth, and plastic. Each coupon was inoculated with 2 mL of SVA (107.5 TCID50/mL) and 1 mL of PBS or 1 g of feces on the top or bottom surface of the coupon and allowed to dry (90 min at 25℃). Coupons were exposed to UVC in a commercially available pass-through chamber (PTC) for 5 min or in a simulated supply entry room (SER) for 120 min. After exposure, virus isolation was attempted from each coupon and virus titers were determined in cell culture. The efficacy of UVC was determined by the reduction in virus titer for the UVC treated groups compared to their respective non-treated positive controls. UVC was effective at inactivating SVA on plastic surface free of organic material. The plastic coupons inoculated with SVA and PBS had a significantly lower virus titer (>7-log reduction) in both the PTC and SER when compared to their relative positive controls. All other groups in the PTC and SER had a 2-log reduction or less. The reduction in virus titer on the top and bottom inoculated surfaces, following exposure to UVC, were not statistically different. The data from this study provide some guidance when applying UVC for disinfection in the field.

Swine medicine resources and caseloads for teaching and supporting extracurricular training activities vary widely among veterinary colleges and are concentrated in specific regions. Student interest and demand for swine medicine training is broader in geographical distribution. This is illustrated by student membership and attendance at the American Association of Swine Veterinarians (AASV) annual meetings, for example. To explore how concentrated resources might be made more widely available in a cost-effective manner, the Swine Medicine Education Center (SMEC) at Iowa State University’s College of Veterinary Medicine looked for ways to leverage existing extracurricular resources with a broader geography of schools and students. This article describes the organization of student chapters of the AASV and the outcomes of a multi-session live audio and video webcast focused on swine medicine topics across North America over a 3-year period. SMEC organized the series with funding provided by the AASV and AASV Foundation. The broadcast series covered a wide range of swine-related topics, including pet pigs, emerging diseases, and regulation of antimicrobials. In its third year, 25 North American and 4 international veterinary schools participated in the series and provided feedback from attendees.

Background Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. Objectives The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. Methods The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. Results Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. Conclusions Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being. Level of Evidence: 4

The title of this research is distributed by some of the statements in the Qur'an about ethics against the property. On the one hand the Qur'an looked positively treasure, on the other hand the Quran as if not condone. This research would like to find a concept of how the Qur'an against ethics against property by emphasizing the ethical discussion of acquiring property, possession and utilization of ethics of property. The type and pattern of this research is a library that is descriptive qualitative analysis. The main object of his research is the Qur'an. Therefore, the method used is the science of tafseer. Because this research is to find a concept, the approach used was thematic tafseer. The texts relating to the subject matter of discussion. As for to analyze the problem, the authors use think inductively, that is, seeks to provide answers to various issues of life with departure from nas Qur'an towards reality (min al-Qur'an ila al-wâqi '). With this approach the authors limit themselves to things that are described by the Qur'an, including in the selection of the theme, and only use the vocabulary or term used Al Qur'an. The discussion in this paper are not directed to the type, quality or quantity of property. Instead it focused on the ethical attitude of man against the property, in which case the problem of acquiring property, possession and utilization of property. Of exposure data in this discussion, several conclusions, among them. The mention of the Qur'an on wealth seems less condone, not aimed at the material, melain aimed at human attitude towards wealth that made the property into a negative. The advice of the Qur'an against the wealth not only technical problems, but rather ethical issues as moral values built in Islam. Judul penelitian ini dilatarbelakangi oleh beberapa pernyataan Al-Qur’an tentang etika terhadap harta. Di satu sisi Al-Qur’an memandang harta secara positif, di sisi lain Al-Qur’an seolah-olah tidak merestui. Penelitian ini ingin mencari konsep bagaimana pandangan Al-Qur’an terhadap etika terhadap harta dengan menekankan pembahasan etika memperoleh harta, memiliki harta dan etika pendayagunaan harta. Jenis dan corak penelitian ini adalah library yang bersifat deskriptif analisis kualitatif. Objek utama penelitiannya adalah Al-Qur’an. Oleh karena itu, metode yang digunakan adalah ilmu tafsir. Karena penelitian ini untuk menemukan konsep, pendekatan yang digunakan adalah tafsir tematik. Ayat-ayat yang berkaitan dengan pokok pembahasan. Adapun untuk menganalisa masalah, penulis menggunakan pikir induktif, yakni berupaya memberikan jawaban terhadap berbagai persoalan kehidupan dengan berangkat dari nas Al-Qur’an menuju realita ( min al-Qur’an ila al-wâqi’). Dengan pendekatan ini penulis membatasi diri pada hal-hal yang dijelaskan oleh Al-Qur’an, termasuk dalam pemilihan tema, dan hanya menggunakan kosa kata atau term yang digunakan Al-Qur’an. Pembahasan dalam tulisan ini tidak diarahkan pada jenis, kualitas atau kuantitas harta. Melainkan difokuskan pada sikap etis manusia terhadap harta, dalam hal masalah memperoleh harta, memiliki harta dan pendayagunaan harta. Dari pemaparan data dalam pembahasan ini, menghasilkan beberapa kesimpulan, di antaranya. Penyebutan Al-Qur’an terhadap kekayaan seolah-olah kurang merestui, bukan ditujukan pada materinya, melain ditujukan pada sikap manusia terhadap kekayaan yang menjadikan harta menjadi negatif. Nasihat Al-Qur’an terhadap harta kekayaan bukan hanya masalah teknis, melainkan masalah etika sebagai nilai-nilai moral yang dibangun dalam Islam.

