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Splenectomy is often required in the pediatric population as part of the treatment of hematologic disorders and can be performed laparoscopically or open. We evaluated the comparative effectiveness of laparoscopic (LS) and open (OS) splenectomies using the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) data set.The NSQIP-P data set was used to identify children who underwent elective splenectomy between January 2012 and December 2016. Thirty-day outcomes between OS and LS, and LS alone and concurrent LS and cholecystectomy were compared using univariate and multivariate analysis.Most of the splenectomies (91%) were performed laparoscopically. There was no difference in overall complications between OS (n = 60) and LS (n = 613), although OS had a higher risk of perioperative transfusion (OR 3.19, 95% CI 1.52-6.69). LS was associated with a shorter median hospital length of stay (2 versus 4 d, P 0.001) and similar mean operative times compared to OS (120 versus 133 min, P = 0.559). There was no difference in outcomes of children undergoing LS versus LS and concurrent cholecystectomy (n = 129).LS has become the standard approach for elective splenectomies in the pediatric population and has minimal morbidity, and when indicated, concurrent cholecystectomies do not increase the risk of complications.III.

BACKGROUND. The small bowel and pancreas are the most common primary sites of neuroendocrine tumors (NETs) giving rise to metastatic disease. Some patients with small bowel NETs (SBNETs) present with synchronous or metachronous pancreatic NETs (PNETs), and it is unclear whether these are separate primaries or metastases from one site to the other. METHODS. A surgical NET database including patients undergoing operations for SBNETs or PNETs was reviewed. Patients with synchronous or metachronous tumors in both the small bowel and pancreas were identified, and available tissues from primary tumors and metastases were examined using a 4-gene quantitative polymerase chain reaction (qPCR) and immunohistochemistry (IHC) panel developed for evaluating NETs of unknown primary. RESULTS. Of 338 patients undergoing exploration, 11 had NETs in both the small bowel and pancreas. Tissues from 11 small bowel tumors, 9 pancreatic tumors, and 10 metastases were analyzed. qPCR and IHC data revealed that three patients had separate SBNET and PNET primaries, and five patients had SBNETs that metastasized to the pancreas. Pancreatic tissue was unavailable in two patients, and qPCR and IHC gave discrepant results in one patient. CONCLUSIONS. NETs in both the small bowel and pancreas were found in 3% of our patients. In nearly two-thirds of evaluable patients, the pancreatic tumor was a metastasis from the SBNET primary, while in the remaining one-third of patients it represented a separate primary. Determining the origin of these tumors can help guide the choice of systemic therapy and surgical management.

Die eosinophile Gastroenteropathie ist eine allergengetriggerte, immunvermittelte, lokal-entzundliche Erkrankung des oberen und unteren Gastrointestinaltrakts, die immer haufiger bereits im Kindes- und Jugendalter diagnostiziert wird. Erweist sich die Erkrankung als therapierefraktar gegenuber gangigen Behandlungsoptionen, kann dies zu einer erheblichen Einschrankung der Lebensqualitat fuhren. Im Rahmen eines „case report“ wird uber die erste erfolgreiche Behandlung mit Dupilumab bei einem 16-jahrigen Jugendlichen mit bisher therapierefraktarer eosinophiler Gastroenteropathie berichtet.

BACKGROUND: Cytoreductive surgery for neuroendocrine tumor liver metastases improves survival and symptomatic control. However, the feasibility of adequate cytoreduction in patients with many liver metastases remains uncertain. We compared patient outcomes based on the number of lesions treated to better define the efficacy of cytoreductive surgery for numerous neuroendocrine tumor liver metastases. METHODS: Patients undergoing hepatic cytoreductive surgery for gastroenteropancreatic neuroendocrine tumors were identified in our institutional surgical neuroendocrine tumor database. Imaging studies were reviewed to determine the liver tumor burden and percent cytoreduced. Overall survival and progressionfree survival were compared, using the number of lesions treated, percent tumor debulked, and additional clinicopathologic characteristics. RESULTS: A total of 188 hepatic cytoreductive procedures were identified and stratified into groups according to the number of metastases treated: 1–5, 6–10, and >10. Median overall survival and progressionfree survival were 89.4 and 22.5 months, respectively, and did not differ significantly between groups. Greater than 70% cytoreduction was associated with significantly better overall survival than 70% cytoreduction led to improved overall survival and progression-free survival and was achieved reliably in patients undergoing debulking of > 10 lesions. These data support an aggressive approach to patients with numerous neuroendocrine tumor liver metastases to achieve >70% cytoreduction.

