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Sailors were often affected by nutritional deficiencies due to the absence of fresh foods on long voyages. One example is the development of scurvy from a lack of vitamin C ingestion. In modern society in which fresh food are available this disease is infrequently recognized. The following case describes a 62-year-old male who presented with “red spots” on his legs and a large area of ecchymosis on his thigh. After initial testing failed to elicit a cause, a dietary history revealed that the patient had a peculiar diet of only ice cream with a total avoidance of fruits and vegetables. This case highlights the importance of a good history and physical examination as the basis for medical diagnosis.

In keeping with the principles of autonomy, beneficence, and non-maleficence, no dental treatment shouldbbe commenced prior to carrying out all the requisite preparatory stages. This includes a thorough initial assessment, establishing an accurate diagnosis, drawing up a list of possible treatment options, presenting these to the patient, and allowing them to make an autonomous and educated decision. This should be followed with the formulation of a structured and carefully considered treatment plan.This case illustrates a case of iatrogenically induced damage suffered by a patient where unplanned treatment was carried out with no consideration of the possible immediate, short term or long terms outcomes. It stresses the need for dentists to consider and pre-empt the consequences of their treatment (or lack there-of) and formulate the best possible plan for each patient. It also needs to be stressed that the proposed management plan must be informed by the principle of ‘shared decision making’ wherein the patient assumes part of the responsibility and accountability in the decisions taken. The ultimate aim of any plan must be to promote the best possible outcome for the patient (beneficence), and as far as possible prevent iatrogenically induced harm (non maleficence).

Introduction: Fibromuscular dysplasia (FMD) is a non-inflammatory vasculopathy associated with arterial stenosis, aneurysm, dissection, and tortuosity. We investigated racial differences in clinical manifestations and events of multifocal FMD. Methods: Demographics, medical history, presenting signs and symptoms, and major vascular events were queried from the US Registry for FMD and stratified into White or Black based on self-identified race. Results: Of the 1897 female patients (pts) with multifocal FMD and race reported from 14 sites as of 12/23/2020, there were 1697 (89.5 %) White, 123 (6.5 %) Black, 52 (2.7%) Hispanic, and 25 (1.3%) pts of other races. Given a small number of pts in other groups, analysis was only performed between White and Black pts. Age at diagnosis and at first sign/symptom was similar between the two groups. Black pts were more likely to have a history of hypertension (p=0.009), stroke (p=0.002), and subarachnoid hemorrhage (p Conclusion: We noted a low number of Black patients enrolled in the US Registry for FMD at FMD specialty centers. There were differences in clinical manifestations, events, and pattern of vascular involvement among Black and White patients enrolled in US Registry, the mechanisms for which require additional study.

Species radiations have long fascinated biologists, but the contribution of adaptation to observed diversity and speciation is still an open question. Here, we explore this question using the clove genus, Syzygium, the world’s largest genus of tree species comprising approximately 1200 species. We dissect Syzygium diversity through shotgun sequencing of 182 distinct species and 58 additional as-yet unidentified taxa, and assess their genetic diversity against a chromosome-level reference genome of the sea apple, Syzygium grande. We show that Syzygium grande shares a whole genome duplication (WGD) event with other Myrtales. Genomic analyses confirm that Syzygium originated in Sahul (Australia-New Guinea), and later diversified eastward to the Hawaiian Islands and westward in multiple independent migration events. The migrations were associated with bursts of speciation events, visible by poorly resolved branches on phylogenies and networks, some of which were likely confounded by incomplete lineage sorting. Clinal genomic variation in some sublineages follows phylogenetic progression, which coupled with sympatric occurrences of distantly related species suggests that both geographic and ecological speciation have been important in the diversification of Syzygium. Together, these results point to a mixture of both neutral and adaptive drivers having contributed to the radiation of the genus.

The application of big data, radiomics, machine learning, and artificial intelligence (AI) algorithms in radiology requires access to large data sets containing personal health information. Because machine learning projects often require collaboration between different sites or data transfer to a third party, precautions are required to safeguard patient privacy. Safety measures are required to prevent inadvertent access to and transfer of identifiable information. The Canadian Association of Radiologists (CAR) is the national voice of radiology committed to promoting the highest standards in patient-centered imaging, lifelong learning, and research. The CAR has created an AI Ethical and Legal standing committee with the mandate to guide the medical imaging community in terms of best practices in data management, access to health care data, de-identification, and accountability practices. Part 1 of this article will inform CAR members on principles of de-identification, pseudonymization, encryption, direct and indirect identifiers, k-anonymization, risks of reidentification, implementations, data set release models, and validation of AI algorithms, with a view to developing appropriate standards to safeguard patient information effectively.

