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Chronic expanding hematoma (CEH) is a rare entity that poses diagnostic and therapeutic challenges due to persistent growth, risk of recurrence, and potential for blood loss anemia. The most common etiologies of CEH are trauma or surgery. It is thought to occur due to irritant effects of blood breakdown products, causing bleeding from capillaries in chronic granulation tissue. Although treatment of CEH is variable, complete surgical excision of the hematoma and its pseudocapsule is the gold standard. We present a case of a 15-year CEH that was initially treated with limited evacuation of the hematoma and cavity decortication, resulting in recurrence. Ultimately, the patient was managed with complete excision of the pseudocapsule, closure of the cavity with quilting sutures, application of an absorbable hemostatic agent, and placement of a large drain, resulting in a successful outcome. This case highlights the efficacy of a comprehensive surgical plan in addressing CEH, emphasizing the importance of pseudocapsule excision in its entirety to prevent recurrence., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. This study was supported in part by the Thomas Jefferson University Open Access Fund., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Aim: To construct an in vitro model of oxygen-glucose deprivation/reperfusion (OGD/R) induced injury to the optic nerve and to study the oxidative damage mechanism of ischemia-reperfusion (I/R) injury in 661W cells and the protective effect of ginsenoside Rg1., Methods: The 661W cells were treated with different concentrations of Na 2 S 2 O 4 to establish OGD/R model in vitro . Apoptosis, intracellular reactive oxygen species (ROS) levels and superoxide dismutase (SOD) levels were measured at different time points during the reperfusion injury process. The injury model was pretreated with graded concentrations of ginsenoside Rg1. Real-time polymerase chain reaction (PCR) was used to measure the expression levels of cytochrome C (cyt C)/B-cell lymphoma-2 (Bcl2)/Bcl2 associated protein X (Bax), heme oxygenase-1 (HO-1), caspase9, nuclear factor erythroid 2-related factor 2 (nrf2), kelch-like ECH-associated protein 1 (keap1) and other genes. Western blot was used to detect the expression of nrf2, phosphorylated nrf2 (pnrf2) and keap1 protein levels., Results: Compared to the untreated group, the cell activity of 661W cells treated with Na 2 S 2 O 4 for 6 and 8h decreased ( P <0.01). Additionally, the ROS content increased and SOD levels decreased significantly ( P <0.01). In contrast, treatment with ginsenoside Rg1 reversed the cell viability and SOD levels in comparison to the Na 2 S 2 O 4 treated group ( P <0.01). Moreover, Rg1 reduced the levels of caspase3, caspase9, and cytC, while increasing the Bcl2/Bax level. These differences were all statistically significant ( P <0.05). Western blot analysis showed no significant difference in the protein expression levels of keap1 and nrf2 with Rg1 treatment, however, Rg1 significantly increased the ratio of pnrf2/nrf2 protein expression compared to the Na 2 S 2 O 4 treated group ( P <0.001)., Conclusion: The OGD/R process is induced in 661W cells using Na 2 S 2 O 4 . Rg1 inhibits OGD/R-induced oxidative damage and alleviates the extent of apoptosis in 661W cells through the keap1/nrf2 pathway. These results suggest a potential protective effect of Rg1 against retinal I/R injury., (International Journal of Ophthalmology Press.)

Purpose: This study aimed to describe and analyze the clinical features of 20 eyes of 15 primary vitreoretinal lymphoma (PVRL) patients., Methods: This was a retrospective case series and a review of the literature. Fifteen PVRL patients (20 affected eyes) referred between February 2011 and December 2019 were recruited, and their medical records were retrospectively reviewed., Results: Among these 15 PVRL patients, seven were men (46.67%), and five had bilateral PVRL (33.33%). The median onset age was 66 ± 9.26 years and six (40%) patients had central nervous system (CNS) involvement, and two of them died of CNS-related complications. The ocular symptoms varied from decreased vision to binocular diplopia. The ocular manifestations were diverse and involved both the anterior and posterior segments, including the vitreous cells, subretinal white-yellow lesions, cotton-wool spots, and ophthalmoplegia. The rate of misdiagnosis and failure to diagnose was 100%, and 30% of them were misdiagnosed as uveitis. We found five cases revealing rare characteristics of this malignancy. Among them, there were two cases with mild hypertensive retinopathy exhibiting cotton-wool spots, one case mimicking age-related macular degeneration (AMD), one case with systemic lupus erythematosus (SLE), and one patient had extraocular muscle involvement. To the best of our knowledge, we reported PVRL exhibiting cotton-wool spots as the main manifestation and coexisting with extraocular myopathy for the first time., Conclusions: PVRL is a rare intraocular malignancy that commonly masquerades as uveitis. As the clinical signs and symptoms are atypical, ophthalmologists must carefully examine patients to avoid misdiagnosis or a failure to diagnose. Cotton-wool spots and extraocular myopathy might be the dominant initial symptoms in PVRL patients, and AMD should be considered a differential diagnosis of PVRL. SLE patients under immunosuppressive treatment could have spontaneous PVRL., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Jing-Yi Luo et al.)

Purpose: To investigate the effect of 20(S)-ginsenoside Rh2 (Rh2) on anti HepG2 liver cancer cells and HepG2 cell-derived xenograft tumors, and explore the underlying mechanisms., Materials and Methods: The activity of total HDACs and HAT were assessed with a HDACs colorimetric kit. Expression of HDAC1, HDAC2, HDAC6, p-ERK, ERK, p-P38, P38, p-JNK and JNK proteins was tested by Western blotting.H3K9 and H3K14 proteins were also checked by immunofluorescence, changes in cell cycle distribution with flow cytometry, cell apoptosis with annexin V-FTIC/PI double staining. Activity of Renilla luciferase (HIF) was detected using the Luciferase Reporter Assay system reagent. Gene expression for CyclinD1, Bcl-2, Bax, HIF, IL-1, IL-6, IL-10 and TNF-α was tested by q-PCR. Expression levels of CD31 and Ki-67 was tested by immunohistochemical staining., Results: Total HDAC activity was decreased and total histone acetyltransferase (HAT)activity was increased in a time-dependent manner. Expression of HDAC1 and p-JNK proteins was significantly increased, expression levels of p-ERK was decreased. H3K9 and H3K14 fluorescence protein were increased. Flow cytometric analysis of the cell cycle revealed that the percentage of cells in the G0/G1 phase in the treatment group(64.35±1.36%) was significantly increased compared with the untreated group(61.61±1.23%).The apoptotic rate of the HepG2 group was 10.03±1.92%, which increased to 17.87±1.67% in the treatment group. Expression levels of the transcription factor HIF were also increased in HepG2 cells following induction by Rh2. Expression of CyclinD1 and Bcl-2 at the genetic level was significantly decreased, while expression levels of Bax, HIF, IL-1, IL-6, IL-10 and TNF-α was increased. In vivo, the expression levels of both CD31 and Ki-67 proteins were significantly down-regulated in the treatment group compared with the control group., Conclusions: The effects of Rh2 were suggested to occur through the inhibition of total HDAC activity, which subsequently induced MAPK signaling and down-regulated the expression of HIF., .