The fundamental thing that is rarely touched by the academics today is the science of tajwid, whereas functionally science of tajwid is a component of science which is the basis for how to read the Qur’an properly and correctly. It is a measure for every letter which is pronounced by qari ‘(reader), because in every letter of the verses of the Qur’an has its right. Another important thing to note is that the science of tajwid is not born of a vacuum, it is formed from various historical entities that surround it, and therefore tracing the historical roots of this study is a necessity. From historical aspect will be found the roots of the science of tajwid formation is inseparable from the development of science qira’ah. This is because qiraah scholars in their masterpiece also attach a lot of rules about science of tajwid. Departing from it, it can be said science of tajwid discipline has given birth to the implications of the development of science qiraah. Nevertheless, the two brothers of this disciplinary scholarship have substantial substantial differences. The science of qiraah discusses the variety of reading articulately, while the science of tajwid discusses the technicalities of the Qur’anic verses.

Introduction While debate persists over how to best prevent or treat amputation neuromas, the more pressing question of how to best marry residual nerves to state-of-the-art robotic prostheses for naturalistic control of a replacement limb has come to the fore. One potential solution involves the transposition of terminal nerve ends into the medullary canal of long bones, creating the neural interface within the bone. Nerve transposition into bone is a long-practiced, clinically relevant treatment for painful neuromas. Despite neuropathic pain relief, the physiological capacity of transposed nerves to conduct motor and sensory signals required for prosthesis control remains unknown. This pilot study addresses the hypotheses that (1) bone provides stability to transposed nerves and (2) nerves transposed into bone remain physiologically active, as they relate to the creation of an osseointegrated neural interface. Methods New Zealand white rabbits received transfemoral amputation, with the sciatic nerve transposed into the femur. Results Morphological examination demonstrates that nerves remain stable within the medullary canal, while compound nerve action potentials evoked by electrical stimulation of the residual nerve within the bone could be achieved at 12 weeks (p Conclusion Transposed nerves retain a degree of physiological function suitable for creating an osseointegrated neural interface.