The application of big data, radiomics, machine learning, and artificial intelligence (AI) algorithms in radiology requires access to large data sets containing personal health information. Because machine learning projects often require collaboration between different sites or data transfer to a third party, precautions are required to safeguard patient privacy. Safety measures are required to prevent inadvertent access to and transfer of identifiable information. The Canadian Association of Radiologists (CAR) is the national voice of radiology committed to promoting the highest standards in patient-centered imaging, lifelong learning, and research. The CAR has created an AI Ethical and Legal standing committee with the mandate to guide the medical imaging community in terms of best practices in data management, access to health care data, de-identification, and accountability practices. Part 2 of this article will inform CAR members on the practical aspects of medical imaging de-identification, strengths and limitations of de-identification approaches, list of de-identification software and tools available, and perspectives on future directions.

Purpose: To determine whether computed tomography radiation dose data could be captured electronically across hospitals to derive regional diagnostic reference levels for quality improvement. Methods: Data on consecutive computed tomography examinations from 8 hospitals were collected automatically in a central database (Repository) from April 2017 to September 2017. The most frequently performed examinations were used to determine the standard protocols for each hospital. Diagnostic reference levels across hospitals were derived using statistical distribution for 2 radiation dose metrics. These values were compared between hospitals, within and between hospitals by scanner and against national Health Canada achievable doses and diagnostic reference levels. Results: Three master protocol groups, Head, Abdomen–Pelvis, and Chest–Abdomen–Pelvis, accounted for 43% of all valid studies (N = 40 277). For the Repository, 11 of 12 mean values and 75th percentile diagnostic reference levels were below the Health Canada mean and 75th percentile values, and one was the same as the Health Canada value. Mean radiation dose by protocol varied by as much as 97% between hospitals. There was no consistent pattern in the difference between mean doses between large and small hospitals. Conclusion: This electronic data acquisition process could be used to continually update achievable doses for frequently used computed tomography examinations in Ontario and eliminate the need for nationwide manual surveys. Results compared across institutions will allow hospitals to maintain achievable doses and lower patient exposure.

Coal seam gas (CSG) or coal bed methane production has grown exponentially in Australia over the last two decades with currently nearly 7000 productive wells and another 18,750 wells planned over the next five to ten years. To address concerns over environmental contamination by hydraulic fracture fluids (HFF) attributed to (i) incidents involving poor surface handling of HFF and other fluids with potential migration pathways in soil and shallow groundwater, and (ii) leakage pathways arising from HFF injection into coal seams and unintended migration of these chemicals, the National assessment of chemicals associated with coal seam gas extraction in Australia (the Assessment) was undertaken. The Assessment included a review of international studies on unconventional gas migration pathways to provide prior knowledge and comparison for use in the Australian study. The international literature highlighted that accidents with HFF were mainly due to surface operations and included leaking equipment and spills. Contamination risks of groundwater from hydraulic fracturing itself were found to be very small based on analysis of micro-seismic and groundwater hydrochemistry data; geologic modelling of vertical fracture growth further reveals a low risk of leakage pathways developing in aquifers confined by deep shale formations. This is due to limitations on the fracture growth vertically across aquitards often hundreds of meters thick, retention within the shale of limited amounts of injected fluid, and preferential fracture growth at shallow depths in the horizontal direction. These arguments are broadly applicable to Australian CSG basins. However, important differences exist, such as the reduced thickness in Australia of the aquitards that separate the targeted gas resource from groundwater. Also, hydraulic fracturing in Australian coal seams is practised only when permeabilities are too low for gas extraction to be economical without stimulation. From the nearly 10,000 CSG wells drilled in the Bowen and Surat Basins in Queensland, only 6% have received hydraulic fracturing to date. The reduced risk of leakage pathways developing during CSG production in Australian basins is further corroborated by geologic criteria based on modelling and observations. Criteria include encountering certain favourable conditions during drilling/injection, i.e. (i) interfaces, such as natural fractures, faults, and bedding planes, which promote offsetting and branching, or rock layers with higher fracture toughness causing the cessation or reduction in fracture growth, (ii) narrow fractures due to a relatively higher elastic modulus, leading to higher viscous flow loss, (iii) high permeability layers, and (iv) overlying layer(s) with a higher confining stress. In addition to the leakage pathways considered in North American shale gas basins involving (i) pre-existing fractures and faults, or (ii) flow up the production well due to poor casing or cementing, plausible chemical migration pathways in Australian CSG basins are due to (iii) connectivity via a fracture in or extended out of the coal seam formation between CSG wells and water bores co-located in the same formation, and (iv) poor integrity water bores enhancing inter-aquifer connectivity. These plausible pathways are described and used in subsequent work as the basis of risk assessments for contamination at the local- and regional scale.