Background: High tibial osteotomy (HTO) is a valuable treatment option in the high-demand patient with chondral damage and an altered mechanical axis. Traditional opening wedge HTO performed with metal plates has several limitations, including hardware irritation, obscuration of detail on magnetic resonance imaging, and complexity of revision surgery. Recently, an all-polyetheretherketone (PEEK) HTO implant was introduced, but no studies to date have evaluated the performance of this implant with minimum 2-year outcomes compared with a traditional metal plate., Purpose: To compare patient outcomes and complications of HTO performed using a traditional metal plate with those performed using an all-PEEK implant., Study Design: Cohort study; Level of evidence, 3., Methods: All patients who underwent HTO by a single surgeon with a minimum 2-year follow-up over a 4-year period were identified. Medical records were reviewed for patient demographics, concomitant procedures, implant used, type and degree of correction, complications, reoperations, and failures. Recorded patient outcomes included EuroQol-5 dimensions (EQ-5D), resiliency, Single Assessment Numeric Evaluation (SANE), Tegner activity level scale, International Knee Documentation Committee (IKDC), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. HTO performed using a traditional metal plate served as the control group. Statistical analysis was performed using the Student t test for continuous variables and chi-square analysis for nonparametric data, with P < .05 considered significant., Results: A total of 41 patients (21 in the all-PEEK group, 20 in the control group) were identified with greater than 2-year follow-up. The mean patient age was 44 years, and there were no differences between the groups with regard to demographics, degree of correction, or concomitant procedures. In addition, no significant differences were found for any of the patient-reported outcomes. Complications (10% vs 15%, respectively; P = .59), failures (10% vs 5%, respectively; P = .58), and reoperations (10% vs 30%, respectively; P = .10) were similar for the all-PEEK and control groups. However, the all-PEEK group did not have any hardware removal, while 4 patients in the control group underwent hardware removal ( P = .03)., Conclusion: This study suggests that an all-PEEK implant may be safely used with comparable outcomes and complication rates to the traditional method but with less need for hardware removal., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