The occurrence of typhoon Herb in 1996 caused massive landslides in the Shenmu area of Taiwan. Many people died and stream and river beds were covered by meters of debris. Debris flows almost always take place in the Shenmu area during the flood season, especially in the catchment areas around Tsushui river and Aiyuzih river. Anthropogenic and natural factors that cause debris flow occurrences are complex and numerous. The precise conditions of initiation are difficult to be identified, but three factors are generally considered to be the most important ones, i.e. rainfall characteristics, geologic conditions and topography. This study proposes a simple and feasible process that combines remote sensing technology and multi-stage high-precision DTMs from aerial orthoimages and airborne LiDAR with field surveys to establish a connection between three major occurrence factors that trigger debris flows in the Shenmu area.

BACKGROUND: The small bowel (SB) is the most common site of neuroendocrine tumors (NETs) of the GI tract. These are described as being predominantly jejunoileal, but their exact locations within the SB have not been well defined. We sought to determine prospectively the spectrum of SBNET locations. METHODS: Patients undergoing exploration for SBNET primaries had measurement of bowel length, tumor locations, and resection length recorded. Correlations of clinicopathologic factors were performed, and analysis done utilizing Welch’s t test, Chi square test, and the Kaplan-Meier method. RESULTS: Measurements were recorded in 123 patients, 107 of whom had complete information. Multifocal tumors (MTs) were found in 69 (56%) and unifocal (UTs) in 54 (44%) patients. Only 1 of 107 patients had a tumor within 100 cm of the ligament of Treitz (LT), whereas 77 of 107 (72%) had tumors within 100 cm of the ileocecal valve (ICV). No MTs were found within 100 cm of LT, whereas 41 of 60 (68%) patients had all (10) or at least one tumor (31) located within 100 cm of the ICV. MTs required a mean resection length of 108 versus 59 cm for UTs (p < 0.01). Seventy-seven percent of UTs (36/47) were within 100 cm of ICV. Tumors occurring only between > 100 cm from the LT and ICV were seen in 29 of 107 (27%) patients. CONCLUSIONS: SBNETs are frequently multifocal and most commonly located within 100 cm of the ICV. SBNETs are less prevalent proximally in the small bowel, which may result from anatomic differences in enterochromaffin cell density, hormonal factors, or environmental exposures in the distal SB.

Despite the relatively indolent course of neuroendocrine tumor (NETs), the incidence of NET liver metastases (NETLMs) is relatively common in patients with NETs. The surgical approach to NETLMs is based upon proper patient selection, the distribution of lesions, percent of liver replacement, and the ability to achieve significant cytoreduction. Goals of therapy are symptom improvement, as well as increased progression-free and overall survival. While other modalities such as systemic therapy, embolic approaches, and peptide receptor radionuclide therapy (PRRT) may slow progression and occasionally show objective responses, surgical debulking leads to the most immediate and potentially substantive reduction in tumor volume.

Objectives Many patients with small bowel neuroendocrine tumors (SBNETs) have multifocal tumors (MFTs), but the frequency of MFTs has varied widely across SBNET studies. It is also unclear whether patients with MFTs have more advanced disease or worse clinical course than do those with unifocal SBNETs. We set out to determine the frequency of multifocal and unifocal SBNETs and compare clinicopathologic factors, somatostatin receptor 2 expression, and survival. Methods Clinicopathologic variables from 179 patients with surgically managed SBNETs were collected. Statistical comparisons were made using Welch t-test, Wilcoxon test, and Fisher's exact test. Survival was assessed using the Kaplan-Meier method. Somatostatin receptor 2 expression was analyzed by quantitative polymerase chain reaction, and Ki-67 expression by immunohistochemistry. Results Multifocal tumors were found in 45% of patients with SBNETs. Clinicopathologic factors such as grade, TNM stage, presence of distant metastases, mean somatostatin receptor 2 expression, success of imaging modalities, and preoperative and postoperative hormone levels were not significantly different between multifocal and unifocal groups. Progression-free survival and overall survival were also not significantly affected by multifocality. Conclusions Clinicopathologic features and survival of patients with MFTs and unifocal tumors are remarkably similar. Although the etiology of MFTs is unclear, patients with MFTs do not have a more aggressive clinical course than patients with unifocal SBNETs.