Artificial intelligence (AI) is rapidly moving from an experimental phase to an implementation phase in many fields, including medicine. The combination of improved availability of large datasets, increasing computing power, and advances in learning algorithms has created major performance breakthroughs in the development of AI applications. In the last 5 years, AI techniques known as deep learning have delivered rapidly improving performance in image recognition, caption generation, and speech recognition. Radiology, in particular, is a prime candidate for early adoption of these techniques. It is anticipated that the implementation of AI in radiology over the next decade will significantly improve the quality, value, and depth of radiology's contribution to patient care and population health, and will revolutionize radiologists' workflows. The Canadian Association of Radiologists (CAR) is the national voice of radiology committed to promoting the highest standards in patient-centered imaging, lifelong learning, and research. The CAR has created an AI working group with the mandate to discuss and deliberate on practice, policy, and patient care issues related to the introduction and implementation of AI in imaging. This white paper provides recommendations for the CAR derived from deliberations between members of the AI working group. This white paper on AI in radiology will inform CAR members and policymakers on key terminology, educational needs of members, research and development, partnerships, potential clinical applications, implementation, structure and governance, role of radiologists, and potential impact of AI on radiology in Canada.

Artificial intelligence (AI) software that analyzes medical images is becoming increasingly prevalent. Unlike earlier generations of AI software, which relied on expert knowledge to identify imaging features, machine learning approaches automatically learn to recognize these features. However, the promise of accurate personalized medicine can only be fulfilled with access to large quantities of medical data from patients. This data could be used for purposes such as predicting disease, diagnosis, treatment optimization, and prognostication. Radiology is positioned to lead development and implementation of AI algorithms and to manage the associated ethical and legal challenges. This white paper from the Canadian Association of Radiologists provides a framework for study of the legal and ethical issues related to AI in medical imaging, related to patient data (privacy, confidentiality, ownership, and sharing); algorithms (levels of autonomy, liability, and jurisprudence); practice (best practices and current legal framework); and finally, opportunities in AI from the perspective of a universal health care system.

The mycoheterotrophic genus Gymnosiphon Blume is recorded for Australia for the first time after the recent discovery of plants at Mossman Gorge, Queensland. On the basis of examination of living plants in the field as well as materials preserved in spirit, the Mossman Gorge Gymnosiphon taxon is a novelty closely related to Gymnosiphon affinis J.J.Sm., which is known only from New Guinea. The new species is here described as Gymnosiphon queenslandicus B.Gray & Y.W.Low based on floral characteristics important for species distinction in the genus.

Source-pathway-receptor analyses involving solute migration pathways through soil and shallow groundwater are typically undertaken to assess how people and the environment could come into contact with chemicals associated with coal seam gas operations. For the potential short-term and long-term release of coal seam gas fluids from storage ponds, solute concentration and dilution factors have been calculated using a water flow and solute transport modelling framework for an unsaturated zone-shallow groundwater system. Uncertainty about dilution factors was quantified for a range of system parameters: (i) leakage rates from storage ponds combined with recharge rates, (ii) a broad combination of soil and groundwater properties, and (iii) a series of increasing travel distances through soil and groundwater. Calculated dilution factors in the soil increased from sand to loam soil and increased with an increasing recharge rate, while dilution decreased for a decreasing leak rate and leak duration. In groundwater, dilution factors increase with increasing aquifer hydraulic conductivity and riverbed conductance. For a hypothetical leak duration of three years, the combined soil and groundwater dilution factors are larger than 6980 for more than 99.97% of bores that are likely to be farther than 100 m from the source. Dilution factors were more sensitive to uncertainty in leak rates than recharge rates. Based on this dilution factor, a comparison of groundwater predicted environmental concentrations and predicted no-effect concentrations for a subset of hydraulic fracturing chemicals used in Australia revealed that for all but two of the evaluated chemicals the estimated groundwater concentration (for a hypothetical water bore at 100 m from the solute source) is smaller than the no-effect concentration for the protection of aquatic ecosystems.

Pathfinding in hospitals is challenging for patients, visitors, and even employees. Many people have experienced getting lost due to lack of clear guidance, large footprint of hospitals, and confusing array of hospital wings. In this paper, we propose Halo; An indoor navigation application based on voice-user interaction to help provide directions for users without assistance of a localization system. The main challenge is accurate detection of origin and destination search terms. A custom convolutional neural network (CNN) is proposed to detect origin and destination search terms from transcription of a submitted speech query. The CNN is trained based on a set of queries tailored specifically for hospital and clinic environments. Performance of the proposed model is studied and compared with Levenshtein distance-based word matching., This paper is accepted for presentation at 2017 IEEE 28th Annual International Symposium on Personal, Indoor, and Mobile Radio Communications