Background: As glenoid failure is one of the primary causes of failure of anatomic total shoulder arthroplasty (TSA), Trabecular Metal-backed glenoid components have become popular. This study reports implant survival and clinical outcomes of patients who received a Trabecular Metal-backed glenoid component during primary anatomic TSA., Methods: Patients who underwent TSA with a Trabecular Metal-backed glenoid component by a single surgeon were identified and reviewed for clinical, radiographic, and patient-reported outcome measures with a minimum of 2 years' follow-up., Results: Of 47 patients identified, radiographic and clinical follow-up was available on 36 patients (77%). Average age was 66.36 years (range, 50-85 years), and the average follow-up 41 months (range, 24-66 months). Three patients showed signs of osteolysis, 4 had radiographic evidence of metal debris, and 1 patient had a catastrophic failure after a fall. Of the 47 TSAs, 5 (11%) were revised to a reverse TSA for subscapularis failure and pain. Visual analog scale for pain scores improved by an average of 4.4. At final follow-up, the average Single Assessment Numeric Evaluation score was 72.4; Penn satisfaction score, 7.5; Penn score, 70.35; and American Shoulder and Elbow Surgeons score, 69.23. Outcome scores were similar in the 7 patients with osteolysis or metal debris compared to those without., Conclusion: Trabecular Metal-backed glenoids had a 25% rate of radiographic metal debris and osteolysis at a minimum 2-year follow-up in this series with one catastrophic failure. This implant should be used with caution, and patients followed closely., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Treatment choices for total shoulder arthroplasty (TSA) in the absence of full-thickness rotator cuff tears (RCTs) are not clearly defined in current literature. This study investigated the prevalence and effect of preoperative partial-thickness RCTs and muscular degenerative changes on postoperative outcomes after TSA., Methods: Medical records and magnetic resonance imaging studies were reviewed for patients who underwent TSA for primary glenohumeral osteoarthritis with minimum 2-year follow-up to determine preoperative tear classification, Goutallier grade, and supraspinatus tangent sign. Postoperative pain on the visual analog scale, range of motion, and patient outcomes scores were obtained to correlate preoperative RCT status, Goutallier grading, tangent sign, and postoperative outcomes. Patients with full-thickness RCT on preoperative magnetic resonance imaging were excluded., Results: Forty-five patients met all inclusion criteria (average age, 65 ± 10 years; average follow-up, 43 months). Of the patients undergoing TSA, 40% had a significant (>50% thickness) partial RCT. Grade 3 to 4 Goutallier changes were noted in 22% of all patients, and 13% demonstrated grade 3 to 4 changes in the context of no tear. Positive tangent sign was present in 7% of all patients. The preoperative Goutallier grade of the infraspinatus was significantly negatively correlated with postoperative forward elevation (P = .02) and external rotation (P = .05), but rotator cuff pathology, including tear status, Goutallier grade, and the presence of a tangent sign, did not correlate with postoperative functional outcome scores., Conclusions: Even in the absence of a full-thickness RCT, rotator cuff atrophy, fatty infiltration, and partial thickness tearing are common findings. Although postoperative range of motion is correlated to Goutallier changes of the infraspinatus, rotator cuff pathology is not correlated to outcomes after TSA; therefore, one may proceed with TSA without concern of their effect on postoperative outcomes., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Pain management strategies following shoulder arthroplasty vary significantly. Liposomal bupivacaine (LB) is an extended-release delivery of a phospholipid bilayer encapsulating bupivacaine that can result in drug delivery up to 72 hours. Prior studies in lower extremity surgery demonstrated efficacy of LB in comparison to a single-shot peripheral nerve block; however, no study has investigated LB in a total shoulder arthroplasty population. Therefore, this study compared LB vs. an indwelling interscalene nerve block (IINB)., Methods: This is a prospective, randomized study of 83 consecutive shoulder arthroplasty patients; 36 patients received LB and a "bridge" of 30 mL of 0.5% bupivacaine, and 47 patients received an IINB. Postoperative visual analog scale pain levels, opiate consumption measured with oral morphine equivalents, length of hospital stay, and postoperative complications were recorded. Continuous variables were compared using an analysis of variance with significance set at P < .05., Results: Visual analog scale pain scores were statistically higher in the LB cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the LB cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). Complication numbers and length of stay were not statistically different., Conclusion: Use of an IINB provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Resilience, characterized by an ability to bounce back or recover from stress, is increasingly recognized as a psychometric property affecting many outcomes' domains including quality of life, suicide risk in active-duty military personnel, and recovery in cancer patients. This study examines the correlation between resilience, as measured by the Brief Resilience Scale (BRS), and traditional outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn scores in patients undergoing total shoulder arthroplasty (TSA)., Methods: Seventy patients undergoing primary anatomic TSA were followed up for a minimum of 2 years (mean, 30 ± 3 months). Patients were stratified into groups a priori, based on deviation from the mean of the BRS score, into low-resilience (LR), normal-resilience (NR), and high-resilience (HR) patients, and outcome scores were calculated for each group., Results: Postoperative BRS scores significantly correlated with ASES, Penn, and SANE scores (r = 0.41-0.44, P < .004 for all scores). When we evaluated patients based on resilience group, the LR group had a Penn score that was 34 points lower than that in the HR group. Likewise, the LR group had a SANE score that averaged 40 points lower than that in the HR group (SANE score of 53 points in LR group and 92 points in HR group, P = .05). When we evaluated ASES subscores, it appeared that the pain subscale was responsible for most of the difference between the LR and HR groups (29 points and 48 points [out of 50 points], respectively; P = .03)., Conclusions: Resilience is a major predictor of postoperative outcomes after TSA. Patients who are classified as having LR have outcome scores that are 30 to 40 points lower on traditional outcome scales than patients with HR., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The use of selective internal radiation therapy (SIRT) is rapidly increasing, and the need for quantification and dosimetry is becoming more widespread to facilitate treatment planning and verification. The aim of this project was to develop an anthropomorphic phantom that can be used as a validation tool for post-SIRT imaging and its application to dosimetry., Method: The phantom design was based on anatomical data obtained from a T1-weighted volume-interpolated breath-hold examination (VIBE) on a Siemens Aera 1.5 T MRI scanner. The liver, lungs and abdominal trunk were segmented using the Hermes image processing workstation. Organ volumes were then uploaded to the Delft Visualization and Image processing Development Environment for smoothing and surface rendering. Triangular meshes defining the iso-surfaces were saved as stereo lithography (STL) files and imported into the Autodesk® Meshmixer software. Organ volumes were subtracted from the abdomen and a removable base designed to allow access to the liver cavity. Connection points for placing lesion inserts and filling holes were also included. The phantom was manufactured using a Stratasys Connex3 PolyJet 3D printer. The printer uses stereolithography technology combined with ink jet printing. Print material is a solid acrylic plastic, with similar properties to polymethylmethacrylate (PMMA)., Results: Measured Hounsfield units and calculated attenuation coefficients of the material were shown to also be similar to PMMA. Total print time for the phantom was approximately 5 days. Initial scans of the phantom have been performed with Y-90 bremsstrahlung SPECT/CT, Y-90 PET/CT and Tc-99m SPECT/CT. The CT component of these images compared well with the original anatomical reference, and measurements of volume agreed to within 9 %. Quantitative analysis of the phantom was performed using all three imaging techniques. Lesion and normal liver absorbed doses were calculated from the quantitative images in three dimensions using the local deposition method., Conclusions: 3D printing is a flexible and cost-efficient technology for manufacture of anthropomorphic phantom. Application of such phantoms will enable quantitative imaging and dosimetry methodologies to be evaluated, which with optimisation could help improve outcome for patients.

The composition of the oral microbiota from 10 individuals with healthy oral tissues was determined using culture-independent techniques. From each individual, 26 specimens, each from different oral sites at a single point in time, were collected and pooled. An 11th pool was constructed using portions of the subgingival specimens from all 10 individuals. The 16S ribosomal RNA gene was amplified using broad-range bacterial primers, and clone libraries from the individual and subgingival pools were constructed. From a total of 11,368 high-quality, nonchimeric, near full-length sequences, 247 species-level phylotypes (using a 99% sequence identity threshold) and 9 bacterial phyla were identified. At least 15 bacterial genera were conserved among all 10 individuals, with significant interindividual differences at the species and strain level. Comparisons of these oral bacterial sequences with near full-length sequences found previously in the large intestines and feces of other healthy individuals suggest that the mouth and intestinal tract harbor distinct sets of bacteria. Co-occurrence analysis showed significant segregation of taxa when community membership was examined at the level of genus, but not at the level of species, suggesting that ecologically significant, competitive interactions are more apparent at a broader taxonomic level than species. This study is one of the more comprehensive, high-resolution analyses of bacterial diversity within the healthy human mouth to date, and highlights the value of tools from macroecology for enhancing our understanding of bacterial ecology in human health.

