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Abstract: Background: Although video-assisted thoracoscopic surgery (VATS) for pulmonary resection was first described more than 15 years ago, it has yet to gain grass-roots acceptance. The majority of surgeons who routinely perform VATS resections work in academic or government institutions. The perceived complexity of the technique, inadequate instrumentation and resources, and concern regarding the potential compromise of surgical and oncologic principles may present a greater barrier to adoption by community-based surgeons. This article illustrates some of the technical aspects of a hybrid technique that enables a single surgeon to perform VATS pulmonary resection on a routine basis in a community-based practice. Methods: From January 2005 to March 2008, 492 VATS pulmonary resections were performed by a community-based, solo-practice surgeon using a hybrid VATS technique. The highlight of this technique is utilization of a thoracoscopy port and a utility incision. The advantages of this dual access are ease in instrumentation, visualization, lighting, and retraction. In addition, this technique allows immediate access under direct vision for urgent control of bleeding, which can be difficult using a conventional thoracoscopic approach. Results: Mean operative time was 52 (median, 48) minutes. Mean length of stay was 7 (median, 4) days. Mean length of ICU stay was 1.7 days, with 85% of patients having no days spent in the ICU. Mean length of chest tube duration was 4 days. Perioperative mortality was 3.5% and overall mortality was 9.8%, with a mean follow-up of 239 days. These results compare favorably with the conventional VATS approach. Conclusions: This series shows that our hybrid VATS approach to pulmonary resection is safe and feasible at community hospital-based practices.

iSHELL is a 1.06–5.3 μm high spectral resolution spectrograph built for the 3.2 m NASA Infrared Telescope Facility (IRTF) on Maunakea, Hawaii. Dispersion is accomplished with a silicon immersion grating in order to keep the instrument small enough to be mounted at the Cassegrain focus of the telescope. The white pupil spectrograph produces resolving powers of up to about R≡ λ/δλ= 80,000 (0.″375 slit). Cross-dispersing gratings mounted in a tiltable mechanism allow observers to select different wavelength ranges and, in combination with a slit wheel and Dekker mechanism, slit widths ranging from 0.″375 to 4.″0 and slit lengths ranging from 5″ to 25″. One Teledyne 2048 × 2048 HAWAII-2RG array is used in the spectrograph, and one Raytheon 512 × 512 Aladdin 2 array is used in a 1–5 μm slit viewer for object acquisition, guiding, and scientific imaging. iSHELL has been in productive regular use on IRTF since first light in 2016 September. In this paper we discuss details of the science case, design, construction and astronomical use of iSHELL.

During the past 5 years, patent ductus arteriosus (PDA) presented in 734 preterm infants (less than 2.5 kg and 37 weeks gestation) of 2,532 admissions (29%). The ductus presented with murmur, bounding pulses, and often congestive heart failure. Medical treatment consisted of the following: fluid restriction, furosemide, respiratory support, and rarely digoxin. The patients who were unresponsive to medical treatment had surgical ligation (306 of 734 or 42%). The patients who had ductal ligation were smaller, i.e., 82% of the surgical patients weighed less than 1.5 kg as compared to 38% of the medical patients. Of those patients weighing less than 1.5 kg, the surgical and medical groups were compared and the following observations made: The incidence of respiratory distress syndrome was greater in the surgical group (86% or 216 of 252 patients versus 69% or 111 of 161 medical patients, p < 0.001) and the long-term survival was better (89% or 224 of 252 surgical patients versus 77% or 124 of 161 medical patients, p < 0.005). In addition, the average duration of intubation was shorter in this surgical subgroup (8.9 versus 13.6 days). Significant left atrial enlargement and echocardiographic left atriallaortic (LA/Ao) ratios of greater than 1.5:1 occurred in 58% or 171 of 290 surgical patients versus 32% or 59 of 190 medical patients (p < 0.001). During the first 3 years of this study (medical treatment averaged 5 days), the duration of intubation in the surgical patients averaged 15.2 days; by comparison, in the last 2 years of this study (medical treatment averaged 1 to 2 days), the duration of intubation was 6.5 days (p < 0.001). Necrotizing enterocolitis (NEC) occurred in 11% or 46 of 428 medical patients versus 0.3% (one of 305 patients) in the ligated group postoperatively (p < 0.001). Late deaths were related to lung disease, central nervous system problems, NEC, and so on. From this study, it was determined that ligation of a significant PDA is associated with (1) zero surgical risk, (2) a reduced incidence of NEC, (3) reduced duration of intubation, especially with early ligation, and (4) improvement in late survival. Thus the surgical approach is our treatment of choice for a refractory PDA.