Convolutional neural networks (CNNs) are a subtype of artificial neural network that have shown strong performance in computer vision tasks including image classification. To date, there has been limited application of CNNs to chest radiographs, the most frequently performed medical imaging study. We hypothesize CNNs can learn to classify frontal chest radiographs according to common findings from a sufficiently large data set.Our institution's research ethics board approved a single-center retrospective review of 35,038 adult posterior-anterior chest radiographs and final reports performed between 2005 and 2015 (56% men, average age of 56, patient type: 24% inpatient, 39% outpatient, 37% emergency department) with a waiver for informed consent. The GoogLeNet CNN was trained using 3 graphics processing units to automatically classify radiographs as normal (n = 11,702) or into 1 or more of cardiomegaly (n = 9240), consolidation (n = 6788), pleural effusion (n = 7786), pulmonary edema (n = 1286), or pneumothorax (n = 1299). The network's performance was evaluated using receiver operating curve analysis on a test set of 2443 radiographs with the criterion standard being board-certified radiologist interpretation.Using 256 × 256-pixel images as input, the network achieved an overall sensitivity and specificity of 91% with an area under the curve of 0.964 for classifying a study as normal (n = 1203). For the abnormal categories, the sensitivity, specificity, and area under the curve, respectively, were 91%, 91%, and 0.962 for pleural effusion (n = 782), 82%, 82%, and 0.868 for pulmonary edema (n = 356), 74%, 75%, and 0.850 for consolidation (n = 214), 81%, 80%, and 0.875 for cardiomegaly (n = 482), and 78%, 78%, and 0.861 for pneumothorax (n = 167).Current deep CNN architectures can be trained with modest-sized medical data sets to achieve clinically useful performance at detecting and excluding common pathology on chest radiographs.

Critical limb ischemia (CLI) is associated with a high risk of major adverse cardiac events (MACE) and major adverse limb events (MALE). Among patients who undergo peripheral vascular intervention (PVI), little is known about in-hospital outcomes and evidence-based medication (EBM) use at discharge

As the Affordable Care Act unfolds, federally qualified health centers (FQHCs) will likely experience an influx of newly insured, low-income patients at disparate risk for cancer. Cancer-focused organizations are seeking to collaborate with FQHCs and the Primary Care Associations (PCAs) that serve them, to prevent cancer and reduce disparities. To guide this collaboration, we conducted 21 interviews with representatives from PCAs and FQHCs across four western states. We asked about: FQHC priorities, barriers and facilitators to cancer prevention, the PCA–FQHC relationship, and collaboration opportunities for external organizations. FQHC priorities include medical home transformation, electronic health records, and clinical care; prevention efforts must integrate with these. Barriers to cancer prevention include competing priorities, inadequate patient insurance, and lack of reimbursement, while facilitators are the presence of patient navigators and cancer-related performance measures. Collaboration opportunities for external organizations include dissemination of culturally appropriate educational materials and support for patient navigators.

We describe the case of a 63-year-old woman with CNS Rosai-Dorfman disease, presenting with diffuse dural infiltration, mimicking idiopathic hypertrophic pachymeningitis, and right vertebral artery dissection. Her symptoms included a progressive 11-month history of vertigo, gait ataxia, and right thalamic stroke. A diagnosis of CNS Rosai-Dorfman disease was made following open dural biopsy, and later confirmed on autopsy studies. The autopsy demonstrated widespread dural infiltration by inflammatory cells, principally large histiocytes, many of which exhibited emperipolesis, a characteristic finding in Rosai-Dorfman disease. A second pathological finding on autopsy was the presence of multiple demyelinating plaques (with preservation of axons), located in the corpus callosum, periventricular white matter, and multiple brainstem segments. These were consistent with a diagnosis of multiple sclerosis. This case description serves to remind clinicians that CNS Rosai-Dorfman disease—although uncommon—may present as a focal, dural-based, hemispheric mass lesion, or as diffuse pachymeningeal inflammation. Our case was also unusual due to the co-existence of CNS Rosai-Dorfman disease, multiple sclerosis, and polycythemia vera (all rare diseases) in a single patient. Although the overlap of disorders may have been co-incidental, one could raise the question whether all three disorders were triggered by the same underlying dysimmune state.

Two optical methods, namely crystal facet reflection and etching pits reflection, were used to orient and high-purity germanium crystals. The X-ray diffraction patterns of three slices that were cut from the oriented and crystals were measured by X-ray diffraction. The experimental errors of crystal facet reflection method and etching pits reflection method are in the range of 0.05° - 0.12°. The crystal facet reflection method and etching pits reflection method are extremely simple and cheap and their accuracies are acceptable for characterizing high purity detector-grade germanium crystals.

To grow high purity germanium (HPGe) crystals in an underground environment for ultra-low background experiments is being studied. In the present work, HPGe crystals along 〈100〉 direction have been grown by the Czochralski method. In order to investigate the distribution of the impurities as a function of length for a grown crystal, i.e. the axial direction, we fabricated a system to measure the resistivity along the axial direction at both room temperature and liquid nitrogen temperature. The distribution of the impurities along the radial direction was measured with a Hall Effect System. The results show that the carrier concentration in some crystals grown in a hydrogen atmosphere has an impurity level of about 10 10 /cm 3 , which meets the requirements of detector-grade crystals.