Tumor grade is an important predictor of survival in gastroenteropancreatic (GEP) neuroendocrine tumors (NETs), as determined by Ki-67 expression and mitotic rate. NETs generally grow indolently, but some cells may acquire traits facilitating metastasis. It is unclear how frequently metastases differ in grade from their primary tumors, and whether increasing grade in metastases affects prognosis. Ki-67 immunohistochemistry was performed on resected GEPNET specimens and cases with results for both primary tumors and concurrent metastases were identified. Grade was determined using a modified World Health Organization classification (Ki-67: G1 = 0–2%; G2 > 2–20%; G3 > 20%). Ki-67 was performed on both the primary tumor and metastases in 103 patients. Tumor grade was higher in metastases from 25 (24%) patients, 24 increased from G1 to G2, and 1 increased from G2 to G3; 68 (66%) patients had no change in grade (42 G1 and 26 G2), and 10 (10%) decreased from G2 to G1. No clinicopathologic factors were predictive of higher grade in metastases. The 5-year progression-free survival (PFS) was 55% for patients with stable grade versus 8% of patients with increased grade, while 5-year overall survival (OS) was 92 and 54%, respectively. The 5-year OS of patients who had stable grade with G1 and G2 primaries was 92 and 64%, respectively. Nearly one-third of patients had metastases with a different grade than their primary, and, when grade increased, both PFS and OS significantly decreased. Determining the grade in both the primary tumor and a metastasis is important for estimating prognosis and to help inform decisions regarding additional therapies.

Background Small bowel neuroendocrine tumors (SBNETs) present frequently with metastases, yet little is known about the molecular basis of this progression. This study sought to identify the serial differential expression of genes between normal small bowel, primary small bowel neuroendocrine tumors, and liver metastases. Methods RNA isolated from matched normal small bowel tissue, primary small bowel neuroendocrine tumors, and liver metastases in 12 patients was analyzed with whole transcriptome expression microarrays and RNA-Seq. Changes in gene expression between primary small bowel neuroendocrine tumors and normal small bowels, and liver metastases versus primary small bowel neuroendocrine tumors were calculated. Common genes that were differentially expressed serially (increasing or decreasing from normal small bowel to primary small bowel neuroendocrine tumors to liver metastases) were identified, and 10 were validated using qPCR. Results Use of 2 transcriptome platforms allowed for a robust discrimination of genes important in small bowel neuroendocrine tumors progression. Serial differential expression was validated in 7/10 genes, all of which had been described previously in abdominal cancers, and with several interacting with members of the AKT, MYC, or MAPK3 pathways. Liver metastases had consistent underexpression of PMP22, while high expression of SERPINA10 and SYT13 was characteristic of both pSBTs and liver metastases. Conclusion Identification of the serial differential expression of genes from normal tissues to primary tumors to metastases lends insight into important pathways for SBNETs progression. Differential expression of various genes, including PMP22, SYT13 and SERPINA10, are associated with the progression of SBNETs and warrant further investigation.

Aim Eighty per cent of patients with Crohn’s disease require surgery, of whom 70% will require a further operation. Recurrence occurs at the anastomosis. Although often recommended, the impact of postoperative colonoscopy and treatment adjustment is unknown. Method Patients with a bowel resection over a 10-year period were reviewed and comparison made between those who did and did not have a postoperative colonoscopy within 1 year of surgery, and those who did or did not have a step-up in drug therapy. Results Of 222 patients operated on, 136 (65 men, mean age 33 years, mean disease duration 8 years, median follow-up 4 years) were studied. Of 70 patients with and 66 without postoperative colonoscopy, clinical recurrence occurred in 49% and 48% (NS) and further surgery in 9% and 5% (NS). Eighty-nine per cent of colonoscoped patients had a decision based on the colonoscopic findings: of these, 24% had a step-up of drug therapy [antibiotics (n = 10), aminosalicylates (n = 2), thiopurine (n = 5), methotrexate (n = 1)] and 76% had no step-up in drug therapy. In colonoscoped patients clinical recurrence occurred in 9 (60%) of 15 patients with, and 23 (49%) of 47 without step-up and surgical recurrence in 2 (13%) of 15 and 4 (9%) of 47 (NS). Conclusion Clinical recurrence occurs in a majority of patients soon after surgery. In this cohort, there was no clinical benefit from colonoscopy or increased drug therapy within 1 year after operation. However, the response to the endoscopic findings was not standardized and immunosuppressive therapy was uncommon. Standardizing timing of colonoscopy and drug therapy, including more intense therapy, may improve outcome, although this remains to be proven.

