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Since a decade, convection-permitting regional climate models (CPRCM) have emerged showing promising results, especially in improving the simulation of precipitation extremes. In this article, the CPRCM CNRM-AROME developed at the Centre National de Recherches Météorologiques (CNRM) since a few years is described and evaluated using a 2.5-km 19-year long hindcast simulation over a large northwestern European domain using different observations through an added-value analysis in which a comparison with its driving 12-km RCM CNRM-ALADIN is performed. The evaluation is challenging due to the lack of high-quality observations at both high temporal and spatial resolutions. Thus, a high spatio-temporal observed gridded precipitation dataset was built from the collection of seven national datasets that helped the identification of added value in CNRM-AROME. The evaluation is based on a series of standard climatic features that include long-term means and mean annual cycles of precipitation and near-surface temperature where CNRM-AROME shows little improvements compared to CNRM-ALADIN. Additional indicators such as the summer diurnal cycle and indices of extreme precipitation show, on the contrary, a more realistic behaviour of the CNRM-AROME model. Moreover, the analysis of snow cover shows a clear added-value in the CNRM-AROME simulation, principally due to the improved description of the orography with the CPRCM high resolution. Additional analyses include the evaluation of incoming shortwave radiation, and cloud cover using satellite estimates. Overall, despite some systematic biases, the evaluation indicates that CNRM-AROME is a suitable CPRCM that is superior in many aspects to the RCM CNRM-ALADIN.

One challenge of contemporary medical education is that shorter lengths of stay and time-limited clerkships often interrupt a student’s relationship with a patient before a diagnosis is made or treatment is completed, limiting the learning experience. Medical students sometimes use electronic health records (EHRs) to overcome these limitations. EHRs provide access to patients’ future medical records, enabling students to track former patients across care venues to audit their diagnostic impressions and observe outcomes. While this activity has potential to improve clinical training, there is a risk of unintended harm to patients through loss of privacy. Students need guidance on how to perform this activity appropriately. This article describes an ethical framework for tracking using an “educational registry,” a list of former patients housed within the EHR that one follows longitudinally for educational purposes. Guiding principles include obtaining permission from patients, having legitimate educational intent, and restricting review of records to those essential for training. This framework could serve as a foundation for institutions seeking to develop a policy on tracking former patients, and may facilitate research on the use of EHRs to improve medical education, such as reducing diagnostic error and promoting self-directed learning.

Colleagues Unknown Generalists and specialists working within the same network increasingly don’t know each other. A secure system that aggregates professional feedback from colleagues — and that i...

Use of social networking sites (SNS) by medical students is increasing, and some students lack awareness of pitfalls arising from the intersection of social networking and medicine. Many institutions have developed guidelines on using SNS, but they are insufficient for students. Educators need new methods to train students on the appropriate use of this technology, but more information is needed before implementing change.Differences in SNS usage between students and faculty were examined. The goal was to evaluate four content areas: SNS usage patterns, attitudes regarding activity on SNS, experience with patient interactions online, and awareness of institutional guidelines on use of SNS.A cross-sectional survey took place at Feinberg School of Medicine, Northwestern University, in 2012. Participants included all students and a cohort of faculty who teach them in a class on professionalism.The response rate was 42% by students (300/711) and 78% by faculty (31/40). Of the students, 94% use SNS, compared to 48% of faculty. Students were more likely than faculty to display content they would not want patients to see (57% vs. 27%), report seeing inappropriate content on colleagues' SNS profiles (64% vs. 42%), and ignore harmful postings by colleagues (25% vs. 7%). Faculty were more likely than students to have been approached by patients on SNS (53% vs. 3%). Most participants were unlikely to conduct Internet searches on patients.Students are more likely than faculty to use SNS and use it very differently than faculty. Students would benefit from training on appropriate use of SNS. Topics that should be addressed include editing one's online presence, managing friend requests from patients, dealing with colleagues who post harmful content, conducting Internet searches on patients, and discussion of boundaries to identify potential harms associated with SNS usage. Differences in usage between students and faculty raise questions if faculty are well suited to provide this training.