Purpose The aim of this study was to examine the frequency and type of outlier dose metrics for three common CT examination types on the basis of a root-cause analysis (RCA) approach. Methods Institutional review board approval was obtained for this retrospective observational study. The requirement to obtain informed consent was waived. Between January 2010 and December 2013, radiation dose metric data from 34,615 CT examinations, including 26,878 routine noncontrast CT head, 2,992 CT pulmonary angiographic (CTPA), and 4,745 renal colic examinations, were extracted from a radiation dose index monitoring database and manually cleaned. Dose outliers were identified on the basis of the statistical distribution of volumetric CT dose index and dose-length product for each examination type; values higher than the 99th percentile and less than the 1st percentile were flagged for RCA. Results There were 397 noncontrast CT head, 52 CTPA, and 80 renal colic outliers. Root causes for high-outlier examinations included repeat examinations due to patient motion (n = 122 [31%]), modified protocols mislabeled as "routine" (n = 69 [18%]), higher dose examinations for patients with large body habitus (n = 27 [7%]), repeat examinations due to technical artifacts (n = 20 [5%]), and repeat examinations due to suboptimal contrast timing (CTPA examinations) (n = 18 [5%]). Root causes for low-outlier examinations included low-dose protocols (n = 112 [29%]) and aborted examinations (n = 8 [2%]). On the basis of examination frequency over a 3-month period, the 90th and 10th percentile values were set in the radiation dose index monitoring database as thresholds for sending notifications to staff members responsible for outlier investigations. Conclusions Systematic RCA of dose outliers identifies sources of variation and dose excess and pinpoints specific protocol and technical shortcomings for corrective action.

Rosai-Dorfman disease is a rare, histiocytic proliferative disorder of unknown etiology commonly affecting lymph nodes. Extranodal lesions with or without nodal involvement also occur. We report the case of a 63 year-old woman with disseminated Rosai-Dorfman disease involving the neurohypophysis and associated with adenohypophysial PRL cell hyperplasia.

To retrospectively evaluate radiation optimization efforts over 4 years for three computed tomography (CT) protocols and to determine institutional (local) diagnostic reference levels for prospective tracking by using automated radiation dose index monitoring software.Approval for this retrospective observational study was obtained from the hospital research ethics board, and the need to obtain informed consent was waived. The study followed a 48-month radiation dose optimization effort in a large academic inner-city trauma and quaternary referral center. Exposure according to equipment, protocol, and year (2010-2013) for adult patients was determined for routine unenhanced head CT examinations, CT pulmonary angiography examinations, and CT examinations for renal colic. Mean exposure (as volume CT dose index [CTDIvol] and dose-length product [DLP]) was averaged to establish local diagnostic reference levels. Means and 75th percentiles for 2013 were compared with findings from surveys in Canada and diagnostic reference levels for similar protocol types internationally. Student t tests were performed to assess significance between annual means, and χ(2) tests were performed for changes in categoric variables.There were 36 996 examinations in 25 234 patients. There was an average exposure reduction of 22% for CTDIvol and 13% for DLP from 2010 to 2013. In 2013, mean CTDIvol for routine head examinations was 50.8 mGy ± 3.7 (standard deviation), 11.8 mGy ± 5.6 for CT pulmonary angiography examinations, and 10.2 mGy ± 4.2 for renal colic CT examinations, while mean DLP was 805.7 mGy · cm ± 124.3, 432.8 mGy-cm ± 219.9, and 469.4 mGy · cm ± 209.2, respectively. The mean CTDIvol and DLP in 2013 were at or close to identified reference values; however, additional optimization is required to reach "as low as reasonably achievable" values for all examinations.Automated methods of radiation dose data collection permit a detailed analysis of radiation dose according to protocol and equipment over time. Radiation dose optimization measures were effective, but their full value may be realized only with changes in internal processes and real-time, prospective data monitoring and analysis.

Geosiris Baill. is a small genus of achlorophyllous, mycoheterotrophic herbs that until now consisted of only two species, Geosiris albiflora Goldblatt & J.C. Manning and Geosiris aphylla Baill., the latter being the type species of the genus. Prior to this study, the genus was known only from two islands off the southeast coast of Africa, Madagascar and Mayotte. A recent discovery in Australia reported here expands its geographic range to the Pacific. The Australian taxon represents a species distinct from the two African taxa based on the key morphological characters for species distinction in the genus, namely stigma characteristics. Geosiris albiflora has a somewhat club-like stigma with three coherent lobes, Geosiris aphylla with a stigma terminates in three fringed broad and flat stigmatic lobes, and the Australian Geosiris has a truncate stigma with a short fimbriate margin. Hence, the Australian taxon is formally described here as Geosiris australiensis B. Gray & Y.W. Low.