Rhinoplasty utilizes cartilage harvested from the nasal septum as autologous graft material. Traditional dogma espouses preservation of the “L-strut” of dorsal and caudal septum, which is less resistant to axial loading than virgin septum. Considering the 90° angle between dorsal and caudal limbs, the traditional L-strut also suffers from localized increases in internal stresses leading to premature septal “cracking,” structural-scale deformation, or both. Deformation and failure of the L-strut leads to nasal deviation, saddle deformity, loss of tip support, or restriction of the nasal valve. The balance between cartilage yield and structural integrity is a topographical optimization problem. Guided by finite element (FE) modelling, recent efforts have yielded important modifications including the chamfering of right-angled corners to reduce stress concentrations and the preservation of a minimum width along the inferior portion of the caudal strut. However, all existing FE studies offer simplified assumptions to make the construct easier to model. This review article highlights advances in our understanding of septal engineering and identifies areas that require more work to further refine the balance between the competing interests of graft acquisition and the maintenance of nasal structural integrity.

Introduction Necrotising soft tissue infection (NSTI) is a rare but life threatening diagnosis. Geographic, economic and social variances influence presentation and prognosis. As the current literature does not reflect a UK metropolitan population, we conducted a retrospective chart review to establish pertinent features relevant to our practice. Methods Patients with histologically confirmed diagnoses of NSTI presenting to two London teaching hospitals between January 2007 and July 2013 were included in the study. Features of presentation, surgical and medical management, microbiological findings and outcome were evaluated. Results Twenty-four patients with histologically confirmed NSTI were included. Two age clusters were identified, with means of 46 years (standard deviation [SD]: 10 years) and 80 years (SD: 6 years). Pain, erythema and sepsis were common findings. Hypertension, hypercholesterolaemia and type II diabetes mellitus were common co-morbidities. A third of younger patients had human immunodeficiency virus or hepatitis C, with a quarter dependent on drugs and/or alcohol. The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 5.8 (SD: 3.3). The lower extremities, groin and perineum were common sites of infection. Fourteen patients required inotropic support and seventeen required transfusions. The median number of surgical procedures was 5 (range: 1–17). Group A Streptococcus was the most frequently identified pathogen. Five patients died. Being elderly, female sex and failure to use clindamycin as a first-line antibiotic were associated with significantly higher mortality. Conclusions In contrast to other recent series, group A streptococcal monomicrobial NSTI remains the most common presentation in our population. Survival is anticipated in young patients, regardless of premorbid status. Elderly patients have a poor prognosis. The negative predictive value of the LRINEC score is questioned. Use of clindamycin as a first-line antibiotic is supported.

The use of goniometers to measure joint angles is a key part of musculoskeletal practice. Recently smartphone goniometry applications have become available to clinicians. This study examined the intra- and inter-measurer reliability of novice and experienced clinicians and the concurrent validity of assessing knee range of motion using a smartphone application (the Knee Goniometer App (Ockendon © )) (KGA) and a standard universal goniometer (UG). Three clinicians, each with over seven years' experience as musculoskeletal physiotherapists and three final year physiotherapy students, measured 18 different knee joint angles three times, using both the universal goniometer and the smartphone goniometric application. The universal goniometer and the smartphone goniometric application were reliable in repeated measures of knee flexion angles (average Concordance Correlation Coefficient (CCC) > 0.98) with both experienced clinicians and final year physiotherapy students (average CCCs > 0.96). There were no significant differences in reliability between the experienced and the novice practitioners for either device. Agreement between the universal goniometer and smartphone goniometric application measurements was also high for all examiners with average CCCs all above 0.96. The Standard Error of Measurement ranged between 1.56° (0.52–2.66) for the UG and 0.62° (0.29–1.27) for the KGA. The universal goniometer and the smartphone goniometric application were reliable in repeated measures of knee flexion angles. Smaller error of measurement values for the smartphone goniometric application might indicate superiority for assessment where clinical situations demand greater precision of knee range of motion.