[1] We determine the 3-D melt geometry of partially molten samples of olivine containing 1.6 and 3.6 vol.% of basaltic melt that were held in a piston cylinder apparatus at upper mantle conditions for 430 h. Our approach involves serial sectioning and high-resolution field emission SEM imaging. Resolution is such that melt pockets approaching ~30 nm in size were resolved while covering an area of ~300 by 230 µm. The principal result of this study is to show that thin layers (typically 100 nm or less in thickness) between adjacent grains observed in 2-D images persist with depth and are therefore wetted two-grain boundaries. Melt geometries most closely resembling triple junction tubules of the isotropic equilibrium model occur at all three-grain edges but are small compared to larger pockets. The wetted grain boundaries at a dihedral angle >0° for this system are inferred to be due to slow expulsion of melt from dynamically reorganizing grain boundaries during steady state grain growth. The attenuation peak observed in forced torsional oscillation experiments on similar samples is likely related to the wetted grain boundaries. Grain growth, driven by surface energy reduction, occurs also at the larger grain sizes expected for the mantle. This suggests the presence of wetted grain boundaries and significant velocity reduction and attenuation in partially molten upper mantle, as observed for example in back-arc basins.

Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.

To review 10-year outcomes of an alternative vesicourethral anastomotic technique performed after radical retropubic prostatectomy (RRP).With institutional review board approval, 307 consecutive RRPs performed by one surgeon (mean patient age, 63.5 years; range, 35 to 77 years) from November 1994 to December 2004 with an alternative anastomosis were reviewed. Cox proportional hazard models with forward selection were used to investigate associations with outcomes and operative parameters.Mean estimated blood loss (EBL) was 550 mL. Sixty-three patients (20.5%) required blood transfusion. Mean anastomotic time ranged from 8 to 22 minutes (median, 11 minutes). Nine patients (2.9%) required surgical drain for more than 2 days. A total of 246 patients were available for at least 1-year continence follow-up (mean, 51 months). Of these, 160 patients (65.0%) never leaked or required a pad at point of last follow-up; 25 patients (10.2%) required 1 non-insurance pad or more per day. Only 3 patients (1.2%) have had incontinence interventions (one artificial sphincter and two collagen injections). Operative parameters statistically associated with wearing 1 pad per day or more were EBL (P = 0.035) and time to continence (P0.001). Forty-three patients (17.5%) required stricture dilation, with a mean time to intervention of 6 months (range, 1 to 33 months). No patient required incision of bladder neck contracture. The only statistically associated factors with stricture formation were increased age and increased EBL.The alternative anastomotic technique is efficient and provides proper urethral alignment with a minimal rate of prolonged urinary extravasation. Long-term urinary continence is excellent, and stricture rates are acceptable compared with other anastomotic techniques.

To analyze the perioperative safety and outcomes of the first 100 robotic-assisted radical prostatectomies (RARPs) performed by a resident trained surgeon entering directly into practice.Following a mentorship-based urology residency training program, the perioperative safety and outcomes of 100 consecutive RARPs were analyzed. Intraoperative complications, surgical pathology results, hospital course, and catheter removal times were all monitored. Urinary catheter time was considered prolonged if left in place for longer than 14 days. Surgical complications were scored using the Clavien grading system.The resident performed portions of 51 RARPs during the training program in resident years 2-5, including 17 as a chief resident under the guidance of a fellowship-trained robotic surgeon. One hundred RARPs were performed following residency training over a 17-month period (mean age, 60 years; mean body mass index, 29 kg/m(2)). Positive margin rate was 21%, and blood transfusion rate was 5%. Clavien grade 1-4 complication rates were 5%, 9%, 1%, and 1%, respectively. There was one intraoperative rectal injury and one conversion to an open operation. Five percent of patients required a urinary catheter longer than 14 days secondary to anastomotic leakage. There were no re-admissions or re-operations in the series.The current study serves as a benchmark for physicians entering practice directly from resident training. Mentorship-based residency programs and early console experience may be factors in contributing to perioperative safety and outcomes with newly trained physicians.

The optimal method of vesico-vaginal fistula (VVF) repair remains undetermined. Almost all previous descriptions of laparoscopic/robotic fistula repair involve utilizing a vertical cystotomy to identify the fisula. Avoidance of an intravesical approach to vesico-vaginal fistula repair may decrease patient morbidity. Patient selection, patient positioning, fistula recognition, port placement, intra-operative dissection techniques, flap formation, and repair are outlined in this video of robotic repair of vesico-vaginal fistula utilizing an extravesical approach. The extravesical robotic repair has been successfully utilized in two patients with VVF following hysterectomy. This manuscript and video demonstrates that vesico-vaginal fistulae can be repaired with a robotic assisted extravesical approach avoiding the morbidity of a large cystotomy.