Spallation Neutron Source is currently in progress of a multiyear plan to ramp ion beam power to the initial design power of 1.4 MW. Key to reaching this goal is understanding and improving the operation of the H(-) ion source. An Allison scanner was installed on the ion source in the test facility to support this improvement. This paper will discuss the hardware and the software control system of the installed Allison scanner. The hardware for the system consists of several parts. The heart of the system is the scanner head, complete with associated bias plates, slits, and signal detector. There are two analog controlled high voltage power supplies to bias the plates in the head, and a motor with associated controller to position the head in the beam. A multifunction data acquisition card reads the signals from the signal detector, as well as supplies the analog voltage control for the power supplies. To synchronize data acquisition with the source, the same timing signal that is used to trigger the source itself is used to trigger data acquisition. Finally, there is an industrial personal computer to control the rest of the hardware. Control software was developed using National Instruments LABVIEW, and consists of two parts: a data acquisition program to control the hardware and a stand alone application for offline user data analysis.

A new Allison-type emittance scanner has been built to characterize the ion sources and low energy beam transport systems at Spallation Neutron Source. In this work, the emittance characteristics of the H(-) beam produced with the external-antenna rf-driven ion source and transported through the two-lens electrostatic low energy beam transport are studied. The beam emittance dependence on beam intensity, extraction parameters, and the evolution of the emittance and twiss parameters over beam pulse duration are presented.

The concept of ecological 'traps' is based in theory from ecology and conservation biology that has now found application to infectious diseases with a study from Paul Turner's group. This study is important because it offers a mathematical model of ecological traps, applies this model to viruses, and tests the model in a bacteria-phage system. Although there will be technical hurdles to overcome, this concept might lead to benefits for both health and industry.

Mathematical models predict that the future of the multidrug-resistant tuberculosis epidemic will depend on the fitness cost of drug resistance. We show that in laboratory-derived mutants of Mycobacterium tuberculosis, rifampin resistance is universally associated with a competitive fitness cost and that this cost is determined by the specific resistance mutation and strain genetic background. In contrast, we demonstrate that prolonged patient treatment can result in multidrug-resistant strains with no fitness defect and that strains with low- or no-cost resistance mutations are also the most frequent among clinical isolates.

A 3-year-old dog with cervical myelopathy resulting from a vascular anomaly is described. Marked intradural-extramedullary spinal cord compression was observed, in association with multilevel ectatic anastomotic radicular arterial branches connecting the left and right vertebral arteries. A nonpatent proximal segment of the right subclavian artery had resulted in compensatory enlargement of the left vertebral artery. Flow within the right vertebral artery was retrograde and fed into the patent distal segment of the right subclavian artery. Multiple imaging techniques including myelography, computed tomography, magnetic resonance imaging, and selective digital angiography were used to document this anomaly. To reduce spinal cord compression the largest collateral vessel was embolized without complication. Good clinical response was observed within 6 weeks and improved clinical neurologic function was maintained at the time of a 12-month re-evaluation.

The gonococcal pilus is a major virulence factor that has well-established roles in mediating epithelial cell adherence and DNA transformation. Gonococci expressing four gonococcal pilin variants with distinct piliation properties under control of the lac regulatory system were grown in different levels of the inducer isopropyl-beta-D-thiogalactopyranoside (IPTG). These pilin variants expressed various levels of pilin message and pilin protein in response to the level of IPTG in the growth medium. Moreover, posttranslational modifications of the variant pilin proteins were detected, including S-pilin production and glycosylation. The ratio of the modified and unmodified pilin forms did not substantially change with different levels of pilin expression, showing that these modifications are not linked to pilin expression levels. DNA transformation competence was also influenced by IPTG levels in the growth medium. Substantial increases in transformation competence over an isogenic, nonpiliated mutant were observed when limited amounts of three of the pilin variants were expressed. Immunoelectron microscopy showed that when limited amounts of pilin are expressed, pili are rare and do not explain the pilin-dependent transformation competence. This pilin-dependent transformation competence required prepilin processing, the outer membrane secretin PilQ, and the twitching-motility-regulating protein PilT. These requirements show that a fully functional pilus assembly apparatus is required for DNA uptake when limited pilin is produced. We conclude that the pilus assembly apparatus functions to import DNA into the bacterial cell in a pilin-dependent manner but that extended pili are not required for transformation competence.

Force production by type IV pilus retraction is critical for infectivity of Neisseria gonorrhoeae and DNA transfer. We investigated the roles of pilus number and the retraction motor, PilT, in force generation in vivo at the single-molecule level and found that individual retraction events are generated by a single pilus fiber, and only one PilT complex powers retraction. Retraction velocity is constant at low forces but decreases at forces greater than 40 pN, giving a remarkably high average stall force of 110 +/- 30 pN. Further insights into the molecular mechanism of force generation are gained from the effect of ATP-depletion, which reduces the rate of retraction but not the stall force. Energetic considerations suggest that more than one ATP is involved in the removal of a single pilin subunit from a pilus. The results are most consistent with a model in which the ATPase PilT forms an oligomer that disassembles the pilus by a cooperative conformational change.

Objective: To determine the sensitivity and specificity of radiographic evaluation of radio-ulnar incongruence in canine elbow joints in vitro., Study Design: Radiographic evaluation of induced radio-ulnar incongruence in canine cadaveric forelimbs by radiologists blinded to study design., Sample Population: Six cadaveric canine left forelimbs., Methods: Extended lateral, 90 degrees flexed lateral, and cranio-caudal projections were taken of the elbow joint of six cadaveric canine forelimbs. A four-pin, type I external skeletal fixator (ESF) with a linear motor side bar was attached to the medial aspect of the radius, and a 2-cm segment of bone was removed from the mid-diaphysis. A 3.5-mm cortical bone screw placed from the medial to lateral styloid processes prevented relative movement between the distal radius and ulna during radial shortening. The ESF was used to progressively shorten the radius in increments of 0.5 mm to a total of 4 mm. The three radiographic projections were repeated after each incremental change of length. After the study, each elbow joint was disarticulated to confirm the presence of a step defect. The original radiographs and three copies were randomized and then evaluated by four radiologists blinded to the study design. Radiologists were asked to evaluate whether the joint was normal or abnormal and if there was evidence of radio-ulnar incongruence. The ability of each radiologist to correctly identify congruent elbows (specificity) and incongruent elbows (sensitivity) was calculated., Results: The median specificity was 86% using the lateral projection and 82% using the cranio-caudal projection. The median sensitivities using the lateral and cranio-caudal radiographic projections were 78% and 79%, respectively. The degree of radial shortening required for individual radiologists to achieve a sensitivity of 90% ranged from 1.5 mm to greater than 4 mm., Clinical Relevance: Standard radiographic evaluation for radio-ulnar incongruence in the dog may be associated with relatively poor sensitivity and specificity. Invasive surgical procedures and screening programs that rely on radiographic diagnosis of radio-ulnar incongruence should be discouraged until a more reliable method of diagnosis of this type of elbow joint incongruence is available., (Copyright 2002 by The American College of Veterinary Surgeons)