Background: Although the anatomy of the individual pectoralis major and minor muscles has been described previously, never before has the anatomic relationship between these muscles been investigated. Objective: The authors identify the anatomic relationship of the costal origins of the pectoralis major and minor muscles. Methods: Bilateral thoracic wall dissection was completed in 102 cadavers. In each dissection, the chest wall soft tissue was removed, and the distance between costal origins of the pectoralis major and the pectoralis minor muscles was measured. Results: In 49 female and 53 male cadavers, 202 pectoralis major muscles were lifted to expose the costal origins of the pectoralis major and minor muscles. Distances between pectoralis major and pectoralis minor muscles were separated into 3 categories: less than 1 cm, between 1 and 3 cm, and greater than 3 cm. Forty-nine (24%) pectoralis muscle dissections displayed a distance of less than 1 cm between costal muscle origins. Eighty-three dissections (41%) showed an intermediate distance of between 1 and 3 cm, while the remaining 70 (35%) were over 3 cm. No significant difference was observed in these percentages with regard to sex. Ten cadavers displayed asymmetry in pectoralis muscle origin distance. Eight specimens displayed shared fibers between pectoralis major and minor muscles. Conclusions: The anatomic relationship between the costal origin of the pectoralis major and minor muscles is highly variable. Understanding this spatial relationship has important implications for cosmetic and reconstructive breast surgery.

La constipation induite par les opioides (CIO) est un effet secondaire du traitement aux opioides qui peut avoir une incidence sur la qualite de vie, la fidelite au traitement, la morbidite, voire la mortalite. Objectifs : Mener des recherches afin de savoir si le docusate sodique, les sennosides et le lactulose ont une efficacite et des profils d’effets secondaires equivalents a ceux du polyethylene glycol (PEG) dans la prise en charge de la CIO chez les adultes. Methodologie : Un examen systematique a ete realise. Des essais cliniques aleatoires aupres d’adultes prenant des opioides pour leur douleur d’origine cancereuse et non cancereuse etaient pris en consideration s’ils satisfaisaient aux criteres d’inclusion. Conclusions : L’agregation statistique etait impossible puisqu’aucune etude ne satisfaisait aux criteres d’inclusion. Des essais cliniques aleatoires de grande envergure et dotes de beaucoup de ressources sont faisables. Des definitions normalisees de la CIO faciliteraient la realisation de ces etudes et en rehausseraient la validite interne et externe. De nouvelles recherches sont vivement encouragees.

The use of potassium trimethylsilanolate as base to induce elimination of potassium arenesulfinate from alkyl aryl sulfones to produce E-alkenes is described. The reaction was appropriate for substrates containing a benzyl or allyl group α to the sulfone residue.

The crocodile or spiny skinks, Tribolonotus, comprise eight secretive semi-fossorial lizards, which are generally found under vegetation in the immediate vicinity of water (Greer and Parker, 1968; O'Shea, 1991, 1994; Rogner, 1997). Tribolonotus gracilis (Figure 1) and Tribolonotus novaeguineae are restricted to New Guinea, while the remaining six species range throughout Indonesia, Manus, New Britain, Bougainville, and the Solomon Islands (McCoy, 1980; O'Shea, 1991, 1994). Because scant life history information is available for the genus Tribolonotus, the purpose of the present contribution is to document the vocalization and parental care of T. gracilis.

Responses by the insectivorous, actively foraging scincid lizard, Scincella lateralis, to chemical cues from a plant food favored by herbivorous lizards, its ability to discriminate prey chemicals from control substances, and its relative response to internal and surface prey chemicals were studied experimentally. We presented chemical cues to the lizards on cotton swabs and recorded their tongue-flicks and biting attacks on the swabs. The lizards exhibited significantly greater tongue-flick rates and biting frequencies to prey surface cues than to plant surface chemicals from romaine lettuce, diluted cologne (pungency control), and deionized water. Responses to the plant stimuli did not differ from those to the two control stimuli, in contrast with strong responses to the same plant cues by herbivores. This finding provides the first information suggesting that chemosensory response may be adapted to diet, with responsiveness to plant stimuli evolving de novo in herbivores. Biting and tongue-flicking responses were significantly greater to cricket chemicals than to all other stimuli, among which there were no differences. Thus, the lizards are capable of prey chemical discrimination, which may be ubiquitous among actively foraging lizards. The lizards exhibited more frequent biting and higher tongue-flick rates to internal than surface prey chemicals. Although different methods of stimulus preparation are appropriate for different purposes, we conclude that prey surface chemicals available to foraging lizards are most desirable for studies bearing on location and identification of prey.