We examined the patient and physician characteristics related to the use and yield of computed tomography pulmonary angiogram (CTPA) for the diagnosis of pulmonary embolism (PE) at a tertiary academic hospital emergency department (ED). A cross-sectional retrospective study was conducted on 835 consecutive ED patients with suspected PE who underwent CTPA. Radiology report data were extracted from our institution's RIS PACS software (Syngo Imaging, Siemens) based on a targeted search of all CTPA reports from 2010 to 2012. Utilization and PE positivity rates of CTPA were calculated and correlated with patient characteristics including age and gender, as well as emergency physician (EP) characteristics including gender, years in practice, and training certification. Acute PE was diagnosed in 17.8 % of patients. A further 32.9 % of the scans were negative for PE but had other clinically significant findings. We found higher utilization rates in female and older patients (p 0.001), however, without corresponding differences in PE positivity rates compared to their male and younger counterparts. There was a high inter-physician variation in CTPA utilization rate (range 0.21-0.77 scans per 100 patients seen) and PE positivity rate (range 6.7-38.9 %). However, neither rates correlated with EP years of experience (p 0.15 with cut-offs at 5, 10, and 20 years post-residency), gender (p = 0.59), or training certification (p = 0.56 between EPs certified by the 5-year program of the Royal College of Physicians of Canada versus the 3-year program of the College of Family Physicians of Canada). Our study demonstrated considerable inter-physician variability in the utilization and PE positivity rates of CTPA. These results suggest an opportunity for a more standardized approach to the use of CTPA among EPs at our institution.

IN MODERN contact sports, any code of player conduct, and the officials administering such a code, face significant pressures. These include: These pressures mean that any sport's code of player conduct needs clearly defined objectives, and a degree of co-operation by participants, for it to operate smoothly. A consideration of the Code of Procedure, Proceedings for Misconduct of the National Rugby League (‘the Code’), and the operation of the judicial process contained in it provides a good opportunity to consider the choices made by the code of rugby league, the benefits available from those choices, and any sacrifices that have been made. The rules of the game of rugby league are comparatively straightforward. Partly because of this, the schedule of offences which a player can commit on the field is also comparatively straightforward. The game is controlled by three match …

Isolated reports have documented enhancement and/or enlargement of spinal nerve roots on magnetic resonance imaging (MRI) in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). This work examines those findings in a consecutive series of 16 patients with CIDP, with blinded comparison to MRI in 13 disease controls, including five patients with Charcot-Marie-Tooth disease type 1A. MRI sequences consisted of T1 weighted sagittal and axial views, before and after administration of gadolinium. Blinded MRI interpretation was performed independently by two neuroradiologists. MRI results were correlated with data collected from chart review. Enhancement of the cauda equina was seen in 11 of 16 CIDP patients (69%), and in none of 13 control subjects. Nerve roots were enlarged, most significantly in the extraforaminal region, in three CIDP patients, and in one patient with Charcot-Marie-Tooth type 1A. MRI findings did not correlate with disease activity and severity, nor with any clinical or laboratory features in patients with CIDP.

Background:Neurenteric cysts are rare spinal lesions of congenital origin. They usually present insidiously with a long history of local spinal pain, radiculopathy and myelopathy. We report a 14-year-old male with a high cervical neurenteric cyst who developed a progressive myelopathy after minor neck trauma. Full recovery followed a partial cyst excision and decompressive procedure.Significance and conclusion:The possible pathogenic mechanisms for this unusual presentation include hemorrhage into the cyst, sudden mechanical compression from abnormal spinal movement of a chronically distorted and compressed spinal cord, or an increase in the size of the cyst secondary to accumulation of cyst fluid. In this case a small increase in the cyst size may have resulted in increased mechanical distortion and spinal cord dysfunction on a compressive and ischemic basis.

Tissue levels of chlorinated dioxins and furans and the physiological and biochemical responses of fish were measured upstream and downstream of a bleached kraft mill in the St. Maurice River, Quebec. Relative to fish 10 km upstream of the source, white suckers (Catostomus commersoni) downstream showed evidence of chemical exposure, chemical metabolism, stress, and altered energy use. Levels of 2,3,7,8–tetrachlorodibenzo-p-dioxin and tetrachlorodibenzofuran in gutted whole fish averaged 23 and 260 pg/g immediately downstream of the plant and declined to 18 and 112 pg/g at 95 km downstream. The activity of hepatic aryl hydrocarbon hydroxylase (AHH) was 10X higher immediately downstream and 5X higher 95 km downstream. There were corresponding increases in relative liver size, hematocrit, serum glucose, serum protein, and fin-ray asymmetries, with a pattern of response that matched enzyme induction. These responses pointed to a strong effluent effect and followed the patterns of tissue contamination by dioxins and furans and of water contamination by chlorinated phenolics and guaiacols. There were strong correlations between AHH induction and tissue contamination. Whereas lipid levels increased at all downstream sites, condition factor decreased at 95 km from the source, indicating that there may be disturbances in energy metabolism. Effects on sexual maturation, as shown by levels of serum hormones and gonad somatic index, were inconclusive.