• To identify which clinical findings serve to differentiate acute epiglottitis from laryngotracheitis and also to evaluate the role of direct inspection of the epiglottis in the evaluation of children initially thought to have laryngotracheitis, we prospectively evaluated 155 children presenting to the emergency room with acute stridor. Three of the findings on physical examination were associated with epiglottitis: absence of spontaneous cough, drooling, and agitation. The diagnosis assigned prior to inspection of the epiglottis was incorrect in two of six patients with epiglottitis and in three of 149 patients with laryngotracheitis. The diagnosis made after inspection was correct in all 155 patients. Minor complications of inspection were seen in seven patients with laryngotracheitis. No complications were seen in the children with epiglottitis. We conclude that drooling, agitation, and absence of cough are predictors of epiglottitis, but clinical findings alone cannot exclude epiglottitis in every child who appears to have laryngotracheitis. When laryngotracheitis is the suspected diagnosis, inspection of the epiglottis by a pediatrician in a hospital emergency room is an effective aid to the evaluation of the child with acute stridor.(AJDC 1988;142:679-682)

• Physicians vary considerably in their opinion as to the duration of hospitalization and degree of surgical intervention for children with pneumococcal empyema. The development of pneumatoceles and persistence of fever or loculated pleural fluid are causes of debate and concern. We reviewed the records of 21 children with confirmed pneumococcal pneumonia. Ten of the 12 with no pleural fluid became afebrile within 48 hours of appropriate antibiotic therapy, whereas the nine with empyema remained febrile an average of 7.1 days (minimum estimate) in spite of documented sterile cultures within 24 hours in five of the patients. Although chest tube and thoracentesis drainage could not remove all the pleural fluid, and pneumatoceles developed in five of the nine children, long-term follow-up studies including chest roentgenograms and pulmonary function testing demonstrated a gradual but complete recovery that did not require long-term hospitalization, continued parenteral antibiotic therapy, or invasive surgical procedures.(Am J Dis Child 134:659-662, 1980)

High mortality rates (20% to 60%) have been reported in the repair of coarctation of the aorta in infancy. During a 4 year period, 34 infants less than 6 months of age had coarctation repair (two prior to 1976). Eleven were less than 2 weeks of age, nine were 2 weeks to 1 month, eight were 1 to 2 months, and six were 2 to 6 months. Associated lesions were patent ductus arteriosus (PDA) (82%), ventricular septal defect (VSD) (53%), and other intracardiac lesions (35%). Twenty-three patients (67%) had emergency operations; the other procedures were semielective. The indications for operation included congestive cardiac failure (91%), acidosis (32%), hypertension (29%), cardiogenic shock (26%), and cardiac arrest (18%). There was one operative death (2.9%) in a patient with severe pulmonary valve insufficiency and multiple VSDs. There was one late death at 4 months (Taussig-Bing complex). Primary repair was used in 15, patch-graft angioplasty in 19 (left subclavian artery in nine, left common carotid in one, and Dacron or pericardial patch in nine). Two (6%) required reoperation for recurrent coarctation (follow-up 3 to 36 months with a mean of 25.8). Of 15 patients with a large VSD, six had pulmonary artery banding with two deaths (one operative and one late), two had debanding plus VSD repair, and two are awaiting operation. The remaining nine patients did not have banding (no operative or late deaths), four patients required late VSD closure, two VSDs closed spontaneously, two VSDs became smaller, and one patient is awaiting VSD closure. The infrequent need for pulmonary artery banding may be partly due to “physiological banding” seen at Denver’s high altitude. The VSD spontaneously closed or became smaller in 44% of nonbanded patients. The low operative mortality can be ascribed to (1) aggressive medical therapy, (2) emergency catheterization and repair, (3) avoidance of hypothermia, and (4) adequate relief of the coarctation.

Discussion of the independent nature of four problems in the management and resolution of international conflicts fills a gap, since these distinct problems are often considered to be a single undifferentiated subject area. The first problem is the existence of multiple conflict structures (patterns of capabilities and interests): different structures follow differing patterns of development. The second problem concerns difficulties in statesmen's abilities to discern accurately the structure and thus the dynamics of the conflict episodes they confront. The third problem involves the strategy requirements of different conflict structures, and the fourth the discrepancies between statesmen's strategy preferences and the requirements of different conflict structures. Increased intellectual recognition of these distinct issues might help to reduce the severity of international conflicts by reducing misperception and inappropriate actions based on misperception. But statesmen would still face problems in gaining domestic political support for their intellectual understanding of international conflicts.

This essay presents data on the thinking of health policy elites in the United States, the United Kingdom and the Federal Republic of Germany. These three national groups are compared in terms of the values they perceive health policy should serve and their conceptions of appropriate policies for realizing these values. The different values and policy conceptions are then related to various propositions as to why social policies differ across nations, particularly to the hypothesis that social policies differ as a consequence of elite values and attitudes.