The Habib 4 × radiofrequency-assisted bipolar hemostatic device (AngioDynamics) was used during select open partial nephrectomies to minimize blood loss and prevent warm renal ischemia. The article and video demonstrate this novel technique for partial nephrectomies in select renal masses.Patients with large renal tumors requiring partial nephrectomy where avoidance of warm ischemia was deemed imperative underwent open partial nephrectomy at our institution utilizing the Habib 4 × radiofrequency ablation device to avoid prolonged warm ischemia time and prevent blood loss.We have used the device successfully in 4 partial nephrectomies (2 patients with solitary kidneys, 2 patients with bilateral large masses). The mean age was 65 years. Mean tumor size was 6.4 cm. All tumors were located either in the upper pole or lower pole of the kidney. Mean hospital stay was 4.6 days. No patient received an intraoperative blood transfusion. Two patients required long-term ureteral stenting and surgical drainage for urine leakage.Bipolar radiofrequency ablation offers avoidance of hilar clamping in carefully selected large partial nehrectomies.

Objectives To complete a prospective evaluation of serum amylase and lipase levels before and after shock wave lithotripsy (SWL) for renal stones. We also compared these serum levels to those of patients undergoing percutaneous and ureteroscopic stone surgery. SWL injury to the pancreas should be noted by an increase in serum amylase and lipase. Methods A prospective evaluation of 38 patients (16 who underwent SWL, 15 who underwent percutaneous nephrostolithotomy, and 7 who underwent ureteroscopic stone manipulation) who underwent treatment of renal calculi at our institution was completed. The control group was the combined group of patients who had undergone percutaneous nephrostolithotomy or ureteroscopic stone manipulation. The serum amylase and lipase levels were measured before the procedure, immediately after the procedure (2 hours), and ≥30 days after the procedure. Results No statistically significant difference was found in the change from before to immediately after the procedure between the SWL group and the controls in amylase (median decrease 6 U/L vs 11 U/L, P = .45) or lipase (median decrease 4 U/L vs 9 U/L, P = .31). Also, no statistically significant evidence was seen in the change from before to >30 days after the procedure between the SWL group and controls in the amylase level (median increase 0 U/L vs 2 U/L, P = 1.00) or lipase (median change 2 U/L increase vs 1 U/L decrease, P = .96). Conclusions SWL does not appear to noticeably increase the serum amylase and lipase level directly postoperatively or >30 days after the procedure compared with baseline or compared with the controls.

Some areas, mainly located in the Southeastern part of France, are characterized by a high seismicity, and the French regulation is rapidly evolving to cope in a satisfactory way with such a major risk. Suitable construction rules to handle various seismic risk levels have been enacted since 1969, and recently simplified measures have been proposed to ensure the protection of detached houses. Straightforward recommendations known as technical solutions, avoiding complex computations, provide an efficient framework adapted to widen the correct use of the techniques contributing to a satisfactory construction design in good compliance with compulsory legal requirements. An intelligent software was devised to ease a step by step computer assisted design process, and to check the correctness of the final construction proposal with regards to constraints arising from the regulation. We describe the cognitive model taking in charge the formal representation of the many entities involved, we present the software implementation accounting for the complex network of inter-dependent concepts, and finally explain the reasoning policies used to provide the system with intelligent capabilities. A short summary of the possible results is reviewed including the labelling of the task-based reasoning path with solutions corresponding to the correction of faulty dispositions, and concluding with a comprehensive report on the project submitted, bringing for each rule fired the analysis of the alleged configuration recognized.