Patients with gastroenteropancreatic neuroendocrine tumors often present with metastases. Identification of the primary tumor is important for operative management, and therefore we sought to determine our success at identifying primary tumors with diagnostic testing and operative exploration.A clinical neuroendocrine tumor database was reviewed to identify patients presenting with metastases and primary tumor in situ. Results of radiologic, endoscopic, and operative procedures were evaluated to determine which correctly identified the primary tumor.There were 197 patients presenting with metastases and unresected primaries, 134 who had an operation and 63 managed nonoperatively. Primaries were identified preoperatively in 168 (84%), at operative exploration in 7, and were not found in 22 patients. Computed tomography found 150/197 primary tumors, somatostatin-receptor scintigraphy 88/155, and endoscopy 43/107. The sensitivity of computed tomography surpassed scintigraphy (76% vs 57%, P .01). The primary was removed in 130/134 (97%) patients, and hepatic debulking was performed in 67%. Median survival for operative patients with small bowel and pancreatic tumors was 145 and 71 months, respectively.Imaging and endoscopy identified the primary tumor in most patients, and the majority of the others were found at exploration. Preoperative testing facilitated operative planning, allowing for resection of the primary and hepatic debulking in most patients.

Background Surgical complications after resection for locally advanced rectal cancer may influence adjuvant treatment outcomes and survival. Few studies have examined this effect. Objective This study aimed to examine the impact of surgical complications on adjuvant therapy delivery and survival in patients with locally advanced rectal cancer treated with long-course chemoradiation followed by surgery. Design This is a retrospective analysis of a prospectively collected multicenter colorectal cancer database. Settings Data were collected from the Australian Comprehensive Cancer Outcomes and Research Database. Patients All patients who completed neoadjuvant chemoradiotherapy followed by surgery for locally advanced rectal cancer between January 2003 and December 2014 were selected. Main outcome measures We examined the types and frequency of surgical complications and their impact on the delivery of adjuvant chemotherapy and survival. Results Data were available for 517 patients, of whom 147 (28%) had a surgical complication. Patients with a surgical complication were less likely to commence adjuvant chemotherapy (33% vs 66%; p = 0.0005) and more likely to have adjuvant treatment commencing more than 8 weeks from surgery (71.8% vs 21.2%; p = 0.004). Wound-related complications (p = 0.001), return to operating theater (p = 0.004), and readmission within 30 days (p = 0.02) had the most significant negative impact on the delivery of adjuvant chemotherapy. Surgical complications were significantly more likely in males (31.6% vs 20.8%, p = 0.003) and laparoscopic converted cases (47.8% vs 21.8%, p = 0.03). For the entire patient population, adjuvant chemotherapy compared with surveillance was not associated with an improved recurrence-free survival (HR, 1.06; p = 0.83) but was associated with an improved overall survival (HR, 0.53; p = 0.04). Limitations This study was limited by its retrospective design. Conclusion Surgical complications in patients having surgery following neoadjuvant chemoradiotherapy for locally advanced rectal cancer were associated with significantly reduced uptake and delays to receiving adjuvant therapy. Surgical complications, however, were not associated with either significantly reduced recurrence-free or overall survival. Adjuvant chemotherapy delivery was associated with improved overall survival.

PURPOSE: Mesenteric embolization is an established treatment for lower gastrointestinal bleeding. The aim of this study was to determine the outcome of angiography and embolization and its influencing factors. METHODS: A prospective database of all mesenteric angiograms performed for lower gastrointestinal bleeding at a tertiary center between 1998 and 2008 was analyzed in combination with chart review. RESULTS: There were 107 angiograms performed during 83 episodes of lower gastrointestinal bleeding in 78 patients. Active bleeding was identified in 40 episodes (48%), and embolizations were performed in 37 (45%). One patient without active bleeding on angiogram also underwent embolization, making a total of 38 embolizations. Overall mortality was 7% with 4 deaths due to rebleeding and 2 deaths due to a medical comorbidity (respiratory failure, pneumonia). Short-term complications of angiography were false aneurysm (1 patient) and Enterobacter sepsis (1 patient). Long-term complications were groin lymphocele (1 patient) and late rebleed from collateralization (1 patient). In 43 episodes, angiography did not demonstrate active bleeding. Twelve (28%) of these patients continued to bleed, 9 of whom had successful surgery. Of the 38 patients who had embolizations, all had immediate cessation of bleeding. Nine patients (24%) later rebled; 5 of these patients required surgery and 3 had reembolizations. Of the 3 patients who underwent reembolization, 2 developed ischemic bowel and 1 stopped bleeding; surgery was required in 1 patient. CONCLUSIONS: Mesenteric angiography for lower gastrointestinal bleeding effectively identifies the site of bleeding in 48% of patients and allows embolization in 45%. Embolization achieves clinical success in 76% of patients but repeat embolization is associated with a high rate of complications.