Digene's Hybrid Capture 2 (HC2) CT/GC, CT-ID, and GC-ID DNA tests were evaluated by comparison to traditional culture methods for detecting Chlamydia trachomatis and Neisseria gonorrhoeae infections in 669 cervical specimens from high-risk female populations attending two sexually transmitted disease clinics. For detection of either or both infections, the HC2 CT/GC test algorithm had 93.8% sensitivity and 95.9% specificity compared to those of culture. After resolution of discrepant results by direct fluorescent-antibody (DFA) staining or PCR assay, the relative sensitivity and specificity of the HC2 CT/GC test algorithm increased to 94.8 and 99.8%, while the values for culture were 83.6% (McNemar's P value, 0.0062) and 100%, respectively. For detection of the individual pathogens, the relative sensitivities for the HC2 CT-ID and GC-ID tests were 97.2 and 92.2% and the specificities were greater than 99% compared to culture adjucated by DFA staining and PCR. Test performance varied at the two clinics: the HC2 CT/GC algorithm, CT-ID, and GC-ID tests had significantly higher sensitivities (McNemar's P value, <0.05) than that of culture for the population at one clinic as well as for the combined populations. At the other clinic, the HC2 tests performed as well as culture.

Objective: To determine the efficacy and safety of percutaneous ethanol injection (PEI) for the treatment of hyperthyroidism caused by bilateral hyperplastic thyroid nodules in cats. DESIGN; Prospective study., Animals: 7 cats., Procedure: Hyperthyroidism was diagnosed on the basis of clinical signs and increased serum total thyroxine (TT4) concentrations. The presence of 2 cervical thyroid nodules was confirmed by use of ultrasonography and technetium Tc 99m albumin thyroid scans. After the death of 1 cat that received PEI in both thyroid nodules at the same time, the protocol was changed to injecting ethanol into 1 nodule at a time, with at least 1 month between injections. Clinical signs, serum TT4 concentrations, serum ionized calcium concentrations, laryngeal function, findings on ultrasonographic examinations of the ventral cervical region, and results of thyroid scans were monitored., Results: Serum TT4 concentrations transiently decreased in all 6 cats (into the reference range in 5 of 6 cats) within 4 days of the first staged ethanol injection. Each subsequent injection resulted in a transient decrease in serum TT4 concentration. The longest period of euthyroidism was 27 weeks. Adverse effects included Horner's syndrome, dysphonia, and laryngeal paralysis. One cat died of unrelated causes. One cat underwent bilateral thyroidectomy, 2 cats were treated with methimazole, and 2 cats that had increased serum TT4 concentrations were not treated further, because they remained clinically normal., Conclusions and Clinical Relevance: Percutaneous ethanol ablation of bilateral thyroid nodules as a treatment for cats with hyperthyroidism is not recommended. This treatment is not as efficacious as the medical and surgical treatments presently used.

Objective: To determine interoperator variance in shunt fraction calculation., Design: Case series., Sample Population: 101 transrectal portoscintigraphic studies., Procedure: Results of dynamic portoscintigraphic studies were reviewed by 4 radiologists without knowledge of signalment, history, or medical profile. Results were judged to be negative or positive on the basis of the dynamic scan. Composite images were formulated, and hand-drawn regions of interest were determined for the heart and liver. Time-activity curves were generated, time-zero points were selected, curves were integrated during a 10-second interval, and shunt fractions were calculated., Results: Radiologists were in agreement regarding positive versus negative results for 99 of 101 studies. Interoperator variance in shunt fraction calculation ranged from 0.4 to 59.6%. For 51 studies with positive results, variance ranged from 2.5 to 59.6% (mean +/- SD, 22.8 +/- 14.5%); differences among reviewers were significant. For 48 studies with negative results, variance in shunt fraction ranged from 0.4 to 25.9% (mean, 5.3 +/- 5.8%); significant differences among reviewers were not detected. Shunt fraction calculations were not exactly reproducible among radiologists in 94 and 100% of studies with negative or positive results, respectively., Conclusions and Clinical Relevance: Results suggest that shunt fraction values are not reproducible among operators. Range in variability was greater in studies with positive results. This factor may be of particular clinical importance in reassessment of patients after incomplete shunt ligation.

Objective: To evaluate the efficacy and safety of ultrasonographically guided radiofrequency heat ablation of parathyroid masses in dogs with primary hyperparathyroidism., Design: Clinical trial., Animals: 11 dogs., Procedure: In all dogs, either 1 or 2 parathyroid masses were evident ultrasonographically. Dogs were anesthetized, and a 20-gauge over-the-needle catheter was directed into the parathyroid mass via ultrasonographic guidance. Radiofrequency heat was applied to the stylet of the catheter until there was sonographically apparent change to the entire parenchyma of the mass. Serum total and ionized calcium and parathyroid hormone concentrations were monitored daily for 5 days after the ablation procedure and again at 1, 2, and 3-month intervals, if possible. Dogs were monitored for adverse effects., Results: One treatment was required in 6 dogs, 2 treatments were required in 2 dogs, and treatment was unsuccessful in 3 dogs. Serum total and ionized calcium concentrations were within reference ranges within 2 days of the last procedure in all 8 successfully treated dogs. Serum parathyroid hormone concentration was decreased 24 hours after treatment in all 8 dogs. Hypocalcemia developed in 5 of the 8 successfully treated dogs, all of which required treatment. One dog had a transient voice change. Other adverse effects were not reported., Conclusions and Clinical Relevance: Ultrasonographically guided radiofrequency heat ablation of parathyroid masses is a safe and effective alternative to surgery in dogs with primary hyperparathyroidism.