Objectives: To explore the circumstances and factors that explain variations in response to a cardiac event and to identify potentially modifiable factors. Design: Qualitative analysis of semistructured, face to face interviews with patients admitted to two district hospitals for a cardiac event and with other people present at the time of the event. Patients were divided into three groups according to the length of delay between onset of symptoms and calling for medical help. Subjects: 43 patients and 21 other people present at the time of the cardiac event. Patients were divided into three groups according to the length of time between onset of symptoms and seeking medical help: non-delayers ( 12 h; n=10). Main outcome measures: Decision making process, strategies for dealing with symptoms, and perception of risk and of heart attacks before the event according to delay in seeking help. Results: The illness and help seeking behaviour of informants had several components, including warning, interpretation, preliminary action, re-evaluation, and final action stages. The length of each stage was variable and depended on the extent to which informants mobilised and integrated resources into a strategy to bring their symptoms under control. There were obvious differences in informants9 knowledge of the symptoms that they associated with a heart attack before the event. Non-delayers described a wider range of symptoms before their heart attack and twice as many (13) considered themselves to be potentially at risk of a heart attack compared with the other two groups. For most informants the heart attack differed considerably from their concept of a heart attack. Conclusion: The most critical factor influencing the time between onset of symptoms and calling for professional medical help is that patients and others recognise their symptoms as cardiac in origin. This study suggests that various points of intervention in the decision making process could assist symptom recognition and therefore faster access to effective treatment. Key messages Research using methods that can explain variations in response to cardiac events has been neglected Informants in this study thought of heart attacks as sudden dramatic events in which people collapse and probably die, rather than as the evolving event that they experienced Those who sought medical help within 4 hours were more likely to see themselves as potentially at risk, knew a wider range of symptoms of a heart attack, and were much less likely to use drugs to treat their symptoms compared with those who waited longer Intervention at various points in the decision making process could help recognition of symptoms and speed access to effective treatment

Opioid-induced constipation (OIC) is a side effect of opioid therapy that can affect quality of life, adherence to treatment, and morbidity and possibly mortality. Objectives: To investigate whether docusate sodium, sennosides, and lactulose have equal efficacy and side effect profiles compared to PEG in the management of OIC in adults. Methods: A systematic review was undertaken. Randomized controlled trials of adults taking opioids for cancer or non-cancer pain were considered if they met inclusion criteria. Conclusions: Statistical pooling was not possible as no studies met inclusion criteria. Large, well-powered, randomized controlled trials are feasible. Standard definitions of OIC would assist with the execution of these studies and contribute to their internal and external validity. Further research is strongly encouraged.

We report the radiological findings of severe bilateral jugular foraminal stenosis along with anomalous basicranial venous drainage in a child with a history of complex nonsyndromic craniosynostosis. CT with 3D reconstructions and MR venography revealed that the lateral sinuses were draining transosseously through several markedly enlarged emissary veins. The main route of transverse and sigmoid sinus drainage was through large mastoid emissaries to the deep cervical veins. There was additional drainage of these mastoid emissaries into the vertebral and paravertebral plexuses as well as into venous collaterals which subsequently reconstituted the internal jugular veins. Basicranial venous anomalies are common among children with complex craniosynostosis, and although they may not resemble intracranial vascular outflow deficiencies, they can pose significant surgical risks. This case emphasizes the need for proper clinical assessment and documentation of anomalous basicranial venous anatomy to facilitate management of complex craniosynostosis patients.