Der Einfluss der Positronenemissionstomographie in der Behandlung des rezidivierenden Rektumkarzinoms steht fest; ihre Rolle bei der Behandlung des primaren Rektumkarzinoms bleibt jedoch ungeklart. Die vorliegende Untersuchung soll daher die Auswirkungen eines Scannings mittels Positronenemissionstomographie auf die Behandlung des primaren Rektumkarzinoms prospektiv bewerten. 46 Patienten mit fortgeschrittenem primaren Rektumkarzinom, bei denen eine adjuvante praoperative Therapie in Betracht gezogen wurde, unterzogen sich einem Scanning mittels Positronenemissionstomographie. Die uberweisenden Arzte zeichneten prospektiv das Stadium jedes einzelnen Patienten nach konventionellen bildgebenden Verfahren sowie den vorgeschlagenen Behandlungsplan vor dem Scanning mittels Positronenemissionstomographie auf. Dies wurde dann mit dem in der Folge eruierten genauen Stadium und der tatsachlich durchgefuhrten Behandlung verglichen; die Genauigkeit der mit Positronenemissionstomographie eruierten Veranderungen wurde in der anschliesenden klinischen Nachuntersuchung festgelegt. Die operative Behandlung von 36 der 46 Patienten (78%) blieb als Ergebnis der Positronenemissionstomographie unverandert, auch wenn die Positronenemissionstomographie das Erkrankungsstadium bei drei dieser 36 Patienten (8%) hoher und bei funf von 36 Patienten (14%) niedriger einstufte. In acht von 46 Fallen (17%) wurde die Behandlung aufgrund der Befunde der Positronenemissionstomographie verandert; dazu gehorten sechs Patienten (13%), bei denen die Operation abgesagt wurde, und zwei weitere Falle (4%), bei denen das Bestrahlungsfeld verandert wurde. Wenn vorhanden, bestatigte die Nachuntersuchung die Zweckmasigkeit der durch die Positronenemissionstomographie induzierten Behandlungsanderung in jedem einzelnen Fall. Bei zwei Patienten wurde die Therapie unabhangig von der Positronenemissionstomographie aufgrund klinischer Umstande geandert. Das Gesamttumorstadium wurde bei 18 der 46 Patienten (39%) nach der Positronenemissionstomographie berichtigt. Ein Scanning mittels Positronenemissionstomographie scheint bei einem Drittel der Patienten mit fortgeschrittenem primaren Rektumkarzinom eine Korrektur des Tumorstadiums bzw. eine Anpassung der Therapie zu ermoglichen. In Anbetracht dessen schlagen wir vor, ein positronenemissionstomographisches Scanning als Teil der standardisierten Behandlung bei diesen Patienten zu erwagen, insbesondere wenn eine neoadjuvante Radiochemotherapie als Teil der Primarbehandlung vorgesehen ist.

Purpose: The influence of positron emission tomography in the management of recurrent rectal cancer is well established but its role in primary rectal cancer remains uncertain. This study therefore prospectively assesses the impact of position emission tomography scanning on the management of primary rectal cancer. Methods: Forty-six patients with advanced primary rectal cancer referred for consideration of adjuvant preoperative therapy underwent position emission tomography scanning. The referring physicians prospectively recorded each patient’s stage following conventional imaging and the proposed treatment plan prior to position emission tomography scanning. This was then compared with subsequent stage and actual management implemented, and the appropriateness of position emission tomography-induced changes was noted by subsequent clinical follow-up. Results: The surgical management of 36 of 46 patients (78 percent) was unchanged as a result of position emission tomography, even though position emission tomography upstaged disease in 3 of 36 cases (8 percent) and downstaged disease in 5 of 36 cases (14 percent). In 8 of 46 cases (17 percent), management was altered because of the position emission tomography scan findings, including 6 cases (13 percent) in which surgery was cancelled and 2 other cases (4 percent) in which the radiotherapy field was changed. Where available, follow-up confirmed the appropriateness of position emission tomography-induced management change in each case. Two patients had a change in therapy independent of the position emission tomography scan due to clinical circumstances. Overall tumor stage was changed following position emission tomography in 18 of 46 patients (39 percent). Conclusion: Position emission tomography scanning appears to accurately change the stage or appropriately alter the therapy of almost a third of patients with advanced primary rectal cancer. In view of this, we suggest that position emission tomography scanning be considered part of standard workup for such patients, particularly if neoadjuvant chemoradiation is being considered as part of primary management.