The gonococcal pilus, a member of the type IV family of pili, is composed of numerous monomers of the pilin protein and plays an important role in the initiation of disease by providing the primary attachment of the bacterial cell to human mucosal tissues. Piliation also correlates with efficient DNA transformation. To investigate the relationships between these pilus-related functions, the piliation state, and the availability of pilin, we constructed a derivative of MS11-C9 (DeltapilE1) in which the lacIOP regulatory sequences control pilE transcription. In this strain, MS11-C9.10, the steady-state levels of pilin mRNA and protein directly correlate with the concentration of IPTG (isopropyl-beta-D-thiogalactopyranoside) in the growth medium and can reach near-wild-type levels of expression. Transmission electron microscopy (TEM) demonstrated that the number of pili per cell correlated with the steady-state expression levels: at a low level of transcription, single long pili were observed; at a moderate expression level, many singular and bundled pili were expressed; and upon full gene expression, increased lateral association between pili was observed. Analysis of pilus assembly by TEM and epithelial cell adherence over a time course of induction demonstrated that pili were expressed as early as 1 h postinduction. Analysis at different steady-state levels of transcription demonstrated that DNA transformation efficiency and adherence of MS11-C9.10 to transformed and primary epithelial cells also correlated with the level of piliation. These data show that modulation of the level of pilE transcription, without a change in pilE sequence, can alter the number of pili expressed per cell, pilus bundling, DNA transformation competence, and epithelial cell adherence of the gonococcus.

"Bloodless" plastic surgery in the Jehovah's Witness patient is an area that has received little attention in the surgical literature. Given the unique and firmly held beliefs of this group of patients, caring for them can be particularly challenging for the plastic surgeon. The authors report a case of bilateral breast reconstruction with saline-filled implants complicated by a postoperative hematoma and one involving a staged approach to massive breast reduction, both in Jehovah's Witness patients. A third patient involving a staged panniculectomy for a complicated wound infection is also described. The historical background, philosophical views, ethical issues, legal aspects, surgical outcomes, and management techniques relevant to caring for this unique patient population are also reviewed in detail.

The aim of this study was to evaluate the diagnostic value of 99mTc-HMPAO leukocyte scintigraphy (LS) by means of a retrospective review of its use in 14 horses that were evaluated for orthopedic infection as a cause of lameness. A total of 17 LS exams were performed in 14 horses. LS studies were positive in 10 of 14 horses. A bacterial infection was confirmed with cytology or culture in 9 of 10 positive horses. Negative LS studies occurred in 4 of 14 horses. Necropsy confirmed the lack of infection in 2 of the 4 horses. Other clinical data and a favorable clinical outcome supported a negative study in the other 2 horses. No false negative or false positive studies were identified. It may be concluded that HMPAO-LS is an effective tool for the diagnosis of orthopedic infection in horses.

No single technique allows one to diagnose all causes of urinary incontinence and abnormal increased frequency of urination. Cystography is indicated for cases of abnormal urinary bladder position, size, or shape. Ultrasonography is best for mass effects, calculi, and extrinsic nonskeletal abnormalities. The combined cystography and excretory urography technique is recommended for diagnosing ectopic ureteral insertions. Computerized tomography and MR imaging are indicated when the techniques described previously fail to elucidate the problem sufficiently, but these methods are usually not selected as primary diagnostic techniques.

Neisseria gonorrhoeae pilin undergoes high-frequency changes in primary amino acid sequence that aid in the avoidance of the host immune response and alter pilus expression. The pilin amino acid changes reflect nucleotide changes in the expressed gene, pilE, which result from nonreciprocal recombination reactions with numerous silent loci, pilS. A series of mini-transposon insertions affecting pilin antigenic variation were localized to three genes in one region of the Gc chromosome. Mutational analysis with complementation showed that a Gc gene with sequence similarity to the Escherichia coli rdgC gene is involved in pilus-dependent colony phase variation and in pilin antigenic variation. Furthermore, we show that the Gc rdgC homologue is transcriptionally linked in an operon with a gene encoding a predicted GTPase. The inability to disrupt expression of this gene suggests it is an essential gene (engA, essential neisserial GTPase). While some of the transposon mutations in rdgC and insertions in the 5'-untranslated portion of engA showed a growth defect, all transposon insertions investigated conferred an aberrant cellular morphology. Complementation analysis showed that the growth deficiencies are due to the interruption of RdgC expression and not that of EngA. The requirement of RdgC for efficient pilin variation suggests a role for this protein in specialized DNA recombination reactions.

Objective: To evaluate the efficacy, feasibility, and safety of ultrasound-guided chemical ablation of parathyroid masses in dogs with primary hyperparathyroidism., Design: Prospective clinical trial., Animals: 8 dogs., Procedure: In all dogs, a solitary parathyroid mass was evident ultrasonographically. Dogs were anesthetized with propofol, and a 27-gauge needle was directed into the parathyroid mass under ultrasound guidance. Ethanol (96%) was injected into the mass until there was evidence of diffusion of fluid throughout the mass. Serum total calcium, ionized calcium, phosphorus, and parathyroid hormone (PTH) concentrations were monitored daily for 5 to 7 days after the ablation procedure and again 1, 3, and 6 months after the procedure. Dogs were also monitored for adverse effects. Follow-up ultrasonography was performed 5 days and 1 month after the ablation procedure., Results: One injection was required in 7 dogs, and 2 injections were required in 1. Serum total and ionized calcium concentrations were within reference ranges within 24 hours after treatment in 7 dogs and within 5 days in 1 dog. Serum PTH concentration decreased and serum phosphorus concentration increased within 24 hours after treatment in all 8 dogs. Transient hypocalcemia developed in 4 dogs during the first 5 days after treatment, but only 1 dog required treatment for hypocalcemic tetany. Hypercalcemia recurred in 1 dog 1 month after the procedure and surgical removal of the parathyroid mass was required. Other adverse effects were not reported., Conclusions and Clinical Relevance: Ultrasound-guided chemical ablation of parathyroid masses is a safe and effective alternative to surgery for dogs with primary hyperparathyroidism.