Although there are empiric data to show that obesity is not a contraindication for laparoscopic radical nephrectomy, similar data are lacking for the use of hand-assisted laparoscopic radical nephrectomy (HALRN) in obese patients. We evaluate whether obese patients undergoing HALRN to manage a renal mass are more likely than nonobese patients to experience poor intraoperative and perioperative outcomes.Between June 1, 1999, and May 31, 2006, 150 patients underwent HALRN for the management of a solid renal mass at our institution. We abstracted detailed demographic, clinical, and follow-up data on all patients in this cohort. As our primary analysis, we evaluated associations between body mass index (BMI) and estimated blood loss, operative time, length of stay, and complications using linear and logistic regression models.There was no evidence that obese patients experienced a statistically significant or clinically relevant increase in blood loss (P = 0.97), operative times (P = 0.87) or length of stay (P = 0.62) compared with persons of normal weight. In contrast, although there was no evidence of a linear trend toward complications in patients with a higher BMI (P = 0.19), obese patients were almost three times more likely to experience a complication compared with normal-weight persons (odds ratio: 2.88; 95% confidence interval: 1.01-8.16). Adjusting for relevant clinical covariates individually did not markedly alter these associations.Obesity is not a contraindication for HALRN to manage a renal mass; however, obese patients should be aware that they may be at increased risk for certain complications after surgery, notably ileus and incisional hernias.

Objectives To prospectively investigate whether vardenafil can effectively treat patients for whom sildenafil (100 mg) has failed. The introduction of two new oral phosphodiesterase type 5 inhibitors (tadalafil and vardenafil) raises the question of whether the new agents will permit us to treat sildenafil nonresponders with another oral agent. Methods Patients were seen at one institution during a 5-year period. A total of 327 patients complaining of sildenafil-refractory erectile dysfunction underwent intracavernous pharmacologic injection and color duplex Doppler ultrasonography. Subsequently 59 of these men tried vardenafil home dosing. Results Of the 327 men in whom sildenafil failed, 16% were younger than 50, 21% were 51 to 60, 34% were 61 to 70, and 28% were older than 70 years. The Doppler diagnoses were arterial insufficiency in 154 (47%), mixed vascular insufficiency in 73 (22%), and cavernous venous occlusive disease in 57 (17%). Forty-three men (13%) had normal erectile responses to prostaglandin E1 (10 to 20 μg). Of the 59 men who tried vardenafil, 19% were younger than 50, 17% were 51 to 60, 40% were 61 to 70, and 23% were older than 70 years. The Doppler diagnoses were arterial insufficiency in 28 (42%), mixed vascular insufficiency in 10 (19%), and cavernous venous occlusive disease in 15 (29%). Six men (8%) had normal erectile responses to prostaglandin E1. Only 7 (12%) of the 59 men reported that home vardenafil dosing resulted in successful intercourse. Conclusions An appropriate diagnostic evaluation and subsequent treatment algorithm have yet to be established for those for whom phosphodiesterase type 5 inhibitors fail. We found that most sildenafil nonresponders had severe arterial insufficiency and were older, with 62% older than 60 years. Our preliminary experience suggests that only a small percentage (12%) of sildenafil nonresponders can be salvaged with vardenafil.

Dans cette etude, on s’interesse a la tenue de l’assemblage de l’Ag-SnO2 sur un support en cuivre. Aucune brasure n’est utilisee. L’assemblage est realise en meme temps que l’operation de frittage de l’ Ag-SnO2 , par soudage diffusion en phase solide. Le but de ces travaux est de caracteriser et de modeliser l’operation d’assemblage. Ce qui constitue l’etape ultime de construction de developpement du modele macroscopique de frittage-assemblage. Pour ceci, des essais interrompus a differentes temperatures, pour differentes cinetiques thermiques ont ete realises afin de mettre en evidence l’effet du temps et de la temperature sur la tenue de l’assemblage. Des tests de cisaillement ont ete effectues a posteriori sur les assemblages obtenus afin d’en caracteriser la tenue. L’exploitation de ces tests a permis de definir un observable et d’etablir un critere de tenue de l’assemblage. Un modele de prediction de la tenue de la liaison a ainsi pu etre mis en place et valide.

In this study we examine a case study of a carve-out for mental health and substance abuse services between a local plan of a national HMO (N=120,213) and a local managed behavioral health care vendor (MBHC). This is one of the first studies which estimates the impact of an HMO carve-out on costs and patterns of MH/SA care. Three years of insurance claims data (1993-1995) were used for the analyses, with a new carve-out contract implemented in May 1994. The new carve-out arrangement included a new vendor, a change in the organizational structure of clinical services, and increased financial risk to the vendor for inpatient care. Descriptive and empirical analyses are reported on a continuously enrolled population (N=49,529). Results from the analyses showed the new carve-out arrangements had a significant impact on spending and utilization of services. Enrollees were 20% less likely to use MH/SA services after the implementation of the new carve-out, and inpatient MH/SA utilization dropped 50% under the new carve-out. Overall, MH/SA spending per enrollee dropped from approximately $4.90 per month to $2.20 per month. Outpatient MH/SA spending per user dropped 35% after the implementation of the new carve-out. Further research should be conducted to evaluate the impact on access and quality of care, given the substantial decrease in utilization and spending.