The 3-D graphs resulting from the methods and procedures described in Part 1 indicate appropriate sites in which to seed or transplant locally common riparian species into the Silver Bow Creek floodplain, if seed or transplants are available. Ten graphs are presented, most of them representative of a broader class of plants and habitats. Two main patterns are evident. One class of plants is restricted to a rather narrow hydrologic range with particle-size class playing a minor role. Another class of species occurs in one of the wetter hydrologic classes on coarse substrates, and also on somewhat drier sites when combined with finer-textured substrates. Ordinations also identified a few species of broad amplitude that can be the best choices for revegetation where long-term hydrology cannot always be predicted with certainty or where it fluctuates greatly. For most species, the soils-hydrology ordinations provided a useful and relatively unambiguous approximation of where plants should be seeded or transplanted into a reconstructed riparian zone. Some species' edaphic habitats must be considered in the context of historical fluvial processes. For example, a set of species might typically establish on raw, moist substrates. Once established, the plants trap sediments during floods while stream downcutting lowers the water table, so that when sampled the remaining original plants are in a drier hydrologic regime than the one required for establishment. Some deep-rooted species persist in the drier habitat by maintaining contact with the capillary fringe; others are replaced by species better adapted to the new hydrologic regime and texture. A revegetation plan based solely on the observed hydrology of mature plants could erroneously indicate sites too dry for seedlings to survive. In some cases, therefore, our results must be tempered with a deeper understanding of species autecologies and fluvial processes. Matching plant species to appropriate habitats remains the basis for adapted-species revegetation. Preliminary practices and results along Silver Bow Creek are briefly mentioned.

SUMMARY The library Web site is a significant access point to a library's collections, resources, and services. A Web site can and should provide information about the library in a way that can be efficiently navigated and used by all library patrons. The usability of a library Web site can be improved through changes in organization and design informed by the experiences of real users. User expectations should be primary in determining the content, purpose, organization, and design of the site.

Mittels elektromechanischen Mappings kann eine Identifizierung der Zielregion fur die perkutane myokardiale Lasertherapie erfolgen. Narbengebiete von vitalem Myokard mit hoher Genauigkeit zu trennen ist dabei von groser Bedeutung. Eine besondere Rolle kommt der unipolaren Voltage als Amplitude des unipolaren endokardialen EKG zu. Werte uber 5 mV weisen mit hoher Sicherheit auf vitales, das heist behandlungswurdiges, myokardiales Gewebe hin. Weiterhin ist durch die hohe raumliche Auflosung eine Abgabe von Laserimpulsen an gleicher Stelle vermeidbar. Sicherheit und Effizienz der myokardialen Lasertherapie konnen somit erhoht werden. Die Wirksamkeit der myokardialen Lasertherapie wird derzeit in einer multizentrischen, randomisierten Studie untersucht.

In response to national and international concerns about soil and water quality, personnel at the United States Department of Agriculture, Natural Resources Conservation Service (USDA‐NRCS), Soil Survey Laboratory are developing standard procedures to determine trace metals in soils. This paper illustrates how trace metal studies, complemented by total analysis, increase the use and value of the modern National Cooperative Soil Survey. Examples include anthropogenic metal contamination (Pb, As, Hg, Cd, Cu, Zn) from a copper smelter in Deer Lodge Valley, Montana; nutrient deficiencies (Ca, N, P, K) and metal enrichment (Co, Cr, Fe, Ni) in serpentinitic soils in Klamath Mountains, Oregon; naturally‐elevated metal concentration (As, Pb, Hg) in hydrothermally active soils in Yellowstone National Park; total P and Fe as measures of weathering, chelation, and translocation of parent material in chronosequence study on Mendenhall Glacier in southeast Alaska; and metal determinations (Ni, Cr, Pb, Cd, Zn,...