The aim of this study was to determine the normal ultrasonographic anatomy of the canine shoulder. Fourteen shoulders from 7 clinically normal mid-sized dogs were radiographed and imaged using high frequency ultrasound. Each shoulder was isolated postmortem, and the ultrasonographic and gross anatomy was studied during dissection. The ultrasonographic appearance of the shoulder specimens was similar to that found in the live dogs. Twenty-four shoulders isolated postmortem from 12 variably sized dogs were also used to characterize the normal ultrasound anatomy over a range of sizes. Important anatomic structures that could be consistently evaluated were the biceps tendon and bursa, the bicipital groove surface, the supraspinatous tendon, the infraspinatous tendon, the teres minor tendon, and the caudal aspect of the humeral head. Results of ultrasonographic examination of 4 dogs with shoulder lameness are described to illustrate some applications of canine shoulder ultrasonography in the evaluation of the canine shoulder. In these dogs, ultrasound was a valuable tool to evaluate effusion and synovial proliferation within the bicipital bursa, supraspinatous and biceps tendinitis, biceps tendon strain, and dystrophic calcification.

Wound care services at a tertiary level teaching hospital were reorganized to improve patient care and control costs. A multidisciplinary wound care team was implemented to develop an aggressive, proactive approach to prevent and minimize pressure ulceration. Outcome data demonstrate the efficacy of the wound care team.

The gonococcal pilus is a primary virulence factor, providing the initial attachment of the bacterial cell to human mucosal tissues. Pilin, the major subunit of the pilus, can carry a wide spectrum of primary amino acid sequences which are generated by the action of a complex antigenic variation system. Changes in the pilin amino acid sequence can produce different pilus-dependent colony morphotypes, which have been previously shown to reflect phase variation of pili on the bacterial cell surface. In this study, we further examined the relationships between changes in pilus-dependent colony morphology, pilin sequence, pilus expression, and pilus function in Neisseria gonorrhoeae FA1090. A group of FA1090 colony variants expressed different pilin sequences and demonstrated different levels of pilin, S-pilin, and pilus expression. The analysis of these colony variants shows that they do not represent two distinct phases of pilus expression, but that changes in pilin protein sequence produce a spectrum of S-pilin production, pilus expression, and pilus aggregation levels. These different levels of pilus expression and aggregation influence not only colony morphology but also DNA transformation efficiency and epithelial cell adherence.

Growth factors play a crucial role in the regulation of cellular proliferation and matrix degradation in wound healing and cancer. We have shown that thrombospondin 1 (TSP-1) and its cysteine-serine-valine-threonine-cysteine-glycine (CSVTCG)-specific receptor play a key role in cell invasion and matrix degradation in different carcinomas. The present study was done to determine whether TSP-1 and its receptor show a similar pattern of expression in wound healing and cancer. Expression and localization of TSP-1 and its receptor were determined in fetal wounds, adult burn wounds, and different human malignancies by immunohistochemical staining and computerized image analysis. In healing wounds, TSP-1 was expressed in the stroma early in the process, followed by a steep decline. The TSP-1 receptor localized to neovessels and highly proliferating cells (i.e., fibroblasts, basal cells), its levels remaining relatively constant. Cancer cells and tumor-associated microvessels expressed the TSP-1 receptor, whereas TSP-1 localized predominantly to the tumor-associated stroma. These data suggest a critical role for TSP-1 and its CSVTCG-specific receptor in wound healing and cancer.

High-grade sarcomas have a high rate of local recurrence as well as distant metastases. This has led to the development of intra-arterial chemotherapy (IAC) as part of a multimodal approach to control local disease and/or reduce the extent of surgical resection. Intra-arterial catheters are positioned by an interventional radiologist into the feeding vessels of the tumor. Adriamycin and 5-fluorodeoxyuridine are infused intra-arterially. Cisplatinum, with or without granulocyte colony stimulating factor, is given systemically. Patients usually experience acute self-limited soft-tissue inflammation in the treated area. In our experience of 118 patients, 3 patients experienced soft-tissue necrosis that required excision and reconstruction. The first was treated for synovial sarcoma of a metatarsal. After IAC with Adriamycin, she sloughed the skin, subcutaneous tissue, and some of the posterior compartment musculature of her calf. This tissue was debrided. A gastrocnemius flap and skin graft were used for coverage. She is free of disease and ambulatory. The second patient was treated with IAC Adriamycin for a radial head chondrosarcoma. She developed soft-tissue slough, which became infected with Pseudomonas. She required extensive debridement of the skin, subcutaneous tissue, and muscle, and was subsequently reconstructed with a latissimus flap and a split-thickness skin graft (STSG). She later developed a local recurrence requiring amputation. The latissimus was elevated and used to cover the distal stump. She also is free of disease. The third patient was treated with IAC Adriamycin for Ewing's sarcoma of the right femur. This was complicated by fat necrosis and persistent pain. Subsequent radiotherapy only worsened her symptoms. She underwent wide excision and muscle flap/STSG repair, which relieved her pain. She is currently ambulatory and free of disease. In conclusion, as the use of IAC continues, its complications may become more common. Our experience with this previously unknown entity is illustrated and therapeutic options are discussed.

A multidisciplinary wound care team was developed at the Medical College of Pennsylvania Hospital in 1993 to standardize wound management, appropriately allocate resources, prevent the occurrence of hospital-acquired decubitus ulcers, and effectively manage existing pressure ulcers. This report presents 4 years of prevalence survey data (n = 690 patients over 4 years), which affords an outcome analysis regarding the efficacy of the multidisciplinary wound care team. A significant reduction in the number of patients with pressure ulcers, hospital acquired pressure ulcers, and patients with hospital acquired ulcers occurred. There was, also, a significant improvement in skin integrity documentation, and in the implementation of nutritional assessments. These findings suggest that the multidisciplinary wound care team has been an effective means of gaining some control of decubitus ulcers, which are associated with increased patient morbidity and have an adverse economic impact on hospitals.