Aim: To determine in vivo whether the lateral geniculate nucleus (LGN) undergoes atrophy in patients with glaucoma and vision loss compared with normal subjects. Methods: Following institutional St Michael’s Hospital Research Ethics Board approval, a prospective and masked neuroimaging study was conducted on glaucoma patients with visual-field defects affecting both eyes (n = 10) and age-matched controls (n = 8). Following informed consent, all subjects underwent 1.5-Tesla MRI. Coronal proton density magnetic resonance images of both LGNs were obtained, and LGN height measurements were measured by consensus by three neuroradiologists masked to the diagnosis. Glaucoma and control groups were compared using the t test. Results: Both LGNs were identified and visualised by 1.5-Tesla MRI for every subject. Compared with controls, the mean LGN heights in glaucoma were decreased in right (4.09 (0.89) mm vs 4.74 (0.54) mm, p>0.05) and left LGNs (3.98 (0.57) mm vs 4.83 (0.95) mm; p = 0.033). The combined right and left LGN height in glaucoma was significantly decreased compared with controls (8.07 (1.06) mm vs 9.56 (0.86) mm; p = 0.005). Conclusion: In vivo MRI evidence of LGN degeneration in human glaucoma is consistent with ex vivo primate and human neuropathological studies. LGN atrophy may be a relevant biomarker of visual system injury and/or progression in some glaucoma patients.

Objective This report presents the 30-day results of the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial and evaluates the safety and efficacy of ENROUTE Transcarotid NPS (Silk Road Medical Inc, Sunnyvale, Calif), a novel transcarotid neuroprotection system that provides direct surgical common carotid access and cerebral embolic protection via high-rate flow reversal during carotid artery stenting (CAS). Methods A prospective, single-arm, multicenter clinical trial was performed to evaluate the use of the ENROUTE Transcarotid NPS during CAS procedures performed in patients considered to be at high risk for complications from carotid endarterectomy. Symptomatic patients with ≥50% stenosis and asymptomatic patients with ≥70% stenosis were eligible to be treated with any U.S. Food and Drug Administration-approved carotid artery stent. The primary end point was the composite of all stroke, myocardial infarction (MI), and death at 30 days postprocedure as defined in the Food and Drug Administration-approved study protocol. Secondary end points included cranial nerve injury; 30-day stroke, death, stroke/death, and MI; acute device, technical, and procedural success; and access site complications. All major adverse events were adjudicated by an independent clinical events committee. Results Between November 2012 and July 2014, 208 patients were enrolled at 18 sites. Sixty-seven patients were enrolled as lead-in cases, and 141 were enrolled in the pivotal phase. In the pivotal cohort, 26% were symptomatic and 75% were asymptomatic. Acute device and technical success were 99% (140 of 141). By hierarchical analysis, the all-stroke rate in the pivotal group was 1.4% (2 of 141), stroke and death was 2.8% (4 of 141), and stroke, death and MI was 3.5% (5 of 141). One patient (0.7%) experienced postoperative hoarseness from potential Xth cranial nerve injury, which completely resolved at the 6-month follow-up visit. Conclusions The results of the ROADSTER trial demonstrate that the use of the ENROUTE Transcarotid NPS is safe and effective at preventing stroke during CAS. The overall stroke rate of 1.4% is the lowest reported to date for any prospective, multicenter clinical trial of CAS.

Natalizumab, an anti-alpha4 integrin antibody, significantly reduces the number of visibly enhancing multiple sclerosis (MS) lesions. In this substudy of a 2-year trial of natalizumab monotherapy versus placebo, contrast-enhanced imaging investigated for subtle blood brain barrier (BBB) leakage in relapsing remitting (RRMS) patients, and whether such leakage is modified by natalizumab. After 24 weeks on treatment, 40 patients from 3 centres (27 on natalizumab and 13 on placebo) were studied. T1 weighted images were obtained before and at set timepoints up to 46 minutes after gadolinium (Gd)-DTPA (0.3 mmol/kg to 18 patients, 0.15 mmol/kg to 22). Paired regions of interest were placed around non-enhancing lesions and contralateral normal appearing white matter (NAWM). BBB leakage was inferred through post-Gd T1 weighted signal intensity (SI) change. SI change was greater in T2 non-enhancing lesions than paired NAWM at all timepoints (P0.005), indicating BBB leakage in lesions. No significant difference in inferred BBB leakage was observed between treatment arms as measured by SI change of lesions (P0.05 for all timepoints, joint test P=0.24), or in SI change of NAWM (joint test P=0.37). T1 hypointense and isointense lesions exhibited similar SI changes (joint test P=0.12). There is evidence of a subtle BBB leakage within visibly non-enhancing lesions in RRMS that was not modified by alpha4 integrin blockade in this substudy cohort.