This study examines the utility of a sleeve anastomosis with comparison to conventional end to end anastomosis. Thirty New Zealand white rabbits were randomized to sleeve (n = 15) or end-to-end (n = 15) small bowel anastomosis. Five rabbits of each group were sacrificed at 3 days, 7 days, and 6 weeks. Anastomoses were assessed for integrity, bursting strength, and stenosis and examined histologically. Ten control specimens of small bowel were tested for bursting pressure. Three rabbits died postoperatively (1 sleeve and 2 end-to-end). A fourth rabbit (sleeve) was sacrificed early at 3 weeks and had a total stenosis at the anastomosis. The remaining 26 rabbits were reoperated at the prescribed times. There was no evidence of infection or dehiscence in any of these rabbits. Both end-to-end and sleeve anastomoses were equivalent for bursting pressure at all times and, at 7 days and 6 weeks, were similar to controls. The stenotic index revealed no evidence of proximal dilation suggestive of obstruction in the 26 rabbits. For sleeve anastomoses the length of the projected bowel into the lumen persisted at the 6-week stage. Histologically there was good evidence of healing in both the sleeve and end-to-end anstomoses and the serosal surface of the sleeved bowel had epithelialized. Sleeve anastomosis has been demonstrated to heal well and to be as strong as conventional end-to-end anastomosis. Further studies are warranted to determine its role in intestinal anastomosis and potential as a valve.

Background: A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported. Methods: Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24–48 h. Results: There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group. Conclusion: Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.

Theology touches almost everyone at one time or another. The librarians who maintain, preserve, and disseminate theological information are critical to the perpetuation of theological study and enlightenment. However, the literature of librarianship is strangely silent on the topic of theological librarianship, and especially on issues that are unique to theological librarians-those who work with theologically or religiously focused collections or libraries that support the education and training of people preparing for the ministry.

3074Background: Humanized mice engrafted with tumors enable in vivo investigation of the interactions between the human immune system and human cancer. We have recently found that humanized NOD-sci...

Eighty per cent of patients with Crohn's disease require surgery, of whom 70% will require a further operation. Recurrence occurs at the anastomosis. Although often recommended, the impact of postoperative colonoscopy and treatment adjustment is unknown.Patients with a bowel resection over a 10-year period were reviewed and comparison made between those who did and did not have a postoperative colonoscopy within 1 year of surgery, and those who did or did not have a step-up in drug therapy.Of 222 patients operated on, 136 (65 men, mean age 33 years, mean disease duration 8 years, median follow-up 4 years) were studied. Of 70 patients with and 66 without postoperative colonoscopy, clinical recurrence occurred in 49% and 48% (NS) and further surgery in 9% and 5% (NS). Eighty-nine per cent of colonoscoped patients had a decision based on the colonoscopic findings: of these, 24% had a step-up of drug therapy [antibiotics (n =10), aminosalicylates (n=2), thiopurine (n=5), methotrexate (n=1)] and 76% had no step-up in drug therapy. In colonoscoped patients clinical recurrence occurred in 9 (60%) of 15 patients with, and 23 (49%) of 47 without step-up and surgical recurrence in 2 (13%) of 15 and 4 (9%) of 47 (NS).Clinical recurrence occurs in a majority of patients soon after surgery. In this cohort, there was no clinical benefit from colonoscopy or increased drug therapy within 1 year after operation. However, the response to the endoscopic findings was not standardized and immunosuppressive therapy was uncommon. Standardizing timing of colonoscopy and drug therapy, including more intense therapy, may improve outcome, although this remains to be proven.

Slow-transit constipation (STC) is recognized in children but the etiology is unknown. Abnormalities in substance P (SP), vasoactive intestinal peptide (VIP) and nitric oxide (NO) have been implicated. The density of nerve fibers in circular muscle containing these transmitters was examined in colon from children with STC and compared to other pediatric and adult samples.Fluorescence immunohistochemistry using antibodies to NO synthase (NOS), VIP and SP was performed on colonic biopsies (transverse and sigmoid colon) from 33 adults with colorectal cancer, 11 children with normal colonic transit and anorectal retention (NAR) and 51 with chronic constipation and slow motility in the proximal colon (STC). The percentage area of nerve fibers in circular muscle containing each transmitter was quantified in confocal images.In colon circular muscle, the percentage area of nerve fibers containing NOSVIPSP (6 : 2 : 1). Pediatric groups had a higher density of nerve fibers than adults. In pediatric samples, there were no regional differences in NOS and VIP, while SP nerve fiber density was higher in sigmoid than proximal colon. STC children had lower SP and VIP nerve fiber density in the proximal colon than NAR children. Twenty-three percent of STC children had low SP nerve fiber density.There are age-related reductions in nerve fiber density in human colon circular muscle. NOS and VIP do not show regional variations, while SP nerve fiber density is higher in distal colon. 1/3 of pediatric STC patients have low SP or VIP nerve fiber density in proximal colon.