A second-generation signal amplification, nucleic acid-based test for the rapid detection and typing of herpes simplex virus (HSV) DNA was developed and evaluated with artificial and clinical specimens. The analytical sensitivity of the Hybrid Capture II (HC II) HSV DNA assay was determined by testing either cloned HSV DNA or total genomic HSV DNA titrations and resulted in detection thresholds of between 5 x 10(3) and 1 x 10(4) copies per assay. Specificity was assessed by testing a panel of bacteria and viruses commonly found in the female genital tract. Sensitivity was assessed by testing 112 ulcerative genital lesions by the HC II assay and comparing the results to those obtained by routine cell culture. Discrepant results were resolved by PCR testing. After resolution of the discrepant results, the sensitivity of the HC II assay compared to the consensus result (the results of two of three tests, the HC II assay, culture, and PCR, were in agreement) was 93.2% (41 of 44 specimens), and the specificity was 100% (60 of 60 specimens). Culture gave a sensitivity of 84.1% (37 of 44 specimens) and a specificity of 100% (60 of 60 specimens) compared to the consensus result. The results of HSV typing by the HC II assay and culture agreed in all cases. The HC II assay is a rapid and accurate assay for detecting and typing HSV types 1 and 2, with a sensitivity comparable to that of culture and greater ease of use than culture.

The case of a 38-year-old woman who was struck by an automobile is presented. The workup for lower extremity injuries revealed stationary arterial waves. Recognition of this arteriographic finding may avoid unnecessary confusion or exploration.

Giant aneurysms of the splenic artery are uncommon. The mean size of splenic artery aneurysms is reported to be 2.1 cm; they are rarely larger than 3 cm. We present two cases in which the splenic artery aneurysm was larger than 8 cm, discuss the management and operative approach to these infrequently encountered entities, and provide a brief review of the relevant literature.

Although free flaps are currently the gold standard for distal lower extremity reconstruction, situations occasionally arise when alternative methods are needed. We present three cases of cross-leg flaps, which have been modernized with current external fixation technology and current understanding of vascular anatomy. All cross-leg flaps were based on the axial blood supply of the posterior descending subfascial cutaneous branch of the popliteal artery. This axial flap afforded considerable length and well-vascularized tissue. All patients were placed in external fixation devices. Adjacent lower extremity joints were exercised during the period of attachment. There were no major complications or flap failures. All patients were ambulatory postoperatively. We conclude that the cross-leg flap, using external fixation techniques and axially based flaps, can be successfully and expeditiously used to cover defects of the lower extremities.

Ultrasonic tissue characterization (UTC) employing slope and Y-intercept parameters from the normalized power spectrum of backscattered echoes was employed in vivo to study compositional changes in the walls of pig jugular veins in which thrombi were experimentally induced. Light microscopy revealed these changes to be intimal hyperplasia with an early predominance of smooth muscle cells and a later mixture of smooth muscle cells and collagen deposits. UTC distinguished intimal hyperplasia from previously reported data from luminal thrombosis UTC. Furthermore, UTC was able to discriminate between early (predominantly smooth muscle cells) and older (smooth muscle cells plus collagen deposits) intimal hyperplasia. The study suggests that intimal hyperplasia in the experimental model used may be organized thrombus and that UTC may be able to follow both the development of wall changes as well as luminal changes occurring in venous thrombosis.

It is a common practice for anesthesia to substitute for one another, especially for short breaks during long surgical procedures. The assets and liabilities of this practice of relief have not been examined previously. In the course of gathering 1,089 reports of preventable errors and failures associated with anesthesia management, we identified 96 which involved a relief anesthetist. This subset was examined in search of common characteristics and patterns of cause and discovery of errors. In 28 incidents, the relief anesthetist discovered an error or the cause of an error. In 10 incidents, the process of relief was identified as having contributed to the commission of an error. Although 70 of the 1,089 incidents were associated with substantive negative outcomes, e.g., death, cardiac arrest, or extended ICU stay, none of those incidents was caused by a relieving anesthetist. There is a strong implication that relief is beneficial more often than not even aside from the presumed beneficial effect on the vigilance of the primary anesthetist (the latter effect was outside the scope of this study). From the descriptions of the causes and discoveries of errors in these relief-related incidents, guidance can be drawn for the safe and effective conduct of the intraoperative exchange of anesthesia personnel.

We evaluated and compared the acute hemodynamic effects of perfluorooctylbromide-100% (PFOB), a fluorocarbon emulsified in lecithin without pluronic-F68 (F68), to those of a standard iodinated contrast agent, renografin-76% (R76), and Fluosol-DA 20% (Fluosol), a fluorocarbon emulsified in part by F68. Five open chest dogs were instrumented to evaluate hemodynamic changes after iv injection of PFOB (1 ml.1 g/kg) and R76 (1 ml.0.37 g of iodine/kg). Fluosol (1 ml.0.2 g/kg) was given to two of the five dogs at the end of their study. Fluosol caused transient hemodynamic collapse in both dogs. R76 caused the known transient effect of hypotension (-15.4 +/- 3.3%) followed by hypertension (6.5 +/- 2.7%) and an increase in aortic flow (29.3 +/- 3.9% at 30 sec). PFOB caused minimal, clinically insignificant decrease in aortic flow (4 +/- 1% at 10 sec).

A modified critical-incident analysis technique was used in a retrospective examination of the characteristics of human error and equipment failure in anesthetic practice. The objective was to uncover patterns of frequently occurring incidents that are in need of careful prospective investigation. Forty-seven interviews were conducted with staff and resident anesthesiologists at one urban teaching institution, and descriptions of 359 preventable incidents were obtained. Twenty-three categories of details from these descriptions were subjected to computer-aided analysis for trends and patterns. Most of the preventable incidents involved human error (82 per cent), with breathing-circuit disconnections, inadvertent changes in gas flow, and drug-syringe errors being frequent problems. Overt equipment failures constituted only 14 per cent of the total number of preventable incidents, but equipment design was indictable in many categories of human error, as were inadequate experience and insufficient familiarity with equipment or with the specific surgical procedure. Other factors frequently associated with incidents were inadequate communication among personnel, haste or lack of precaution, and distraction. Results from multi-hospital studies based on the methodology developed could be used for more objective determination of priorities and planning of specific investments for decreasing the risk associated with anesthesia.

Human error and mechanical failure in anesthesia frequently cause incidents which, if not detected and corrected in time, could lead to increased patient morbidity or mortality. A study was conducted to analyze the human and technical factors that contribute to such incidents. The data thus obtained proved useful in reducing preventable anesthesia mishaps in specific institutions and generated recommendations for improving anesthesia practice in general.