Legionella pneumophila is an important cause of community-acquired pneumonia. Domestic sources of infection have been increasingly recognised among community-acquired cases. This report summarises the public health investigations and management of a single community-acquired case of Legionnaires' disease in Queensland, commenced in the context of a suspected outbreak. Legionellae from the case's domestic water supply were indistinguishable from the clinical isolate. The implications for future investigation of sporadic cases are discussed.

Selective internal radiation therapy (SIRT) with SIR-Spheres(R) is a new technique for selectively targeting high doses of radiation to tumours within the liver. The primary objectives of this randomised trial were to compare the response rate, time to progressive disease (PD), and toxicity of a regimen of systemic fluorouracil/leucovorin chemotherapy versus the same chemotherapy plus a single administration of SIR-Spheres in patients with advanced colorectal liver metastases. The trial was designed to presage a larger trial that would have survival as the primary outcome.Twenty-one patients with previously untreated advanced colorectal liver metastases, with or without extrahepatic metastases, were randomised into the study.Using RECIST criteria, the response rate for 11 patients receiving the combination treatment was significantly greater than for 10 patients receiving chemotherapy alone (First Integrated Response; 10 PR, 1 SD vs. 0 PR, 6 SD, 4 PD, P0.001 and Best Confirmed Response; 8 PR, 3 SD vs. 0 PR, 6 SD, 4 PD P0.001). The time to PD was greater for patients receiving the combination treatment (18.6 months vs. 3.6 months, P0.0005). Median survival was significantly longer for patients receiving the combination treatment (29.4 months vs. 12.8 months, P = 0.02). One patient in the combination arm died from chemotherapy induced neutropenic sepsis after the fourth chemotherapy cycle. There were more Grade 3 and 4 toxicity events in patients receiving the combination treatment. There was no difference in quality-of-life over a 3 month period between the two treatments when rated by patients (P = 0.96) or physicians (P = 0.98).This small phase 2 randomised trial demonstrated that the addition of a single administration of SIR-Spheres to a regimen of systemic fluorouracil/leucovorin chemotherapy significantly increased both treatment related response, time to PD, and survival with acceptable toxicity. The combination of SIR-Spheres plus systemic chemotherapy is now the subject of ongoing trials to further define patient benefit.

Rapid bioassessment (RBA) techniques for evaluating river health are now commonplace and there is much debate on the best methods that should be used. One of the important features of RBA is subsampling of large qualitative or semi-quantitative samples to reduce the costs associated with handling and identifying animals. In Australia, the Australian River Assessment System (known as “AusRivAS”) has been widely used since 1994 to monitor and assess river health. To test the efficacy of AusRivAS protocols, four live-sorting protocols, the standard Australian River Assessment Scheme (AusRivAS) and three suggested improvements, were evaluated in three habitat types and in clear and turbid rivers. The suggested improvements included using magnification during the live-sort process, separate sorting of coarse and fine fractions and increasing the amount of time or animals collected. There was no statistically significant difference between any of the trialed live-sort protocols in terms of the number of taxa collected compared to the number remaining, the community composition, the abundances of individual families collected, or the AusRivAS Observed/Expected taxa ratios. The lack of differences between the live-sort protocols suggests that technicians using the current standard AusRivAS protocols are able to effectively obtain a representative subsample of animals from the whole kick or sweep net qualitative sample. This has the advantage of cost savings because no retraining will be required, field procedures will remain uncomplicated and previous river health assessments will remain valid.

Neurotransmitter release is frequently regulated by peptides that modulate neuronal calcium channels. Whole-cell recordings show that the ion permeability and voltage dependence of these channels are controlled by a membrane-associated pathway involving GTP-binding proteins. Here we use perforated-patch recordings to show that, in addition to this pathway, the peptide somatostatin inhibits the calcium current in chick ciliary ganglion neurons by a second soluble pathway involving a cyclic GMP-dependent protein kinase (cGMP-PK). This somatostatin inhibition of Ca2+ current did not desensitize and was not characterized by the slowing of Ca(2+)-current activation (kinetic slowing) observed in whole-cell recordings. When cGMP-PK was inhibited, somatostatin inhibition of Ca2+ current resembled that observed with whole-cell recordings. cGMP agonists mimic the effect of somatostatin only in perforated patch recordings. An endogenous cGMP-PK therefore forms part of the mechanism by which somatostatin induces a sustained inhibition of neuronal calcium channels.