In this study we examine a case study of a carve-out for mental health and substance abuse services between a local plan of a national HMO (N=120,213) and a local managed behavioral health care vendor (MBHC). This is one of the first studies which estimates the impact of an HMO carve-out on costs and patterns of MH/SA care. Three years of insurance claims data (1993-1995) were used for the analyses, with a new carve-out contract implemented in May 1994. The new carve-out arrangement included a new vendor, a change in the organizational structure of clinical services, and increased financial risk to the vendor for inpatient care. Descriptive and empirical analyses are reported on a continuously enrolled population (N=49,529). Results from the analyses showed the new carve-out arrangements had a significant impact on spending and utilization of services. Enrollees were 20% less likely to use MH/SA services after the implementation of the new carve-out, and inpatient MH/SA utilization dropped 50% under the new carve-out. Overall, MH/SA spending per enrollee dropped from approximately $4.90 per month to $2.20 per month. Outpatient MH/SA spending per user dropped 35% after the implementation of the new carve-out. Further research should be conducted to evaluate the impact on access and quality of care, given the substantial decrease in utilization and spending.

It is misleading to divide human actions into 'art', 'science', or 'technology, for the artist has something of the scientist in him, and the engineer of both, and the very meaning of these terms varies with time so that analysis can easily degenerate into semantics. Nevertheless, one man may be mainly motivated by a desire to promote utility, while others may seek intellectual understanding or aesthetic experience. The study of interplay among these is not only interesting but is necessary for suggesting routes out of our present social confusion.

A double-blind, controlled trial of levamisole in the prevention and treatment of recurrent cold sores was performed. Forty-eight subjects received levamisole in a dosage of 2.5 mg/kg on two consecutive days each week for six months. The 51 control subjects were given a placebo identical to the drug in appearance. Both groups were given the same instructions. Nineteen subjects receiving levamisole and eight receiving placebo withdrew during the six months of the study. There were no significant differences between the levamisole-treated and control groups in the duration or severity of the lesions during the trial period or in the subjective assessment of drug efficacy by the participants at the end of the trial. Before treatment the frequency of lesions in the levamisole group was higher than in the control group. Only when this factor was taken into account by analysis of covariance did the decreased frequency of lesions during therapy appear significantly lower in the group receiving levamisole than in the placebo group. The difference remained clinically unimpressive. This study does not support earlier suggestions that levamisole, in these doses, is useful in the treatment of recrudescent circumoral herpesvirus infections.

We develop a representation for the topological structure of subdivided manifolds (with and without boundary) of dimension d ≥ 1 which allows straightforward access of the available order information. It is shown that there exists a large amount of ordering information in subdivided manifolds: given a (k-2)-cell in the boundary of a (k+1)-cell, 1 ≤ k ≤ d, all of the k- and (k-1)-cells 'between them' can be ordered 'around' the (k-2)-cell. This includes the usual orderings in 2- and 3-dimensional objects. We introduce the 'cell-tuple structure', a simple, uniform representation of the incidence and ordering information in a subdivided manifold. It includes the quad-edge data structure of Guibas and Stolfi [GS 85] and the facet-edge data structure of Dobkin and Laszlo [DL 87] as special cases in dimensions 2 and 3, respectively.

Pre- and post transplant sera from 51 cases of bone marrow transplants performed for severe aplastic anemia were tested on monocytes (M) and corresponding B cells (B) from a panel of unrelated donors. One-third of the sera were cytotoxic for B and M either from different or from the same individuals, while 45% reacted only to M and appeared to recognize non-HLA M-associated antigens. No significant reaction to endothelial cells was obtained from these sera. The subsequent clinical course was not associated with any reaction pattern of pre-transplant sera. There was a significant relationship between rejection and the development of M antibodies after grafting, but since these were also found in many other patients without rejection, their occurrence has no predictive value for an individual patient.