Rho family GTPases are molecular switches best known for their pivotal role in dynamic regulation of the actin cytoskeleton. The prototypic members of this family are Cdc42, Rac1, and RhoA; these GTPases contribute to the breakdown of glomerular filtration and the resultant proteinuria, but their functions in normal podocyte physiology remain poorly understood. Here, mice lacking Cdc42 in podocytes developed congenital nephropathy and died as a result of renal failure within 2 weeks after birth. In contrast, mice lacking Rac1 or RhoA in podocytes were overtly normal and lived to adulthood. Kidneys from Cdc42-mutant mice exhibited protein-filled microcysts with hallmarks of collapsing glomerulopathy, as well as extensive effacement of podocyte foot processes with abnormal junctional complexes. Furthermore, we observed aberrant expression of several podocyte markers and cell polarity proteins in the absence of Cdc42, indicating a disruption of the slit diaphragm. Kidneys from Rac1- and RhoA-mutant mice, however, had normal glomerular morphology and intact foot processes. A nephrin clustering assay suggested that Cdc42 deficiency, but not Rac1 or RhoA deficiency, impairs the polymerization of actin at sites of nephrin aggregates. Taken together, these data highlight the physiological importance of Cdc42, but not Rac1 or RhoA, in establishing podocyte architecture and glomerular function.

Within the glomerulus, the scaffolding protein nephrin bridges the actin-rich foot processes that extend from adjacent podocytes to form the slit diaphragm. Mutations affecting a number of slit diaphragm proteins, including nephrin, cause glomerular disease through rearrangement of the actin cytoskeleton and disruption of the filtration barrier. We recently established that the Nck family of Src homology 2 (SH2)/SH3 cytoskeletal adaptor proteins can mediate nephrin-dependent actin reorganization. Formation of foot processes requires expression of Nck in developing podocytes, but it is unknown whether Nck maintains podocyte structure and function throughout life. Here, we used an inducible transgenic strategy to delete Nck expression in adult mouse podocytes and found that loss of Nck expression rapidly led to proteinuria, glomerulosclerosis, and altered morphology of foot processes. We also found that podocyte injury reduced phosphorylation of nephrin in adult kidneys. These data suggest that Nck is required to maintain adult podocytes and that phosphotyrosine-based interactions with nephrin may occur in foot processes of resting, mature podocytes.

Despite a paucity of safety and efficacy data, the use of recombinant activated factor VII in children for off-label indications has now surpassed its use in hemophilia. A retrospective chart review was conducted of 46 subjects (age, 6.7 ± 6 years; weight, 26 ± 20 kg) who received recombinant activated factor VII for nonhemophiliac indications between January 1, 2004, and September 1, 2005. Indications for use included prevention (n = 6) or treatment (n = 40) of bleeding due to general surgery, hepatic failure, gastrointestinal bleeding, severe traumatic brain injury, bone marrow transplant, cardiac, acetaminophen overdose, and multiorgan system failure. Decreases in prothrombin time, partial thromboplastin time, and international normalized ratio were observed. No inappropriate thrombotic events were noted. Administration of recombinant activated factor VII was associated with a reduction in coagulation markers without obvious adverse thrombotic events at cost of $4189 per dose. These findings should be confirmed in a prospective trial.

Objectives Southeast Arkansas is a primarily rural, low-income area with low breastfeeding rates. Given the demonstrated positive impacts of breastfeeding on a variety of health indicators, it is important to understand and counteract this situation. Methods We reviewed the medical records of 1,260 women who delivered infants at the only major hospital in southeastern Arkansas between February 1997 and January 1998 to determine the rate of breastfeeding initiation and to assess associated factors. Results Only 18% of mothers initiated breastfeeding. Black mothers, unmarried mothers, and those with less than high school education were least likely to breastfeed. Participation in childbirth education classes was positively associated with breastfeeding, but participation in the Supplemental Food Program for Women, Infants, and Children, health care provider, and hospital variables were not predictive in multivariate models. Conclusions Breastfeeding promotion programs are clearly needed in this region, and health care providers and the Supplemental Food Program for Women, Infants, and Children can play significant roles.