Clenbuterol [4-amino-c~ [(tert.-butylamino)methyl]-3.5-dichlorobenzylalcohol] is a very potent #-2-mimetic drug, which differs from the other drugs of this class in its long half-life of about 30 h. Until now, only metabolic pattern have been published [1, 2]. There is no detailed information about the structure of metabolites. We isolated the metabolites of dog urine with HPLC-techniques and compared the metabolic pattern with those of man, rabbit and rat. 98% of the metabolites in urine (= 88% of administered dose!) were elucidated by NMR, MS, FAB-MS, derivatisation and comparison with reference material. As all positions of metabolic attack for enzymes which are able to metabolize catechol-structures are blocked in Clenbuterol, its biotransformation is rather different to catechols. The main excretion products in dog urine are (Fig. 1) parent compound (24%), degradation products of the aliphatic side chain: 4-Amino-3,5-dichloro-mandelic-acid (20%), the corresponding benzoic acid (9%), the corresponding hippuric acid (19%). There are four conjugation products of the parent compound: N-Sulfamate (5%), Oand N-Gtucuronides (5%) and an interestingly O-ethylation (2%) of the alcohol function. We further found indications of the C-C cleavage between the aromatic moiety and the aliphatic side chain yielding a phenol and the aliphatic aminoacid t-butylglycine (2%). The metabolic patterns in dog, man, rat, rabbit are qualitatively rather similar in these species. However, there are quantitative differences, e.g. the amount of unchanged drug is highest in man 61%, 37% in rabbit, 26% in rat and 24% in dog.

Multilayer dielectric (MLD) diffraction gratings are an essential component for the OMEGA EP short-pulse, highenergy laser system. The MLD gratings must have both high-optical-diffraction efficiency and high laser-damage threshold to be suitable for use within the OMEGA EP Laser System. Considerable effort has been directed toward optimizing the process parameters required to fabricate gratings that can withstand the 2.6-kJ output energy delivered by each beam. In this paper, we discuss a number of conventional semiconductor chemical cleaning processes that have been investigated for grating cleaning, and present evidence of their effectiveness in the critical cleaning of MLD gratings fabricated at LLE. Diffraction efficiency and damage-threshold data were correlated with both scanning electron microscopy (SEM) and time-of-flight secondary ion-mass spectrometry (ToF-SIMS) to determine the best combination of cleaning process and chemistry. We found that using these cleaning processes we were able to exceed both the LLE diffraction efficiency (specification >97%) and laser-damage specifications (specification >2.7 J/cm2).

The OMEGA EP Facility includes two high-energy, short-pulse laser beams that will be focused to high intensity in the OMEGA target chamber, providing backlighting of compressed fusion targets and investigating the fast-ignition concept. To produce 2.6-kJ output energy per beam, developments in grating compressor technology are required. Gold-coated diffraction gratings limit on-target energy because of their low damage fluence. Multilayer dielectric (MLD) gratings have shown promise as high-damage-threshold, high-efficiency diffraction gratings suitable for use in high-energy chirped-pulse amplification [ B. W. Shore et al., J. Opt. Soc. Am. A 14 , 1124 (1997).] Binary 100-mm-diam MLD gratings have been produced at the Laboratory for Laser Energetics (LLE) using large-aperture, holographic exposure and reactive ion-beam etching systems. A diffraction efficiency of greater than 99.5% at 1053 nm has been achieved for gratings with 1740 grooves/mm, with a 1:1 damage threshold of 5.49 J/cm 2 diffracted beam fluence at 10 ps. To demonstrate the ability to scale up to larger substrates, several 100-mm substrates have been distributed over an aperture of 47 × 43 cm and successfully etched, resulting in high efficiency over the full aperture. This paper details the manufacture and development of these gratings, including the specifics of the MLD coating, holographic lithography, reactive ion etching, reactive ion-beam cleaning, and wet chemical cleaning.