Prayer and religious ceremonies may help patients near the end of life and their relatives find comfort and discover meaning in their lives. In this paper, we analyze how physicians might respond in two situations regarding prayer and religious ceremonies. First, how should physicians respond when such patients or their families ask physicians to pray for them or with them? Physicians' responses to such requests will depend on their own religious and spiritual beliefs, the congruence of their beliefs with those of the patient and family, and their relationship with the patient. Many physicians may be willing to be present and stand silently while the patient prays. Second, how should physicians respond when such patients and families seek to carry out their religious and spiritual practices in the hospital? Religious ceremonies can provide meaning, hope, and solace to patients and families. Institutional guidelines regarding religious ceremonies should allow as much leeway as is compatible with good care both for the patient for whom the ritual is offered and also for other patients within the facility. Physicians should inquire whether there are religious and spiritual practices that patients and families would like to engage in. However, physicians should be cautious about recommending specific ceremonies or pratices. Physicians can respond to requests and respect patients' spiritual needs in ways that may deepen the therapeutic doctor-patient relationship, without compromising their own religious and spiritual beliefs or professional roles.

The epidemiology of tuberculosis in urban populations is changing. Combining conventional epidemiologic techniques with DNA fingerprinting of Mycobacterium tuberculosis can improve the understanding of how tuberculosis is transmitted.We used restriction-fragment-length polymorphism (RFLP) analysis to study M. tuberculosis isolates from all patients reported to the tuberculosis registry in San Francisco during 1991 and 1992. These results were interpreted along with clinical, demographic, and epidemiologic data. Patients infected with the same strains were identified according to their RFLP patterns, and patients with identical patterns were grouped in clusters. Risk factors for being in a cluster were analyzed.Of 473 patients studied, 191 appeared to have active tuberculosis as a result of recent infection. Tracing of patients' contacts with the use of conventional methods identified links among only 10 percent of these patients. DNA fingerprinting, however, identified 44 clusters, 20 of which consisted of only 2 persons and the largest of which consisted of 30 persons. In patients under 60 years of age, Hispanic ethnicity (odds ratio, 3.3; P = 0.02), black race (odds ratio, 2.3; P = 0.02), birth in the United States (odds ratio, 5.8; P0.001), and a diagnosis of the acquired immunodeficiency syndrome (odds ratio, 1.8; P = 0.04) were independently associated with being in a cluster. Further study of patients in clusters confirmed that poorly compliant patients with infectious tuberculosis have a substantial adverse effect on the control of this disease.Despite an efficient tuberculosis-control program, nearly a third of new cases of tuberculosis in San Francisco are the result of recent infection. Few of these instances of transmission are identified by conventional contact tracing.

As patients near the end of life, their spiritual and religious concerns may be awakened or intensified. Many physicians, however, feel unskilled and un- comfortable discussing these concerns. This article suggests how physicians might respond when patients or families raise such concerns. First, some pa- tients may explicitly base decisions about life-sustaining interventions on their spiritual or religious beliefs. Physicians need to explore those beliefs to help patients think through their preferences regarding specific interventions. Sec- ond, other patients may not bring up spiritual or religious concerns but are troubled by them. Physicians should identify such concerns and listen to them empathetically, without trying to alleviate the patient's spiritual suffering or offering premature reassurance. Third, some patients or families may have re- ligious reasons for insisting on life-sustaining interventions that physicians advise against. The physician should listen and try to understand the pa- tient's viewpoint. Listening respectfully does not require the physician to agree with the patient or misrepresent his or her own views. Patients and families who feel that the physician understands them and cares about them may be more willing to consider the physician's views on prognosis and treatment. By responding to patients' spiritual and religious concerns and needs, physi- cians may help them find comfort and closure near the end of life.

Bellcore develops software products conforming to the OSCA TM architecture. Aimed at ensuring interoperability in a heterogeneous environment, the OSCA architecture separates concerns into three types of entities: data layer building blocks, user layer building blocks (ULBBs), and processing layer building blocks (PLBBs). In 1990, we undertook a project to refine the User Layer (UL) of the OSCA architecture. In this poster, we briefly describe the refined architecture and explore reasons for our success. To account for this, we have had to answer the question: Who are the users of an architecture? We found that acceptance of a user centered architecture (i.e., centered on the end user) is greatly enhanced by the use of a user centered design process of that architecture (i.e., centered on the development users of the architecture).